ICU中的血液净化治疗：最新进展_免费下载.pptVIP

Blood Purification in the ICU: State of the ArtICU中的血液净化治疗：最新进展 A/Prof. Rinaldo Bellomo Austin Repatriation Medical Centre Melbourne Australia Similarities between sepsis and renal failure感染与肾功能衰竭之间的相似之处 “Uremia” 尿毒症 Organ dysfunction induces “toxemia” 器官功能不全导致的“毒血症” “Toxemia” induces widespread injury 毒血症导致的广泛损伤 The mediators of “toxemia” are ill-defined 关于毒血症的因子定义是错误的 Continuous removal beneficial 持续清除是有益的 Use Hemofiltration 使用血滤 “Septicemia” 败血症 Organ dysfunction induces “toxemia” 器官功能不全导致的“毒血症” “Toxemia” induces widespread injury 毒血症导致的广泛损伤 The mediators of “toxemia” are ill-defined 关于毒血症的因子定义是错误的 Continuous removal beneficial ? 持续地清除是否有益？ Use Hemofiltration? 是否可使用血滤？ The Mediators of Sepsis (the Humoral Theory of Sepsis) TNF (MW 17,500-trimer) IL-1 (MW 17,000); IL-8 (MW9,000); IL-6 (MW22,000) Complement: Factor D (MW 25,000), C3a, C5a (MW 11,500) Eicosanoids: TxB2, PGE2 (MW 500) PAF: MW 600 血小板活化因子 Others: VIP, vasopressin, endorphin, myocardial depressant factors (MW5,000), Phospholipase 其它：Vasoactive intestinal peptide,血管活性药物，内皮素，心肌抑制因子小于5千道尔顿，磷脂酶 The CRRT Membranes  Nominal Pore size: 20- 30 kD 普通孔径为2－3万道尔顿 Highly absorptive capacity 高黏附性 Can bind many mediators in vitro 在体外试验中可以黏附许多因子 Can bind mediators in vivo 在体内试验中也可以黏附细胞因子 Can filter some mediators in vitro Can filter some mediators in vivo 在体内及体外试验均可滤出一定的因子 CRRT and complementCRRT与补体 TNF levels: CVVH vs. CVVHD High Volume Hemofiltration The term was first used by Grootendorst in 1992 这一术语是在1992年，由Grootendorst 首次提出的 Animal experiments in pigs (weight 36-39 kg) 所选动物为体重在36－39公斤的猪 Blood flow 300 ml/min UF flow 6000 ml/hr Replacement fluid given pre-filter Polysulfone filters (Amicon, USA) 多聚砜膜 IV endotoxin over 30 minutes HVHF and RVEF右室 HVHF and MAP Effect of septic UF on MAP Effect of HVHF on ischemic gut injury HVHF HVHF may be beneficial in human septic shock 高容量血滤可能对感染性休克病人有益 If Hct of 30% and blood flow of 300 ml/min and pre-dilution...small solute clearance = approx. 60-70 ml/min (110ml/k