icu中血液净化的应用指南

ICU 中血液净化的应用指南 血液净化(blood purification)技术指各种连续或间断清除体内过多水分、溶 质方法的总称，该技术是在肾脏替代治疗技术的基础上逐步发展而来。血液净 化方法有肾脏替代治疗、血液灌流、免疫吸附、内毒素吸附和血浆置换等。每 一种血液净化方式都各有特点，且各适用于不同疾病或不同疾病状态。本指南 仅对 ICU 中应用最多的肾脏替代治疗(renal replacement therapy, RRT)进行讨论 并提出建议。血液净化概念和常见种类 上世纪 70 年代末，RRT 主要用于治疗重症急性肾功能衰竭患者。随着技术 不断发展，近 30 年， RRT 已用于全身过度炎症反应(如严重创伤、重症急性胰 腺炎等) 、脓毒血症、中毒和多脏器功能衰竭等危重症的救治。另外，对重症患 者并发的特殊情况，如严重电解质紊乱、过高热等， RRT 也能显示良好疗效。 RRT 在重症患者救治中起着极其重要的作用，是 ICU 医师应予掌握的基本 技术。基于此，国内 ICU 有关专家根据循证医学证据制定本指南。 制定本指南的意义 循证医学证据按照 Delphi 分级标准(见表 1)。循证医学证据时间跨度为 1999 年 1 月至 2009 年 3 月；数据主要来自 Medline、Evidence-Based Medicine Reviews (EBMR)、Lippincott Williams 13(6):385-402. 2. Rogiers P, Zhang H, Pauwels D, et al. Comparison of polyacrylonitrile (AN69) and polysulphone membrane during hemofiltration in canine endotoxic shock. Crit Care Med. Apr 2003;31(4):1219-1225. 3. Kellum JA, Dishart MK. Effect of hemofiltration filter adsorption on circulating IL-6 levels in septic rats. Crit Care. Oct 2002;6(5):429-433. 4. Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet. Jul 1 2000;356(9223):26-30. 5. Huang Z, Letteri JJ, Clark WR, et al. Ultrafiltration rate as a dose surrogate in pre-dilution hemofiltration. Int J Artif Organs. Feb 2007;30(2):124-132. 6. Gotch FA. Kt/V is the best dialysis dose parameter. Blood Purif. 2000;18(4):276- 285. 7. Ricci Z, Salvatori G, Bonello M, et al. In vivo validation of the adequacy calculator for continuous renal replacement therapies. Crit Care. Jun 2005;9(3):R266-273. 8. Tordoir J, Canaud B, Haage P, et al. EBPG on Vascular Access. Nephrol Dial Transplant. May 2007;22 Suppl 2(ii88-117. 9. Schetz M. Vascular access for HD and CRRT. Contrib Nephrol. 2007;156(275- 286. 10. Parienti JJ, Thirion M, Megarbane B, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. Jama. May 28 2008;299(20):2413-2422. 11. Klouche K, Amigues L, Deleuze S, et al. Complications, effects on dialysis dose, and survival of tunneled femoral dialysis catheters in acute renal failure. Am J Kidney Dis.Jan 2007;49(1):99-108. 12. Canaud B, Desmeules S, Klouche K, et al. Vascular access for dialysis in the intensive care unit. Best Pract Res Clin Anaesthesiol. Mar 2004;18(1):159-174. 13. Leblanc M, Fedak S, Mokris G, et al. Blood recirculation in temporary central catheters for acute hemodialysis. Clin Nephrol. May 1996;45(5):315-319. 14. Canaud B, Chenine L, Henriet D, et al. Optimal management of central venous catheters for hemodialysis. Contrib Nephrol. 2008;161(39-47. 15. Kellum JA, Mehta RL, Angus DC, et al. The first international consensus conference on continuous renal replacement therapy. Kidney Int. Nov 2002;62(5):1855-1863. 16. Thomas CM, Zhang J, Lim TH, et al. Concentration of heparin-locking solution and risk of central venous hemodialysis catheter malfunction. Asaio J. Jul-Aug 2007;53(4):485-488. 17. Aucella F, Di Paolo S, Gesualdo L. Dialysate and replacement fluid composition for CRRT. Contrib Nephrol. 2007;156(287-296. 18. Maccariello E, Rocha E, Dalboni MA, et al. Customized bicarbonate buffered dialysate and replacement solutions for continuous renal replacement therapies: effect of crystallization on the measured levels of electrolytes and buffer. Artif Organs. Nov 2001;25(11):870-875. 