CRRT：严重脓毒症与MODS(邱海波)课件.ppt

1、CRRT CRRT Severe sepsis and Severe sepsis and MODSMODS邱海波邱海波东南大学附属中大医院东南大学附属中大医院ICU东南大学急诊与危重医学研究所东南大学急诊与危重医学研究所1.CRRT vs IRRT2.Early vs late CRRT 3.High vs normal flow4.Current opinion in CRRT Current opinion in CRRT Mode of RRT differences among continentsBellomo,et al.2001Understanding Renal Repla

2、cement Therapy and Acute Renal Failure in the ICU(The B.E.S.T kidney study)Retrospective cohort study Pats with ARF and required dialysis between April 1,1996,and March 31,1999 2 ICU in Canada.N=261CRRT对对ARF肾功能恢复的影响肾功能恢复的影响CRRTCRRT促进肾功能恢复促进肾功能恢复CRRTIHDPAPACHE II2725.10.10Baseline SCr1361800.002MAP B

3、efore RRT74.787.20.001Hosp Mortality71.9%42.2%0.01Renal recovery in hosp80.0%62.5%0.06Duration of RRT14.7d14.5d0.91Cost per week(Can$)3486-51171341Survivor(Cost per y)No-RRT RRT$11,192$73,273Crit Care Med 2003;31:449 455IHD vs CRRTICU RRTn=116 RRT for overdosen=7Pre-existing CRFn=16ICU RRT for ARF/M

4、OFn=66Initial CRRTn=66Initial IHDn=28Jacka MJ,Ivancinova X,Gibney RTN.Can J Anaesth 2005;52:327-332 Munns et al观察危重急性肾衰竭患者 IHD CRRT CCr下降25%7%尿量下降50%10%钠排泄分数下降46%12%肾功能下降的原因:IHD平均动脉压下降，导致肾脏低灌注，加重肾脏缺血性损伤，延迟急性肾衰竭肾功能的恢复 为什么为什么CRRT促进肾功能恢复促进肾功能恢复?160 pats with ARF:Daily vs every-other-160 pats with ARF:D

5、aily vs every-other-day IHDday IHD Mean Mean ultrafiltration volumeultrafiltration volumeDaily:1.2 Daily:1.2 0.5 L 0.5 L Every-other-day:3.5 Every-other-day:3.5 0.3 L(P 0.001).0.3 L(P 0.001).HypotensionHypotension occurred in occurred in Daily:5 Daily:5 2%2%Every-other-day:25 Every-other-day:25 5%(P

6、 0.001)5%(P 0.001)Time to recovery of renal function Time to recovery of renal function Daily:9 Daily:9 2 days 2 days Every-other-day:16 Every-other-day:16 6 Days P=0.001 6 Days P=0.001N Engl J Med 2002;346:305-310为什么为什么CRRTCRRT有助于肾脏功能的恢复？有助于肾脏功能的恢复？Effect of Effect of RRT doseRRT dose on recovery o

7、n recovery of renal function?of renal function?P=NS Ronco C et al.Effects of different doses in CVVH on outcomes of ARF:A prospective RCT20ml/h/kg 35/ml/kg/h45ml/kg/h95%92%90%N=425SurvivalLancet 2000;356:26-30lCRRT vs IRRTon return of renal functionOn mortalityMortality:Which is better CRRT or IHD?S

8、wzrtz.RD.Comparing continuous HF with HD in patients with severe ARF Am J Kidney 1999;34:424-432Mehti.RL.Collaborative Group for Treatment of ARF in ICU:A RCT of continuous versus IHD for ARF.Kidney Int 2001;60:1154-63Kellum JA.Continuous versus intermittent RRT.A meta-analysis.Intensive Care Med 20

9、02;162:197-202 Conclusion:There is no conclusive evidence to support the superiority of CRRT vs IHD.Both techniques are complimentaryCRRT vs IRRT对危重病患者的影响对危重病患者的影响CRRT可降低危重病患者病死率可降低危重病患者病死率nQuality score 5:definitely equalCRRT vs IRRT对危重病患者的影响对危重病患者的影响CRRT可降低危重病患者病死率可降低危重病患者病死率Hospital mortality:CRR

