icu中血液凈化的應(yīng)用指南

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羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅蒆螅膅蒁薅袇莁莇薄羀膄芃薃膂羆蟻薃袁節(jié)薇薂羄肅蒃薁肆芀荿薀螆肅芅蕿袈羋薄蚈羀肁蒀蚇肅芇莆蚇螂肀莂蚆羅蒞羋蚅肇膈薇蚄螇莃蒃蚃衿膆莈螞羈莂芄螁肄膄薃螁螃羇葿螀袆膃蒅蝿肈肆莁螈螇芁芇螇袀肄薆螆羂艿蒂螅肄肂莈裊螄羋芄襖袆肀薂袃聿芆薈袂膁腿蒄袁袁莄莀蒈羃膇芆蕆肅莂薅ICU中血液凈化的應(yīng)用指南血液凈化BLOODPURIFICATION技術(shù)指各種連續(xù)或間斷清除體內(nèi)過(guò)多水分、溶質(zhì)方法的總稱，該技術(shù)是在腎臟替代治療技術(shù)的基礎(chǔ)上逐步發(fā)展而來(lái)。血液凈化方法有腎臟替代治療、血液灌流、免疫吸附、內(nèi)毒素吸附和血漿置換等。每一種血液凈化方式都各有特點(diǎn)，且各適用于不同疾病或不同疾病狀態(tài)。本指南僅對(duì)ICU中應(yīng)用最多的腎臟替代治療RENALREPLACEMENTTHERAPY,RRT進(jìn)行討論并提出建議。血液凈化概念和常見種類上世紀(jì)70年代末，RRT主要用于治療重癥急性腎功能衰竭患者。隨著技術(shù)不斷發(fā)展，近30年，RRT已用于全身過(guò)度炎癥反應(yīng)如嚴(yán)重創(chuàng)傷、重癥急性胰腺炎等、膿毒血癥、中毒和多臟器功能衰竭等危重癥的救治。另外，對(duì)重癥患者并發(fā)的特殊情況，如嚴(yán)重電解質(zhì)紊亂、過(guò)高熱等，RRT也能顯示良好療效。RRT在重癥患者救治中起著極其重要的作用，是ICU醫(yī)師應(yīng)予掌握的基本技術(shù)?；诖耍瑖?guó)內(nèi)ICU有關(guān)專家根據(jù)循證醫(yī)學(xué)證據(jù)制定本指南。制定本指南的意義循證醫(yī)學(xué)證據(jù)按照DELPHI分級(jí)標(biāo)準(zhǔn)見表1。循證醫(yī)學(xué)證據(jù)時(shí)間跨度為1999年1月至2009年3月；數(shù)據(jù)主要來(lái)自MEDLINE、EVIDENCEBASEDMEDICINEREVIEWSEBMR、LIPPINCOTTWILLIAMS1363854022ROGIERSP,ZHANGH,PAUWELSD,ETALCOMPARISONOFPOLYACRYLONITRILEAN69ANDPOLYSULPHONEMEMBRANEDURINGHEMOFILTRATIONINCANINEENDOTOXICSHOCKCRITCAREMEDAPR2003314121912253KELLUMJA,DISHARTMKEFFECTOFHEMOFILTRATIONFILTERADSORPTIONONCIRCULATINGIL6LEVELSINSEPTICRATSCRITCAREOCT2002654294334RONCOC,BELLOMOR,HOMELP,ETALEFFECTSOFDIFFERENTDOSESINCONTINUOUSVENOVENOUSHAEMOFILTRATIONONOUTCOMESOFACUTERENALFAILUREAPROSPECTIVERANDOMISEDTRIALLANCETJUL12000356922326305HUANGZ,LETTERIJJ,CLARKWR,ETALULTRAFILTRATIONRATEASADOSESURROGATEINPREDILUTIONHEMOFILTRATIONINTJARTIFORGANSFEB20073021241326GOTCHFAKT/VISTHEBESTDIALYSISDOSEPARAMETERBLOODPURIF20001842762857RICCIZ,SALVATORIG,BONELLOM,ETALINVIVOVALIDATIONOFTHEADEQUACYCALCULATORFORCONTINUOUSRENALREPLACEMENTTHERAPIESCRITCAREJUN200593R2662738TORDOIRJ,CANAUDB,HAAGEP,ETALEBPGONVASCULARACCESSNEPHROLDIALTRANSPLANTMAY200722SUPPL2II881179SCHETZMVASCULARACCESSFORHDANDCRRTCONTRIBNEPHROL200715627528610PARIENTIJJ,THIRIONM,MEGARBANEB,ETALFEMORALVSJUGULARVENOUSCATHETERIZATIONANDRISKOFNOSOCOMIALEVENTSINADULTSREQUIRINGACUTERENALREPLACEMENTTHERAPYARANDOMIZEDCONTROLLEDTRIALJAMAMAY282008299202413242211KLOUCHEK,AMIGUESL,DELEUZES,ETALCOMPLICATIONS,EFFECTSONDIALYSISDOSE,ANDSURVIVALOFTUNNELEDFEMORALDIALYSISCATHETERSINACUTERENALFAILUREAMJKIDNEYDISJAN20074919910812CANAUDB,DESMEULESS,KLOUCHEK,ETALVASCULARACCESSFORDIALYSISINTHEINTENSIVECAREUNITBESTPRACTRESCLINANAESTHESIOLMAR200418115917413LEBLANCM,FEDAKS,MOKRISG,ETALBLOODRECIRCULATIONINTEMPORARYCENTRALCATHETERSFORACUTEHEMODIALYSISCLINNEPHROLMAY199645531531914CANAUDB,CHENINEL,HENRIETD,ETALOPTIMALMANAGEMENTOFCENTRALVENOUSCATHETERSFORHEMODIALYSISCONTRIBNEPHROL2008161394715KELLUMJA,MEHTARL,ANGUSDC,ETALTHEFIRSTINTERNAT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