急性肝功能衰竭诊治课件.ppt

1、急性肝功能衰竭1急性肝功能衰竭的定义lAcute liver failure(ALF)is defined as life-threatening liver injury in the absence of preexisting liver disease with coagulopathy(prothrombin time 15 seconds or international normalized ratio INR 1.5)and hepatic encephalopathy(HE)that develops within 26 weeks of initial symptomslT

2、he term fulminant hepatic failure(FHF)is used when HE develops within 8 weeks of jaundice2Etiology of acute liver failure34肝性脑病的分期临床上按临床上按神经精神症状神经精神症状的轻重把的轻重把肝性脑病肝性脑病分为分为四期四期：一期一期(前驱期前驱期):):轻微轻微的神经精神症状的神经精神症状,可表现出欣快、反可表现出欣快、反 应迟钝、睡眠节律的变化。应迟钝、睡眠节律的变化。二期二期(昏迷前期昏迷前期):):一期症状一期症状加重加重,可出现可出现:行为异常、嗜行为异常、嗜

3、睡、精神错乱睡、精神错乱.经常出现经常出现扑翼样震颤扑翼样震颤等等.三期三期(昏睡期昏睡期):):有有明显明显的的精神错乱精神错乱、昏睡、肌张力昏睡、肌张力等症等症 状状.四期四期(昏迷期昏迷期):):神志丧失神志丧失,不能唤醒不能唤醒,没有扑翼样震颤等没有扑翼样震颤等.56肝性脑病发病机制 氨中毒学说氨中毒学说 假性神经递质学说假性神经递质学说 血浆氨基酸失衡学说血浆氨基酸失衡学说 GABAGABA学说学说 其他神经毒质在肝性脑病发病中的作用其他神经毒质在肝性脑病发病中的作用7氨中毒氨中毒(ammonia intoxication)学说学说血氨增高的原因：血氨增高的原因：氨清除不足（主要）氨

4、清除不足（主要）图肝脏合成尿素的鸟氨酸循环图肝脏合成尿素的鸟氨酸循环OCTOCT：鸟氨酸氨基甲酰转移酶：鸟氨酸氨基甲酰转移酶 CPSCPS：氨基甲酰磷酸合成酶：氨基甲酰磷酸合成酶氨的清除：氨的清除：8proteinNH3NH3urea9proteinNH3NH3ureaBlood NH310proteinNH3NH3urea血血 NH3 11Cerebral Edema and Intracranial Hypertensionammoniainflammationaltered neurotransmissionpathwayscerebral hemodynamic dysautoregu

5、lationHepatic encephalopathy12Cerebral Edema and Intracranial HypertensionOther common triggers for ICP elevation:l volume overloadl hyponatremial severe hypercarbial severe acidosisl increased thoracic and abdominal compartment pressures13Neuromonitoring strategiesl Invasive neuromonitoring strateg

6、iesl Noninvasive neuromonitoring strategies1.serial head computed tomography(CT)2.transcranial Doppler3.jugular bulb oximetry4.pupillometry14Algorithm for the diagnostic and therapeutic management of acute liver failure with advanced hepaticencephalopathy and intracranial hypertensionEmerging strate

7、gies for the treatment of patients with acute hepatic failure,Curr Opin Crit Care 2016,22:00000015Algorithm for the diagnostic and therapeutic management of acute liver failure with advanced hepaticencephalopathy and intracranial hypertensionEmerging strategies for the treatment of patients with acu

8、te hepatic failure,Curr Opin Crit Care 2016,22:00000016Annual Update in Intensive Care and Emergency Medicine 201517Intensive care supportive strategies directed at cerebral edema in acute liver failureEmerging strategies for the treatment of patients with acute hepatic failure,Curr Opin Crit Care 2

9、016,22:00000018Intensive care supportive strategies directed at cerebral edema in acute liver failureEmerging strategies for the treatment of patients with acute hepatic failure,Curr Opin Crit Care 2016,22:00000019AKI in ALFlAcute renal failure develops in 5568%of all patients who present with ALF a

10、nd in the vast majority of cases reverses with resolution of liver injury or with transplantationlmechanism1.direct renal toxicity2.functional impairment as seen in the hepatorenal syndromeMoore K.Renal failure in acute liver failure.Eur J Gastroenterol Hepatol 1999;11:967975.Leithead JA,Ferguson JW

11、,Bates CM,et al.The systemic inflammatory response syndrome is predictive of renal dysfunction in patients with nonparacetamol-induced acute liver failure.Gut 2009;58:443449.2021临床问题该患者无明显活动性出血征象，监测凝血功能该患者无明显活动性出血征象，监测凝血功能：INR 3.2，APTT 65s，FIB 1.2 g/L，PLT 40 109/Ll 需要输注血制品（血浆、冷沉淀、血小板）需要输注血制品（血浆、冷沉淀、

12、血小板）以纠正凝血功能障碍？以纠正凝血功能障碍？22Prothrombin Time,PT2324252627凝血功能再平衡健康人 VS 肝功能不全28l Peripheral-Vein Thrombosisl Arterial Thrombosisl Portal-Vein Thrombosis：等待肝移植的患者中发生率8-25%Francoz C,Belghiti J,Vilgrain V,et al.Splanchnic vein thrombosis in candidates for liver transplantation:usefulness of screening and

13、anticoagulation.Gut 2005;54:691-7.29Hematological Supportl Hb 7.0 g/dll INR 20 109/Ll Fibrinogen 1.0 g/lAnnual Update in Intensive Care and Emergency Medicine 201530临床问题对于肝功能衰竭需要进行对于肝功能衰竭需要进行CRRT的患者，监的患者，监测其凝血功能显著异常（测其凝血功能显著异常（APTT、INR显著升显著升高），怎样开展高），怎样开展CRRT治疗？治疗？l 无无抗凝？抗凝？l 枸橼枸橼酸抗凝？酸抗凝？31该试验共纳入71例

14、患者，共更换539次滤器管路。平均的滤器寿命为9(616)小时。其中51例患者接受完全无抗凝CRRT，其滤器寿命为 12(7-24)小时。余下20例患者开始也行无抗凝CRRT，其滤器寿命为 7(5-11)小时，但其后即使予以全身肝素抗凝或局部肝素抗凝使得APTT显著延长，也并不增加其滤器的寿命32所有43个滤器寿命均超过24小时，其中32个(74%)的滤器寿命达到72小时在提前更换滤器的事件中，只有3例是因为总钙/游离钙2.5尽管在严重肝功能衰竭患者中进行局部枸橼酸抗凝的CVVHD治疗会造成体内枸橼酸蓄积，但并没有造成酸碱平衡紊乱及电解质紊乱在严重肝功能衰竭患者中进行局部枸橼酸抗凝的血液净化治疗是安全、可行的，但仍有必要密切监测总钙/游离钙以保障患者安全33目的目的：研究心脏术后并发肝、肾功能不全患者进行局部枸橼酸抗凝的CRRT治疗的安全性及有效性结果结果：共纳入15例心脏外科术后并发肝、肾功能不全患者，在治疗过程中肝酶（AST、ALT）、胆红素、r-GT均没有显著改变。滤器后游离钙、患者体内游离钙及患者体内总钙/游离钙水平均稳定，未发现枸橼酸中毒结论结论：在急性肝功能衰竭患者中进行局部枸橼酸抗凝是有效、安全的34