CVVH時(shí)治療劑量的計(jì)算總結(jié)課件

1、CVVH時(shí)治療劑量的計(jì)算北京協(xié)和醫(yī)院杜斌CVVH時(shí)治療劑量的計(jì)算北京協(xié)和醫(yī)院內(nèi)容CVVH清除溶質(zhì)的原理CVVH治療劑量的計(jì)算CVVH提高劑量的方法內(nèi)容CVVH清除溶質(zhì)的原理CVVH治療劑量的計(jì)算CVVH提高腎臟的生理功能腎臟的生理功能腎臟替代治療 vs. 腎臟heparinVVPVPAUFBLDSADRheaterhigh-flux腎小球原尿腎小管腎臟替代治療 vs. 腎臟heparinVVPVPAUFBL濾器剖面圖濾器剖面圖濾器清除物質(zhì)的原理超濾(ultrafiltration)對流(convection)彌散(diffusion)吸附(adsorption)濾器清除物質(zhì)的原理超濾(ultr

2、afiltration)超濾作用的原理: 跨膜壓跨膜壓(TMP): 半透膜兩側(cè)的壓力差溶劑的移動(dòng)從壓力高的一側(cè)向壓力低的一側(cè)增加壓力差可以增加溶劑的超濾超濾作用的原理: 跨膜壓跨膜壓(TMP): 半透膜兩側(cè)的壓力UFR = BFRin BFRout超濾作用的原理: 超濾率通過超濾作用清除的溶劑量(UFR)BFRinBFRout= BFRin UFRUFR = BFRin BFRout超濾作用的原理: 超UFR = Lp.A.P = Kuf.P超濾率的影響因素Lp: 膜超濾系數(shù)ml/(hr.mmHg.m2)Kuf: 濾器超濾系數(shù)ml/(hr.mmHg)P: TMPUFR = Lp.A.P = K

3、uf.P超濾率的影響因素高通量濾器低通量濾器超濾率的影響因素: 膜超濾系數(shù)Lp (ml/(hr.mmHg.m2)1020膜對溶劑(水)的通透性高通量濾器低通量濾器超濾率的影響因素: 膜超濾系數(shù)Lp (m超濾率的影響因素: 跨膜壓超濾率的影響因素: 跨膜壓UFR = Lp.A.P = Kuf.P超濾率的影響因素Lp: 膜超濾系數(shù)ml/(hr.mmHg.m2)Kuf: 濾器超濾系數(shù)ml/(hr.mmHg)P: TMPUFR = Lp.A.P = Kuf.P超濾率的影響因素對流作用的原理跨膜壓(TMP): 半透膜兩側(cè)的壓力差溶質(zhì)的移動(dòng)隨溶劑移動(dòng)從壓力高的一側(cè)向壓力低的一側(cè)對流作用的原理跨膜壓(TMP

4、): 半透膜兩側(cè)的壓力差對流作用的原理對流作用的原理對流清除溶質(zhì)的效率腎臟CCr = Ucr x UO / ScrCVVHC = Ufcr x UFR / ScrBFRBFRUFR對流清除溶質(zhì)的效率腎臟CVVHBFRBFRUFR對流作用的原理: 篩選系數(shù)篩選系數(shù)(S, sieving coefficient)S = UF / plasmaplasmaUF對流作用的原理: 篩選系數(shù)篩選系數(shù)(S, sieving c對流作用的原理: 對流清除率C = S.UFRKuf.P = Lp.A.P篩選系數(shù): UF / plasma對流作用的原理: 對流清除率C = S.UFRKuf.P 對流作用的原理:

5、篩選系數(shù)溶質(zhì)篩選系數(shù)溶質(zhì)篩選系數(shù)鈉0.993纈氨酸1.069鉀0.975 0.99胱氨酸1.047氯1.05 1.088蛋氨酸1.0碳酸氫根1.12 1.137異亮氨酸1.010鈣0.64 0.677亮氨酸1.014磷1.04酪氨酸1.089白蛋白0.0002 0.01苯丙胺酸1.078尿素氮1.019 1.05賴氨酸1.080肌酐1.02 1.037組氨酸1.109葡萄糖1.04蘇氨酸1.256尿酸1.02總蛋白0.02鎂0.9總膽紅素0.03對流作用的原理: 篩選系數(shù)溶質(zhì)篩選系數(shù)溶質(zhì)篩選系數(shù)鈉0.99對流清除溶質(zhì)的效率腎臟CCr = Ucr x UO / ScrCVVHC = Ufcr x

