CRRT治疗容量如何控制课件

CRRT治疗容量如何控制CRRT治疗中的容量管理CRRT清除水和溶质的机制及其相关概念；重症患者容量失衡及其危害；CRRT容量管理目标及其监测；CVVHDFRϱb=100-200ml/min;ϱd=20-40ml/min;ϱf=8-15ml/min透析液透析液+UFCRRT治疗中水和溶质清除机制水：超滤；溶质：弥散、对流与吸附；弥散弥散是溶质通过半透膜的一种方式，主要驱动力是离子浓度梯度差；在一个限定的分布空间，半透膜两侧的物质有达到相同浓度的趋势。Chest2007;132:1379–1388对流对流是溶质通过半透膜的另一种方式，在跨膜压差作用下，溶质及溶剂一起通过半透膜。Chest2007;132:1379–1388Totalultrafiltrate

总超滤液量是RRT回路清除液体的总量；Ultrafiltrationrate超滤率是单位时间清除液体的总量，是在一定时间段内完成预定TotalUF；CRRT水的清除机制及其相关概念IntJArtiforgans.2008;31(2):145-55CVVHDFR透析液透析液+UFReplacementrate置换率Qr是单位时间置换入回路的液体总量，为达到目标净超滤率，置换率应依超滤率而设定；TotalreplacementTR是回路置换液的总量，血液滤过模式TR代表治疗效果和液体平衡；血液透析滤过模式TR同样也意味着疗效和液体平衡；CRRT水的清除机制及其相关概念IntJArtiforgans.2008;31(2):145-55透析液CVVHDFR透析液+UFCRRT水的清除机制及其相关概念IntJArtiforgans.2008;31(2):145-55透析液CVVHDFR透析液+UF超滤应在RRT治疗全身状态稳定之后进行；RRT治疗开始前应充分冲洗管路；应规律评价对超滤率的临床反应情况并相应调整；IntJArtiforgans.2008;31(2):145-55CRRT治疗中的容量管理CRRT清除水和溶质的机制及其相关概念；重症患者容量失衡及其危害；CRRT容量管理目标及其监测；FluidimbalanceExcessivepositivebalance(Patientfluidoverload)Excessivenegativebalance(Hypovolemia)InsufficientfluidremovalFluidgain(specialcase)Cumulativeexcessivefluidremoval(TotalUF)Excessivefluidremovalrate(TotalUF)Harm:Hazardoussituation:重症患者容量失衡及其危害IntJArtiforgans.2008;31(2):145-55KidneyInternational.2009;76:422–427Fluidoverloadwasdefinedasmorethana10%increaseinbodyweightrelativetobaseline;measuredin618patientsenrolledinaprospectivemulticenterobservationalstudy;Fluidaccumulation,survivalandrecoveryofkidneyfunctionincriticallyillpatientswithAKIKidneyInternational.2009;76:422–427Fluidaccumulation,survivalandrecoveryofkidneyfunctionincriticallyillpatientswithAKIKidneyInternational.2009;76:422–427TheimportanceoffluidmanagementinAcutelunginjurysecondarytosepticshockChest.2009;136:102-109Thestudycohortwasmadeupof212patientswithALIcomplicatingsepticshock.Adequateinitialfluidresuscitation(AIFR)wasdefinedasthe

administrationofaninitialfluidbolusof>20mL/kgpriortoandachievementofaCVP>8mmHgwithin6haftertheonsetoftherapywithvasopressors.Conservativelatefluidmanagement(CLFM)wasdefinedaseven-tonegativefluidbalancemeasuredonatleast2consecutivedaysduringthefirst7daysaftersepticshockonset.Chest.2009;136:102-109BloodPurif2010;29:331–338TheimportanceoffluidmanagementinAcutelunginjurysecondarytosepticshockConclusions:BothearlyandlatefluidmanagementofsepticshockcomplicatedbyALIcaninfluencepatientoutcomes.TheimportanceoffluidmanagementinAcutelunginjurysecondarytosepticshockChest.2009;136:102-109CRRT治疗中的容量管理CRRT清除水和溶质的机制及其相关概念；重症患者容量失衡及其危害；CRRT容量管理目标及其监测；Clinical

SkinTurgorCapillaryrefillVenousdistentionOrthostasisBloodPressureOrganomegalyPulmonaryedemaUrinevolumeUrineOsmolalityMonitoringInvasiveCentralVenousPressurePulmonaryArteryPressureCardiacOutput(PAC,PICCO)Pre-LoadparametersVolumeresponsiveness(SPV,PPV)Non-InvasiveEchocardiographyBioimpedanceSpectroscopyAssessmentofVolumeStatusDesign:Prospective,nonrandomized,nonblindedinterventionalstudy；健康志愿受试者(n=12group1,n=32group2)；组1肺动脉导管置入并进行血管造影组2容量测量的超声心动检测并在3小时内输注生理盐水3000mlCritCareMed.2004;32:691–699CritCareMed.2004;32:691–699CritCareMed.2004;32:691–699CritCareMed.2004;32:691–699CritCareMed.2004;32:691–699AssessmentofVolumeStatus压力仅仅是压力，压力不能准确反映容量状态容量状态评估---困难！应密切监测下综合评价CRRT治疗中的液体平衡总体负平衡：脱水，运用于所有液体超负荷的少尿/无尿病人；总体平衡：病人的容量状况在正常范围或前期脱水治疗后需要维持在平衡状态；机器零平衡：对于急性肾衰的恢复期以及部分非肾衰危重病人，血滤仅仅用于清除机体代谢产物或炎性介质；FluidRemovalonDialysisInte