CRRT基础百特版

CreatedbySamQiu名称?CRRT：Continuousrenalreplacementtherapy↶CBP：ContinuousBloodpurification↶ICBP:IntensivecarebloodpurificationCreatedbySamQiuCRRT的特点和优越性CRRT是缓慢、连续排除水分，模拟尿的排泄方式。更符合生理状态，能较好地维护血流动力学稳定；容量波动小；溶质清除率高；有利于营养改善及能清除细胞因子，从而改善危重ARF患者的预后。、更好的血液动力学稳定性更好的溶液控制能力和清除多余水分累积的更好溶质清除性维持尿排泄并保存残余肾功能清除炎症介质改善营养支持CreatedbySamQiu定义CRRTisanyextracorprealbloodpurificattiontherapyintendedtosubstituteforimpairedrenalfunctionoveranextendedperiodoftimeandappliedfororaimedatbeingappliedfor24hours/day.CRRT是指任何一种旨在替代受损的肾脏概念而进行的持续至少24小时的体外血液净化治疗技术。AJKD1996;ADQI2000CreatedbySamQiu内容原理与机制特点与优越性治疗方式适应症与开始时机建立CRRT治疗的临床步骤血管通路滤器选择抗凝技术液体管理药物应用并发症CreatedbySamQiu原理与机制CreatedbySamQiu原理与机制: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Glucose180CreatedbySamQiu原理与机制:中分子物质多肽PeptideA778VitB12VitaminB121355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TumorNecrosisFactor39000-225000CreatedbySamQiu原理与机制:大分子物质Pre-albumin55000Antithrombin365000Albumin66000Hemoglobin68000Prothrombin68000Transferrin76500IgG160000Fibrinnogen341000Fibronectin(dimer)450000CreatedbySamQiuLPS1000000TNF-a174000.1-1.0Il-b170000.3IL-622000-29000ndIL-88000-90000.05-0.2IL-1035000-400000C3a25000.2-0.8C5a28000.02-0.07TCC10000缓激肽1060B内非肽4000外毒素的分子量LPS200000-900000类脂A相关片断2000-4000肽聚糖1000-20000胞壁酸400-1000外毒素20000-50000外毒素片断小于5000炎症介质和外毒素的分子量CreatedbySamQiu原理与机制弥散对流吸附500500050000CreatedbySamQiu治疗方式CVVHDCVVHFDCVVCAVCVVHHVHFCAVHDCAVHCAVHDFCVVHDFHDHFHDFCreatedbySamQiuSCUF：缓慢持续超滤AccessReturnEffluentHFCreatedbySamQiuAccessReturnEffluentReplacement+CVVH&HVHFCreatedbySamQiuCVVHDPSAccessReturnEffluentDialysateHF+CreatedbySamQiuMaximumPt.fluidremovalrate=2000ml/hrSAccessReturnEffluentDialysateReplacementHFCVVHDFCreatedbySamQiu治疗方式置换液无置换液CVVHCAVHHVHFCVVHDCAVHDSCUFCPFACVVHDF无透析液有透析液CreatedbySamQiu疗法及适应症A/肾科急性肾衰应用疗法趋势单纯(10-12%)HDI-----HDI复杂(85-90%)HDI------CRRT儿童(1-2%)PD------CRRTB/非肾科败血症/多器官衰竭临床尚未定论(drugsvsor+CRRT)严重水肿急性肺损伤(ARDS)(drugs-NO-CRRT)充血性心衰(drugs------CRRT)CreatedbySamQiu适应症急性肾功能衰竭ARF多器官功能衰竭MODSSIRS急性肺水肿Acutepulmonaryoedema/SCUF严重液体超负荷Severeoedema中毒Drugintoxication/HDFOtherintoxication/HDFSeverelactateacidosis/HDF败血症休克Septicshock/HF高钾血症Hyperthermia/HDorHF横纹肌溶解综合症Rhabdomyolysis/HDFCreatedbySamQiuNewApplicationsforCRRTCRRTMarketPotentialCasespermillionCHF2965Stage4495ARF450SIRS1900SepsisSyndrome&SepticShock725+230ARDS90TPE25ARF:AcuteRenalFailureCHF:CongestiveHeartFailureSIRS:SystemicInflammatoryResponseSyndromeARDS:AdultRespiratoryDistressSyndromeConTPE:TherapeuticPlasmaExchangeCreatedbySamQiu开始时机.