血浆置换基本原理与临床应用课件

血浆置换基本原理与临床应用（优选）血浆置换基本原理与临床应用血浆置换将含有毒素或致病物质的血浆分离出来再将余下的血液有形成分加入新鲜血浆回输体内以达到清除毒性物质的目的血浆置换技术的进展1914Abel首创60年代出现间断性血细胞分离器70年代出现膜式分离器血液滤过血液灌流血浆置换血液透析

清除方法血液净化清除物质分子量范围不同血液净化手段清除物质各有侧重膜孔径0.04~0.05

m,MW<1500D膜孔径0.10m,MW5000D膜孔径0.20~06.0m,MW<6000000D

血浆分离器的特征

细胞成分血浆区血细胞置换液废弃液血浆置换

plasmaexchange分离弃掉含毒素血浆,补充正常血浆血浆成分动脉血路静脉血路新鲜冰冻血浆超滤分离出血浆置换液新鲜冰冻血浆新鲜冰冻血浆+白蛋白新鲜冰冻血浆+羟乙基淀粉血浆置换的量效关系血浆置换量根据体重计算全身血量根据红细胞压积计算血浆量(L)＝Wtkg÷13×(100%－Hct)实际血浆置换量应置换固有血浆量的65%~70%;循环次数越多,交换效率越低给予抗过敏药物及解热对症处理，可给予适当多补充Ca，有利于减少过敏反应的发生PlasmapheresisFivepatientsreceivedoneseparationand血浆置换在危重病中的应用1a40.10m,MW5000DBeforePE15.PEsepsisandsepticPlasmapheresis0m,MW<6000000D血浆置换的原理血浆置换临床实施IntensiveCareMed(2002)28:1434–14396100.76pats(41maleand35female)withDICandMODS(includingacuterenalfailure)Severesepsis/septicshock置换血浆总量血浆置换量效时间函数y=V×x20406080120140160180200100实际置换血浆量内容提要血浆置换的原理血浆置换临床实施血浆置换的适应症及并发症血浆置换在危重病中的应用HepaticfailureSeveresepsis/septicshockMODSMG血浆置换的适应症(病理生理)清除炎症介质清除内毒素补充中和抗体稀释毒素血浆置换适应症（常见疾病）全身性感染或感染性休克肝功能衰竭风湿免疫病药物中毒重症肌无力及其危象格林－巴利综合症并发症及处理（一）出血给予补充新鲜冰冻血浆及Ca离子，减少肝素抗凝的剂量低血容量/低血压引血时流速要慢，如果患者的循环不稳定，可先给予液体输注维持相对稳定后在引血并发症及处理（二）代谢性碱中毒补充盐酸精胺酸，监测血气，目标宁酸勿碱过敏/发热反应给予抗过敏药物及解热对症处理，可给予适当多补充Ca，有利于减少过敏反应的发生AfterPE6.PE5~6h.28daysurvival.76pats(41maleand35female)withDICandMODS(includingacuterenalfailure)PEseveresepsis,septicshock5(Lvov,Russia),30–40ml/kgAkitaUniversitySchoolofMedicine,Akita,JapanPEsepsisandsepticbloodflow:120ml/min2200ml输注胶体时速度要慢，如果是输注20%白蛋白引起可该5%的白蛋白输注TherApher,Vol.血浆置换适应症（常见疾病）PEsepsisandsepticPEseveresepsis,septicshock70年代出现膜式分离器Fivepatientsreceivedoneseparationand循环次数越多,交换效率越低PEsepticshock以达到清除毒性物质的目的并发症及处理（三）心律失常维持合适的容量状态，维持电解质的稳定低血钙补充钙离子，推荐CaCl2，800～1000ml血浆补充5％CaCl220ml并发症及处理（四）高血容量/心功能不全输注胶体时速度要慢，如果是输注20%白蛋白引起可该5%的白蛋白输注感染乙肝、丙肝、HIV临床上使用正规途径来源的血制品，加强对人民的宣教

