急性肝功能衰竭诊治ppt课件.pptVIP

急性肝功能衰竭,1,急性肝功能衰竭的定义,Acuteliverfailure(ALF)isdefinedaslife-threateningliverinjuryintheabsenceofpreexistingliverdiseasewithcoagulopathy(prothrombintime15secondsorinternationalnormalizedratioINR1.5)andhepaticencephalopathy(HE)thatdevelopswithin26weeksofinitialsymptomsThetermfulminanthepaticfailure(FHF)isusedwhenHEdevelopswithin8weeksofjaundice,2,Etiologyofacuteliverfailure,3,4,肝性脑病的分期,临床上按神经精神症状的轻重把肝性脑病分为四期：,一期(前驱期):轻微的神经精神症状,可表现出欣快、反应迟钝、睡眠节律的变化。二期(昏迷前期):一期症状加重,可出现:行为异常、嗜睡、精神错乱.经常出现扑翼样震颤等.三期(昏睡期):有明显的精神错乱、昏睡、肌张力等症状.四期(昏迷期):神志丧失,不能唤醒,没有扑翼样震颤等.,5,肝性脑病分期,6,肝性脑病发病机制,氨中毒学说假性神经递质学说血浆氨基酸失衡学说GABA学说其他神经毒质在肝性脑病发病中的作用,7,氨中毒(ammoniaintoxication)学说,血氨增高的原因：氨清除不足（主要）,图肝脏合成尿素的鸟氨酸循环OCT：鸟氨酸氨基甲酰转移酶CPS：氨基甲酰磷酸合成酶,氨的清除：,8,protein,NH3,NH3,urea,Normalmetabolism,9,Liverfailure肝衰竭,protein,NH3,NH3,urea,BloodNH3,10,Liverfailure肝衰竭,protein,NH3,NH3,urea,血NH3,ShuntingCirculation门-体分流,11,CerebralEdemaandIntracranialHypertension,12,CerebralEdemaandIntracranialHypertension,OthercommontriggersforICPelevation:volumeoverloadhyponatremiaseverehypercarbiasevereacidosisincreasedthoracicandabdominalcompartmentpressures,13,Neuromonitoringstrategies,InvasiveneuromonitoringstrategiesNoninvasiveneuromonitoringstrategiesserialheadcomputedtomography(CT)transcranialDopplerjugularbulboximetrypupillometry,14,Algorithmforthediagnosticandtherapeuticmanagementofacuteliverfailurewithadvancedhepaticencephalopathyandintracranialhypertension,Emergingstrategiesforthetreatmentofpatientswithacutehepaticfailure,CurrOpinCritCare2016,22:000000,15,Algorithmforthediagnosticandtherapeuticmanagementofacuteliverfailurewithadvancedhepaticencephalopathyandintracranialhypertension,Emergingstrategiesforthetreatmentofpatientswithacutehepaticfailure,CurrOpinCritCare2016,22:000000,16,AnnualUpdateinIntensiveCareandEmergencyMedicine2015,17,Intensivecaresupportivestrategiesdirectedatcerebraledemainacuteliverfailure,Emergingstrategiesforthetreatmentofpatientswithacutehepaticfailure,CurrOpinCritCare2016,22:000000,18,Intensivecaresupportivestrategiesdirectedatcerebraledemainacuteliverfailure,Emergingstrategiesforthetreatmentofpatientswithacutehepaticfailure,CurrOpinCritCare2016,22:000000,19,AKIinALF,Acuterenalfailuredevelopsin5568%ofallpatientswhopresentwithALFandinthevastmajorityofcasesreverseswithresolutionofliverinjuryorwithtransplantationmechanismdirectrenaltoxicityfunctionalimpairmentasseeninthehepatorenalsyndrome,MooreK.Renalfailureinacuteliverfailure.EurJGastroenterolHepatol1999;11:967975.,LeitheadJA,FergusonJW,BatesCM,etal.Thesystemicinflammatoryresponsesyndromeispredictiveofrenaldysfunctioninpatientswithnonparacetamol-inducedacuteliverfailure.Gut2009;58:443449.,20,21,临床问题,该患者无明显活动性出血征象，监测凝血功能：INR3.2，APTT65s，FIB1.2g/L，PLT40109/L需要输注血制品（血浆、冷沉淀、血小板）以纠正凝血功能障碍？,22,ProthrombinTime,PT,23,24,25,26,27,凝血功能再平衡,健康人VS肝功能不全,28,Peripheral-VeinThrombosisArterialThrombosisPortal-VeinThrombosis：等待肝移植的患者中发生率8-25%,FrancozC,BelghitiJ,VilgrainV,etal.Splanchnicveinthrombosisincandidatesforlivertransplantation:usefulnessofscreeningandanticoagulation.Gut2005;54:691-7.,29,HematologicalSupport,Hb7.0g/dlINR20109/LFibrinogen1.0g/l,AnnualUpdateinIntensiveCareandEmergencyMedicine2015,30,临床问题,对于肝功能衰竭需要进行CRRT的患者，监测其凝血功能显著异常（APTT、INR显著升高），怎样开展CRRT治疗？无抗凝？枸橼酸抗凝？,31,该试验共纳入71例患者，共更换539次滤器管路。平均的滤器寿命为9(616)小时。其中51例患者接受完全无抗凝CRRT，其滤器寿命为12(7-24)小时。余下20例患者开始也行无抗凝CRRT，其滤器寿命为7(5-11)小时，但其后即使予以全身肝素抗凝或局部肝素抗凝使得APTT显著延长，也并不增加其滤器的寿命,32,所有43个滤器寿命均超过24小时，其中32个(74%)的滤器寿命达到72小时在提前更换滤器的事件中，只有3例是因为总钙/游离钙2.5尽管在严重肝功能衰竭患者中进行局部枸橼酸抗凝的CVVHD治疗会造成体内枸橼酸蓄积，但并没有造成酸碱平衡紊乱及电解质紊乱在严重肝功能衰竭患者中进行局部枸橼酸抗凝的血液净化治疗是安全、可行的，但仍有必要密切监测总钙/游离钙以保