CVVHD时治疗剂量的计算(精品)

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,CVVHD,时治疗剂量的计算,北京协和医院,杜,斌,内容,CVVH,D,清除溶质的原理,CVVHD,治疗剂量的计算,CVVHD,提高剂量的方法,肾脏的生理功能,肾脏替代治疗,vs.,肾脏,heparin,V,V,PV,PA,UF,BLD,SAD,R,heater,high-flux,肾小球,原尿,肾小管,滤器剖面图,滤器清除物质的原理,超滤,(,ultrafiltration,),对流,(convection),弥散,(diffusion),吸附,(adsorption),弥散作用的原理,:,浓度梯度,半透膜两侧的溶质浓度梯度,溶质的移动,从浓度高的一侧向浓度低的一侧,浓度差消失时溶质的移动停止,弥散作用的原理,:,浓度梯度,弥散作用的原理,弥散作用的原理,:,溶质的清除,半透膜,血液,透析液,弥散作用的原理,:,溶质的清除,半透膜,血液,透析液,弥散作用的原理,:,逆流,半透膜,血液,透析液,弥散作用的原理,:,透析液饱和度,透析液饱和度,Sd,=,dialysate,/plasma,plasma,dialysate,弥散作用的原理,:,弥散清除率,Kd,=,Sd.Qd,=f(,Qb,Qd,KoA,),透析液饱和度,dialysate,/plasma,影响溶质清除的因素,质量转运系数,(,Ko,),中空纤维对溶质的弥散阻力,溶质大小,滤器通透性,膜面积,(A),血流量,(,Qb,),透析液流量,(,Qd,),溶质分子量与清除,溶质,(,分子量,),筛选系数,弥散系数,尿素氮,(60),1.01,0.05,1.01,0.07,肌酐,(113),1.00,0.09,1.01,0.06,尿酸,(168),1.01,0.04,0.97,0.04*,万古霉素,(1448),0.84,0.10,0.74,0.04*,*P 0.05 vs.,筛选系数,*P 0.01 vs.,筛选系数,Jeffrey RF,Khan AA,Prabhu,P,et al.A comparison of molecular clearance rates during continuous,hemofiltration,and,hemodialysis,with a novel volumetric continuous renal replacement system.,Artif,Organs 1994;18(6):425-428,弥散作用的应用,:,持续血液透析,(CVVHD),heparin,V,V,PV,PA,D,UF,D,BLD,SAD,heater,low-flux,弥散作用的原理,:,溶质的清除,0,40,80,120,10,10,2,10,3,10,4,10,5,urea,creatinine,Vit.B,12,2,-M,albumine,clearance ml/min,MW dalton,HD,Kidney,IL-1,TNF,IL-6,IL-8,弥散,vs.,对流,弥散清除率,对流清除率,Kd,=,Qd,out,xCd,out,/Cb,in,后稀释,Cd,=,Sx,Quf,前稀释,Cd,=,Sx,Quf,xQb/(Quf+Qb,),小分子溶质,Cd,out,/Cb,in,1,S=1,S=1,中大分子溶质,Cd,out,/Cb,in,Kd,Cd,Kd,CVVH vs.IHD,清除效率,0,40,80,120,10,10,2,10,3,10,4,10,5,urea,creatinine,Vit.B,12,2,-M,albumine,clearance ml/min,MW dalton,HF,HD,Kidney,Cut-off,IL-1,TNF,Hrl,(1996):Biocompatible membranes are linked with low incidence of infections,recovement of renal function and mortality in ARF,IL-6,IL-8,内容,CVVHD清除溶质的原理,CVVHD,治疗剂量的计算,CVVHD,提高剂量的方法,CVVHD,的剂量计算,heparin,V,V,PV,PA,D,UF,D,BLD,SAD,heater,low-flux,BWt,60 kg,BFR=150 ml/min,RFR=2400 ml/hr,平衡,=0 ml/hr,流出液,=2400 ml/hr,交换量,40 ml/kg/hr,影响溶质清除的因素,:,Qd,Qd,ml/min,Kurea,ml/min,KoA,=765 ml/min,Qb,=500,Qb,=450,Qb,=350,Qb,=250,Qb,=100,影响溶质清除的因素,:,KoA,&,Qb,Qb,ml/min,Kurea,ml/min,Qd,=500,KoA,=900,KoA,=700,KoA,=500,影响溶质清除的因素,:MW,Qb,ml/min,Kd,ml/min,PMNA,膜,KoA,=765 ml/min,尿素,肌酐,尿酸,VitB12,菊酚,内容,CVVHD清除溶质的原理,CVVHD,治疗剂量的计算,CVVHD,提高剂量的方法,肾脏替代治疗的剂量,:,Ronco,Ronco,C,Bellomo,R,Homel,P,et al.Effects of different doses in continuous,veno,-venous,haemofiltration,on outcomes of acute renal failure:A prospective,randomised,trial.Lancet 2000;356:26-30,ARF,的治疗剂量,:,Kellum,“Patients with ARF should be treated with at least 35,mL/kg/h,of,hemofiltration,/,hemodiafiltration,or daily,hemodialysis,until or unless ongoing multi-center clinical trials show otherwise.”,肾脏替代治疗的原理,机制,清除物质,超滤,(,ultrafiltration,),溶剂,(,水,),对流,(convection),小分子物质,中分子物质,弥散,(diffusion),小分子物质,吸附,(adsorption),特殊分子,增加对流清除溶质能力的方法,增加,UFR,提高跨膜压,(TMP),超滤液一侧的负压,血液一侧的正压,增加膜超滤系数,(,Lp,),增加滤器膜面积,(A),提高血流量,(BFR),采用前稀释方式,增加弥散清除,C=S.UFR=,S.Lp.A.P,C=S.UFR.BFR/(BFR+RFR),K,T,=K,D,+UFR.S.(1 K,D,/BFR),弥散,+,对流的应用,:,血液透析滤过,(CVVHDF),heparin,V,V,PV,PA,R,D,UF,D,BLD,SAD,heater,high-flux,增加对流清除能力,:,弥散,+,对流,总清除率,对流清除率,Clark WR,Ronco,C.CRRT efficiency and efficacy in relation to solute size.Kidney International 1999;56:S3-S7,增加对流清除能力,:,弥散,+,对流,K,T,=K,D,+(UFR x,Tr,),S x(1 K,D,/BFR),弥散清除率,(,超滤,=0,时,),弥散,+,对流的原理,Kd,=Kd0+,Tr,x,Quf,Kd0,相同血流量及透析液流量而无超滤时的清除率,Tr,超滤率增加所致清除率增加的系数,Quf,0 85 ml/min,时,Tr,为,0.4 0.52,Tr,=0.453+0.00083 x,Quf,Kd,=Kd0+0.453Quf+8.3 x 10,-4,(Quf),2,溶质清除,:CVVH vs.CVVHD vs.CVVHDF,总,结,CVVHD,的针对小分子溶质,CVVHD,的治疗剂量影响,模式选择,参数设置,