1、1,CRRT治療容量如何控制,2,CRRT治療中的容量管理,CRRT清除水和溶質(zhì)的機(jī)制及其相關(guān)概念； 重癥患者容量失衡及其危害； CRRT容量管理目標(biāo)及其監(jiān)測(cè)；,3,CRRT治療中水和溶質(zhì)清除機(jī)制,水：超濾； 溶質(zhì)：彌散、對(duì)流與吸附；,4,彌 散,彌散是溶質(zhì)通過半透膜的一種方式，主要驅(qū)動(dòng)力是離子濃度梯度差；在一個(gè)限定的分布空間，半透膜兩側(cè)的物質(zhì)有達(dá)到相同濃度的趨勢(shì)。,Chest 2007; 132:13791388,5,對(duì) 流,對(duì)流是溶質(zhì)通過半透膜的另一種方式，在跨膜壓差作用下，溶質(zhì)及溶劑一起通過半透膜。,Chest 2007; 132:13791388,6,Total ultrafiltra

2、te 總超濾液量是RRT回路清除液體的總量； Ultrafiltration rate 超濾率是單位時(shí)間清除液體的總量，是在一定時(shí)間段內(nèi)完成預(yù)定Total UF；,CRRT水的清除機(jī)制及其相關(guān)概念,Int J Artif organs.2008;31(2):145-55,透析液,透析液+UF,7,單純超濾模式Total UF代表凈清除液體量； 血液濾過模式Total UF意味治療效果，而不指液體平衡狀態(tài)；,CRRT治療中水和溶質(zhì)清除機(jī)制,Int J Artif organs.2008;31(2):145-55,8,血液透析模式Total UF控制平衡，僅代表額外治療效果； CVVHDF模式To

3、tal UF僅代表治療效果，不影響液體平衡；,CRRT治療中水和溶質(zhì)清除機(jī)制,Int J Artif organs.2008;31(2):145-55,9,Replacement rate 置換率Qr是單位時(shí)間置換入回路的液體總量，為達(dá)到目標(biāo)凈超濾率，置換率應(yīng)依超濾率而設(shè)定； Total replacement TR是回路置換液的總量，血液濾過模式TR代表治療效果和液體平衡；血液透析濾過模式TR同樣也意味著療效和液體平衡；,CRRT水的清除機(jī)制及其相關(guān)概念,Int J Artif organs.2008;31(2):145-55,10,Net ultrafiltration 凈超濾量是凈清除的

4、液體總量； (Total ultrafiltration total replacement) Net ultrafiltration rate 凈超濾率是單位時(shí)間凈清除液體的總量； (Ultrafiltration rate replacement rate) Total effluent 總流出(廢)液量是收集 到引流袋中的液體總量；,CRRT水的清除機(jī)制及其相關(guān)概念,Int J Artif organs.2008;31(2):145-55,11,超濾應(yīng)在RRT治療全身狀態(tài)穩(wěn)定之后進(jìn)行； RRT治療開始前應(yīng)充分沖洗管路； 應(yīng)規(guī)律評(píng)價(jià)對(duì)超濾率的臨床反應(yīng)情況并相應(yīng)調(diào)整；,Int J Artif

5、 organs.2008;31(2):145-55,12,CRRT治療中的容量管理,CRRT清除水和溶質(zhì)的機(jī)制及其相關(guān)概念； 重癥患者容量失衡及其危害； CRRT容量管理目標(biāo)及其監(jiān)測(cè)；,13,重癥患者容量失衡及其危害,Int J Artif organs.2008;31(2):145-55,14,Kidney International.2009;76: 422427,Fluid overload was defined as more than a 10% increase in body weight relative to baseline; measured in 618 patien

6、ts enrolled in a prospective multicenter observational study;,15,Fluid accumulation,survival and recovery of kidney function in critically ill patients with AKI,Kidney International.2009;76: 422427,16,Fluid accumulation,survival and recovery of kidney function in critically ill patients with AKI,Kid

7、ney International.2009;76: 422427,17,The importance of fluid management in Acute lung injury secondary to septic shock,Chest.2009;136:102-109,The study cohort was made up of 212 patients with ALI complicating septic shock. Adequate initial fluid resuscitation (AIFR) was defined as the administration

8、 of an initial fluid bolus of 20 mL/kg prior to and achievement of a CVP 8 mm Hg within 6 h after the onset of therapy with vasopressors. Conservative late fluid management (CLFM) was defined as even-to negative fluid balance measured on at least 2 consecutive days during the first 7 days after sept

9、ic shock onset.,18,Chest.2009;136:102-109 Blood Purif 2010;29:331338,The importance of fluid management in Acute lung injury secondary to septic shock,19,Conclusions: Both early and late fluid management of septic shock complicated by ALI can influence patient outcomes.,The importance of fluid manag

10、ement in Acute lung injury secondary to septic shock,Chest.2009;136:102-109,20,CRRT治療中的容量管理,CRRT清除水和溶質(zhì)的機(jī)制及其相關(guān)概念； 重癥患者容量失衡及其危害； CRRT容量管理目標(biāo)及其監(jiān)測(cè)；,21,Clinical Skin Turgor Capillary refill Venous distention Orthostasis Blood Pressure Organomegaly Pulmonary edema Urine volume Urine Osmolality,Monitoring I

11、nvasive Central Venous Pressure Pulmonary Artery Pressure Cardiac Output (PAC, PICCO) Pre-Load parameters Volume responsiveness (SPV, PPV) Non-Invasive Echocardiography Bioimpedance Spectroscopy,Assessment of Volume Status,22,Design: Prospective, nonrandomized, nonblinded interventional study； 健康志愿受

12、試者(n=12 group 1, n=32 group 2)； 組1 肺動(dòng)脈導(dǎo)管置入并進(jìn)行血管造影 組2 容量測(cè)量的超聲心動(dòng)檢測(cè)并在3小時(shí)內(nèi)輸注生理鹽水3000ml,Crit Care Med.2004; 32:691699,23,Crit Care Med.2004; 32:691699,24,Crit Care Med.2004; 32:691699,25,Crit Care Med.2004; 32:691699,26,Crit Care Med.2004; 32:691699,27,Assessment of Volume Status,壓力僅僅是壓力，壓力不能準(zhǔn)確反映容量狀態(tài) 容量狀態(tài)評(píng)估-困難！ 應(yīng)密切監(jiān)測(cè)下綜合評(píng)價(jià),28,CRRT治療中的液體平衡,總體負(fù)平衡：脫水，運(yùn)用于所有液體超負(fù)荷的少尿/無尿病人； 總體平衡：病人的容量狀況在正常