医学crrt严重脓毒症与mods邱海波

CRRT Severe sepsis and MODS 邱海波 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 1. CRRT vs IRRT 2. Early vs late CRRT 3. High vs normal flow 4.P Possible ways to increase ossible ways to increase mediators clearancemediators clearance Current opinion in CRRT 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) 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 CRRTIHDP APACHE II2725.10.10 Baseline SCr1361800.002 MAP Before RRT74.787.2 5060 ml/kg/hr OR: 60 L/d including net ultrafiltration in continuous hemofiltration mode 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 Mean Norepinephrine Dose Mean C3a concentration Mean C5a concentration Effect of HVHF on mortalityEffect of HVHF on mortality Oudemans-van Straaten Hm et al, Intens Care Med 1999;25:814-821. Oudemans-van Straaten Hm et al, Intens Care Med 1999;25:814-821. *=Madrid ARF score*=Madrid ARF score HV-CVVH明显改善感染性休克预后 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 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 Higher Uf volumesHigher Uf volumes Higher membraneHigher membrane cut-off cut-off PermeabilityPermeability ConvectionConvection Grootendorst AF et al , 1992Grootendorst AF et al , 1992 Bellomo R et al, 1998Bellomo R et al, 1998 Leese T et al. 1987Leese T et al. 1987 Berlot G et al. 1997Berlot 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 1 2 2 Efficacy of membrane pore size on morbidity Efficacy of membrane pore size on morbidity and mortality in an immature swine model of and mortality in an immature swine model of Staph. AureusStaph. Aureus induced sepsis induced sepsis James R. Matson, Crit Care Med, 26: 730-737, 1998James R. Matson, Crit Care Med, 26: 730-737, 1998 Cut-offCut-off 100 KD100 KD Higher Uf volumesHigher Uf volumes Higher membraneHigher membrane cut-off cut-off PermeabilityPermeability ConvectionConvection Grootendorst AF et al , 1992Grootendorst AF et al , 1992 Bellomo R et al, 1998Bellomo R et al, 1998 Leese T et al. 1987Leese T et al. 1987 Berlot G et al. 1997Berlot G et al. 1997 1 1 2 2 Use of sorbents inUse of sorbents in c combination therapiesombination therapies AdsorptionAdsorption Ronco C Ronco C et al. 19 et al. 199999 Tetta CTetta C et al. et al. 20012001 3 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 SorbenSorben t t Coupled plasmafiltration-adsorption, by regenerating Coupled plasmafiltration-adsorption, by regenerating the plasmafiltrate, avoids unwanted losses, avoids the the plasmafiltrate, avoids unwanted losses, avoids the contact of RBC, WBC and platelets with the sorbent, contact of RBC, WBC and platelets with the sorbent, and prevents treatment induced thrombocytopenia. and prevents treatment induced thrombocytopenia. HemodiafilterHemodiafilter PlasmafilterPlasmafilter DialysateDialysate 30 ml/min30 ml/min PlasmafilterPlasmafilter 20 ml/min20 ml/min 100-200 ml/min100-200 ml/min CPFA: Hemodynamics and Biological EffectsCPFA: Hemodynamics and Biological Effects P 0.01P 0.01 NANAMAPMAP at 10 hours of treatment versus baselineat 10 hours of treatment versus baseline D D- - Norepinephrine Dose Norepinephrine Dose and and D D+ + MAPMAP 0 0 2020 4040 6060 8080 100100 % P 0.01P 0.01 TNF Prod.TNF Prod. PhagocytosisPhagocytosis D D Monocyte TNF production Monocyte TNF production and Phagocytic Capacityand Phagocytic Capacity 0 0 2020 4040 6060 8080 100100 P 0.01P 0.01 0 0 50500 0 1001000 0 1501500 0 % at 10 hours of treatment versus baselineat 10 hours of treatment versus baseline pg/mlpg/ml P 0.0P 0.05 5 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 CRRT i