《急性肝功能衰竭诊治(武汉中心医院icu)》由会员分享，可在线阅读，更多相关《急性肝功能衰竭诊治(武汉中心医院icu)（34页珍藏版）》请在金锄头文库上搜索。
1、急性肝功能衰竭,武汉市中心医院 汪毓君,急性肝功能衰竭的定义,Acute 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
2、initial symptoms The term fulminant hepatic failure (FHF) is used when HE develops within 8 weeks of jaundice,Etiology of acute liver failure,肝性脑病的分期,临床上按神经精神症状的轻重把肝性脑病分为四期：,一期(前驱期):轻微的神经精神症状,可表现出欣快、反 应迟钝、睡眠节律的变化。 二期(昏迷前期):一期症状加重,可出现:行为异常、嗜 睡、精神错乱.经常出现扑翼样震颤等. 三期(昏睡期):有明显的精神错乱、昏睡、肌张力等症 状. 四期(昏迷期):神志丧
3、失,不能唤醒,没有扑翼样震颤等.,肝性脑病分期,肝性脑病发病机制,氨中毒学说 假性神经递质学说 血浆氨基酸失衡学说 GABA学说 其他神经毒质在肝性脑病发病中的作用,氨中毒(ammonia intoxication)学说,血氨增高的原因：氨清除不足（主要）,图 肝脏合成尿素的鸟氨酸循环 OCT：鸟氨酸氨基甲酰转移酶 CPS：氨基甲酰磷酸合成酶,氨的清除：,protein,NH3,NH3,urea,Normal metabolism,Liver failure 肝衰竭,protein,NH3,NH3,urea,Blood NH3,Liver failure 肝衰竭,protein,NH3,NH3
4、,urea,血 NH3,Shunting Circulation 门- 体分流,Cerebral Edema and Intracranial Hypertension,Cerebral Edema and Intracranial Hypertension,Other common triggers for ICP elevation: volume overload hyponatremia severe hypercarbia severe acidosis increased thoracic and abdominal compartment pressures,Neuromonit
5、oring strategies,Invasive neuromonitoring strategies Noninvasive neuromonitoring strategies serial head computed tomography (CT) transcranial Doppler jugular bulb oximetry pupillometry,Algorithm for the diagnostic and therapeutic management of acute liver failure with advanced hepatic encephalopathy
6、 and intracranial hypertension,Emerging strategies for the treatment of patients with acute hepatic failure, Curr Opin Crit Care 2016, 22:000000,Algorithm for the diagnostic and therapeutic management of acute liver failure with advanced hepatic encephalopathy and intracranial hypertension,Emerging
7、strategies for the treatment of patients with acute hepatic failure, Curr Opin Crit Care 2016, 22:000000,Annual Update in Intensive Care and Emergency Medicine 2015,Intensive care supportive strategies directed at cerebral edema in acute liver failure,Emerging strategies for the treatment of patient
8、s with acute hepatic failure, Curr Opin Crit Care 2016, 22:000000,Intensive care supportive strategies directed at cerebral edema in acute liver failure,Emerging strategies for the treatment of patients with acute hepatic failure, Curr Opin Crit Care 2016, 22:000000,AKI in ALF,Acute renal failure de
9、velops in 5568% of all patients who present with ALF and in the vast majority of cases reverses with resolution of liver injury or with transplantation mechanism direct renal toxicity functional impairment as seen in the hepatorenal syndrome,Moore K. Renal failure in acute liver failure. Eur J Gastr
10、oenterol 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.,临床问题,该患者无明显活动性出血征象，监测凝血功能：INR 3.2，APTT 65s，FIB 1.2 g/L，PLT 40
11、109/L 需要输注血制品（血浆、冷沉淀、血小板）以纠正凝血功能障碍？,Prothrombin Time, PT,凝血功能再平衡,健康人 VS 肝功能不全,Peripheral-Vein Thrombosis Arterial Thrombosis Portal-Vein Thrombosis：等待肝移植的患者中发生率8 - 25%,Francoz C, Belghiti J, Vilgrain V, et al. Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screenin
12、g and anticoagulation. Gut 2005;54:691-7.,Hematological Support,Hb 7.0 g/dl INR 20 109/L Fibrinogen 1.0 g/l,Annual Update in Intensive Care and Emergency Medicine 2015,临床问题,对于肝功能衰竭需要进行CRRT的患者，监测其凝血功能显著异常（APTT、INR显著升高），怎样开展CRRT治疗？ 无抗凝？ 枸橼酸抗凝？,该试验共纳入71例患者，共更换539次滤器管路。平均的滤器寿命为9 (616)小时。其中51例患者接受完全无抗凝CR
13、RT，其滤器寿命为 12 (7-24)小时。余下20例患者开始也行无抗凝CRRT，其滤器寿命为 7 (5-11)小时，但其后即使予以全身肝素抗凝或局部肝素抗凝使得APTT显著延长，也并不增加其滤器的寿命,所有43个滤器寿命均超过24小时，其中32个(74%)的滤器寿命达到72小时 在提前更换滤器的事件中，只有3例是因为总钙/游离钙2.5 尽管在严重肝功能衰竭患者中进行局部枸橼酸抗凝的CVVHD治疗会造成体内枸橼酸蓄积，但并没有造成酸碱平衡紊乱及电解质紊乱 在严重肝功能衰竭患者中进行局部枸橼酸抗凝的血液净化治疗是安全、可行的，但仍有必要密切监测总钙/游离钙以保障患者安全,目的：研究心脏术后并发肝、肾功能不全患者进行局部枸橼酸抗凝的CRRT治疗的安全性及有效性 结果：共纳入15例心脏外科术后并发肝、肾功能不全患者，在治疗过程中肝酶（AST、ALT）、胆红素、r-GT均没有显著改变。滤器后游离钙、患者体内游离钙及患者体内总钙/游离钙水平均稳定，未发现枸橼酸中毒 结论：在急性肝功能衰竭患者中进行局部枸橼酸抗凝是有效、安全的,