10、T was associated with a reduced risk of hospital death in the six studies in which baseline severity of illness was similar RR 0.48,0.340.69,p0.0005 Intensive Care Med,2002,28:29-371.CRRT vs IRRT2.Early vs late CRRT 3.High vs normal flow4.Current opinion in CRRT Current opinion in CRRT 19891997：100例

11、创伤后ARF 早期后期的临界：BUN 60mg/dl 两组病人创伤评分、GCS、发生休克的比例、年龄、性别和创伤分布均无差异早期后期早期后期CRRT对危重病患者的影响对危重病患者的影响早期或预防性早期或预防性CRRT可降低可降低ARF患者病死率患者病死率Gettings LG.Intensive Care Med,1999,25:805-813早期后期早期后期CRRT对危重病患者的影响对危重病患者的影响早期或预防性早期或预防性CRRT可降低可降低ARF患者病死率患者病死率n生存率明显差异生存率明显差异Gettings LG.Intensive Care Med,1999,25:805-813E

12、arly vs.Late RRT RCT(n=106)Oliguria(30cc/hr)refractory to high-dose furosemide(500mg over 6hrs)Randomized to 3 groups:Early(12h)high-volume hemofiltration(n=35;72-96L/24 h)Early(5060 ml/kg/hr OR:60 L/d including net ultrafiltration in continuous hemofiltration modeq目的：目的：评估高流量血滤对感染性休克患者评估高流量血滤对感染性休克

13、患者(n-11)血流动力血流动力学和细胞因子的影响学和细胞因子的影响q方法：方法：随机随机cross-over试验，患者随机接受试验，患者随机接受8h HVHF(6L/h)(AN69滤器，滤器，1.6m2)或或8h CVVH(1L/h)(AN69滤器，滤器，1.2m2)q检测指标：检测指标：血流动力学、去甲肾上腺素需要量、血清血流动力学、去甲肾上腺素需要量、血清C3a、C5a、IL-2、IL-8、IL-10和和TNF的含量的含量HVHF组与组与CVVH组组CVP、CI、PAWP和液体平衡无差异和液体平衡无差异维持维持MAP70mmHg，HVHF组组NE剂量显著低于剂量显著低于CVVHNE剂量分

14、别降低剂量分别降低10.5ug/min和和1.0ug/min P=0.02高流量血滤在感染性休克患者中的作用高流量血滤在感染性休克患者中的作用HVHF显著降低感染性休克显著降低感染性休克NE用量用量Cole L,et al.Intensive Care Med,2001,27:978-986Mean Norepinephrine DoseMean C3a concentrationMean C5a concentrationHV-CVVHHV-CVVH明显改善感染性休克预后明显改善感染性休克预后46.0%46.0%75.0%75.0%70.5%70.5%65.0%65.0%0%0%20%20%

15、40%40%60%60%80%80%100%100%HV-CVVHHHV-CVVHHSOFA-SOFA-PredictedPredictedLOD-LOD-predictedpredictedMODS-MODS-predictedpredictedMortality(%)Mortality(%)脉冲式高容量血液滤过脉冲式高容量血液滤过(Pulse HVHF)极高容量很难维持24h以上，而且对溶质动力学无明显改进 Ranco提出了脉冲式高容量血液滤过Seminars in Dialysis,2006,19(1):69-746420PulseL/hHVHF-As salvage therapyin

16、 severe septic shock Objectives:To evaluate the effect PHVHF(12-h)in reversing progressive refractory hypotension in pats with sshock N=20 sshock pats with NE 0.3 g/kg.min and and lactic acidosis Responders vs Non-R(NE and lactate levels at 6h after PHVHF)Intensive Care Med(2006)32:713722CVVH+CVVH+血

17、浆吸附对感染性休克血流动力学的影响血浆吸附对感染性休克血流动力学的影响Hemodynamic response to coupledHemodynamic response to coupledplasmafiltration-adsorption in human septic shockplasmafiltration-adsorption in human septic shock N=12 mechanically ventilated pats with septic shock Intervention:A median of 10 consecutive sessions(prescribed treatment time:10 h/session;delivered duration:8.431.37 h/min)of coupled plasmafiltration-adsorptionIntensive Care Med(2003)29:703708