CRRT模式选择

CRRT：溶质分子与模式选择Case男性，50岁单纯高钾血症循环稳定CRRT策略：高流量的CVVH？？？？内容提要CRRT的基本概念CRRT的溶质清除原理CRRT的基本模式CRRT在ICU中的应用CRRT:所有连续性清除水和溶质的治疗技术CAVH,CVVH,SCUF,CAVHD,CVVHD,CAVHDF,CVVHDF,CVVH,HVHF……..CBP:连续性血液净化1995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CRRTamajortreatmentoptionforARF??AcuteRenalFailureTreatmentoptions:Drugtherapy(fluids,diuretics)IntermittentHemodialysis(IHD)PeritonealDialysisContinuousRenalReplacementTherapies(CRRT)AdditionalindicationsforCRRTChronicHeartFailureandoverhydrationMulti-organFailure(MOF)AcuteRespiratoryDistressSyndrome(ARDS)BurnPatientsLiverFailureSepsis内容提要CRRT的基本概念CRRT的溶质清除原理CRRT的基本模式CRRT在ICU中的应用CRRT水和溶质清除原理清除水Ultrafiltration清除溶质DiffusionConvectionAdsorptionHollowfibrestructureFiltrateoutletFiltratecompartmentBloodinletHousingmaterialPolycarbonateBloodInlet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氯化钠SodiumChloride58.5尿素Urea60磷酸PhosphateAcid96肌酐Creatinine113尿酸UricAcid168葡萄糖Glucose180中分子物质多肽PeptideA778维生素B12VitaminB121355菊糖Inulin5200微球蛋白B2-microglobulin11800肝素Heparin11200肌球蛋白Myoglobin17000因子DFactorD24000白介素1Interleukin-131000蛋白酶Pepsin35000肿瘤坏死因子TumorNecrosisFactor39000-225000大分子物质前白蛋白Pre-albumin55000抗凝血酶原3Antithrombin365000白蛋白Albumin66000血红蛋白Hemoglobin68000凝血酶原Prothrombin68000转铁蛋白Transferrin76500免疫球蛋白GIgG160000纤维蛋白原Fibrinnogen341000纤维连接蛋白Fibronectin(dimer)450000DiffusionSolutesmovefromaHigherconcentration(Blood)toaLowerconcentration(Dialysate)VeryefficientforremovingsmallmoleculesInHemodialysis….BFRdependentInCRRT….DialysateFlowDependentDiffusionRedBloodcellBicarbonateCréatinineChlorurePotassiumUreaBloodMembraneFiltrateAssociatedwith«Dialysate»Efficientforremovingsmallmolecules小分子物质血液浓度高膜内外浓度差大小分子物质易于扩散相同膜对小分子物质阻力小ConvectionSoluteremovalwitha“waterflow”…SoluteDrag(Pressuregradient)GoodforlargermolecularweightsubstancesThefastertheflow,thebettertheclearanceReplacementsolutionsmustbephysiologicalandsterile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AdsorptionRedBloodcellCreatinineChlorurePotassiumUreaSangMembraneFiltrateInflammatoryMediators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CRRT的基本概念CRRT的溶质清除原理CRRT的基本模式CRRT在ICU中的应用CRRT治疗方式27SCUFCVVHCVVHDCVVHDFAccessReturnEffluentReplacement(preorpostdilution)AccessReturnEffluentAccessReturnEffluentDialysateReplacement(preorpostdilution)IAccessReturnEffluentDialysateContinuousRenalReplacementTherapiesSCUFCAVHCVVHCAVHDCVVHDCVVHDFSPONTANEOUSBloodCirculationPUMPEDBloodCirculationHEMOFILTRATIONCONVECTIONHEMODIALYSISDIFFUSIONHVHFRemovalofwaterisdonebyUFNoSubstitutionliquidisusedUsedmainlyforCHF+FluidOverloadSCUF(SlowContinuousUltrafiltration)CVVHD(ContinuousVeno-VenousHemodialysis)Theprinciple(clearances)isDiffusionEliminatemainlySmallMoleculesNetFluidRemovalisdesiredUsedofSterileDialysateSolutionCVVHPostdilution(ContinuousVeno-VenousHemofiltration)Theprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpost-DilutionFluidsarereturningaftertheFilterinsidethevenouslineCVVHPre-dilutionTheprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpre-DilutionFluidsarereturningbeforetheFilterthroughthepre–DilutionlineCVVH-HVHFPre/PostdilutionAssociatedwithHighVolumeHemofiltrationTheprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpre+post-DilutionFluidsarereturningtothepatientbeforeandaftertheFilterTheprinciple(clearances)isConvection+DiffusionEliminateSmall+MidmoleculesNetFluidremovalifdesiredUseofSterileDialysate+ReplacementSolutionsCVVHDF(ContinuousVeno-VenousHemodiafiltration)CRRT特点稳定的血流动力学持续稳定的控制氮质血症和水电/酸碱平衡能够不断清除循环中的毒素或中分子物质按需提供营养补充和药物治疗CRRTvsIRRTIHDPDCRRTHemodynamicstability…+++Osmopressurestability…++++Fluidremoval++++++Correctionofacidosis++++++UnlimitedPN/EN……++ClearancesSmallsolutes(500d)++++++Largesolutes(500d)…++++Mediatorremoval……++?Accessmorbidity++++Anticoagulationneeds+…+Simplicity++++++内容提要CRRT的基本概念CRRT的溶质清除原理CRRT的基本模式CRRT在ICU中的应用CRRT病理生理指征1.液体过负荷－保持水平衡2.代谢产物堆积(氮质血症)－清除代谢产物3.严重的酸碱失衡－恢复酸碱失衡4.严重的电介质紊乱－恢复电介质平衡5.容量治疗受限－营养支持，补充胶体6.严重的组织器官水肿7.炎症反应－清除或吸附炎症介质8.中毒－清除毒物或药物9.恶性高热－降温BellomoRandRoncoC.CritCare,2000,4:339-345血流动力学不稳定的ARF严重的SIRS－重症胰腺炎，烧伤重症感染和感染性休克MODS与ARDS水中毒与急性肺水肿顽固性心衰中毒恶性高热容量治疗受限的ARF/CRFCRRT临床指征BellomoRandRoncoC.CritCare,2000,4:339-345CRRTIndicationsAcutepulmonaryoedema:SCUFToavoidkalium-hydricoverloadduringcardiacsurgerywithEBC(extracorporealbloodcirculation):SCUFSevereoedemain:congestivecardiacfailureliverfailureSCUF/HDnephroticsyndromeCRRT:IndicationsARF/CVVH(DF)Burnpatients/CVVH(D)Severelactateacidosis/CVVH(DF)ARDS/CVVHSepsis&SepticShock/CVVH-HVHFCase男性，50岁单纯高钾血症循环稳定替代策略：HDTHANKYOU