6、 UFR / ScrBFRBFRUFR對流清除溶質(zhì)的效率腎臟CVVHBFRBFRUFR超濾率的影響因素: 濾過分?jǐn)?shù)BFR血細(xì)胞 BFR x Hct血漿 BFR x (1 Hct)BFR血細(xì)胞 BFR x Hct血漿 BFR x (1 Hct) - UFRUFR超濾率的影響因素: 濾過分?jǐn)?shù)BFRBFRUFR超濾率的影響因素: 濾過分?jǐn)?shù)FF% = UFR x 100 / QpQp = BFR x (1 Hct)FF% 30%以防止血液濾器凝血超濾率的影響因素: 濾過分?jǐn)?shù)FF% = UFR x 100 超濾率的影響因素: 濾過分?jǐn)?shù)BFR血細(xì)胞 BFR x Hct血漿 BFR x (1 Hct)BFR

7、血細(xì)胞 BFR x Hct血漿 BFR x (1 Hct) - UFRUFR100 ml/minHct 30%血細(xì)胞 30 ml/min血漿 70 ml/minBFR血細(xì)胞 30 ml/min血漿 70 - UFRUFR超濾率的影響因素: 濾過分?jǐn)?shù)BFRBFRUFR100 ml/超濾率的影響因素: 濾過分?jǐn)?shù)BFR = 100 ml/min, Hct = 0.30Qp = BFR x (1 Hct) = 70 ml/minFF 30%,UFR FF x Qp = 21 ml/min血流量是影響超濾率的最主要因素*后稀釋超濾率的影響因素: 濾過分?jǐn)?shù)BFR = 100 ml/min內(nèi)容CVVH清除溶

8、質(zhì)的原理CVVH治療劑量的計(jì)算CVVH提高劑量的方法內(nèi)容CVVH清除溶質(zhì)的原理CVVH治療劑量的計(jì)算CVVH提高腎臟替代治療的劑量: Ronco篩選患者(n = 492)隨機(jī)分組(n = 425)排除患者(n = 67)UFR 35 ml/kg/hr(n = 139)UFR 20 ml/kg/hr(n = 146)UFR 45 ml/kg/hr(n = 140)Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes o

9、f acute renal failure: A prospective randomised trial. Lancet 2000; 356: 26-30腎臟替代治療的劑量: Ronco篩選患者(n = 492)隨腎臟替代治療的劑量: RoncoRonco 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. Lan

10、cet 2000; 356: 26-30腎臟替代治療的劑量: RoncoRonco C, Bello腎臟替代治療的劑量: RoncoRonco 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腎臟替代治療的劑量: RoncoRonco C, BelloARF的治療劑量

11、: 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.” ARF的治療劑量: Kellum“Patients withCVVH的參數(shù)設(shè)置RheaterheparinVVPVPAUFBLDSADBWt 60 kgHct 30%后稀釋BFR = 150 ml/mi

12、nRFR = 2000 ml/hr平衡 = -100 ml/hr流出液 = 2100 ml/hr交換量 35 ml/kg/hr但是FF% = 35 / (150 x 70%) = 33%CVVH的參數(shù)設(shè)置RheaterheparinVVPVPAUCVVH的參數(shù)設(shè)置RheaterheparinVVPVPAUFBLDSADBWt 60 kg后稀釋交換量 35 ml/kg/hrBFR應(yīng)當(dāng)設(shè)置為多少?FF% 30%以防止血液濃縮流出液 35 x 60 = 2100 ml/hr流出液 35 ml/min血漿流量(Qp) 35 / 30% = 117 ml/minBFR = 117 / 70% = 167

13、 ml/minCVVH的參數(shù)設(shè)置RheaterheparinVVPVPAUCVVH的參數(shù)設(shè)置如果BFR只能維持150 ml/min如何達(dá)到35 ml/kg/hr的交換量?CVVH的參數(shù)設(shè)置如果BFR只能維持150 ml/min增加對流清除能力: 前稀釋 vs. 后稀釋RheaterheparinVVPVPAUFBLDSAD增加對流清除能力: 前稀釋 vs. 后稀釋Rheaterhe前稀釋的優(yōu)點(diǎn)與缺點(diǎn)BFRBFRUFRBFRBFRUFRRFRRFR后稀釋前稀釋有血液濃縮過程UFR受到濾過分?jǐn)?shù)的限制沒有血液濃縮過程UFR不受濾過分?jǐn)?shù)的限制前稀釋的優(yōu)點(diǎn)與缺點(diǎn)BFRBFRUFRBFRBFRUFRRFR

