ncludingbased life support (BLS), seniorheart life support (ACLS), basedtrauma life support (BTLS) seniortrauma life support (ATLS) basedknowledge; common emergency technology application;common emergency causesidentification, clinicalperformance processingspecification; common emergency auxiliary check selectrefers resultsjudge clinicalmeaning; Indications, effects commonemergency drugs, side effects, specificapplications (medicine, vasoactivedrugs, cardiac diuretic, antispasmodic anti-asthmaticdrugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, Cortina).Understand: newdevelopment lifesupport; cardiac respiratory cardiopulmonaryresuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, basicrequirements studyrequirements: disease disease fever acute abdominal pain chest pain difficultybreathing faint coma shock acutepoisoning cardiacrespiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires least45 cases basicskills requirements name name heart lung 血液透析与血液透析滤过的区别 血液透析与血液透析滤过的区别 随着医疗技术的进步,尿毒症病人对透析方式有越来越多的选择,从以 往血液透析,逐步发展到血液滤过、血液透析滤过。三者之间到底有 哪些区别和联系,无论是对医生还是病人来说,都有必要详细了解一 下,以便做出更适合自身的选择。 血液透析1.1 定义及作用机制 血液透析是根据膜平衡的原理将病人血液与含一定化学成分的透 析液同时引入透析器内,在透析膜两侧流过,分子透过半透膜做跨膜 移动,达到动态平衡。病人体内积累的小分子有害 物质得以清除,人体所需物质也可由透析液得到补充。血 液透析主要是依靠半透膜两侧的溶质浓度差所产生的弥散作用进行溶 质清除,其清除率与分子量成反比,对尿素、肌酐等小分子物质有较 高的清除率,而对中分子物质的清除效能较差。血液透析具有以下优 点:(1)迅速清除血钾,纠正酸中毒(2)价格比较便宜,可以被广 大患者及家属接受。 1.2 血液透析适应证 (1)急性肾衰竭;(2)慢性肾衰竭;(3)急性药物或毒物中毒: (4)其他 顽固性心力衰竭伴有严重的液体潴留及难治的致死性高 钾血症、肾衰竭或BUN 明显升高;肝脏疾病,如肝硬化腹水。 1.3 血液透析相对禁忌证 相对禁忌证有:(1)严重感染可引起播散;(2)出血;(3)严ncluding based life support (BLS), seniorheart life support (ACLS), basedtrauma life support (BTLS) seniortrauma life support (ATLS) basedknowledge; common emergency technology application;common emergency causesidentification, clinicalperformance processingspecification; common emergency auxiliary check selectrefers resultsjudge clinicalmeaning; Indications, effects commonemergency drugs, side effects, specificapplications (medicine, vasoactivedrugs, cardiac diuretic, antispasmodic anti-asthmaticdrugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, Cortina).Understand: newdevelopment lifesupport; cardiac respiratory cardiopulmonaryresuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, basicrequirements studyrequirements: disease disease fever acute abdominal pain chest pain difficultybreathing faint coma shock acutepoisoning cardiacrespiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires least45 cases basicskills requirements name name heart lung 重心功能不全伴有休克、低蛋白血症、严重的低氧血症;(4)严重低 血压或休克。 1.4 临床急性并发症 (1)失衡综合征:失衡综合征是在透析中或透析结束后数小时出 现的暂时性中枢神经系统及骨骼系统的急性医源性症状的总称。其原 因目前普遍认为主要是由于血液中溶质浓度(主要是尿素)急速降低, 使血液和脑组织间产生渗透压差,低钠透析液造成的钠平衡失调和透 析液碱化剂的组成,血液pH 的变化和HCO3 在血液与脑脊液间的浓度 差也是不可忽视的原因。高效能透析器的使用,超滤量过大、过快等 都是造成失衡综合征的因素。(2)透析低血压:透析中出现显著血压 下降以致休克,使透析不可能充分进行。(3)心律失常。(4)高血 压(5)肌肉痉挛。(6)突然死亡。 1.5 血液透析并发症的原因及处理 低血压在血液透析的并发症中,低血压的发病率为30%,其发生机制未完 全阐明。但它受多种因素的影响,其中最重要的是由于低蛋白所致的 循环血量不足,除水量过多或过快,超过细胞外液向血浆再充盈的速 度,使循环血量急剧下降,产生低血压。另外,患者在透析中清除肝 素、肌酐等溶质,血浆渗透压迅速下降,驱使水分移向组织间液或细 胞内,有效循环血容量减少,导致血压下降。还有内分泌神经功能紊 乱,透析膜的生物相容性等都对血压有影响。 