肾替代性治疗大全.ppt

RenalReplacementTherapy(RRT)腎替代性治療,ByR4董國盈,AcuteKidneyInjury(AKI)AcuteRenalFailureARF,Prevention,Identificationofhigh-riskpatientsforpharmacologicagents-inducednephrotoxicityiodinatedradiocontrastmedium,NSAIDsAggressivesurveillancefornephrotoxin-inducedrenaldysfunctioncisplatin,amphotericinB,aminoglycosideUseofvolumeexpansioninselectedclinicalsettingsHyperpigmenturia:hemoglobinuria,myoglobinuriaCrystaluria:uricacid,acyclovir,methotrexate,sulfonamidesMinimalizationofcathetersusetoavoidnosocomialsepsis,EtiologyTreatment,CorrectpostrenalfactorCorrectprerenalfactorTreatunderlyingsepsisStopnephrotoxicdrugs,Evaluationofintravascularvolume,GuideofVolumeExpansion,CVP8-14cmH2OPAWP12-16mmHgUrineoutput0.5-1.0ml/kg/hourWeighingthepatientdailyInsensiblewaterlossfromtheskinandrespiratorytract(500ml/day),ConservativeMeasurement,FluidbalanceCarefulmonitoringofI/OandbodyweightFluidrestriction(usuallylessthan1L/dayinoliguricARF)Totalintake15hyperphosphatemiaTreathypocalcemiaonlyifsymptomatic,Uremia-nutritionRestrictionproteinbutmaintaincaloricintakeCarbohydrate100gm/daytominimizeketosisandproteincatabolismDrugReviewallmedication,Stopmagnesium-containingmedicationAdjusteddosageforrenalfailure,ReadjustwithimprovementofGFR,ConservativeMeasurement,Dietarymodification,Totalcaloricintake3550kcal/kg/daytoavoidcatabolismSaltrestriction24g/dayPotassiumintake40meq/dayPhosphorusintake800mg/day,RenalReplacementTherapy,IndicationsforRenalReplacementTherapy,Prophylacticdialysis:BUN80-100mg/dl,creatinine8-10mg/dlVolumeoverloadingwithrefractorytodiureticsPulmonaryedemaHyperkalemia6.5mEq/lSeveremetabolicacidosis50%)重症病患常合併有低血壓，血行動力不穩，多重器官衰竭；且常需大量輸液(升壓劑,輸血)合併急性腎衰竭需透析時常合併(1)血行動力不穩定(2)大量輸液無法依需要給予（如TPN)CRRT提供另類腎替代療法的選擇，並可避免傳統間歇性血液透析(intermittenthemodialysis,IHD)執行上的缺點,CRRT,CRRT種類,連續性動脈靜脈血液過濾術(CAVH)Continuousarteriovenoushemofiltraton連續性靜脈靜脈血液過濾術（CVVH）Continuousvenous-venoushemodialysis連續性動脈靜脈血液透析術（CAVHD）連續性靜脈靜脈血液透析術（CVVHD）Continuousvenous-venoushemodialysis連續性動脈靜脈血液透析過濾術（CAVHDF）連續性靜脈靜脈血液透析過濾術（CVVHDF）Continuousvenous-venoushemodiafiltration,CAVH,CVVH,CRRT的適應症,A.Renalindications-hemodynamicinstability-multipleorgansdysfunctionsyndromeaccompaniedbyrenalfailure-acuterenalfailurewithcerebraledemaB.Non-Renalindications-possibleremovalofsubstancesactiveasmediators,適應症,(1)急慢性腎衰竭及血壓不穩定休克患者之併發症。(2)呼吸窘迫症候群。(3)多重器官衰竭。(4)鬱血性心衰竭、或肝衰竭。(5)敗血性休克。(6)燙傷併血壓不穩。(7)器官移植後急性腎衰竭。(8)毒藥物中毒。,CRRT的優點,Avoidanceofelectrolyte,waterandureafluctuationGradualurearemovalHemodynamicstabilitywithslowultrafiltrationOptimalfluidbalanceandunlimitedalimentationEliminationofsepticmediatorsLowerintracranialpressureImprovedoutcome,CRRT的缺點,出血危險性（常需使用抗凝劑）limitedmobilityslowersoluteandfluidremoval,MMHCRRTOrder,Modality:(CVVH,CVVHD,CVVHDF)AKpriming:N/S500ccx2BTaaheparin0.5ccAnticoagulation:PrepareHeparin12,500U+N/S500ccIVD10cc/hrwithpumptokeepaPPT1.5-2andadjustasfollowedaPTTholddose(ml/h)2.5x60mins-4Ifnon-heparin,N/S(250)ccQ30minstorinsetheAK,Predilution:run999cc/hralternatelyasfollowedviaarteryend1stbottleN/S500cc+Sinca1amp2ndbottleN/S500cc+10%MgSO44cc3rdbottleN/S500cc4thbottleD5W500cc+NaHCO35ampDialysate:1.5%PDsolutionrun999cc/hrWarmPredilutionMgQW1,4aPTTQ12HKClsupplement:,MMH配方(Predilution),Predilutionrun500cc/hralternatelyasfollowedviaarteryend:1stbottleN/S500cc+Sinca1amp2ndbottleN/S500cc+10%MgSO44cc3rdbottleN/S500cc4thbottleD/W500cc+NaHCO35amp,KClSupplement,CRRT結語,連續性腎替代療法提供另一種治療選擇，特別在急性腎衰竭病患併有血行動力狀態不穩，輸液之給予及體液恆定不易維持時。採用hemofiltration治療時，有大量過濾液濾出，補充液需兼顧容易流失的血中成分及酸鹼和電解質異常。採用hemodialysis治療則要調整透析之成分以利用擴散原理達到治療目標。,CRRT結語,電解質異常可藉由改變補充液/透析液的濃度來治療；由於病