CRRT模式选择[共0页]

1、CRRT：溶质分子与模式选择,Case,男性，50岁 单纯高钾血症 循环稳定 CRRT策略：高流量的CVVH,？,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,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,CRRT a major treatment option for ARF?,Acute Renal Failure,Trea

2、tment options: Drug therapy (fluids, diuretics) Intermittent Hemodialysis (IHD) Peritoneal Dialysis Continuous Renal Replacement Therapies (CRRT),Additional indications for CRRT,Chronic Heart Failure and overhydration Multi-organ Failure (MOF) Acute Respiratory Distress Syndrome (ARDS) Burn Patients

3、 Liver Failure Sepsis,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,CRRT水和溶质清除原理,清除水 Ultrafiltration 清除溶质 Diffusion Convection Adsorption,Hollow fibre structure,Blood Inlet,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,CRRT溶质清除原理,清除溶质 Diffusion Convection Adsorption,小分子物质,氯化钠 Sodium Chloride 58.5 尿素 U

4、rea 60 磷酸 Phosphate Acid 96 肌酐 Creatinine 113 尿酸 Uric Acid 168 葡萄糖 Glucose 180,中分子物质,多肽 Peptide A 778 维生素B12 Vitamin B12 1355 菊糖 Inulin 5200 微球蛋白 B2-microglobulin 11800 肝素 Heparin 11200 肌球蛋白 Myoglobin 17000 因子D Factor D 24000 白介素1 Interleukin-1 31000 蛋白酶 Pepsin 35000 肿瘤坏死因子 Tumor Necrosis Factor 390

5、00-225000,大分子物质,前白蛋白 Pre-albumin 55000 抗凝血酶原3 Antithrombin 3 65000 白蛋白 Albumin 66000 血红蛋白 Hemoglobin 68000 凝血酶原 Prothrombin 68000 转铁蛋白 Transferrin 76500 免疫球蛋白G IgG 160000 纤维蛋白原 Fibrinnogen 341000 纤维连接蛋白 Fibronectin (dimer) 450000,Diffusion,Solutes move from a Higher concentration (Blood) to a Lower

6、concentration (Dialysate) Very efficient for removing small molecules In Hemodialysis.BFR dependent In CRRT.Dialysate Flow Dependent,Diffusion,Red Blood cell,Bicarbonate,Cratinine,Chlorure,Potassium,Urea,Blood,Membrane,Filtrate,Associated with Dialysate,Efficient for removing small molecules,小分子物质血液

7、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,Convection,Solute removal with a “water flow” Solute Drag ( Pressure gradient ) Good for larger molecular weight substances The faster the flow, the better the clearance Replacement solutions must be physiological and sterile,对流,溶质随水流移动， “溶剂拖移”,影响对流作用的因素,增加某种溶质的对流清

8、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*UFR UFR=Lp*A*TMP,S:筛过系数,Adsorption,Red Blood cell,Creatinine,Chlorure,Potassium,Urea,Sang,Membrane,Filtrate,Inflammatory Mediators,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,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

9、,CRRT治疗方式,27,Continuous Renal Replacement,Therapies,SCUF,C,A,V,H,SPONTANEOUS,Blood Circulation,PUMPED,Blood Circulation,HEMOFILTRATION,CONVECTION,HEMODIALYSIS,DIFFUSION,HVHF,Removal of water is done by UF No Substitution liquid is used Used mainly for CHF + Fluid Overload,SCUF,(Slow Continuous Ultra

10、filtration),CVVHD,(Continuous Veno-Venous Hemodialysis),The principle ( clearances ) is Diffusion Eliminate mainly Small Molecules Net Fluid Removal is desired Used of Sterile Dialysate Solution,CVVH Post dilution,(Continuous Veno-Venous Hemofiltration),The principle ( clearances ) is Convection Eli

11、minate Small , Mid + Large molecules Net Fluid removal if desired In post-Dilution Fluids are returning after the Filter inside the venous line,CVVH Pre-dilution,The principle ( clearances ) is Convection Eliminate Small , Mid + Large molecules Net Fluid removal if desired In pre-Dilution Fluids are

12、 returning before the Filter through the pre Dilution line,CVVH -HVHF Pre/Post dilution,Associated with High Volume Hemofiltration,The principle ( clearances ) is Convection Eliminate Small , Mid + Large molecules Net Fluid removal if desired In pre + post -Dilution Fluids are returning to the patie

13、nt before and after the Filter,The principle ( clearances ) is Convection + Diffusion Eliminate Small + Mid molecules Net Fluid removal if desired Use of Sterile Dialysate + Replacement Solutions,CVVHDF,(Continuous Veno-Venous Hemodiafiltration),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

14、 按需提供营养补充和药物治疗,CRRT vs IRRT,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,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,Bellomo R and Ronco C. Crit Care, 2000,4:339-345,血流动力学不稳定的ARF 严重的SIRS重症

15、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,Bellomo R and Ronco C. Crit Care, 2000,4:339-345,CRRT Indications,Acute pulmonary oedema : SCUF To avoid kalium-hydric overload during cardiac surgery with EBC (extra corporeal blood circulation) : SCUF Severe oedema in : congestive card