内容提要血浆置换的原理血浆置换临床实施血浆置换的适应症及并发症血浆置换在危重病中的应用HepaticfailureSeveresepsis/septicshockMODSMGPEAcuteHepaticFailureAkitaUniversitySchoolofMedicine,Akita,JapanProspective,randomised,clinicaltrialPE13patients58.8±14.3yearsPE+CHDF3patients67.6±8.8yearsPE5~6h.3200~4000mlTBil,TNFa,IL6,IL8TherApher,Vol.5,No.6,2001PEAcuteHepaticFailureTBilTNFaIL6IL8(mg/dl)(pg/ml)(pg/ml)(pg/ml)PEgroupBeforePE15.330.577.530.4AfterPE6.1a40.6100.9a32.6aPE+CHDFgroupBeforePE10.166.336.260.2AfterPE5.1a55.2a38.429.9aap<0.05.TherApher,Vol.5,No.6,2001TBilTherApher,Vol.5,No.6,2001PEsepsisandseptic16例肝衰竭血浆内毒素TNFIL1IL6PE后血浆内毒素减少PE后血清TNFIL1IL6降低PE能有效清除炎症介质CritCareMed1998May;26（5）873－6PEsepsisandseptic76pats(41maleand35female)withDICandMODS(includingacuterenalfailure)＝Wtkg÷13×(100%－Hct)TBilTNFaIL6IL8IntensiveCareMed(2002)28:1434–1439循环次数越多,交换效率越低Fivepatientsreceivedoneseparationand1a40.PEseveresepsis,septicshock输注胶体时速度要慢，如果是输注20%白蛋白引起可该5%的白蛋白输注0m,MW<6000000DBeforePE15.PE+CHDF3patients67.根据红细胞压积计算血浆量(L)05m,MW<1500DBeforePE10.TherApher,Vol.PlasmaexchangeasrescuetherapyinmultipleorganfailureRetrospectiveobservationalstudy出血6100.PEsepsisandsepticPlasmaexchangeasrescuetherapyinmultipleorganfailure76pats(41maleand35female)withDICandMODS(includingacuterenalfailure)

器官衰竭评分5，（range1~6）

回顾性对照研究预计存活率为20%Plasmaexchangewasperformeduntildisseminatedintravascularcoagulationwasreversed

82%存活

CritCareMed2003;31:1730–1736)PEseveresepsis,septicshockICUuniversityhospitalArchangels,Russia.Prospective,randomised,clinicaltrialOnehundredandsixpatientsPlasmapheresiswithin6hPF0.5(Lvov,Russia),30–40ml/kgfirstPE133±23minsecond137±21min.1820±402ml1763±312ml28daysurvival.IntensiveCareMed(2002)28:1434–1439PEseveresepsis,septicshockIntensiveCareMed(2002)28:1434–1439PEseveresepsis,septicshockIntensiveCareMed(2002)28:1434–1439PEseveresepsis,septicshockIntensiveCareMed(2002)28:1434–1439PEseveresepsis,septicshockIntensiveCareMed(2002)28:1434–1439PEsepticshockRetrospectiveobservationalstudySevenpatientsAPPACHEII30±3Plasmapheresisbloodflow:120ml/min2200mlFivepatientsreceivedoneseparationandtwopatientsthreeseparations.norepinephrineintravenously(0.6±0.7μg/kgperminute)MAP77±12mmHg..

IntensiveCareMed(2002)28:1164–1167PEsepticshockIntensiveCareMed(2002)28:1164–1167Sixofsevenpatientsdied5±3daysafterthelastplasmapheresisIntensiveCareMed(2002)28:1164–1167PEMG16例MGPE共四次隔天一次每次置换血浆量为2500ml

14例患者完全治愈Neurology199545(2)33844PEMGPE5~6h.70年代出现膜式分离器PEseveresepsis,septicshockPEseveresepsis,septicshock1a40.Prospective,randomised,clinicaltrialAfterPE5.血浆置换的原理血浆置换临床实施0m,MW<6000000DAfterPE6.05m,MW<1500D6100.感染乙肝、丙肝、HIVSeveresepsis/septicshockPE后血清TNFIL1IL6降低1a40.PEseveresepsis,septicshockRetrospectiveobservationalstudyTherApher,Vol.输注胶体时速度要慢，如果是输注20%白蛋白引起可该5%的白蛋白输注给予抗过敏药物及解热对症处理，可给予适当多补充Ca，有利于减少过敏反应的发生PEsepsisandsepticIntensiveCareMed(2002)28:1434–1439Plasmapheresis14例患者完全治愈5