少尿(尿量少于200ml/12小时)；.无尿(尿量小于50ml/12小时).严重的代谢性酸中毒(PH小于7。1).氮质血症(血尿素浓度大于30mmol/L);.高钾血症(血钾浓度大于6。5mmol/L)；.可疑尿毒症引起的多器官并发症(心包炎/脑病/神经病变/肌病)；.严重的钠失衡(血钠大于160或小于115mmol/L);.高热(体温大于39。5C)；.临床表现明显的脏器水肿(特别是急性肺水肿)；.可滤过或透析的药物过量；.在有肺水肿/ARDS危险时需要输入大量血制品。临床符合其中一项，应开始CRRT治疗；符合两项应立即开始治疗。R.Bellomo,C.Ronco:IntensiveCareMed,25:781-789,1999CreatedbySamQiu建立CRRT的临床步骤血管通路滤器选择抗凝技术置换液配方与液体管理药物应用CreatedbySamQiu血管通路VascularAccess中心静脉置管股静脉颈内静脉锁骨下静脉CreatedbySamQiu导管结构与特点双腔导管Double-lumencatheters1.Double-D2.Double-O双导管Double-Catheters1.Dual-Catheter2.Split-CatheterCreatedbySamQiu导管选择要点能够提供的血流量；导管材料；导管型号价格CreatedbySamQiu血滤器Hemofilters种类polysulfone•polyacrylonitrile•polyamideThehemofiltrationmembraneconsistsofrelativelystraightchannelsofever-increasingdiameterthatofferlittleresistancetofluidflow.CreatedbySamQiu溶质清除血滤器可以自由清除分子量小于100道尔顿的溶质和毒素(e.g.urea,creatinine,uricacid,sodium,potassium,ionizedcalciumandalmostalldrugsnotboundtoplasmaproteins).所有CVVH血滤器不能通过白蛋白及其他超过50,000道尔顿的物质.CreatedbySamQiu滤过分数filtrationfraction滤过分数表示血液脱水的程度，filtrationfraction(FF),whichisthefractionofplasmawaterremovedbyultrafiltration:FF(%)=(UFRx100)/QPQP为滤器血浆流量ml/min.QP=BFR*x(1-Hct)*BFR:血流速CreatedbySamQiu超滤率ultrafiltraterateFF(%)=(UFRx100)/QPQP=BFR*x(1-Hct)例如BFR=100ml/minHct=0.30(i.e.30%),QP=70ml/min.滤过分数30%滤器易凝血.因此themaximumallowableFFissetat30%,aBFRof100ml/minyieldsaUFR=21ml/min.QP:thefilterplasmaflowrateinml/min.CreatedbySamQiuSIEVINGCOEFFICIENT1.005600inulin11800b2-m21000RBP44000orosomucoide54000a1AT66500albuminMOLECULARWEIGHT=SOLUTESIZEDEFINITION:Thecut-offpointofasoluteforanymembraneisasievingcoefficientof0.1.Thismeansthat10%ofthemoleculeswillpassand90%willnotpass.0.560ureaCut-offpointO.1筛选系数与截留分子量CreatedbySamQiu超滤系数与膜流量UltrafiltrationcoefficientKUfLowfluxmembrane:6ml/h.mmHg.m2=KUfMidfluxmembrane:15ml/h.mmHg.m2=KUfHighfluxmembrane:30ml/h.mmHg.m2=KUfCreatedbySamQiuSolidProteinSolid/solutioninterfaceProteininsolutionPolarIonicIonicHydrophobic蛋白质的吸附机制CreatedbySamQiu压力与超滤0123456050100150200250UFrate(l/h)TMP(mmHg)HIGHFLUXMIDFLUXLOWFLUXCreatedbySamQiuBoscJYetal.JASN1997不同膜材料的清除效果79.571.161.571.978.17259.371.775.263.65362.85055606570758085AN69(1.65m²)HFPMMA(2.1m²)UreaCreatininePhosphorusB2mCreatedbySamQiuChanardJ.etal.Kidneyint.1988血滤中蛋白质的清除与丢失229211224290.7312.6013.7530.688050100150200250AN69(1.3m²)PS(1.3m²)HFCA(1.4m²)PAN(1.4m