ICU中的血液净化治疗最新进展.ppt
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Blood Purification in the ICU: State of the Art
ICU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 (MW<9,000); IL-6 (MW<22,000)
? 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 (MW<5,000), 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 complement
CRRT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/kg/hr)
? 假设HCT＝30%，血流速度＝300ml/min,而且采用前置换...那么小分子物质的清除率(SC)≈60-70ml/min(110ml/kg/hr)
? In 70 kg patient in pre-dilution......need about 11 L/hr of UF rate.....less if post-dilution but need big blood flows (>400 ml/min)
? 在一个70公斤的病人进行前置换时，超滤量(UF)＝11L/hr，小于后置换，但后置换需要更大的血流速度(>400ml/min)
HVHF
? 11L/hr of UF is technically demanding/very difficult in human beings
? 病人身上实现11L/hr的超滤量，在技术上是极难实现的
? Can we achieve similar results at lower UF rates?
? 是否我们能够使用较小一点的超滤量而达到相似的治疗效果呢？ ......
Blood Purification in the ICU: State of the Art
ICU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 (MW<9,000); IL-6 (MW<22,000)
? 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 (MW<5,000), 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 complement
CRRT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/kg/hr)
? 假设HCT＝30%，血流速度＝300ml/min,而且采用前置换...那么小分子物质的清除率(SC)≈60-70ml/min(110ml/kg/hr)
? In 70 kg patient in pre-dilution......need about 11 L/hr of UF rate.....less if post-dilution but need big blood flows (>400 ml/min)
? 在一个70公斤的病人进行前置换时，超滤量(UF)＝11L/hr，小于后置换，但后置换需要更大的血流速度(>400ml/min)
HVHF
? 11L/hr of UF is technically demanding/very difficult in human beings
? 病人身上实现11L/hr的超滤量，在技术上是极难实现的
? Can we achieve similar results at lower UF rates?
? 是否我们能够使用较小一点的超滤量而达到相似的治疗效果呢？ ......
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