急性肝功能衰竭诊治

1、急性肝功能衰竭诊治lAcute liver failure (ALF) is defined as life-threatening liver injury in the absence of preexisting liver disease with coagulopathy (prothrombin time 15 seconds or international normalized ratio INR 1.5) and hepatic encephalopathy (HE) that develops within 26 weeks of initial symptomslThe

2、term fulminant hepatic failure (FHF) is used when HE develops within 8 weeks of jaundice临床上按神经精神症状的轻重把肝性脑病分为四期：临床上按神经精神症状的轻重把肝性脑病分为四期：一期一期( (前驱期前驱期):):轻微的神经精神症状轻微的神经精神症状, ,可表现出欣快、反可表现出欣快、反 应迟钝、睡眠节律的变化。应迟钝、睡眠节律的变化。二期二期( (昏迷前期昏迷前期):):一期症状加重一期症状加重, ,可出现可出现: :行为异常、嗜行为异常、嗜 睡、精神错乱睡、精神错乱. .经常出现扑翼样震颤等经常出现扑翼

3、样震颤等. .三期三期( (昏睡期昏睡期):):有明显的精神错乱、昏睡、肌张力有明显的精神错乱、昏睡、肌张力等症等症 状状. .四期四期( (昏迷期昏迷期):):神志丧失神志丧失, ,不能唤醒不能唤醒, ,没有扑翼样震颤等没有扑翼样震颤等. . 氨中毒学说 假性神经递质学说 血浆氨基酸失衡学说 GABA学说 其他神经毒质在肝性脑病发病中的作用氨中毒氨中毒( (ammonia intoxication) )学说学说血氨增高的原因：氨清除不足（主要）血氨增高的原因：氨清除不足（主要）图图肝脏合成尿素的鸟氨酸循环肝脏合成尿素的鸟氨酸循环OCTOCT：鸟氨酸氨基甲酰转移酶：鸟氨酸氨基甲酰转移酶 CPS

4、CPS：氨基甲酰磷酸合成酶：氨基甲酰磷酸合成酶氨的清除：氨的清除：proteinNH3NH3ureaproteinNH3NH3ureaBlood NH3proteinNH3NH3urea血血 NH3 Other common triggers for ICP elevation: lvolume overloadlhyponatremialsevere hypercarbialsevere acidosisl increased thoracic and abdominal compartment pressureslInvasive neuromonitoring strategieslNo

5、ninvasive neuromonitoring strategieslserial head computed tomography (CT)ltranscranial Dopplerljugular bulb oximetry1.pupillometryEmerging strategies for the treatment of patients with acute hepatic failure, Curr Opin Crit Care 2016, 22:000000Emerging strategies for the treatment of patients with ac

6、ute hepatic failure, Curr Opin Crit Care 2016, 22:000000Annual Update in Intensive Care and Emergency Medicine 2015Emerging strategies for the treatment of patients with acute hepatic failure, Curr Opin Crit Care 2016, 22:000000Emerging strategies for the treatment of patients with acute hepatic fai

7、lure, Curr Opin Crit Care 2016, 22:000000lAcute renal failure develops in 5568% of all patients who present with ALF and in the vast majority of cases reverses with resolution of liver injury or with transplantationlmechanismldirect renal toxicity1.functional impairment as seen in the hepatorenal sy

8、ndromeMoore K. Renal failure in acute liver failure. Eur J Gastroenterol Hepatol 1999; 11:967975.Leithead JA, Ferguson JW, Bates CM, et al. The systemic inflammatory response syndrome is predictive of renal dysfunction in patients with nonparacetamol-induced acute liver failure. Gut 2009; 58:443449.

9、该患者无明显活动性出血征象，监测凝血功能：，APTT 65s，FIB 1.2 g/L，PLT 40 109/Ll需要输注血制品（血浆、冷沉淀、血小板）以纠正凝血功能障碍？健康人 VS 肝功能不全lPeripheral-Vein ThrombosislArterial ThrombosislPortal-Vein Thrombosis：等待肝移植的患者中发生率8 - 25%Francoz C, Belghiti J, Vilgrain V, et al. Splanchnic vein thrombosis in candidates for liver transplantation: use

10、fulness of screening and anticoagulation. Gut 2005;54:691-7.lHb 7.0 g/dllINR 20 109/LlFibrinogen 1.0 g/lAnnual Update in Intensive Care and Emergency Medicine 2015对于肝功能衰竭需要进行CRRT的患者，监测其凝血功能显著异常（APTT、INR显著升高），怎样开展CRRT治疗？l无抗凝？l枸橼酸抗凝？该试验共纳入71例患者，共更换539次滤器管路。平均的滤器寿命为9 (616)小时。其中51例患者接受完全无抗凝CRRT，其滤器寿命为 12 (7-24)小时。余下20例患者开始也行无抗凝CRRT，其滤器寿命为 7 (5-11)小时，但其后即使予以全身肝素抗凝或局部肝素抗凝使得APTT显著延长，也并不增加其滤器的寿命所有43个滤器寿命均超过24小时