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首页> 外文期刊>Critical care : >Bench-to-bedside review: treating acid-base abnormalities in the intensive care unit--the role of renal replacement therapy.
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Bench-to-bedside review: treating acid-base abnormalities in the intensive care unit--the role of renal replacement therapy.

机译：病床到病床检查：在重症监护病房中治疗酸碱异常-肾脏替代疗法的作用。

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Acid-base disorders are common in critically ill patients. Metabolic acid-base disorders are particularly common in patients who require acute renal replacement therapy. In these patients, metabolic acidosis is common and multifactorial in origin. Analysis of acid-base status using the Stewart-Figge methodology shows that these patients have greater acidemia despite the presence of hypoalbuminemic alkalosis. This acidemia is mostly secondary to hyperphosphatemia, hyperlactatemia, and the accumulation of unmeasured anions. Once continuous hemofiltration is started, profound changes in acid-base status are rapidly achieved. They result in the progressive resolution of acidemia and acidosis, with a lowering of concentrations of phosphate and unmeasured anions. However, if lactate-based dialysate or replacement fluid are used, then in some patients hyperlactatemia results, which decreases the strong ion difference and induces an iatrogenic metabolic acidosis. Such hyperlactatemic acidosis is particularly marked in lactate-intolerant patients (shock with lactic acidosis and/or liver disease) and is particularly strong if high-volume hemofiltration is performed with the associated high lactate load, which overcomes the patient's metabolic capacity for lactate. In such patients, bicarbonate dialysis seems desirable. In all patients, once hemofiltration is established, it becomes the dominant force in controlling metabolic acid-base status and, in stable patients, it typically results in a degree of metabolic alkalosis. The nature and extent of these acid-base changes is governed by the intensity of plasma water exchange/dialysis and by the 'buffer' content of the replacement fluid/dialysate, with different effects depending on whether lactate, acetate, citrate, or bicarbonate is used. These effects can be achieved in any patient irrespective of whether they have acute renal failure, because of the overwhelming effect of plasma water exchange on nonvolatile acid balance. Critical care physicians must understand the nature, origin, and magnitude of alterations in acid-base status seen with acute renal failure and during continuous hemofiltration if they wish to provide their patients with safe and effective care.
机译：酸碱失调在重症患者中很常见。代谢酸基础疾病在需要急性肾脏替代治疗的患者中特别常见。在这些患者中，代谢性酸中毒是常见的，并且是多因素起源。使用Stewart-Figge方法进行的酸碱状态分析表明，尽管存在低白蛋白性碱中毒，但这些患者的酸血症更高。这种酸血症主要是继发于高磷酸盐血症，高乳酸血症和未测阴离子的积累。一旦开始连续的血液滤过，酸碱状态就会发生深刻的变化。它们导致酸血症和酸中毒的逐步解决，同时降低了磷酸盐和未测阴离子的浓度。但是，如果使用基于乳酸盐的透析液或替代液，则在某些患者中会导致高乳酸血症，从而降低强离子差异并诱发医源性代谢性酸中毒。这种高乳酸血症性酸中毒在乳酸耐受性不佳的患者中尤其明显（患有乳酸性酸中毒和/或肝病的休克），如果在伴随高乳酸负荷的情况下进行大容量血液滤过，则尤其强烈，这会克服患者乳酸的代谢能力。在这类患者中，碳酸氢盐透析似乎是可取的。在所有患者中，一旦建立了血液滤过，它就会成为控制代谢酸碱状态的主导力量，而在稳定的患者中，血液滤过通常会导致一定程度的代谢性碱中毒。这些酸碱变化的性质和程度取决于血浆水交换/透析的强度以及置换液/透析液的“缓冲液”含量，其影响取决于乳酸盐，乙酸盐，柠檬酸盐或碳酸氢盐是否用过的。由于血浆水交换对非挥发性酸平衡具有压倒性的影响，无论是否患有急性肾功能衰竭，任何患者都可以实现这些效果。重症监护医师如果希望为患者提供安全有效的护理，必须了解急性肾衰竭和连续血液滤过期间酸碱状态改变的性质，起源和程度。

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