CRRT模式选择ppt课件

CRRT：溶质分子与模式选择,1,Case,男性，50岁单纯高钾血症循环稳定CRRT策略：高流量的CVVH,？,2,内容提要,CRRT的基本概念CRRT的溶质清除原理CRRT的基本模式CRRT在ICU中的应用,3,CRRT:所有连续性清除水和溶质的治疗技术CAVH,CVVH,SCUF,CAVHD,CVVHD,CAVHDF,CVVHDF,CVVH,HVHF.CBP:连续性血液净化1995年第一届CRRT学术会议在美国圣地亚哥举行，每年一次学术会议,CRRT基本概念,4,CRRTamajortreatmentoptionforARF?,AcuteRenalFailure,Treatmentoptions:Drugtherapy(fluids,diuretics)IntermittentHemodialysis(IHD)PeritonealDialysisContinuousRenalReplacementTherapies(CRRT),AdditionalindicationsforCRRT,ChronicHeartFailureandoverhydrationMulti-organFailure(MOF)AcuteRespiratoryDistressSyndrome(ARDS)BurnPatientsLiverFailureSepsis,5,内容提要,CRRT的基本概念CRRT的溶质清除原理CRRT的基本模式CRRT在ICU中的应用,6,CRRT水和溶质清除原理,清除水Ultrafiltration清除溶质DiffusionConvectionAdsorption,7,Hollowfibrestructure,BloodInlet,8,9,压力梯度差形成的液体移动,超滤作用,正压,负压,不能通过膜的溶质做成胶体渗透压,10,CRRT溶质清除原理,清除溶质DiffusionConvectionAdsorption,11,小分子物质,氯化钠SodiumChloride58.5尿素Urea60磷酸PhosphateAcid96肌酐Creatinine113尿酸UricAcid168葡萄糖Glucose180,12,中分子物质,多肽PeptideA778维生素B12VitaminB121355菊糖Inulin5200微球蛋白B2-microglobulin11800肝素Heparin11200肌球蛋白Myoglobin17000因子DFactorD24000白介素1Interleukin-131000蛋白酶Pepsin35000肿瘤坏死因子TumorNecrosisFactor39000-225000,13,大分子物质,前白蛋白Pre-albumin55000抗凝血酶原3Antithrombin365000白蛋白Albumin66000血红蛋白Hemoglobin68000凝血酶原Prothrombin68000转铁蛋白Transferrin76500免疫球蛋白GIgG160000纤维蛋白原Fibrinnogen341000纤维连接蛋白Fibronectin(dimer)450000,14,Diffusion,SolutesmovefromaHigherconcentration(Blood)toaLowerconcentration(Dialysate)VeryefficientforremovingsmallmoleculesInHemodialysis.BFRdependentInCRRT.DialysateFlowDependent,15,Diffusion,RedBloodcell,Bicarbonate,Cratinine,Chlorure,Potassium,Urea,Blood,Membrane,Filtrate,AssociatedwithDialysate,16,17,Efficientforremovingsmallmolecules,小分子物质血液浓度高膜内外浓度差大小分子物质易于扩散相同膜对小分子物质阻力小,18,Convection,Soluteremovalwitha“waterflow”SoluteDrag(Pressuregradient)GoodforlargermolecularweightsubstancesThefastertheflow,thebettertheclearanceReplacementsolutionsmustbephysiologicalandsterile,19,对流,溶质随水流移动，“溶剂拖移”,20,影响对流作用的因素,增加某种溶质的对流清除率有两种方法:1.选择一块更易于溶质通过的簿膜2.增加超滤出来的容量,C=S*UFRUFR=Lp*A*TMP,S:筛过系数,21,22,Adsorption,RedBloodcell,Creatinine,Chlorure,Potassium,Urea,Sang,Membrane,Filtrate,InflammatoryMediators,23,吸附作用,有些膜材料带有吸附特性:(例如AN69膜)发生在膜表面的吸附如果份子能通过膜表皮，更大规模的吸附发生在膜的深层,份子粘附在膜的表面或深层,24,25,内容提要,CRRT的基本概念CRRT的溶质清除原理CRRT的基本模式CRRT在ICU中的应用,26,CRRT治疗方式,27,ContinuousRenalReplacement,Therapies,SCUF,C,A,V,H,SPONTANEOUS,BloodCirculation,PUMPED,BloodCirculation,HEMOFILTRATION,CONVECTION,HEMODIALYSIS,DIFFUSION,HVHF,28,RemovalofwaterisdonebyUFNoSubstitutionliquidisusedUsedmainlyforCHF+FluidOverload,SCUF,(SlowContinuousUltrafiltration),29,CVVHD,(ContinuousVeno-VenousHemodialysis),Theprinciple(clearances)isDiffusionEliminatemainlySmallMoleculesNetFluidRemovalisdesiredUsedofSterileDialysateSolution,30,CVVHPostdilution,(ContinuousVeno-VenousHemofiltration),Theprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpost-DilutionFluidsarereturningaftertheFilterinsidethevenousline,31,CVVHPre-dilution,Theprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpre-DilutionFluidsarereturningbeforetheFilterthroughthepreDilutionline,32,CVVH-HVHFPre/Postdilution,AssociatedwithHighVolumeHemofiltration,Theprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpre+post-DilutionFluidsarereturningtothepatientbeforeandaftertheFilter,33,Theprinciple(clearances)isConvection+DiffusionEliminateSmall+MidmoleculesNetFluidremovalifdesiredUseofSterileDialysate+ReplacementSolutions,CVVHDF,(ContinuousVeno-VenousHemodiafiltration),34,CRRT特点,稳定的血流动力学持续稳定的控制氮质血症和水电/酸碱平衡能够不断清除循环中的毒素或中分子物质按需提供营养补充和药物治疗,35,CRRTvsIRRT,36,内容提要,CRRT的基本概念CRRT的溶质清除原理CRRT的基本模式CRRT在ICU中的应用,37,CRRT病理生理指征,1.液体过负荷保持水平衡2.代谢产物堆积(氮质血症)清除代谢产物3.严重的酸碱失衡恢复酸碱失衡4.严重的电介质紊乱恢复电介质平衡5.容量治疗受限营养支持，补充胶体6.严重的组织器官水肿7.炎症反应清除或吸附炎症介质8.中毒清除毒物或药物9.恶性高热降温,BellomoRandRoncoC.CritCare,2000,4:339-345,38,血流动力学不稳定的ARF严重的SIRS重症胰腺炎，烧伤重症感染和感染性休克MODS与ARDS水中毒与急性肺水肿顽固性心衰中毒恶性高热容量治疗受限的ARF/CRF,CRRT临床指征,BellomoRandRoncoC.CritCare,2000,4:339-345,39,CRRTIndications,Acutepulmonaryoedema:SCUFToavoidkalium-hydricoverloadduringcardiacsurgerywithEBC(extracorporealbloodcirculation):SCUFSevereoedemain:congestivec