急性肝功能衰竭診治

1、急性肝功能衰竭診治lAcute liver failure (ALF) is defined as life-threatening liver injury in the absence of preexisting liver disease with coagulopathy (prothrombin time 15 seconds or international normalized ratio INR 1.5) and hepatic encephalopathy (HE) that develops within 26 weeks of initial symptomslThe

2、term fulminant hepatic failure (FHF) is used when HE develops within 8 weeks of jaundice臨床上按神經(jīng)精神癥狀的輕重把肝性腦病分為四期：臨床上按神經(jīng)精神癥狀的輕重把肝性腦病分為四期：一期一期( (前驅(qū)期前驅(qū)期):):輕微的神經(jīng)精神癥狀輕微的神經(jīng)精神癥狀, ,可表現(xiàn)出欣快、反可表現(xiàn)出欣快、反 應(yīng)遲鈍、睡眠節(jié)律的變化。應(yīng)遲鈍、睡眠節(jié)律的變化。二期二期( (昏迷前期昏迷前期):):一期癥狀加重一期癥狀加重, ,可出現(xiàn)可出現(xiàn): :行為異常、嗜行為異常、嗜 睡、精神錯(cuò)亂睡、精神錯(cuò)亂. .經(jīng)常出現(xiàn)撲翼樣震顫等經(jīng)常出現(xiàn)撲翼

3、樣震顫等. .三期三期( (昏睡期昏睡期):):有明顯的精神錯(cuò)亂、昏睡、肌張力有明顯的精神錯(cuò)亂、昏睡、肌張力等癥等癥 狀狀. .四期四期( (昏迷期昏迷期):):神志喪失神志喪失, ,不能喚醒不能喚醒, ,沒(méi)有撲翼樣震顫等沒(méi)有撲翼樣震顫等. . 氨中毒學(xué)說(shuō) 假性神經(jīng)遞質(zhì)學(xué)說(shuō) 血漿氨基酸失衡學(xué)說(shuō) GABA學(xué)說(shuō) 其他神經(jīng)毒質(zhì)在肝性腦病發(fā)病中的作用氨中毒氨中毒( (ammonia intoxication) )學(xué)說(shuō)學(xué)說(shuō)血氨增高的原因：氨清除不足（主要）血氨增高的原因：氨清除不足（主要）圖圖肝臟合成尿素的鳥(niǎo)氨酸循環(huán)肝臟合成尿素的鳥(niǎo)氨酸循環(huán)OCTOCT：鳥(niǎo)氨酸氨基甲酰轉(zhuǎn)移酶：鳥(niǎo)氨酸氨基甲酰轉(zhuǎn)移酶 CPS

4、CPS：氨基甲酰磷酸合成酶：氨基甲酰磷酸合成酶氨的清除：氨的清除：proteinNH3NH3ureaproteinNH3NH3ureaBlood NH3proteinNH3NH3urea血血 NH3 Other common triggers for ICP elevation: lvolume overloadlhyponatremialsevere hypercarbialsevere acidosisl increased thoracic and abdominal compartment pressureslInvasive neuromonitoring strategieslNo

5、ninvasive neuromonitoring strategieslserial head computed tomography (CT)ltranscranial Dopplerljugular bulb oximetry1.pupillometryEmerging strategies for the treatment of patients with acute hepatic failure, Curr Opin Crit Care 2016, 22:000000Emerging strategies for the treatment of patients with ac

6、ute hepatic failure, Curr Opin Crit Care 2016, 22:000000Annual Update in Intensive Care and Emergency Medicine 2015Emerging strategies for the treatment of patients with acute hepatic failure, Curr Opin Crit Care 2016, 22:000000Emerging strategies for the treatment of patients with acute hepatic fai

7、lure, Curr Opin Crit Care 2016, 22:000000lAcute renal failure develops in 5568% of all patients who present with ALF and in the vast majority of cases reverses with resolution of liver injury or with transplantationlmechanismldirect renal toxicity1.functional impairment as seen in the hepatorenal sy

8、ndromeMoore K. Renal failure in acute liver failure. Eur J Gastroenterol Hepatol 1999; 11:967975.Leithead JA, Ferguson JW, Bates CM, et al. The systemic inflammatory response syndrome is predictive of renal dysfunction in patients with nonparacetamol-induced acute liver failure. Gut 2009; 58:443449.

9、該患者無(wú)明顯活動(dòng)性出血征象，監(jiān)測(cè)凝血功能：，APTT 65s，F(xiàn)IB 1.2 g/L，PLT 40 109/Ll需要輸注血制品（血漿、冷沉淀、血小板）以糾正凝血功能障礙？健康人 VS 肝功能不全lPeripheral-Vein ThrombosislArterial ThrombosislPortal-Vein Thrombosis：等待肝移植的患者中發(fā)生率8 - 25%Francoz C, Belghiti J, Vilgrain V, et al. Splanchnic vein thrombosis in candidates for liver transplantation: use

10、fulness of screening and anticoagulation. Gut 2005;54:691-7.lHb 7.0 g/dllINR 20 109/LlFibrinogen 1.0 g/lAnnual Update in Intensive Care and Emergency Medicine 2015對(duì)于肝功能衰竭需要進(jìn)行CRRT的患者，監(jiān)測(cè)其凝血功能顯著異常（APTT、INR顯著升高），怎樣開(kāi)展CRRT治療？l無(wú)抗凝？l枸櫞酸抗凝？該試驗(yàn)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 (616)小時(shí)。其中51例患者接受完全無(wú)抗凝CRRT，其濾器壽命為 12 (7-24)小時(shí)。余下20例患者開(kāi)始也行無(wú)抗凝CRRT，其濾器壽命為 7 (5-11)小時(shí)，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(zhǎng)，也并不增加其濾器的壽命所有43個(gè)濾器壽命均超過(guò)24小時(shí)