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行CRRT治疗时应注意：①CRRT尤其是置换量大时，营养物质丢失较多，Mokrzychi报告CRRT时超滤液中蛋白质丢失达1.3g/L，如果CRRT排出量为50L/d，则总的蛋白质丢失达65g/d。所以CRRT时要适当增加能量、蛋白质、氨基酸、微量元素的补充。②CRRT对不同药物有不同的清除，有必要根据CRRT的置换量调节药物用量，以免影响药效。③CRRT系体外循环，既要抗凝又要预防危重病患者出血，掌握合适的抗凝方法非常重要，具体可根据患者的凝血状态、出血情况以及医生的经验，采用小剂量肝素抗凝、低分子肝素抗凝、无肝素技术、枸橼酸、体外局部抗凝技术及抗凝基团吸附滤过器等。
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【思考题】
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1．试述Sepsis、SIRS、CARS、MODS、MOF的概念及相互的关系。
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2．试述MODS治疗的原则和新进展。
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参考文献
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[1] 李春盛，王佩燕．多脏器功能障碍综合征．中华急诊医学杂志，2001，10(1)
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[2] 黄重敏，陆富刚．MODS免疫发病机制研究进展．中国急救性医学，2002，22(12)
:739-740.
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[3] 王锦权，陶晓根．连续性血液净化对细胞因子清除机制的研究进展．中国急救医学，2002，22(10)
:615-616.
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[4] 谢红浪，季大玺．连续性肾脏替代疗法治疗脓毒症．肾脏病与透近肾移植杂志，2002，11(4)
:381-385.
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[5] 袁伟杰，吴灏，于光．连续性高容量血液滤过对重症急性肾功能衰竭患者外周血细胞因子的影响．中华急诊医学杂志，2003，12(2)
:86-88.
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[6] Raymond V, Wim VB, Norbert L. What is the renal replacement method of first choice for intensive care patients. J Am Soc Nephrol, 2001, 12, S40-43.
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[7] Emre F, Tim S, Sharam Z, et al. Impact of different modalities of continous venoneous hemofiltration on sepsis-induced alterations in experimental pancreatitis, Kidney Inter, 2002, 62
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[8] Cole L, Bellomo R, Journois D, et al. High-volume haemofiltration in human septic shock. Intensive Care Med. 2001, 27(6)
:978-86.
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[9] Ronco C, Tetta C, Mariano F, et al. Interpreting the mechanisms of continuous renal replacement therapy in sepsis: the peak concentration hypothesis, Artif Organs, 2003, 27(9)
:792-801.
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[10] Patel GP, Gurka DP, Balk RA. New treatment strategies for severe sepsis and septic shock. Curr Opin Crit Care. 2003; 9(5)
:390-6.
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[11] A yala A, Chung CS, Grutkoski PS, et al. Mechanisms of immune resolution. Crit Care Med. 2003, 31（8 Suppl)
:S558-71.
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（陈江华 张萍）
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内科学新进展 第八章 心肺复苏新进展
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摘 要 基本生命支持包括判断技能和支持技术。判断技能需要快速准确的识别患者有无生命体征；支持技术包括开放气道、呼吸支持、胸外按压和电除颤，简称A、B、C、D四项步骤。有效的循环支持依靠有效的胸外按压、合适的胸外按压／通气比例和电除颤。2005年指南推荐成人的按压／通气比例无论单人或双人均为30
:2，这与2000年指南有着明确的不同。电除颤分为单向波除颤和双向波除颤，如为单向波除颤能量应用360J, 而双向波除颤能量≤200J与单向波除颤同样安全有效的。BLS成功的标志是自主循环恢复。随后实施的进一步生命支持包括建立静脉通路，应用各种血管活性药物、抗心律失常药物，进行脏器功能监测。复苏后治疗能够改善早期由于血液动力学不稳定和多脏器功能衰竭引起的死亡率。
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Abstract Basic life support（BLS）includes the technology of recognition and support. Recognition of signs of cardiac arrest should be quick and accurate, then support maneuvers including opening the airway, delivering rescue breathing, chest compressions and defibrillation are exerted sequentially, four support maneuvers are abbreviated to ABCD according to their words. Effective support of circulation depends on effective chest compressions, appropriate compression ventilation ratio and defibrillation. The compression ventilation ratio has been changed from 15:2 to 30:2 according to the 2005 AHA Guidelines for CPR and ECC, in despite of one or two rescuers. It is definitely difference from the 2005 guidelines. Modern defibrillators are classified according to 2 types of waveforms: monophasic and biphasic. The consensus was that rescuers using monophasic waveform defibrillator should give an initial shock of 360 J; if ventricular fibrillation（VF）persists after the first shock, second and subsequent shocks of 360 J should be given. Defibrillation with biphasic waveforms of relatively low energy（≤200 J）is safe and has equivalent or higher efficacy for termination of VF than monophasic waveform shocks of equivalent or higher energy. Return of spontaneous circulation（ROSC）is the symbol of success of BLS. At the period of ACLS, establish or verify existing intravenous access, and verify the function of any catheters in place. Vasoactive agents and anti-arrhythmic drugs should be used to keep hemodynamics stabilization. The function of organs should be monitored. And post-resuscitation care has significant potential to improve early mortality caused by hemodynamic instability.
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《国际心肺复苏和心血管急救指南2000》颁布后，近年又有新的科学研究证据，以及专家们对其进一步的学术评价，经过5年之久的使用后，再度获得科学上的意见共识，在此基础上重新修订了《国际心肺复苏和心血管急救指南2005》，使推荐方案更适于挽救患者生命。现代心肺复苏术的确立是临床医学的一个里程碑。
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