CRRT模式选择.ppt

CRRT：溶质分子与模式选择Caseo男性，50岁n单纯高钾血症n循环稳定oCRRT策略：高流量的CVVH？内容提要oCRRT的基本概念oCRRT的溶质清除原理oCRRT的基本模式oCRRT在ICU中的应用oCRRT:所有连续性清除水和溶质的治疗技术nCAVH,CVVH,SCUF,CAVHD,CVVHD,CAVHDF,CVVHDF,CVVH,HVHF.oCBP:连续性血液净化o1995年第一届CRRT学术会议在美国圣地亚哥举行，每年一次学术会议CRRT基本概念CRRT a major treatment option for ARF?Acute Renal FailurevTreatment options:v Drug therapy(fluids,diuretics)v Intermittent Hemodialysis(IHD)v Peritoneal DialysisvContinuous Renal Replacement Therapies(CRRT)Additional indications for CRRTvChronic Heart Failure and overhydrationvMulti-organ Failure(MOF)vAcute Respiratory Distress Syndrome(ARDS)vBurn PatientsvLiver FailurevSepsis内容提要oCRRT的基本概念oCRRT的溶质清除原理oCRRT的基本模式oCRRT在ICU中的应用 CRRT水和溶质清除原理清除水Ultrafiltration清除溶质DiffusionConvectionAdsorptionHollow fibre structure Filtrate outlet Filtrate compartment Blood inletHousing material PolycarbonateBlood Inlet压力梯度差形成的液体移动超滤作用正压负压不能通过膜的溶质做成胶体渗透压 CRRT溶质清除原理清除溶质DiffusionConvectionAdsorption小分子物质o氯化钠 Sodium Chloride 58.5o尿素 Urea 60o磷酸 Phosphate Acid 96o肌酐 Creatinine 113o尿酸 Uric Acid 168o葡萄糖 Glucose 180中分子物质o多肽 Peptide A 778o维生素B12 Vitamin B12 1355o菊糖 Inulin 5200o微球蛋白 B2-microglobulin 11800o肝素 Heparin 11200o肌球蛋白 Myoglobin 17000o因子D Factor D 24000o白介素1 Interleukin-1 31000o蛋白酶 Pepsin 35000o肿瘤坏死因子 Tumor Necrosis Factor 39000-225000 大分子物质o前白蛋白 Pre-albumin 55000o抗凝血酶原3 Antithrombin 3 65000o白蛋白 Albumin 66000o血红蛋白 Hemoglobin 68000o凝血酶原 Prothrombin 68000o转铁蛋白 Transferrin 76500o免疫球蛋白G IgG 160000o纤维蛋白原 Fibrinnogen 341000o纤维连接蛋白 Fibronectin(dimer)450000 DiffusionoSolutes move from a Higher concentration(Blood)to a Lower concentration(Dialysate)oVery efficient for removing small moleculesoIn Hemodialysis.BFR dependentoIn CRRT.Dialysate Flow DependentDiffusionRed Blood cellRed Blood cellBicarbonateBicarbonateCratinineCratinineChlorureChlorurePotassiumPotassiumUreaUreaBloodBlood Membrane Membrane Filtrate FiltrateAssociated with DialysateEfficient for removing small moleculeso小分子物质血液浓度高小分子物质血液浓度高o膜内外浓度差大膜内外浓度差大o小分子物质易于扩散小分子物质易于扩散o相同膜对小分子物质阻力小相同膜对小分子物质阻力小ConvectionoSolute removal with a“water flow”Solute Drag(Pressure gradient)oGood for larger molecular weight substancesoThe faster the flow,the better the clearanceoReplacement solutions must be physiological and sterile对 流溶质随水流移动，“溶剂拖移”影响对流作用的因素 增加某种溶质的对流清除率有两种方法:1.选择一块更易于溶质通过的簿膜2.增加超滤出来的容量 C=S*UFRUFR=Lp*A*TMPS:筛过系数Adsorption Red Blood Red Blood cellcellCreatinineCreatinineChlorureChlorurePotassiumPotassiumUreaUreaSangSangMembraneMembraneFiltrateFiltrateInflammatory MediatorsInflammatory Mediators吸附作用吸附作用有些膜材料带有吸附特性:(例如AN69膜)发生在膜表面的吸附 如果份子能通过膜表皮，更大规模的吸附发生在膜的深层 份子粘附在膜的表面或深层内容提要oCRRT的基本概念oCRRT的溶质清除原理oCRRT的基本模式oCRRT在ICU中的应用CRRT治疗方式治疗方式27SCUFCVVHCVVHDCVVHDFAccessAccessReturnReturnEffluentEffluentReplacementReplacement(pre or post(pre or post dilution)dilution)AccessAccessReturnReturnEffluentEffluentAccessAccessReturnReturnEffluentEffluentDialysateDialysateReplacementReplacement(pre