CRRT：溶質分子與模式選擇,1,Case,男性，50歲單純高鉀血癥循環穩定CRRT策略：高流量的CVVH,？,2,內容提要,CRRT的基本概念CRRT的溶質清除原理CRRT的基本模式CRRT在ICU中的應用,3,CRRT:所有連續性清除水和溶質的治療技術CAVH,CVVH,SCUF,CAVHD,CVVHD,CAVHDF,CVVHDF,CVVH,HVHF.CBP:連續性血液凈化1995年第一屆CRRT學術會議在美國圣地亞哥舉行，每年一次學術會議,CRRT基本概念,4,CRRTamajortreatmentoptionforARF?,AcuteRenalFailure,Treatmentoptions:Drugtherapy(fluids,diuretics)IntermittentHemodialysis(IHD)PeritonealDialysisContinuousRenalReplacementTherapies(CRRT),AdditionalindicationsforCRRT,ChronicHeartFailureandoverhydrationMulti-organFailure(MOF)AcuteRespiratoryDistressSyndrome(ARDS)BurnPatientsLiverFailureSepsis,5,內容提要,CRRT的基本概念CRRT的溶質清除原理CRRT的基本模式CRRT在ICU中的應用,6,CRRT水和溶質清除原理,清除水Ultrafiltration清除溶質DiffusionConvectionAdsorption,7,Hollowfibrestructure,BloodInlet,8,9,壓力梯度差形成的液體移動,超濾作用,正壓,負壓,不能通過膜的溶質做成膠體滲透壓,10,CRRT溶質清除原理,清除溶質DiffusionConvectionAdsorption,11,小分子物質,氯化鈉SodiumChloride58.5尿素Urea60磷酸PhosphateAcid96肌酐Creatinine113尿酸UricAcid168葡萄糖Glucose180,12,中分子物質,多肽PeptideA778維生素B12VitaminB121355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腫瘤壞死因子TumorNecrosisFactor39000-225000,13,大分子物質,前白蛋白Pre-albumin55000抗凝血酶原3Antithrombin365000白蛋白Albumin66000血紅蛋白Hemoglobin68000凝血酶原Prothrombin68000轉鐵蛋白Transferrin76500免疫球蛋白GIgG160000纖維蛋白原Fibrinnogen341000纖維連接蛋白Fibronectin(dimer)450000,14,Diffusion,SolutesmovefromaHigherconcentration(Blood)toaLowerconcentration(Dialysate)VeryefficientforremovingsmallmoleculesInHemodialysis.BFRdependentInCRRT.DialysateFlowDependent,15,Diffusion,RedBloodcell,Bicarbonate,Cratinine,Chlorure,Potassium,Urea,Blood,Membrane,Filtrate,AssociatedwithDialysate,16,17,Efficientforremovingsmallmolecules,小分子物質血液濃度高膜內外濃度差大小分子物質易于擴散相同膜對小分子物質阻力小,18,Convection,Soluteremovalwitha“waterflow”SoluteDrag(Pressuregradient)GoodforlargermolecularweightsubstancesThefastertheflow,thebettertheclearanceReplacementsolutionsmustbephysiologicalandsterile,19,對流,溶質隨水流移動，“溶劑拖移”,20,影響對流作用的因素,增加某種溶質的對流清除率有兩種方法:1.選擇一塊更易于溶質通過的簿膜2.增加超濾出來的容量,C=S*UFRUFR=Lp*A*TMP,S:篩過系數,21,22,Adsorption,RedBloodcell,Creatinine,Chlorure,Potassium,Urea,Sang,Membrane,Filtrate,InflammatoryMediators,23,吸附作用,有些膜材料帶有吸附特性:(例如AN69膜)發生在膜表面的吸附如果份子能通過膜表皮，更大規模的吸附發生在膜的深層,份子粘附在膜的表面或深層,24,25,內容提要,CRRT的基本概念CRRT的溶質清除原理CRRT的基本模式CRRT在ICU中的應用,26,CRRT治療方式,27,ContinuousRenalReplacement,Therapies,SCUF,C,A,V,H,SPONTANEOUS,BloodCirculation,PUMPED,BloodCirculation,HEMOFILTRATION,CONVECTION,HEMODIALYSIS,DIFFUSION,HVHF,28,RemovalofwaterisdonebyUFNoSubstitutionliquidisusedUsedmainlyforCHF+FluidOverload,SCUF,(SlowContinuousUltrafiltration),29,CVVHD,(ContinuousVeno-VenousHemodialysis),Theprinciple(clearances)isDiffusionEliminatemainlySmallMoleculesNetFluidRemovalisdesiredUsedofSterileDialysateSolution,30,CVVHPostdilution,(ContinuousVeno-VenousHemofiltration),Theprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpost-DilutionFluidsarereturningaftertheFilterinsidethevenousline,31,CVVHPre-dilution,Theprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpre-DilutionFluidsarereturningbeforetheFilterthroughthepreDilutionline,32,CVVH-HVHFPre/Postdilution,AssociatedwithHighVolumeHemofiltration,Theprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpre+post-DilutionFluidsarereturningtothepatientbeforeandaftertheFilter,33,Theprinciple(clearances)isConvection+DiffusionEliminateSmall+MidmoleculesNetFluidremovalifdesiredUseofSterileDialysate+ReplacementSolutions,CVVHDF,(ContinuousVeno-VenousHemodiafiltration),34,CRRT特點,穩定的血流動力學持續穩定的控制氮質血癥和水電/酸堿平衡能夠不斷清除循環中的毒素或中分子物質按需提供營養補充和藥物治療,35,CRRTvsIRRT,36,內容提要,CRRT的基本概念CRRT的溶質清除原理CRRT的基本模式CRRT在ICU中的應用,37,CRRT病理生理指征,1.液體過負荷保持水平衡2.代謝產物堆積(氮質血癥)清除代謝產物3.嚴重的酸堿失衡恢復酸堿失衡4.嚴重的電介質紊亂恢復電介質平衡5.容量治療受限營養支持，補充膠體6.嚴重的組織器官水腫7.炎癥反應清除或吸附炎癥介質8.中毒清除毒物或藥物9.惡性高熱降溫,BellomoRandRoncoC.CritCare,2000,4:339-345,38,血流動力學不穩定的ARF嚴重的SIRS重癥胰腺炎，燒傷重癥感染和感染性休克MODS與ARDS水中毒與急性肺水腫頑固性心衰中毒惡性高熱容量治療受限的ARF/CRF,CRRT臨床指征,BellomoRandRoncoC.CritCare,2000,4:339-345,39,CRRTIndications,Acutepulmonaryoedema:SCUFToavoidkalium-hydricoverloadduringcardiacsurgerywithEBC(extracorporealbloodcirculation):SCUFSevereoedemain:congestivec