14、前稀釋的優(yōu)點(diǎn)與缺點(diǎn)BFRBFRUFRBFRBFRUFRRFRRFR后稀釋前稀釋血液沒有被稀釋UF中溶質(zhì)濃度與血漿濃度相似SC = 1血液被稀釋UF中溶質(zhì)濃度低于血漿濃度SC 1前稀釋的優(yōu)點(diǎn)與缺點(diǎn)BFRBFRUFRBFRBFRUFRRFR前稀釋CVVH時(shí)交換量的計(jì)算BWt 60 kgHct 30%BFR 150 ml/min全部前稀釋RFR 2000 ml/hr平衡-100 ml/hrRheaterheparinVVPVPAUFBLDSADBFR 150 ml/minRFR 2000 ml/hrUFR2100 ml/hr前稀釋CVVH時(shí)交換量的計(jì)算BWt 60 kgRheater前稀釋CVVH時(shí)

15、交換量的計(jì)算首先按照完全后稀釋方式計(jì)算交換量UFR 2100 ml/hr = 35 ml/kg/hrC = SC x UFR = 35 ml/kg/hr其次計(jì)算稀釋比例BFR = 150 ml/min, Hct = 30%Qp = 150 x (1 30%) = 105 ml/min前稀釋RFR = 2000 ml/hr = 33 ml/min稀釋比例 = Qp / (Qp + RFR) = 105 / (105 + 33) = 76%最后計(jì)算校正后交換量C = 35 x 76% = 26.6 ml/kg/hr流出液量相同的情況下溶質(zhì)清除效率前稀釋 后稀釋前稀釋CVVH時(shí)交換量的計(jì)算首先按照完

16、全后稀釋方式計(jì)算交換量前稀釋CVVH時(shí)交換量的計(jì)算BWt 60 kgHct 30%BFR 150 ml/min全部前稀釋平衡-100 ml/hrRFR x ml/hr才能保證交換量35 ml/kg/hrRheaterheparinVVPVPAUFBLDSADBFR 150 ml/minRFR x ml/hrUFRX+100 ml/hr前稀釋CVVH時(shí)交換量的計(jì)算BWt 60 kgRheater前稀釋CVVH時(shí)交換量的計(jì)算首先按照完全后稀釋方式計(jì)算交換量UFR x + 100 ml/hr = (x + 100) / 60 ml/kg/hrC = SC x UFR = (x + 100) / 60

17、 ml/kg/hr其次計(jì)算稀釋比例BFR = 150 ml/min, Hct = 30%Qp = 150 x (1 30%) = 105 ml/min前稀釋RFR = x ml/hr = x / 60 ml/min稀釋比例 = Qp / (Qp + x / 60) = 105 / (105 + x / 60)最后計(jì)算校正后交換量C = (x + 100) / 60 . 105 / (105 + x / 60) = 35 ml/kg/hrRFR = x = 3000 ml/hr前稀釋CVVH時(shí)交換量的計(jì)算首先按照完全后稀釋方式計(jì)算交換量CVVH時(shí)交換量的計(jì)算BWt 60 kgHct 30%BFR

18、 150 ml/min平衡-100 ml/hrRFR 3000 ml/hr如何保證交換量40 ml/kg/hrRheaterheparinVVPVPAUFBLDSADCVVH時(shí)交換量的計(jì)算BWt 60 kgRheaterhepCVVH時(shí)交換量的計(jì)算全部前稀釋RFR 3000 ml/hrUFR 3100 ml/hrC 35 ml/kg/hr全部后稀釋RFR 3000 ml/hrUFR 3100 ml/hrC 51.7 ml/kg/hrFF% 50%滿足C 40 ml/kg/hr部分前稀釋+部分后稀釋?CVVH時(shí)交換量的計(jì)算全部前稀釋全部后稀釋滿足C 40 mlCVVH時(shí)交換量的計(jì)算BWt 60

19、kgHct 30%BFR 150 ml/min平衡-100 ml/hrRFR 3000 ml/hr如何保證交換量40 ml/kg/hrRheaterheparinVVPVPAUFBLDSADpreRFR 3000 x pre% ml/hrpostRFR 3000 x (1 - pre%) ml/hrBFR 150 ml/minUFR3100 ml/hrCVVH時(shí)交換量的計(jì)算BWt 60 kgRheaterhep前稀釋+后稀釋交換量的計(jì)算首先按照完全后稀釋方式計(jì)算交換量UFR 3100 ml/hr = 51.7 ml/kg/hrC = SC x UFR = 51.7 ml/kg/hr其次計(jì)算稀釋比例BFR = 150 ml/min, Hct = 30%Qp = 150 x (1 30%) = 105 ml/min前稀釋RFR = 3000 x pre% ml/hr = 50 x pre% ml/min稀釋比例 = Qp / (Qp + 50 x pre%) = 105 / (105 + 50 x pre%)最后計(jì)算校正后交換量C = 51.7 x 105 / (105 + 50 x pr