ICU中血液净化的应用指南-中华医学会重症医学会分会

11-9-108:14ICU_118=34.html|||||||||||EnglishICU2010-10-285440ICU(bloodpurification)ICU(renalreplacementtherapy,RRT)70RRT30RRT()RRTRRTICUICUDelphi(1)1999120093MedlineEvidence-BasedMedicineReviews(EBMR)LippincottWilliams&Wilkins(LWW)4hemofiltrationdialysisrenalreplacementtherapycontinuousrenalreplacementtherapycriticalillnessacuterenalfailureDelphiA2!B1!CD1#E$%!/#$%RRThemoperfusionHPplasmaexchangePERRTHPPERRTRRTRRT[1]hemodialysisHDhemofiltrationHFhemodiafiltrationHDFHDHF11-9-108:15ICU_218=34.htmlHDFRRT[2,3]24hRRT(intermittentrenalreplacementtherapy,IRRT)!24hRRT(continuousrenalreplacementtherapy,CRRT)IRRT(IHDIHDFSLEDPHVHF(SVVH)CRRTCHDCHFCHDFSCUF23RRTRRT/mL/kg·h[4,5]IHDKt/VKtV[6]CRRT35mL/kg·hIHD1.4Kt/V·d[7]RRT1.12.231RRT11-9-108:15ICU_318=34.htmlCRRTCRRTRRTcatheter-relatedbloodstreaminfection,CRBICRRTCRBI[8,9][V]CRBI[10][I][11]ICUICU[12][V]1014F2535cm[13][8,14]/[15]RRT120%1.21.4mL[16]1RRT[B][17]3HCO3-HCO3-HCO3-HCO3-[18][]11-9-108:15ICU_418=34.htmlHCO3-HCO3-[18][](5mmol/L)[19][!]HCO3-RRTHCO3-100mmol/h[20][#]HCO3-RRTHCO3-RRT[21][$]2RRT[B]CRRTPANPSPA(PMMA)PCPA[22][]IL-6IL-1[23][]3[C]CRRTPAN[24][]32PMMA24[25,26][$]RRTRRTCRRT500010000IU/L()112000IU/L10000IU/L[28][][28][%][29][]4CRRT[C]()()11-9-108:15ICU_518=34.html()()[30][][31][#][32][]RRTCRRT60109/LINR2APTT60s24hRRT530ku11.5h[33][34](heparin-inducedthrombocytopenia,HIT)AT#1.20005000IU500-2000IU/h[35]2530IU/kg510IU/kg·h[36,37]46hAPTTAPTT11.4[38]5RRT,APTTACT[E]2.[39][$][30]10001666IU/h1mg:100IUACT250sACT180s[30,39,40][]29ku,34h[41][]&a0.250.35IU/mL[38]HITHIT[42][%]PGI2PGE1,RRT[43][][44][]4%,0.250.4mmol/L[45,46][][47][!]11-9-108:15ICU_618=34.html[21][%]6RRT[A]HITRRTCRRT200300mL/min[48][]APTTLMWH[49][#]][50][%]7CRRT[D]CRRTICUCRRT1.2000RoncoBellomo[51,52]ARF(UO200mL/12h)(UO50mL/12h)(pH7.1)(BUN30mmol/L)(K+6.5mmol/L)(Na+160mmol/L115mmol/L)()(39.5')1CRRT2CRRTRRT“”RIFLEARFRRT[53]RIFLERRT560ICURRT[54]Bou-manCARF(n=106)RCT((12h)28d40mmol/L150mmHgPEEP10cmH2O[55]BUN40mmol/LCVVHCVVH8h100mlCVVH(BUN!30mmol/LCr!250µmol/L-K+!6mmol/L)CVVHCVVH[56][$]Demirkilic19921996443µmol/L-5.5mmol/LCVVHDF199620018100ml50mg11-9-108:15ICU_718=34.htmlCVVHDFCVVHDFICU[57][$]#309µmol/LRRT309µmol/LRRT[58][#]BUNRRTn=100BUN15mmol/LRRTBUN43mmol/LRRT(39%vs20%)RRT,[59][#]2RRT5RRTCRRT[60]RRTBUNCr8RRT[D]2.ICURRTCVVHCVVHDCVVHDFIHDARFCVVHARFIHD[61][!]CVVHIHD[62][!]Augustine80ARFRCTCVVHDIHD[63][!]3CRRTMehtaCVVHDFIHDCVVHDF(92.3%)IHD(59.4%)CVVHDFIHD(44.7%)IHDCVVHDF(6.7%)[64][!]JackaCVVHDF(87.5%)IHD(35.7%)[65][$]286090ICUCVVHDFIHD[66][!]2002Kellum[67][!]CRRTARFCRRTIRRT6CRRTTonelliCRRTIRRT[68][!]20073CRRTIRRTARF[69-71][!]CRRTIRRTARFCRRTIRRTICUARFCRRTCRRTIRRTCVVHIHDCVVHDFIHDCRRTIRRTCRRTIRRT9ARFCRRT[D](Slowextendeddailydialysis/sustainedlow-efficiencydialysis,SLED)2004KumarSLEDCVVHD[15,72]SLEDCVVHDSLED3.CVVHCVVHDFIHDCVVHCVVHDFIHD(1)CVVH11-9-108:15ICU_818=34.html(1)CVVHRonco425ARFRCTCVVH20ml/kg/h35ml/kg/h45ml/kg/h320ml/kg/h2ARFCVVH35ml/kg/h[4][!]RCT11ARFCVVH6L/h[73]ARF)35ml/kg/hCVVHCVVH3510ARFCVVH35ml/kg/h[B](2)CVVHDFCVVHDFCVVH206ARFRCTCVVH(1-2.5L/h,25ml/kg/h)1-1.5L/hCVVHDF(42ml/kg/h)2890CVVH[75][I]2008RCT(1124)(35.8ml/kg/h)60(22ml/kg/h)(51.2%vs48%)RRTIHDCVVHDFSLED[76][I]Tolwani(200)CVVHDF35ml/kg/h30(49%)20ml/kg/h(56%)(69%)(80%)[77][!]CVVHDF(3)IHDKt/VKtV[6]146RCT[78][I]IHDIHDIHD35ml/kg/hCVVHIHD1.4Kt/V/day[7]IHDARFIHD[79-81]RCT[82]2002RoncoC[74][]CVVHARF80RCT[83][](25ml/kg/h)CVVHCVVHCVVHHVHF20(APACHEIISOFA)[84]#]CVVHDFTNF-alphaIL-1betaIL-6IL-8[85][]Bellomo[86,87]HVHFMOF[79,88]HVHFRRT336hCVVH(35ml/kg/h)6hHVHF(100ml/kg/h)HVHFIL-6IL-1SOFACVVH[89][]11-9-108:15ICU_918=34.html[84][#]HVHF12HVHF20(APACHEIISOFA)HVHFCVVH[90][]RRTHVHF[86,87]MOF[79]HVHFRRT100mL/kg/hSOFA35mL/kg/h[89][]20(0.3µg/kg/min)12HVHF(100ml/kg/h)pH[84][%]100ml/kg/h300ml/min80[80][#]6HVHF(45ml/kg/h)CVVH28ICU35L/4h[87][$]40-60ml/kg/h[86]85ml/kg/h(6~8hHVHFCVVH16-18)[79][%]100ml/kg/h(12h)[84]HVHF45ml/kg/h100ml/kg/h45-100.11HVHF45ml/kg/h[D]severeacutepancreatitis,SAPsystemicinflammatoryresponsesyndrome,SIRSSAPSAP20RCT[91][]72APACHE84-12h(P0.05)14CT10APACHEII7272RCT48CVVH96[92][]2006[93][#]72CVVH(SVVH)7211-9-108:15ICU_1018=34.html12SAP[C](SVVH)RCTSAPSVVH[91][]SAP[94][#]200372SVVHCVVHSAP72[95][#](CVVH)CVVHSVVH[96][]RCT[92][]48CVVHCVVH[97][%]CVVHSAPCVVH72SVVHCVVHCTAPACHE[98][]SVVHSAPCVVHFAP13SVVHCVVH[C]37RCTCVVH(4L/h)[92][]3L/h3~4SAP[96][#]50ml/kg/h48~96[99][%]ml/kg/h14SAP[D]SIRS29CVVH(12)(14)IL-6(P0.001)CVVH[100][]24ARFCVVH[101][]CVVH/CRRT(CVVHCVVHDFCVVHD)[102]ARFCVVH(295mmol/L506.4)168mmol/L2.2%[103]CPB()RRT[104]RRT38-48CVVHGlasgowAPACHE11-9-108:15ICU_1118=34.html[105]24-48CRRT[106,107]24CVVH24RRTRRT48120mmol/L15mmol/L1~2mmol/L/h130mmol/L130~1