血液净化治疗剖析.ppt

病例： 王某，女，87岁，诊断：1、肺部感染 感染性休克 2、肾功能不全 尿毒症 3、冠心病 心功能不全 4、MDS 5、消化道出血。转我科前已开始IRRT 6天,碳酸氢钠液120ml/h。目前患者在大剂量多巴胺、去甲肾维持下血压102-140/30-58mmHg，无尿。 血气分析：PH 7.41 PCO2 5.1 HCO3- 24.1 BE -0.5 Lac 3.7 生化八项：Na＋ 140.6 K＋3.61 Cl- 101.4 Ca2+ 2.34 Mg2+ 0.85 凝血指标：APTT 51 FIB 2.37 PT 21.7 INR 1.81 PTA 45 血常规： WBC 5.86 RBC 2.64 HB 80 PLT 3 CVVH治疗处方？ 治疗处方 血流速度：患者感染性休克，血流动力学不稳定，血流速宜慢， 100- 200ml/min 置换途径：血小板低，血液不易凝固，选后稀释 置换液流量：2L/h 超滤率：感染性休克，血流动力学不稳定，超滤不宜太快，但心 功能不全，要顾及前负荷；综合：保持液体出入平衡， 量情调整 超滤量：同上 置换液的配置 抗凝：血小板低，消化道出血，无肝素 监测方案：密切监测心率、血压、酸碱、电解质、凝血功能 治疗处方 5%NaHCO3输注速度的确定: 血气酸碱平衡，按HCO3 –中间值， 5%NaHCO3速度 84ml/h ? 患者感染性休克，体内代酸，普通病房CVVH 5%NaHCO3速度120ml/h，血气酸碱平衡，继续120ml/h 治疗处方 谢谢！ * The transport of a molecule through a membrane is governed primarily by its molecular weight. Generally, the more a molecule weighs, the larger it is in size and the more resistant it is to transport. The chart gives an indication of relative molecular weights for some of the common molecules that we are concerned with in CRRT. Molecular weights are measured in units called daltons. urea, electrolytes, creatinine - “small” molecules vitamin B12, inulin - “middle” molecules beta 2, albumin - “large” molecules * There are a number of key scientific principles used to accomplish the goals of CRRT. They are listed here and before we discuss the individual therapies, I would like to review them. Understanding the principles of diffusion, ultrafiltration, convection and adsorption will clarify which therapy will best produce the desired outcome whether used alone or in combination. * To illustrate the principle of diffusion, picture a cup of water as seen here on the slide. In the cup on the left, a quantity of salt is poured. The salt gradually diffuses through the water from the high salt concentration area to the low salt concentration area until it is evenly distributed. A uniformly salty solution