1、Bouman CS et al.Effects of early high-volume CVVH on survival and recovery of renal function in IC patients with ARF.Crit Care Med 2002;30:2205(n=106)Critical Care 2009,13:R57Lancet 2000;356:26-30high-volume、血液入口血液入口血液出口血液出口透析液入口透析液和滤出液出口横截面横截面空心纤维膜空心纤维膜肾小球囊肾小管肾小球溶溶质随液体质随液体移移动动“溶溶剂剂拖移拖移”CVVHCVVH治疗定量
2、评价指标?治疗定量评价指标?Blood flow150 mls/minBlood flow115 mls/min基于血浆的滤过分数基于血浆的滤过分数 30%前稀前稀后稀后稀要达到要达到35mL/h/kg35mL/h/kg剂量,需剂量,需设置多少设置多少置换液置换液量量?QB(ml/min)208150208300稀释因子稀释因子QB/(QB+QRF)Post(1.00)0.770.830.87UFR(ml/kg/h)352729(35*0.83)30.5假设假设:75 kg;Hct=0.30;dose=35 ml/hr/kg(post),后稀释:后稀释:置换液:置换液:35*75=2625ml
3、 前稀稀释比例:前稀稀释比例:208/(208+2625/60)=0.83,208血流速为上述条件下维持FF30%的最低血流速。前稀释时,同样置换液下,血液在进入滤器前已被稀释,血液中溶质的 浓度减少,单位时间内滤器接触的溶质少。与后稀释CVVH相比,这意味 着在流出液速率确定的情况下,被清除到流出液中的溶质要少一些。溶 质清除效率较后稀释降低血流速越高,效率的损失降低,前稀释的相对效果减少置换液置换液2625(后后)2625(前前)300要达到要达到UFR40ml/kg/h 前稀和后稀置换液量如何分配?前稀和后稀置换液量如何分配?higher-dose(ml/kg/h)lower-dose(
4、ml/kg/h)Outcome(90-d mortality)timeRonco et alLancet,2000Saudan et alKidneyInt,2006Bouman et alCrit Care Med,2002Tolwani et alJ Am Soc Nephrol,2008The RENAL Replacement Therapy Study InvestigatorsN Engl J Med,2009higher-dose(ml/kg/h)lower-dose(ml/kg/h)Outcome(90-d mortality)timeTolwani et alJ Am Soc Nephrol,2008The RENAL Replacement Therapy Study InvestigatorsN Engl J Med,2009True dose in Continuous Renal-Replacement Therapy in Critically Ill PatientsTrue dose is critical