CRRT：溶质分子与模式选择.ppt

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 CVVH Pre-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 CVVH -HVHF Pre/Post dilution Associated with High Volume Hemofiltration The principle ( clearances ) is Convection Eliminate Small , Mid + Large molecules Net Fluid removal if desired In pre + post -Dilution Fluids are returning to the patient before and after the Filter The principle ( clearances ) is Convection + Diffusion Eliminate Small + Mid molecules Net Fluid removal if desired Use of Sterile Dialysate + Replacement Solutions CVVHDF (Continuous Veno-Venous Hemodiafiltration) CRRT特点 稳定的血流动力学 持续稳定的控制氮质血症和水电/酸碱平衡 能够不断清除循环中的毒素或中分子物质 按需提供营养补充和药物治疗 CRRT vs IRRT IHD PD CRRT Hemodynamic stability … + ++ Osmo pressure stability … + +++ Fluid removal ++ + +++ Correction of acidosis ++ + +++ Unlimited PN/EN … … ++ Clearances Small solutes (500d) ++ + +++ Large solutes (500d) … + +++ Mediator removal … … ++? Access morbidity + ++ + Anticoagulation needs + … + Simplicity + +++ ++ 内容提要 CRRT的基本概念 CRRT的溶质清除原理 CRRT的基本模式 CRRT在ICU中的应用 CRRT病理生理指征 1. 液体过负荷－保持水平衡 2. 代谢产物堆积(氮质血症)－清除代谢产物 3. 严重的酸碱失衡－恢复酸碱失衡 4. 严重的电介质紊乱－恢复电介质平衡 5. 容量治疗受限－营养支持，补充胶体 6.严重的组织器官水肿 7.炎症反应－清除或吸附炎症介质 8.中毒－清除毒物或药物 9.恶性高热－降温 Bellomo R and Ronco C. Crit Care, 2000,4:339-345 血流动力学不稳定的ARF 严重的SIRS－重症胰腺炎，烧伤 重症感染和感染性休克 MODS与ARDS 水中毒与急性肺水肿 顽固性心衰 中毒 恶性高热 容量治疗受限的ARF/CRF CRRT临床指征 Bellomo R and Ronco C. Crit Care, 2000,4:339-345 CRRT Indications Acute pulmonary oedema : SCUF To avoid kalium-hydric overload during cardiac surgery with EBC (extra corporeal blood circulation) :