19. Barenbrock M, Hausberg M, Matzkies F, et al. Effects of bicarbonate- and lactate-buffered replacement fluids on cardiovascular outcome in CVVH patients. Kidney Int.Oct 2000;58(4):1751-1757. 20. Heering P, Ivens K, Thumer O, et al. The use of different buffers during continuous hemofiltration in critically ill patients with acute renal failure. Intensive Care Med. Nov 1999;25(11):1244-1251. 21. Palsson R, Laliberte KA, Niles JL. Choice of replacement solution and anticoagulant in continuous venovenous hemofiltration. Clin Nephrol. Jan 2006;65(1):34-42. 22. Morgera S, Haase M, Rocktaschel J, et al. High permeability haemofiltration improves peripheral blood mononuclear cell proliferation in septic patients with acute renal failure. Nephrol Dial Transplant. Dec 2003;18(12):2570-2576. 23. Morgera S, Haase M, Kuss T, et al. Pilot study on the effects of high cutoff hemofiltration on the need for norepinephrine in septic patients with acute renal failure. Crit Care Med. Aug 2006;34(8):2099-2104. 24. Haase M, Silvester W, Uchino S, et al. A pilot study of high-adsorption hemofiltration in human septic shock. Int J Artif Organs. Feb 2007;30(2):108-117. 25. Nakada TA, Oda S, Matsuda K, et al. Continuous hemodiafiltration with PMMA Hemofilter in the treatment of patients with septic shock. Mol Med. May-Jun 2008;14(5-6):257-263. 26. Hirasawa H, Oda S, Matsuda K. Continuous hemodiafiltration with cytokine- adsorbing hemofilter in the treatment of severe sepsis and septic shock. Contrib Nephrol.2007;156(365-370. 27. Opatrny K, Jr., Polanska K, Krouzecky A, et al. The effect of heparin rinse on the biocompatibility of continuous veno-venous hemodiafiltration. Int J Artif Organs. Jun 2002;25(6):520-528. 28. Davies H, Leslie G. Maintaining the CRRT circuit: non-anticoagulant alternatives. Aust Crit Care. Nov 2006;19(4):133-138. 29. Ramesh Prasad GV, Palevsky PM, Burr R, et al. Factors affecting system clotting in continuous renal replacement therapy: results of a randomized, controlled trial. Clin Nephrol. Jan 2000;53(1):55-60. 30. van der Voort PH, Gerritsen RT, Kuiper MA, et al. Filter run time in CVVH: pre- versus post-dilution and nadroparin versus regional heparin-protamine anticoagulation.Blood Purif. 2005;23(3):175-180. 31. Uchino S, Fealy N, Baldwin I, et al. Pre-dilution vs. post-dilution during continuous veno-venous hemofiltration: impact on filter life and azotemic control. Nephron Clin Pract. 2003;94(4):c94-98. 32. de Pont AC, Bouman CS, Bakhtiari K, et al. Predilution versus postdilution during continuous venovenous hemofiltration: a comparison of circuit thrombogenesis. Asaio J. Jul-Aug 2006;52(4):416-422. 33. Shulman RI, Singer M, Rock J. Continuous renal replacement therapy. Keeping the circuit open: lessons from the lab. Blood Purif. 2002;20(3):275-281. 34. Singer M, McNally T, Screaton G, et al. Heparin clearance during continuous veno-venous haemofiltration. Intensive Care Med. 1994;20(3):212-215. 35. Monchi M, Berghmans D, Ledoux D, et al. Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study. Intensive Care Med. Feb 2004;30(2):260-265. 36. Hirsh J, Raschke R. Heparin and low-molecular-weight heparin: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. Sep 2004;126(3 Suppl):188S-203S. 37. Bagshaw SM, Laupland KB, Boiteau PJ, et al. Is regional citrate superior to systemic heparin anticoagulation for continuous renal replacement therapy? A prospective observational study in an adult regional critical care system. J Crit Care. Jun 2005;20(2):155-161. 