1、CRRT：溶质分子与模式选择1ppt课件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？2ppt课件内容提要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3ppt课件o CRRT:所有连续性清除水和溶质的治疗技术n CAVH,CVVH,SCUF,CAVHD,CVVHD,CAVHDF,CVVHDF,CVVH,HVHF.o CBP:连续性血液净化o 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4ppt课件CRRT a major treatment option for ARF?
2、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
3、(ARDS)vBurn PatientsvLiver FailurevSepsis5ppt课件内容提要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6ppt课件 CRRT水和溶质清除原理清除水Ultrafiltration清除溶质DiffusionConvectionAdsorption7ppt课件Hollow fibre structure Filtrate outlet Filtrate compartment Blood inletHousing material PolycarbonateBlood Inlet8ppt课件9ppt课件压力梯度
4、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10ppt课件 CRRT溶质清除原理清除溶质DiffusionConvectionAdsorption11ppt课件小分子物质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 18012ppt课件中分子物质o 多肽 Peptide A 778o 维生素B12 Vitamin B12 1355o 菊糖 Inulin 5200o 微球蛋白 B2-microglobul
5、in 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 13ppt课件大分子物质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 Transf
6、errin 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 14ppt课件DiffusionoSolutes move from a Higher concentration(Blood)to a Lower concentration(Dialysate)oVery efficient for removing small moleculesoIn Hemodialysis.BFR dependentoIn CRRT.Dialysate Flow Dependent15pp
7、t课件DiffusionDiffusion16ppt课件17ppt课件Efficient 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18ppt课件ConvectionoSolute removal with a“water flow”Solute Drag(Pressure gradient)oGood for larger molecular weight substancesoThe faster the fl
8、ow,the better the clearanceoReplacement solutions must be physiological and sterile19ppt课件对 流溶质随水流移动，“溶剂拖移”20ppt课件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21ppt课件22ppt课件Adsorption 23ppt课件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
9、面或深层24ppt课件25ppt课件内容提要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26ppt课件CRRT治疗方式治疗方式SCUFCVVHCVVHDCVVHDFI 27ppt课件Continuous Renal Replacement TherapiesSCUFCAVHCVV HCAVHDCVV HDCVV HDFSPONTANEOUS Blood CirculationPUMPED Blood CirculationHEMOFILTRATION CONVECTION HEMODIALYSIS DIFFUSIONHVHF28ppt课件 Remo
10、val of water is done by UF No Substitution liquid is used Used mainly for CHF +Fluid OverloadSCUFSCUF(Slow Continuous Ultrafiltration)29ppt课件CVVHDCVVHD(Continuous Veno-Venous Hemodialysis)The principle (clearances)is Diffusion Eliminate mainly Small Molecules Net Fluid Removal is desired Used of Ste
11、rile Dialysate Solution30ppt课件CVVH 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 31ppt课件CVVH CVVH Pre-dilutionPr
12、e-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 32ppt课件CVVH-HVHF CVVH-HVHF Pre/Post dilutionPre/Post dilutionAssociated with High Volume Hemofiltrat
13、ion The principle(clearances)is ConvectionThe principle(clearances)is Convection Eliminate Small,Mid+Large molecules Eliminate Small,Mid+Large molecules Net Fluid removal if desired Net Fluid removal if desired In pre+post-Dilution Fluids are returning to the In pre+post-Dilution Fluids are returnin
14、g to the patient before and after the Filter patient before and after the Filter33ppt课件The principle(clearances)is Convection+Diffusion Eliminate Small+Mid molecules Net Fluid removal if desired Use of Sterile Dialysate+Replacement SolutionsCVVHDFCVVHDF(Continuous Veno-Venous Hemodiafiltration)34ppt
15、课件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35ppt课件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+
16、36ppt课件内容提要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37ppt课件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
17、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,2000,4:339-34538ppt课件o 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o MODSMODS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 C
18、are,2000,4:339-34539ppt课件CRRT Indications n Acute 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/HD nephrotic syndrome40ppt课件 CRRT:Indications ARF /CVVH(DF)Burn patients /CVVH(D)Severe lactate acidosis /CVVH(DF)ARDS/CVVH Sepsis&Septic Shock /CVVH-HVHF41ppt课件Caseo男性，50岁n 单纯高钾血症n 循环稳定o替代策略：HD42ppt课件THANK YOU43ppt课件
