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Crit Care 2003。h）持續(xù)16～18h中、小分子溶質(zhì)清除能力強(qiáng)IHDF高高高通量100～2003510～20中、小分子溶質(zhì)清除能力強(qiáng)注： （Lp＞20）；低通量濾器（Lp＜10）. Lp即單位面積膜超濾系數(shù)，單位為mL/⒉置換 (透析)液速率和血流速率可根據(jù)實(shí)際情況調(diào)整⒊Qb Qf Qd 表3各種CRRT模式的要點(diǎn)和主要特點(diǎn) 治療原理濾器超濾系數(shù)血流量置換 (透析)液速率主要特點(diǎn) 對(duì)流彌散Qb(mL/min)Qf(mL/kg抗生素在RRT過程中影響因素表2各種IRRT模式的要點(diǎn)和主要特點(diǎn) 治療原理濾器超濾系數(shù)血流量置換 (透析)液速率主要特點(diǎn) 對(duì)流彌散Qb(mL/min)Qf(mL/kg因此，疾病狀態(tài)、藥物和CRRT的機(jī)械因素顯著降低了常規(guī)藥代動(dòng)力學(xué)計(jì)算公式?jīng)Q定抗生素劑量應(yīng)用的可能性[133]。血流速率和透析液速率的升高可改變跨膜壓而增加藥物的清除率。同樣，容易穿透組織且與組織結(jié)合的抗生素具有較大容積分布，CRRT清除也較少；另外，全身感染本身也可以增加抗生素的容積分布而半衰期延長(zhǎng)，從而改變多種抗生素的蛋白結(jié)合。接受CRRT治療的重癥患者，其藥代動(dòng)力學(xué)非常復(fù)雜，有多個(gè)因素影響清除率，而根據(jù)這些參數(shù)推薦一個(gè)統(tǒng)一的抗生素治療劑量也非常困難。IRRT持續(xù)時(shí)間較短，對(duì)藥物的影響較小，因此文獻(xiàn)報(bào)道較少。RRT過程中，動(dòng)脈和靜脈內(nèi)的藥物濃度不同，為更加精確計(jì)算SC，取動(dòng)脈和靜脈濃度的平均值。 ([A] + [V] ) 247。藥物的篩漏系數(shù)(Sieving coefficient, SC )在不同RRT模式下各異，而藥物的清除效率與滲漏系數(shù)相關(guān)。 主要介紹氨基酸和蛋白質(zhì)丟失量以及如何補(bǔ)充二、藥物劑量調(diào)整RRT過程中，藥物清除率與腎臟、CRRT、其他器官代謝等三個(gè)因素相關(guān)。~ g/kg/ d的蛋白，目的在于維持正氮平衡。一、蛋白質(zhì)和氨基酸。CRRT時(shí)可增加除脂肪以外的營(yíng)養(yǎng)素如氨基酸、糖及微量元素的丟失，丟失量報(bào)導(dǎo)不一，可能與超濾液中糖的含量、置換液與血漿濃度梯度、CRRT通透量諸因素有關(guān)。血流速率與血小板關(guān)系 第五部分CRRT過程中的藥物劑量調(diào)整及營(yíng)養(yǎng)支持血液凈化過程中，不但有害物質(zhì)被清除體外，而且機(jī)體原有的電解質(zhì)、蛋白質(zhì)或氨基酸以及藥物等也可被清除體外。感染的預(yù)防㈢ 血小板降低CRRT可引起血小板降低，嚴(yán)重者需中止RRT治療。導(dǎo)管穿刺處的血腫可并發(fā)感染，應(yīng)積極預(yù)防。低血壓原因和處理㈡ 感染管道連接、取樣、置換液和血濾器更換是外源性污染的主要原因；最為嚴(yán)重的是透析液或置換液被污染引起嚴(yán)重的血流感染。這可以采用生物相容性高的濾器或透析器加以避免。下述嚴(yán)重并發(fā)癥應(yīng)及時(shí)處理：常見并發(fā)癥描述：4大類㈠ 低血壓低血壓是血液透析模式下的常見并發(fā)癥，血液濾過時(shí)少見。而一項(xiàng)回顧性研究表明，采用碳酸氫鈉配方進(jìn)行血濾治療時(shí)可出現(xiàn)低血糖[126]，因此，應(yīng)根據(jù)需要選擇恰當(dāng)?shù)难潜O(jiān)測(cè)和控制方案。RRT過程中凝血發(fā)生動(dòng)態(tài)變化而需檢測(cè)：抗凝劑、HIT、無(wú)抗凝后凝血恢復(fù)㈣RRT中血電解質(zhì)和血糖監(jiān)測(cè)RRT過程中可能出現(xiàn)電解質(zhì)、酸堿紊亂，應(yīng)定期監(jiān)測(cè)。定期行凝血的化驗(yàn)檢查，以便及時(shí)調(diào)整抗凝方案和發(fā)現(xiàn)HIT綜合征。 正水平衡病人死亡率高㈢凝血功能監(jiān)測(cè)RRT應(yīng)用抗凝劑時(shí)易發(fā)生出血?；谝陨匣A(chǔ)，該中心應(yīng)用利尿劑、小劑量多巴胺及RRT策略控制并發(fā)ARF的干細(xì)胞移植兒童的液體量，觀察發(fā)現(xiàn)有效糾正液體過負(fù)荷可降低病死率[125]。Vincent等在24個(gè)歐洲國(guó)家的198個(gè)ICU進(jìn)行的回顧性觀察顯示：ICU病死率除與sepsis的發(fā)生率相關(guān)外，還同年齡和正水平衡密切相關(guān)[123]。血液動(dòng)力學(xué)監(jiān)測(cè)的理由：IHD可有低血壓；負(fù)水治療㈡體液量監(jiān)測(cè)CRRT過程中監(jiān)測(cè)體液量的目的在于恢復(fù)患者體液的正常分布比率。重癥患者常伴有體液潴留而需負(fù)水平衡，但是在負(fù)水平衡開始過程中必需密切監(jiān)測(cè)血流動(dòng)力學(xué)，防止引發(fā)醫(yī)源性有效容量缺乏導(dǎo)致組織器官的低灌注。多種毒物的清除模式 第四部分 治療過程中的監(jiān)測(cè)和并發(fā)癥處理一、監(jiān)測(cè)㈠血流動(dòng)力學(xué)重癥患者RRT過程中易發(fā)生血流動(dòng)力學(xué)不穩(wěn)定，特別是IHD治療時(shí)發(fā)生率更高?？刹捎玫哪Ｊ接蠧VVH(毒鼠強(qiáng))[118]、低流量血液透析(如丙戊酸鈉中毒)[119]、血液透析序貫CVVHD(如金屬鋰中毒)[120]、高效血液透析(萬(wàn)古霉素過量)[121]、CAVHD(如乙二醇中毒)[122]等。血液灌流依賴于吸附劑、酶、活細(xì)胞等對(duì)血液某些成分進(jìn)行吸