医院培训课件：《血浆置换及临床应用》

血浆置换及临床应用

血浆置换(plasmaexchange，PE）将患者的血液抽出体外将血浆中的致病成分选择性地分离后弃去将血浆的其他成分以及所补充的平衡液或白蛋白输回体内清除血浆内的致病物质的一种血液净化方法。血浆置换技术的进展1914Abel首创沉淀法60年代离心分离装置70年代膜式分离器1980年Agishi双重滤过血浆置换

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膜孔径0.04~0.05

m,MW<1500D膜孔径0.10m,MW5000D膜孔径0.20~0.60m,MW<6000000D

SPECTRUMOFBLOODPURIFICATIONBun28,Urea60VitaminB121,355Vancomycin1,468

2-microglobulin11.600Albumin69,000IgG180,000IgM900,000LDL-cholesterol1,300,000CellHDHFPlasmaexchangeDoublefiltrationplasmapheresisCytapheresis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Threemodalitiesofplasmapheresisplasmaexchange(PE)doublefiltrationplasmapheresis(DFPP)plasmaadsorption(PA)

动脉血路静脉血路新鲜冰冻血浆超滤分离出血浆

PlasmaExchange(PE)Doublefiltrationplasmapheresis（DFPP）通过对一级分离后的致病血浆进行二级分离,然后将弃除致病因子后的血浆与血液有形成分一同输回体内，从而达到治疗疾病目的的一种选择性血浆分离疗法。PrincipleofDFPPClinicalperformanceofDFPPMECHANISMSOFDFPPPlasmaPlasmaseparatorBloodcellsPlasmafilterIgG,Immunecomplex,Lipoprotein,etc.DFPP

Comparisonofplasmapheresismodalities

RationaleForTPE

UseofconcomitantimmunosuppressionEarlytreatmentPharmacokineticsOfIgRemovalPharmacokineticsOfIgRemovalMembraneplasmaseparation(MPS)Theidealbloodflowrate(Qb)：100-150mL/minTMP(<500mmHg)toavoidhemolysisThebloodflowrateshouldexceed50mL/mintoavoidclottingTheplasmaremovalrate：30-50mL/min

Estimationofplasmavolumeapproximately35-40mL/kgofleanbodyweightVp=(1-Hct)(b+cW)whereW=leanbodyweightb=1,530formales,864forfemalesc=41formales,47.2forfemalesDoubleFiltrationPlasmapheresis(DFPP)QB=Bloodflowratetotheplasmaseparator

100ml/minQF1=filtratedplasmaflowrateoftheplasmaseparator

25ml/minQD=discardedplasmaflowrateoftheplasmafractionator

5ml/minQs=supplementationfluidflowrate

5ml/minTechnicalConsiderationsTechnicalConsiderationsVascularAccessperipheralvenousaccesscentralvenousaccessarteriovenousfistulaAnticoagulationHeparinCitrateReplacementFluidComplicationsofTPE血浆置换在危重病中的应用HepaticfailureSeveresepsis/septicshockMODSMGPE-AcuteHepaticFailureAkitaUniversitySchoolofMedicine,Akita,JapanProspective,randomised,clinicaltrialPE13patients58.8±14.3yearsPE+CHDF3patients67.6±8.8yearsPE5~6h.3200~4000mlT-Bil,TNF-a,IL-6,IL-8TherApher,Vol.5,No.6,2001PE-AcuteHepaticFailure

T-BilTNF-aIL-6IL-8(mg/dl)(pg/ml)(pg/ml)(pg/ml)PEgroupBeforePE15.330.577.530.4

AfterPE6.1a40.6100.9a

32.6aPE+CHDFgroupBeforePE10.166.336.260.2

AfterPE5.1a

55.2a

38.429.9aa

p<0.05.

TherApher,Vol.5,No.6,2001PE-sepsisandseptic

PE能有效清除炎症介质

CritCareMed1998May;26（5）873－6在成人亚组，血浆置换治疗有助于降低死亡率。Plasmaexchangeasrescuetherapyinmultipleorganfailure76pats(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;31:1730–1736Inconclusion,TPE