急性肝功能衰竭診治(武漢中心醫(yī)院ICU)課件

急性肝功能衰竭急性肝功能衰竭的定義Acuteliverfailure(ALF)isdefinedaslife-threateningliverinjuryintheabsenceofpreexistingliverdiseasewithcoagulopathy(prothrombintime>15secondsorinternationalnormalizedratio[INR]1.5)andhepaticencephalopathy(HE)thatdevelopswithin26weeksofinitialsymptomsTheterm‘‘fulminanthepaticfailure’’(FHF)isusedwhenHEdevelopswithin8weeksofjaundiceEtiologyofacuteliverfailure肝性腦病的分期臨床上按神經(jīng)精神癥狀的輕重把肝性腦病分為四期：一期(前驅(qū)期):輕微的神經(jīng)精神癥狀,可表現(xiàn)出欣快、反應(yīng)遲鈍、睡眠節(jié)律的變化。二期(昏迷前期):一期癥狀加重,可出現(xiàn):行為異常、嗜睡、精神錯亂.經(jīng)常出現(xiàn)撲翼樣震顫等.三期(昏睡期):有明顯的精神錯亂、昏睡、肌張力↑等癥狀.四期(昏迷期):神志喪失,不能喚醒,沒有撲翼樣震顫等.肝性腦病分期肝性腦病發(fā)病機制

氨中毒學(xué)說假性神經(jīng)遞質(zhì)學(xué)說血漿氨基酸失衡學(xué)說

GABA學(xué)說其他神經(jīng)毒質(zhì)在肝性腦病發(fā)病中的作用氨中毒(ammoniaintoxication)學(xué)說血氨增高的原因：氨清除不足（主要）圖肝臟合成尿素的鳥氨酸循環(huán)

OCT：鳥氨酸氨基甲酰轉(zhuǎn)移酶

CPS：氨基甲酰磷酸合成酶氨的清除：Liverfailure肝衰竭proteinNH3NH3urea×BloodNH3↑CerebralEdemaandIntracranialHypertensionNeuromonitoringstrategiesInvasiveneuromonitoringstrategiesNoninvasiveneuromonitoringstrategiesserialheadcomputedtomography(CT)transcranialDopplerjugularbulboximetrypupillometryAlgorithmforthediagnosticandtherapeuticmanagementofacuteliverfailurewithadvancedhepatic

encephalopathyandintracranialhypertensionEmergingstrategiesforthetreatmentofpatientswithacutehepaticfailure,CurrOpinCritCare2016,22:000–000Algorithmforthediagnosticandtherapeuticmanagementofacuteliverfailurewithadvancedhepatic

encephalopathyandintracranialhypertensionEmergingstrategiesforthetreatmentofpatientswithacutehepaticfailure,CurrOpinCritCare2016,22:000–000AnnualUpdateinIntensiveCareandEmergencyMedicine2015IntensivecaresupportivestrategiesdirectedatcerebraledemainacuteliverfailureEmergingstrategiesforthetreatmentofpatientswithacutehepaticfailure,CurrOpinCritCare2016,22:000–000AKIinALFAcuterenalfailuredevelopsin55–68%ofallpatientswhopresentwithALFandinthevastmajorityofcasesreverseswithresolutionofliverinjuryorwithtransplantationmechanismdirectrenaltoxicityfunctionalimpairmentasseeninthehepatorenalsyndromeMooreK.Renalfailureinacuteliverfailure.EurJGastroenterolHepatol1999;11:967–975.LeitheadJA,FergusonJW,BatesCM,etal.Thesystemicinflammatoryresponsesyndromeispredictiveofrenaldysfunctioninpatientswithnonparacetamol-inducedacuteliverfailure.Gut2009;58:443–449.ProthrombinTime,PT凝血功能再平衡健康人VS肝功能不全HematologicalSupportHb>7.0g/dlINR<6Plateletcount>20109/LFibrinogen>1.0g/lAnnualUpdateinIntensiveCareandEmergencyMedicine2015臨床問題對于肝功能衰竭需要進行CRRT的患者，監(jiān)測其凝血功能顯著異常（APTT、INR顯著升高），怎樣開展CRRT治療？無抗凝？枸櫞酸抗凝？該試驗共納入71例患者，共更換539次濾器管路。平均的濾器壽命為9(6–16)小時。其中51例患者接受完全無抗凝CRRT，其濾器壽命為12(7-24)小時。余下20例患者開始也行無抗凝CRRT，其濾器壽命為7(5-11)小時，但其后即使予以全身肝素抗凝或局部肝素抗凝使得APTT顯著延長，也并不增加其濾器的壽命所有43個濾器壽命均超過24小時，其中32個(74%)的濾器壽命達到72小時在提前更換濾器的事件中，只有3例是因為總鈣/游離鈣>2.5盡管在嚴(yán)重肝功能衰竭患者中進行局部枸櫞酸抗凝的CVVHD治療會造成體內(nèi)枸櫞酸蓄積，但并沒有造成酸堿平衡紊亂及電解質(zhì)紊亂在嚴(yán)重肝功能衰竭患者中進行局部枸櫞酸抗凝的血液凈化治療是安全、可行的，但仍有必要密切監(jiān)測總鈣/游離鈣以保障患者安全目的：研究心臟術(shù)后并發(fā)肝、腎功能不全患者