连续静脉静脉血液滤过在营养支持的影响.ppt

Implicationsofnutritionalsupportduringcontinuousveno venoushaemofiltration PresentbyRi陳宇光 Introduction CVVHWideacceptedtherapyforacuterenalfailureinintensivecareCorrecturemia fluidoverloadandeliminatemetabolicwastes IntheapplicationofclearancebyconvectionOnetypeoftheCRRT continuousrenalreplacementtherapy Advantages ImprovehamodynamicstabilityPossibilityforunlimitednutrition optimalfluidbalanceGradualtoxinremovalwithoutfluctuations Indication ARF CRIandhemodynamicunstableP tRespiratorydistresssyndromeMultipleorganfailureCHForhepaticfailureARFafterorgantransplantationIntoxication NutrientlossbyCRRT LossofNutrientsduringCVVH Water solublenutrientswithlowmolecularsizeandlowproteinbinding aminoacidsorvitaminsLipidsandliposolublevitamins nearlynolossCholesteroland ortriglycerides onlytraceamountloss Aminoacidslosses Losses approximately10 15g day10 ofinfusedaminoacidsarelostDependupontherateofultrafiltrationandfreeserumaminoacidlevelsNotuponmolecularsizeorchargeAminoacidsupply increasedby0 2g kg day Carbohydrates Dextrose containingdialysate significantamountcanbeabsorbed 35 45 Fluidreplacementwithdextrosecontainingelectrolyte significantgainsofenergy PossibleHyperglycemiaTogetherwiththeenergyderivedfromthemetabolismoflactate 45mmoloflactateyields12kcal l takeintoaccountwhendesigningregiments GainsofenergyinCVVH Water solublevitaminandtraceelementlosses ParticipateinavarietyofphysiologicalfunctionsMayattenuatetheeffectsoftheinflammatorycascade particularlytheeffectsofoxygen derivedfreeradicalsSignificantlowervitaminsandtraceelementsduringthefirst24hofCVVHActualmicronutrientrequirement unknown BloodconcentrationsofmicronutrientsincriticallyillpatientsreceivingCVVHcomparedwithcontrols Proposedvitaminsupplementationinacuterenalfailure Glutaminelosses EssentialaminoacidduringillnessMaintenanceofmusclePreservationofgastrointestinaltractintegrityAcidbasebalanceEnhancementoftheimmunesystemAnenergysourceinrapidlygrowingtissues gutmucosaandimmunecells Glutaminelosses Linkedtomultipleorganfailure MOF Received20g dayintravenousglutaminesupplementation decreasedeathsCVVHDinduceschangesinglutaminemetabolism initialdecreaseofupto33 SubsequentlossesduringCRRT 25 35 3000mg day Glutaminelosses Adosageof0 3 0 5g kg day 30 35g dayforadult Thestabilityofaglutamine vitaminreplacementsolution L glutamine 4g vitaminC 100mg andfolicacid 400ug in160mlsterilewater Effectofglutaminesupplementationoncriticallyillpatients Antioxidantlosses Reactiveoxygenspecies pathogenesisofrenaldiseasesCRRT Aggravatedeprivationoftheoxygenradicalscavengersystembyeliminationofwater solubleantioxidantsEnhancelipidperoxidation increasemalondialdehyde Antioxidantlosses AntioxidantlossescanbeobservedinARFpatientstreatedwithintermittenthaemodialysisandCRRTIncreaseddemandfortheliposolubleantioxidantvitaminEandintracellularantioxidantglutathione againstlipidperoxidation Plasmalevelsofantioxidantsinmultipleorganfailureandacuterenalfailurepatientsoncontinuousrenalreplacementtherapycomparedwithcontrols Conclusion CVVHisassociatedwithabroadspectrumofmetabolicsideeffects including thelossofaminoacidssuchasglutamine water solublevitamin minerals andantioxidantsNutritioninconjunctionwithaggressivetreatmentoftheunderlyingdiseaseprocesstoincreaserecoveryofrenalfunctioncouldimprovesurvivalrateProteinrestrictionisunnecessaryinpatientswithARFreceivingCRRT optimalamountofdailyproteinandtotalenergyrequirefurtherresearch References AngelaMarinandGilHardy Practicalimplicationsofnutritionalsupportduringcontinuousrenalreplacementtherapy Lingtak NeanderChan Nutritionalsupportinacuterenalfailure CurrOpinClinNutrMetabCare7 207 212Story DavidA MBBS Hons BMedSci Hons FANZCA Ronco ClaudioMD Bellomo RinaldoMBBS Hons MD FRACPTraceelementandvitaminconcentrationsandlossesincritica