高血压常见原因有失衡综合征、输入高张溶液过多或过快、精神紧张、 ncluding based life support (BLS), seniorheart life support (ACLS), basedtrauma life support (BTLS) seniortrauma life support (ATLS) basedknowledge; common emergency technology application;common emergency causesidentification, clinicalperformance processingspecification; common emergency auxiliary check selectrefers resultsjudge clinicalmeaning; Indications, effects commonemergency drugs, side effects, specificapplications (medicine, vasoactivedrugs, cardiac diuretic, antispasmodic anti-asthmaticdrugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, Cortina).Understand: newdevelopment lifesupport; cardiac respiratory cardiopulmonaryresuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, basicrequirements studyrequirements: disease disease fever acute abdominal pain chest pain difficultybreathing faint coma shock acutepoisoning cardiacrespiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires least45 cases basicskills requirements name name heart lung 交感神经兴奋以及超滤太快或过多,激活肾素-血管紧张素-醛固酮系 统,使外周血管收缩,心输出量增加等。患者在透析中发生的高血压, 很少能自行缓解,对降压药物反应也较差。有些病人甚至被迫停止透 失衡综合征对轻者可静脉注射高张溶液,给予镇静剂等。要考虑缩短治疗时 间。对重症患者,如抽搐、昏迷等,则中断透析,静滴甘露醇。 肌肉痉挛较常见。发生率为10%~15%。一般发生在透析的中后期。多见于 足部、双手指、腓肠肌和腹壁。主要原因是超滤过快和过多及低血钠, 引起细胞外液容量急剧减少或渗透压降低所致。最有效的处理是在静 脉回路管中注射生理盐水100ml 或高渗糖50ml 或碳酸氢盐溶液。 心律失常原因很多,如心脏病、电解质紊乱等。发生率为10%~30%,甚至 更高。可用常规处理方法处理。 突然死亡较少见。多与心血管疾病或并发症有关。若患者在透析中突然感 到胸闷、心动过速或过缓、呼吸急促、血压下降、发绀等,往往提示 严重意外可能发生,应立即停止透析,寻找原因。 血液滤过ncluding based life support (BLS), seniorheart life support (ACLS), basedtrauma life support (BTLS) seniortrauma life support (ATLS) basedknowledge; common emergency technology application;common emergency causesidentification, clinicalperformance processingspecification; common emergency auxiliary check selectrefers resultsjudge clinicalmeaning; Indications, effects commonemergency drugs, side effects, specificapplications (medicine, vasoactivedrugs, cardiac diuretic, antispasmodic anti-asthmaticdrugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, Cortina).Understand: newdevelopment lifesupport; cardiac respiratory cardiopulmonaryresuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, basicrequirements studyrequirements: disease disease fever acute abdominal pain chest pain difficultybreathing faint coma shock acutepoisoning cardiacrespiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires least45 cases basicskills requirements name name heart lung 2.1 定义及作用机制 血液滤过模仿肾单位的滤过重吸收原理设计,将患者的动脉血液 引入具有良好的通透性并与肾小球滤过膜面积相当的半透膜滤过器 中,当血液通过滤器时,血浆内的水分就被滤出(类 似肾小球滤过),以达到清除潴留于血中过 多的水分和溶质的治疗目的。为了补偿被滤 出的液体和电解质,保持机体内环境的平衡,需要在滤器后(前)补 回相应的液量和电解质以代替肾小管的重吸收功能。 2.2 血液滤过的适应证 急、慢性肾衰竭血液滤过与血液透析一样适用于急慢性肾衰竭的治疗。但由于 血液滤过的特点,更适用于血流动力学不稳定, 体内中分子物质聚集、皮肤及神经系统损 害的患者,一般在血液透析的间隔配合应用血液滤过治疗。 肝肾综合征与血液透析相同。但由于血液滤过治疗时患者血流动力学比较 稳定,对心血管方面的影响较小,患者耐受性好;以及血液滤过对肾 衰竭和肝衰竭时体内蓄积的中分子物质的清除明显优于血液透析,因此,血液滤过可作为肝肾综合征患者血液透析的一项补充治疗,尤其 ncluding based life support (BLS), seniorheart life support (ACLS), basedtrauma life support (BTLS) seniortrauma life support (ATLS) basedknowledge; common emergency technology application;common emergency causesidentification, clinicalperformance processingspecification; common emergency auxiliary check selectrefers resultsjudge clinicalmeaning; Indications, effects commonemergency drugs, side effects, specificapplications (medicine, vasoactivedrugs, cardiac diuretic, antispasmodic anti-asthmaticdrugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, Cortina).Understand: newdevelopment lifesupport; cardiac respiratory cardiopulmonaryresuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, basicrequirements studyrequirements: disease disease fever acute abdominal pain chest pain difficultybreathing faint coma shock acutepoisoning cardiacrespiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires least45 cases basicskills requirements name name heart lung 是不能耐受血液透析治疗的患者,如心功能不全、胸腹腔大量积液、 透析时低血压及高血压等情况。 