CVVHD时治疗剂量的计算学习教案

1、会计学1CVVHD时治疗剂量的计算时治疗剂量的计算CVVHD清除溶质的原理CVVHD治疗剂量的计算CVVHD提高剂量的方法第1页/共36页第2页/共36页heparinVVPVPAUFBLDSADRheaterhigh-flux肾小球原尿肾小管第3页/共36页第4页/共36页第5页/共36页第6页/共36页第7页/共36页第8页/共36页半透膜血液透析液第9页/共36页半透膜血液透析液第10页/共36页半透膜血液透析液第11页/共36页plasmadialysate第12页/共36页Kd = Sd.Qd = f (Qb, Qd, KoA)透析液饱和度透析液饱和度dialysate / plas

2、ma第13页/共36页第14页/共36页溶质溶质(分子量分子量)筛选系数筛选系数弥散系数弥散系数尿素氮(60)1.01 0.051.01 0.07肌酐(113)1.00 0.091.01 0.06尿酸(168)1.01 0.040.97 0.04*万古霉素(1448)0.84 0.100.74 0.04* P 0.05 vs. 筛选系数* P 0.01 vs. 筛选系数Jeffrey RF, Khan AA, Prabhu P, et al. A comparison of molecular clearance rates during continuous hemofiltration a

3、nd hemodialysis with a novel volumetric continuous renal replacement system. Artif Organs 1994; 18(6): 425-428第15页/共36页heparinVVPVPADUFDBLDSADheaterlow-flux第16页/共36页0408012010102103104105ureacreatinineVit. B122-Malbumineclearance ml/minMW daltonHDKidneyIL-1TNFIL-6IL-8第17页/共36页弥散清除率弥散清除率对流清除率对流清除率Kd

4、= QdoutxCdout/Cbin后稀释Cd = SxQuf前稀释Cd = SxQufxQb/(Quf+Qb)小分子溶质Cdout/Cbin 1S = 1S = 1中大分子溶质Cdout/Cbin KdCd Kd第18页/共36页0408012010102103104105ureacreatinineVit. B122-Malbumineclearance ml/minMW daltonHFHDKidneyCut-offIL-1TNFHrl (1996): Biocompatible membranes are linked with low incidence of infections,

5、 recovement of renal function and mortality in ARFIL-6IL-8第19页/共36页CVVHD清除溶质的原理CVVHD治疗剂量的计算CVVHD提高剂量的方法第20页/共36页heparinVVPVPADUFDBLDSADheaterlow-fluxBWt 60 kgBFR = 150 ml/minRFR = 2400 ml/hr平衡平衡 = 0 ml/hr流出液流出液 = 2400 ml/hr交换量交换量 40 ml/kg/hr第21页/共36页Qd, ml/minKurea, ml/minKoA = 765 ml/minQb = 500Qb

6、= 450Qb = 350Qb = 250Qb = 100第22页/共36页Qb, ml/minKurea, ml/minQd = 500KoA = 900KoA = 700KoA = 500第23页/共36页Qb, ml/minKd, ml/minPMNA膜KoA = 765 ml/min尿素肌酐尿酸VitB12菊酚第24页/共36页CVVHD清除溶质的原理CVVHD治疗剂量的计算CVVHD提高剂量的方法第25页/共36页Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-veno

7、us haemofiltration on outcomes of acute renal failure: A prospective randomised trial. Lancet 2000; 356: 26-30第26页/共36页第27页/共36页机制机制清除物质清除物质超滤(ultrafiltration)溶剂(水)对流(convection)小分子物质, 中分子物质弥散(diffusion)小分子物质吸附(adsorption)特殊分子第28页/共36页C = S.UFR = S.Lp.A.PC = S.UFR.BFR / (BFR + RFR)KT = KD + UFR.S.(1 KD/BFR)第29页/共36页heparinVVPVPARDUFDBLDSADheaterhigh-flux第30页/共36页总清除率对流清除率Clark WR, Ronco C. CRRT efficiency and efficacy in relation to solute size. Kidney Inte