血浆置换基本原理与临床应用.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,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,Seven patients APPACHE II 30 3,血浆置换的原理血浆置换临床实施,血浆置换的适应症(病理生理),器官衰竭评分 5，（range 16）,血浆置换基本原理与临床应用,血浆置换的适应症及并发症,Retrospective observational study,Plasmapheresis within 6 h,1914 Abel 首创,60年代出现间断性血细胞分离器,PE-sepsis and septic,Intensive Care Med(2002)28:14341439,1914 Abel 首创,Five patients received one separation and,Akita University School of Medicine,Akita,Japan,10 m,MW5 000D,2a 38.,感染：乙肝、丙肝、HIV,1914 Abel 首创,Plasma exchange as rescue therapy in multiple organ failure,PE 共四次 隔天一次,PE 5 6 h.,PE-severe sepsis,septic shock,05 m,MW1 500D,PE能有效清除炎症介质,5(Lvov,Russia),3040 ml/kg,Intensive Care Med(2002)28:11641167,Intensive Care Med(2002)28:14341439,4 29.,血浆置换技术的进展,1914 Abel 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0.040.05,m,MW1 500D,膜孔径0.10,m,MW5 000D,膜孔径0.2006.0,m,MW6 000 000D,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,plasma exchange,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),Wt,kg,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,置换血浆总量,血浆置换量效时间函数,y,=,V,x,20,40,60,80,120,140,160,180,200,100,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,Hepatic failure,Severe sepsis/septic shock,MODS,MG,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,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CaCl,2，,8001000ml血浆补充5CaCl,2,20ml,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,Hepatic failure,Severe sepsis/septic shock,MODS,MG,PE-Acute Hepatic Failure,Akita University School of Medicine,Akita,Japan,Prospective,randomised,clinical trial,PE 13 patients 58.8 14.3 years,PE+CHDF 3 patients 67.6 8.8 years,PE 5 6 h.3200 4000 ml,T-Bil,TNF-a ,IL-6,IL-8,Ther Apher,Vol.5,No.6,2001,PE-Acute Hepatic Failure,T-Bil TNF-,a,IL-6 IL-8,(mg/dl)(pg/ml)(pg/ml)(pg/ml),PE group,Before PE 15.3 30.5 77.5 30.4,After PE 6.1,a,40.6 100.9,a,32.6,a,PE+CHDF group,Before PE 10.1 66.3 36.2 60.2,After PE 5.1,a,55.2,a,38.4 29.9,a,a,p 0.05.,Ther Apher,Vol.5,No.6,2001,T-Bil,Ther Apher,Vol.5,No.6,2001PE-sepsis and septic,16例肝衰竭,血浆内毒素 TNF IL-1 IL-6,PE 后血浆内毒素减少,PE 后血清TNF IL-1 IL-6降低,PE能有效清除炎症介质,Crit Care Med 1998 May;26（5）8736,PE-sepsis and septic,PE-sepsis and septic,Plasma exchange as rescue therapy in multiple organ failure,76 pats(41 male and 35 female)with DIC and MODS(including acute renal failure),器官衰竭评分 5，（range 16）,回顾性对照研究,预计存活率为20%,Plasma exchange was,performed until disseminated intravascular coagulation was reversed,82%存活,Crit Care Med 2003;31:1730 1736),PE-severe sepsis,septic shock,ICU university hospital Archangels,Russia.,Prospective,randomised,clinical trial,One hundred and six patients,Plasmapheresis within 6 h,PF-0.5(Lvov,Russia),3040 ml/kg,first PE 13323 min second 13721 min.,1820402 ml 1763312 ml,28-day survival.,Intensive Care Med(2002)28:14341439,PE-severe sepsis,septic shock,Intensive Care Med(2002)28:14341439,PE-severe sepsis,septic shock,Intensive Care Med(2002)28:14341439,PE-severe sepsis,septic shock,Intensive Care Med(2002)28:14341439,PE-severe sepsis,septic shock,Intensive Care Med(2002)28:14341439,PE-septic shock,Retrospective observational study,Seven patients APPACHE,II 30,3,Plasmapheresis,blood flow:120 ml/min 2200 ml,Five patients received one separation and,two patients three separations.,norepinephrine intravenously(0.60.7 g/kg perminute)MAP 7712 mmHg.,.,Intensive Care Med(2002)28:11641167,Six of seven patients died 53 daysafter the last plasmapheresis,ICU university hospital Archangels,Russia.,血浆置换plasma exchange,1914 Abel 首创,根据红细胞压积计算血浆量(L),a p 0.,82%存活,（优选）血浆置换基本原理与临床应用,Retrospective observational study,PE-severe sepsis,septic shock,PE-sepsis and septic,2a 38.,PE-severe sepsis,septic shock,5(Lvov,Russia),3040 ml/kg,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,PE-septic shock,Intensive Care Med(2002)28:11641167,Six of seven patients died 53 daysafter the last plasmapheresis,Intensive Care Med(2002)28:11641167,PE-MG,16例MG,PE 共四次 隔天一次,每次置换血浆量为2500ml,14例患者完全治愈,Neurology 1995 45(2)338-44,PE-MG,PE-MG,