顽固性高血压血透治疗的病人发生顽固性高血压可达 50%(高肾素型),而 血滤治疗时,可降至1%,有的可停用降压药。血压下降原因除有效清 除过量水、钠外,可能还有其他原因。有学者曾反复测定血浆和滤液 中血管紧张素,发现两者的浓度相近,表明血滤能清除血浆中的某 些加压物质。另一方面血滤时,心血管系统及细胞外液容量均比较稳 定,明显减少了对肾素-血管紧张素系统的刺激。 低血压和严重水、钠潴留接受血滤治疗的病人,其心血管稳定性明显优于血透,血透治疗 期间低血压发生率达25%~50%,但在血滤治疗时低血压发生率可降至 5%。 尿毒症心包炎在持续血透病人,尿毒症心包炎发病率达20%~25%,原因未明, 改做血滤后,发现心包炎治疗时间较血透短,可能是血滤脱水性能好, 清除“中分子”毒性物质较好之故。 肝昏迷许多学者认为血滤对肝昏迷治疗效果比血透好,但比血浆置换 血液灌流差。主要因为肝昏迷时的病理重量学改变比较复杂,血液透 析的治疗作用有限。 ncluding based life support (BLS), seniorheart life support (ACLS), basedtrauma life support (BTLS) seniortrauma life support (ATLS) basedknowledge; common emergency technology application;common emergency causesidentification, clinicalperformance processingspecification; common emergency auxiliary check selectrefers resultsjudge clinicalmeaning; Indications, effects commonemergency drugs, side effects, specificapplications (medicine, vasoactivedrugs, cardiac diuretic, antispasmodic anti-asthmaticdrugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, Cortina).Understand: newdevelopment lifesupport; cardiac respiratory cardiopulmonaryresuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, basicrequirements studyrequirements: disease disease fever acute abdominal pain chest pain difficultybreathing faint coma shock acutepoisoning cardiacrespiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires least45 cases basicskills requirements name name heart lung 2.3 血液滤过的并发症 置换液污染由于置换液输入量大,污染机会多,故有可能发生败血症,但 几率极低。 氨基酸与蛋白质丢失氨基酸平均分子量140,蛋白质丢失量各家报道不一,有3~1 4g 之间,也有为2~4g。 激素丢失滤液中发现有胃泌素、胰岛素、抑胃泌素、生长激素刺激素 和甲状旁腺素,但对血浆浓度影响不大。可能是血滤时可清除激素降解产物,这些降解产物是干扰激素生物活性的物质。 血压下降主要是液体平衡掌握不好,脱水速度过快所致。 2.4 血液滤过的禁忌证 同血液透析。有严重出血倾向,重症心脏疾病及血容量严重不 足,血压过低者应禁用或慎用血液滤过。 大多数研究发现:(1)在血液滤过中,血浆渗透压的改变比 血液透析相对较小,低血压和失衡综合征发生率也较少。(2)血液滤 过透析中能很好地控制钠和分子的入量,高血压患者血压则可以相对 稳定。(3)在血肌酐和尿素氮下降幅度与血液透析相似的情况下,血ncluding based life support (BLS), seniorheart life support (ACLS), basedtrauma life support (BTLS) seniortrauma life support (ATLS) basedknowledge; common emergency technology application;common emergency causesidentification, clinicalperformance processingspecification; common emergency auxiliary check selectrefers resultsjudge clinicalmeaning; Indications, effects commonemergency drugs, side effects, specificapplications (medicine, vasoactivedrugs, cardiac diuretic, antispasmodic anti-asthmaticdrugs, analgesic drugs, Hemostatic, antiarrhythmic drugs, Cortina).Understand: newdevelopment lifesupport; cardiac respiratory cardiopulmonaryresuscitation after cardiac syndrome etiology, pathophysiology, clinical manifestations, diagnosis, basicrequirements studyrequirements: disease disease fever acute abdominal pain chest pain difficultybreathing faint coma shock acutepoisoning cardiacrespiratory arrest bleeding (hemoptysis, hematemesis, hematuria, etc) requires least45 cases basicskills requirements name name heart lung 液滤过患者的脑电图明显趋于正常。 3、血液透析、血液滤过和血液透析滤过三者间的区别和联系 从血液透析到血液滤过,再到血液透析滤过,应该说,这是为了提 高慢性肾功能不全病人生活质量和生存空间而不断改进的血液净化技 术。血液透析仅仅能够将病人体内的小分子代谢产物、有毒物质和多 余的水分排出体外;而血液滤过则可以将病人体内的中、小分子物质 全部滤过而排出体外,其效果优于前者。 血液透析滤过技术综合了普通血液透析和血液滤过两者的优点,不 但能够高效的清除病人体内的小分子物质,还能充分地清除体内的中 分子代谢废物。这样就大大减少了因普通血液透析对中分子代谢毒素 清除不足和因血液透析滤过对小分子毒素不能充分清除所引发的并发 症的发生,从而大大改善了患者的生活质量,进一步降低了死亡率。 另外,血液透析滤过与普通的血液透析相比,更具有稳定的血流动力 学状态,使患者在透析过程中低血压、头痛、恶心、呕吐等不良反应 明显减少。因此,血液透析滤过尤其适用于对普通透析不能耐受的病