严重脓毒症与MODSppt课件VIP

CRRT Severe sepsis and MODS 1 1. CRRT vs IRRT 2. Early vs late CRRT 3. High vs normal flow 4.Possible ways to increase mediators clearance Current opinion in CRRT 2 Mode of RRT differences among continents Bellomo, et al. 2001 Understanding Renal Replacement Therapy and Acute Renal Failure in the ICU (The B.E.S.T kidney study) 3 Retrospective cohort study Pats with ARF and required dialysis between April 1,1996, and March 31, 1999 2 ICU in Canada. N=261 CRRT对 ARF肾功能恢复的影响 CRRT促进肾功能恢复 CRRT IHD P APACHE II 27 25.1 0.10 Baseline SCr 136 180 0.002 MAP Before RRT 74.7 87.2 5060 ml/kg/hr OR: 60 L/d including net ultrafiltration in continuous hemofiltration mode 28 q目的： 评估高流量血滤对感染性休克患者 (n-11)血流动力 学和细胞因子的影响 q方法： 随机 cross-over试验，患者随机接受 8h HVHF (6L/h) (AN69滤器， 1.6m2)或 8h CVVH (1L/h) (AN69滤器 ， 1.2m2) q检测指标： 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 TNF的含量 HVHF组与 CVVH组 CVP、 CI、 PAWP和液体平衡无差异 维持 MAP70mmHg， HVHF组 NE剂量显著低于 CVVH NE剂量分别降低 10.5ug/min和 1.0ug/min P=0.02 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 NE用量 Cole L, et al. Intensive Care Med, 2001, 27: 978-986 29 Mean Norepinephrine Dose Mean C3a concentration Mean C5a concentration 30 Effect of HVHF on mortality Oudemans-van Straaten Hm et al, Intens Care Med 1999;25:814-821. *=Madrid ARF score 31 HV-CVVH明显改善感染性休克预后 32 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): 69-74 6 4 2 0 Pulse L/h 33 34 HVHF- As salvage therapy in 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) 32:713722 35 Higher Uf volumes Higher membrane cut-off Permeability Convection Grootendorst AF et al , 1992 Bellomo R et al, 1998 Leese T et al. 1987 Berlot G et al. 1997 促进介质清除促进介质清除 /遏制炎症反应的可能途径遏制炎症反应的可能途径 1 2 36 Efficacy of membrane pore size on morbidity and mortality in an immature swine model of Staph. Aureus induced sepsis James R. Matson, Crit Care Med, 26: 730-737, 1998 Cut-off 100 KD 37 Higher Uf volumes Higher membrane cut-off Permeability Convection Grootendorst AF et al , 1992 Bellomo R et al, 1998 Leese T et al. 1987 Berlot G et al. 1997 1 2 Use of sorbents in combination therapies Adsorption Ronco C et al. 1999 Tetta C et al. 2001 3 促进介质清除促进介质清除 /遏制炎症反应的可能途径遏制炎症反应的可能途径 38 Sorben t Coupled plasmafiltration-adsorption, by regenerating the plasmafiltrate, avoids unwanted losses, avoids the contact of RBC, WBC and platelets with the sorbent, and prevents treatment induced thrombocytopenia. HemodiafilterPlasmafilter Dialysate 30 ml/min Plasmafilter 20 ml/min 100-200 ml/min 39 CPFA: Hemodynamics and Biological Effects P 0.01 NA MAP at 10 hours of treatment versus baseline D- Norepinephrine Dose and D+ MAP 0 20 40 60 80 100 % P 0.01 TNF Prod. Phagocytosis D Monocyte TNF production and Phagocytic Capacity 0 20 40 60 80 100 P 0.01 0 500 1000 1500 %at 10 hours of treatment versus baseline pg/ml P 0.05 40 CVVH + 血浆吸附对感染性休克血流动力学的影响 Hemodynamic response to coupled plasmafiltration-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-adsorption Intensive Care Med (2003) 29:703708 41 CRRT in ICU Early CRRT: 改善创伤合并