肝衰竭治疗.ppt

肝衰竭的治疗,XXX市人民医院,.,支持治疗,1,病因治疗,2,并发症治疗,4,其他治疗,3,C,ONTENTS,目录,.,一、支持治疗,Bedrest,reducingenergyconsumption,andalleviating(缓解)theburdenoftheliver();MonitoringPTA/INR,bloodammonia(血氨)andbloodbiochemicalindices,analyzingarterialbloodlactate（乳酸）,endotoxin（内毒素）,hepadnavirusmarkers（嗜肝DNA病毒）,ceruloplasmin（铜兰蛋白）,antibodiesofautoimmuneliverdiseases（自免肝抗体）,andexaminingabdomenbyB-ultrasound(liver,gallbladder,spleenandpancreas,ascites),takingchestX-rayandelectro-cardiography(ECG)();,.,一、支持治疗,c.Enteralnutritionispreferred,includinghigh-carbohydrate（碳水化合物）,low-fat,moderateproteindiet,providing35-40kcal/kgtotalcalories;forpatientswithHE,proteinintakebyintestinalshouldbelimited;forpatientswithhypoalimentation（营养不良）,adequateliquidandvitaminsupplementationshouldbedeliveredintravenouslytoguaranteeadailytotalenergyintake();d.Itisnecessarytoactivelyrectify（纠正）lowproteinemia,andsupplyalbuminorfreshplasmaandbloodcoagulationfactorsasappropriate();,.,e.Monitoringarterialbloodgasisdoneifrequired,correctingthedisturbanceofwaterandelectrolytesaswellasacid-baseequilibrium,especiallyhyponatremia（低钠血症）,hypochloraemia（低氯血症）,hypopotassaemia（低钾血症）andalkalosis（碱中毒）();Hyponatremiaisacommoncomplicationofdecompensated(失代偿)cirrhosis.Hyponatremia,refractoryascites（顽固性腹水）andacutekidneyinjury(AKI)arecommonlyinterrelatedwitheachother.Waterrestriction,asappropriate,combinedwithdiuretics（利尿剂）,iseffectiveforhyponatremiaandthus,preventsthesubsequentcomplications;,一、支持治疗,.,ForHBVDNA(+)patientswithliverfailure,antiviraltherapyisrelativelyeffectiveintheearlyandmiddlestages;butforpatientswithadvancedstageofliverfailure,duetotheseverelydamageofresidualhepatocytesandregenerativecapacityoftheliver,antiviraltreatmentisunlikelytoimproveoutcome；Fordrug-inducedliverinjury(DILI),anypresumedorpossibleoffendingagentshouldbestoppedimmediately(),documentingallagentstakenoverthepastsixmonthsincludingprescriptiondrugs,non-prescriptiondrugs,herbs,dietarysupplements(),二、病因治疗,.,Forpatientsaffectedbyparacetamol（醋氨酚）、acetaminophen(APAP)（对乙酰氨基酚）,N-acetylcysteine(NAC)（乙酰半胱氨酸）therapyispreferred；NACmayalsoimprovetheoutcomeforpatientswithALFcausedbynon-APAP.Fortoadstool(毒菌)poisoning,silymarin（水飞蓟宾）orpenicillinG15-18canbeused()ForALFinducedbyacutefattyliverofpregnancy/HELLP(hemolysis,elevatedliverenzymes,lowplatelets)syndrome,theimmediateterminationofpregnancyisrecommended.Ifthediseasecontinuestoprogress,artificialliversupportandlivertransplantationarerecommended().,二、病因治疗,.,Glucocorticoid（激素）:Expertshavenotcometoanagreementontheapplicationofglucocorticoidinthetreatmentofliverfailure.Itisoptimallyindicatedfornon-viralinfectiousliverfailuresuchasautoimmuneliverdiseases,etc,andglucocorticoid(prednisone,40to60mg/d)maybeconsidered.Forearlystageliverfailurecausedbyotheretiologies,ifthediseasedevelopsrapidlyandwithoutcomplicationssuchasseriousinfectionsandhemorrhages（出血）,glucocorticoidisalsorecommended().,三、其他治疗,.,Hepatocyteregenerationtherapy:Torelievethenecrosis（坏死）andpromotetheregenerationofhepatocytes,drugsincludinghepatocytegrowth-promotingfactors（促肝细胞生长因子）andprostaglandinE1(PGE1)（前列腺素1）liposome()canbeused,buttheirefficaciesneedfurtherobservation.,三、其他治疗,.,Microecologicaltherapy（微生态治疗）:Patientswithliverfailureexhibitgutmicroflora（肠道菌群）imbalancewithreducednormalfloraandincreasedpathogenicintestinalbacteria.Theapplicationofintestinalprobioticsmayimprovetheprognosis.Microecologicalmodulatorssuchaslactulose（乳果糖）orlactitol（乳糖醇）canbeusedtoreducetheentericbacteriatranslocation,endotoxemia（内毒素血症）,orHE（肝性脑病）().,.,Cerebraledema（脑水肿）:a)Forpatientswithintracranial（颅内）hypertension,mannitol（甘露醇）(0.5-1.0g/kg)canbeused(-2);b)Diuretics,usuallyfurosemide（呋塞米）,canbeusedwithosmoticdehydrantalternatively();c)Artificialliversupporttherapyisused();d)Glucocorticoidisnotrecommendedforintracranialhypertension();e)Hypothermiatherapy（低温治疗）iseffectiveinpreventingcerebraledema,anddecreasingintracranialpressure().,四、并发症治疗,.,HE（肝性脑病）:a)eliminatingtheincitingfactorssuchasseriousinfections,hemorrhage,electrolytedisturbance();b)protein-restricteddiet();c)orallactuloseorlactitol,ortransferredbyhighenema（高位灌肠）,whichcanacidify（酸化）theintestinaltract,acceleratetheexcretionofammonia,modulateintestinalmicroecology,andreducetheabsorptionofenterotoxin();d)usingbranchedchainaminoacid（支链氨基酸）ormixedpreparationofbranchedchainaminoandwitharginine（精氨酸）torectifytheinbalanceofaminoacid();e)trachealintubationforpatientswithgrade+HE();f)artificialliversupporttherapy().,四、并发症治疗,.,Bacterialorfungalinfections（细菌、真菌感染）:a)Routineexaminationofbloodandbodyfluidsisperformed();b)Prophylactic（预防）useofantibacterialagentsisnotrecommendedexceptforpatientswithCLFwhomayorallytakequinolones（喹诺酮）topreventintestinalinfections();c)Onceinfected,broadspectrumantimicrobialagentsorcombineduseofantibioticsarepreferred,andthetherapyisadjustedaccordingtotheresultsofthesensitivitytest(-2).Superinfection（多重感染）offungi（真菌）ispreventedduringpotentantibioticstreatmentorantibioticsplusadrenalcorticalhormone（肾上腺皮质激素）treatment().,四、并发症治疗,.,Hyponatremia（低钠血症）andintractableascites（顽固性腹水）:Tolvaptan（托伐普坦）isanargininevasopressin（精氨酸加压素/抗利尿激素）V2receptorblocker（阻滞剂）,whichcanpromotefreewaterdrainage（排泄）throughselectivelyblockingcollectingduct（集合管）principalcellsV2receptors,andhasbecomeanewmethodforthetreatmentofhyponatremiaandintractableascites.,四、并发症治疗,.,AKIandhepatorenalsyndrome:a)Systemicvasoactive（血管活性药物）drugssuchasterlipressin（特利加压素）,norepinephrine（去甲）,albumin（白蛋白）canbeusedforpatientswithintractablehypovolemic（血容量减少）hypotension（低血压）,butnotforsevereencephalopathypatientswithintracranialhypertensionwhohavetheriskofexacerbationofcerebraledemawiththeincreaseofcerebralbloodflow(-2)b)Meanarterialpressureof75mmHgwasmaintained()c)Fluidintakeisrestricted,andthetotalintakeshouldnotexceedtheurinevolumeplus500-700mLwithin24hours();d)Artificialliversupporttherapyisrecommended().,四、并发症治疗,.,Hemorrhage:a)Prophylacticuseofhistamine-2(H2)receptorblockingagents（H2受体阻滞剂）orprotonpumpinhibitors（质子泵抑制剂）isrecommended();b)Forpatientswithportalhypertensionhemorrhage,somatostatinanalogues（生长抑素类似物）arepreferred();transjugularintrahepaticportosystemicshunt(TIPS)canbeused