38. Oudemans-van Straaten HM, Wester JP, de Pont AC, et al. Anticoagulation strategies in continuous renal replacement therapy: can the choice be evidence based?Intensive Care Med. Feb 2006;32(2):188-202. 39. Biancofiore G, Esposito M, Bindi L, et al. Regional filter heparinization for continuous veno-venous hemofiltration in liver transplant recipients. Minerva Anestesiol. Jun 2003;69(6):527-534; 534-528. 40. Fealy N, Baldwin I, Johnstone M, et al. A pilot randomized controlled crossover study comparing regional heparinization to regional citrate anticoagulation for continuous venovenous hemofiltration. Int J Artif Organs. Apr 2007;30(4):301- 307. 41. Reeves JH, Cumming AR, Gallagher L, et al. A controlled trial of low-molecular- weight heparin (dalteparin) versus unfractionated heparin as anticoagulant during continuous venovenous hemodialysis with filtration. Crit Care Med. Oct 1999;27(10):2224-2228. 42. Abramson S, Niles JL. Anticoagulation in continuous renal replacement therapy. Curr Opin Nephrol Hypertens. Nov 1999;8(6):701-707. 43. Kozek-Langenecker SA, Kettner SC, Oismueller C, et al. Anticoagulation with prostaglandin E1 and unfractionated heparin during continuous venovenous hemofiltration.Crit Care Med. Jul 1998;26(7):1208-1212. 44. Birnbaum J, Spies CD, Klotz E, et al. Iloprost for additional anticoagulation in continuous renal replacement therapy-a pilot study. Ren Fail. 2007;29(3):271- 277. 45. Vargas Hein O, Kox WJ, Spies C. Anticoagulation in continuous renal replacement therapy. Contrib Nephrol. 2004;144(308-316. 46. Swartz R, Pasko D, OToole J, et al. Improving the delivery of continuous renal replacement therapy using regional citrate anticoagulation. Clin Nephrol. Feb 2004;61(2):134-143. 47. Brophy PD, Somers MJ, Baum MA, et al. Multi-centre evaluation of anticoagulation in patients receiving continuous renal replacement therapy (CRRT). Nephrol Dial Transplant. Jul 2005;20(7):1416-1421. 48. Tan HK, Baldwin I, Bellomo R. Continuous veno-venous hemofiltration without anticoagulation in high-risk patients. Intensive Care Med. Nov 2000;26(11):1652- 1657. 49. Uchino S, Fealy N, Baldwin I, et al. Continuous venovenous hemofiltration without anticoagulation. Asaio J. Jan-Feb 2004;50(1):76-80. 50. Morabito S, Guzzo I, Solazzo A, et al. Continuous renal replacement therapies: anticoagulation in the critically ill at high risk of bleeding. J Nephrol. Jul-Aug 2003;16(4):566-571. 51. Ronco C, Bellomo R, Kellum JA. Continuous renal replacement therapy: opinions and evidence. Adv Ren Replace Ther. Oct 2002;9(4):229-244. 52. Bellomo R, Ronco C. Blood purification in the intensive care unit: evolving concepts. World J Surg. May 2001;25(5):677-683. 53. Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. Aug 2004;8(4):R204-212. 54. Ricci Z, Ronco C, DAmico G, et al. Practice patterns in the management of acute renal failure in the critically ill patient: an international survey. Nephrol Dial Transplant.Mar 2006;21(3):690-696. 55. Bouman CS, Oudemans-Van Straaten HM, Tijssen JG, et al. Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial. Crit Care Med. Oct 2002;30(10):2205-2211. 56. Elahi MM, Lim MY, Joseph RN, et al. Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure. Eur J Cardiothorac Surg. Nov 2004;26(5):1027-1031. 57. Demirkilic U, Kuralay E, Yenicesu M, et al. Timing of replacement therapy for acute renal failure after cardiac surgery. J Card Surg. Jan-Feb 2004;19(1):17-20. 58. Bagshaw SM, Uchino S, Bellomo R, et al. Timing of renal replacement therapy and clinical outcomes in critically ill patients with severe acute kidney injury. J Crit Care.Mar 2009;24(1):129-140. 59. Gettings LG, Reynolds HN, Scalea T. Outcome in post-traumatic acute renal failure when continuous renal replacement therapy is applied early vs. late. Intensive Care Med. Aug 1999;25(8):805-813. 60. Seabra VF, Balk EM, Liangos O, et al. Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis. Am J Kidney Dis. Aug 2008;52(2):272-284. 61. Bell M, Granath F, Schon S, et al. Continuous renal replacement therapy is associated with less chronic renal failure than intermittent haemodialysis after acute renal failure.Intensive Care Med. May 2007;33(5):773-780. 62. Gasparovic V, Filipovic-Grcic I, Merkler M, et al. Continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD)-what is the procedure of choice in critically ill patients? Ren Fail. Sep 2003;25(5):855-862. 63. Augustine JJ, Sandy D, Seifert TH, et al. A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis. Dec 2004;44(6):1000-1007. 64. Mehta RL, McDonald B, Gabbai FB, et al. A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int. Sep 2001;60(3):1154-1163. 65. Jacka MJ, Ivancinova X, Gibney RT. Continuous renal replacement therapy improves renal recovery from acute renal failure. Can J Anaesth. Mar 2005;52(3):327-332. 66. Vinsonneau C, Camus C, Combes A, et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet. Jul 29 2006;368(9533):379-385. 67. Kellum JA, Angus DC, Johnson JP, et al. Continuous versus intermittent renal replacement therapy: a meta-analysis. Intensive Care Med. Jan 2002;28(1):29-37. 68. Tonelli M, Manns B, Feller-Kopman D. Acute renal failure in the intensive care unit: a systematic review of the impact of dialytic modality on mortality and renal recovery.Am J Kidney Dis. Nov 2002;40(5):875-885. 69. Rabindranath K, Adams J, Macleod AM, et al. Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database Syst Rev.2007;3):CD003773. 70. Bagshaw SM, Berthiaume LR, Delaney A, et al. Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: a meta-analysis.Crit Care Med. Feb 2008;36(2):610-617. 71. Ghahramani N, Shadrou S, Hollenbeak C. A systematic review of continuous renal replacement therapy and intermittent haemodialysis in management of patients with acute renal failure. Nephrology (Carlton). Oct 2008;13(7):570-578. 72. Kumar VA, Yeun JY, Depner TA, et al. Extended daily dialysis vs. continuous hemodialysis for ICU patients with acute renal failure: a two-year single center report. Int J Artif Organs. May 2004;27(5):371-379. 73. Cole L, Bellomo R, Journois D, et al. High-volume haemofiltration in human septic shock. Intensive Care Med. Jun 2001;27(6):978-986. 74. Cole L, Bellomo R, Hart G, et al. A phase II randomized, controlled trial of continuous hemofiltration in sepsis. Crit Care Med. Jan 2002;30(1):100-106. 75. Saudan P, Niederberger M, De Seigneux S, et al. Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int. Oct 2006;70(7):1312-1317. 76. Palevsky PM, Zhang JH, OConnor TZ, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. Jul 3 2008;359(1):7- 20. 77. Tolwani AJ, Campbell RC, Stofan BS, et al. Standard versus high-dose CVVHDF for ICU-related acute renal failure. J Am Soc Nephrol. Jun 2008;19(6):1233-1238. 78. Schiffl H, Lang SM, Fischer R. Daily hemodialysis and the outcome of acute renal failure. N Engl J Med. Jan 31 2002;346(5):305-310. 79. Ratanarat R, Brendolan A, Piccinni P, et al. Pulse high-volume haemofiltration for treatment of severe sepsis: effects on hemodynamics and survival. Crit Care. Aug 2005;9(4):R294-302. 80. Schortgen F, Vinsonneau C. Early isovolemic hemofiltration in oliguric patients with septic shock. Intensive Care Med. Jul 2006;32(7):1097; author reply 1098. 81. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. Jan 2008;36(1):296-327. 82. Best C, Ramage I. Evidence for the use of haemofiltration in sepsis. Current Paediatrics. 2003;13(1):18-22. 83. Payen D, Mateo J, Cavaillon JM, et al. Impact of continuous venovenous hemofiltration on organ failure during the early phase of severe sepsis: a randomized controlled trial. Crit Care Med. Mar 2009;37(3):803-810. 84. Cornejo R, Downey P, Castro R, et al. High-volume hemofiltration as salvage therapy in severe hyperdynamic septic shock. Intensive Care Med. May 2006;32(5):713-722. 85. Peng Y, Yuan Z, Li H. Removal of inflammatory cytokines and endotoxin by veno-venous continuous renal replacement therapy for burned patients with sepsis. Burns.Aug 2005;31(5):623-628. 86. Joannes-Boyau O, Rapaport S, Bazin R, et al. Impact of high volume hemofiltration on hemodynamic disturbance and outcome during septic shock. Asaio J. Jan-Feb 2004;50(1):102-109. 87. Honore PM, Jamez J, Wauthier M, et al. Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock. Crit Care Med. Nov 2000;28(11):3581-3587. 88. Bellomo R, Baldwin I, Ronco C. High volume hemofiltration. Current Opinion in Critical Care. 2000;6(6):442-445. 89. Ghani RA, Zainudin S, Ctkong N, et al. Serum IL-6 and IL-1-ra with sequential organ failure assessment scores in septic patients receiving high-volume haemofiltration and continuous venovenous haemofiltration. Nephrology (Carlton). Oct 2006;11(5):386-393. 90. Ronco C, Brendolan A, Lonnemann G, et al. A pilot study of coupled plasma filtration with adsorption in septic shock. Crit Care Med. Jun 2002;30(6):1250- 1255. 91. 毛恩强, 汤耀卿, 张圣道. 短时血液滤过对重症胰腺炎的影响. 中华外科杂志 . 1999;37(3):141-143. 92. Jiang HL, Xue WJ, Li DQ, et al. Influence of continuous veno-venous hemofiltration on the course of acute pancreatitis. World J Gastroenterol. Aug 21 2005;11(31):4815-4821. 93. 毛恩强, 汤耀卿, 张圣道. 暴发性胰腺炎治疗经验. 中华外科杂志 . 2006;44(17): 1185-1188. 94. 陶京, 王春友, 杨智勇等. 血液滤过治疗对重症急性胰腺炎患者血浆炎性细胞 因子水平的影响. 中华普通外科杂志 . 2004;19(4):231-236. 95. Mao EQ, Tang YQ, Zhang SD. Effects of time interval for hemofiltration on the prognosis of severe acute pancreatitis. World J Gastroenterol. Feb 2003;9(2):373- 376. 96. 毛恩强, 汤耀卿, 张圣道. 血液滤过持续时间对重症急性胰腺炎治疗的作用. 肝胆胰外科杂志 . 2007;19(6):385-386. 97. Xie H, Ji D, Gong D, et al. Continuous veno venous hemofiltration in treatment of acute necrotizing pancreatitis. Chin Med J (Engl). Apr 2003;116(4):549-553. 98. 封光华, 蔡阳, 贾鹏辉等. 联合血液滤过和腹膜透析治疗急性重症胰腺炎. 中 华外科杂志 . 2004;42(5):272-275. 99