or(pre orpost dilutionpost dilution)I AccessAccessReturnReturnEffluentEffluentDialysateDialysateContinuous Renal Replacement TherapiesSCUFCAVHCVV HCAVHDCVV HDCVV HDFSPONTANEOUS Blood CirculationPUMPED Blood CirculationHEMOFILTRATION CONVECTION HEMODIALYSIS DIFFUSIONHVHF Removal of water is done by UF No Substitution liquid is used Used mainly for CHF +Fluid OverloadSCUF(Slow Continuous Ultrafiltration)CVVHD(Continuous Veno-Venous Hemodialysis)The principle (clearances)is Diffusion Eliminate mainly Small Molecules Net Fluid Removal is desired Used of Sterile Dialysate SolutionCVVH Post dilution(Continuous Veno-Venous Hemofiltration)The principle(clearances)is Convection Eliminate Small,Mid+Large molecules Net Fluid removal if desired In post-Dilution Fluids are returning after the Filter inside the venous line CVVH Pre-dilution The principle(clearances)is Convection Eliminate Small,Mid+Large molecules Net Fluid removal if desired In pre-Dilution Fluids are returning before the Filter through the pre Dilution line CVVH-HVHF Pre/Post dilutionAssociated with High Volume Hemofiltration The principle(clearances)is Convection Eliminate Small,Mid+Large molecules Net Fluid removal if desired In pre+post-Dilution Fluids are returning to the patient before and after the FilterThe principle(clearances)is Convection+Diffusion Eliminate Small+Mid molecules Net Fluid removal if desired Use of Sterile Dialysate+Replacement SolutionsCVVHDF(Continuous Veno-Venous Hemodiafiltration)CRRT特点o稳定的血流动力学o持续稳定的控制氮质血症和水电/酸碱平衡o能够不断清除循环中的毒素或中分子物质o按需提供营养补充和药物治疗CRRT vs IRRTIHDPDCRRTHemodynamic stability+Osmo pressure stability+Fluid removal+Correction of acidosis+Unlimited PN/EN+Clearances Small solutes(500d)+Mediator removal+?Access morbidity+Anticoagulation needs+Simplicity+内容提要oCRRT的基本概念oCRRT的溶质清除原理oCRRT的基本模式oCRRT在ICU中的应用CRRTCRRT病理生理指征病理生理指征1.1.液体过负荷保持水平衡液体过负荷保持水平衡2.2.代谢产物堆积代谢产物堆积(氮质血症氮质血症)清除代谢产物清除代谢产物3.3.严重的酸碱失衡恢复酸碱失衡严重的酸碱失衡恢复酸碱失衡4.4.严重的电介质紊乱恢复电介质平衡严重的电介质紊乱恢复电介质平衡5.5.容量治疗受限营养支持，补充胶体容量治疗受限营养支持，补充胶体6.6.严重的组织器官水肿严重的组织器官水肿7.7.炎症反应清除或吸附炎症介质炎症反应清除或吸附炎症介质8.8.中毒清除毒物或药物中毒清除毒物或药物9.9.恶性高热降温恶性高热降温Bellomo R and Ronco C.Crit Care,2000,4:339-345o血流动力学不稳定的血流动力学不稳定的ARFARFo严重的严重的SIRSSIRS重症胰腺炎，烧伤重症胰腺炎，烧伤o重症感染和感染性休克重症感染和感染性休克oMODSMODS与与ARDSARDSo水中毒与急性肺水肿水中毒与急性肺水肿o顽固性心衰顽固性心衰o中毒中毒o恶性高热恶性高热o容量治疗受限的容量治疗受限的ARF/CRFARF/CRFCRRT临床指征Bellomo R and Ronco C.Crit Care,2000,4:339-345CRRT Indications nAcute pulmonary oedema:SCUFn To avoid kalium-hydric overload during cardiac surgery with EBC(extra corporeal blood circulation):SCUFn Severe oedema in:congestive cardiac failure liver failure SCUF/HDnephrotic syndrome CRRT:Indications ARF /CVVH(DF)Burn patients /CVVH(D)Severe lactate acidosis /CVVH(DF)ARDS/CVVH Sepsis&Septic Shock /CVVH-HVHFCaseo男性，50岁n单纯高钾血症n循环稳定o替代策略：HDTHANKYOU