CRRT：严重脓毒症与MODS(邱海波).ppt

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.Possible ways to increase mediators 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,Crit Care Med 2003; 31:449 455,IHD vs CRRT,ICU RRT n=116,RRT for overdose n=7,Pre-existing CRF n=16,ICU RRT for ARF/MOF n=66,Initial CRRT n=66,Initial IHD n=28,Jacka 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CRRT促进肾功能恢复?,160 pats with ARF: Daily vs every-other-day IHD Mean ultrafiltration volume Daily: 1.2 0.5 L Every-other-day: 3.5 0.3 L (P 0.001). Hypotension occurred in Daily: 5 2% Every-other-day: 25 5% (P 0.001) Time to recovery of renal function Daily: 9 2 days Every-other-day:16 6 Days P = 0.001,N Engl J Med 2002; 346:305-310,为什么CRRT有助于肾脏功能的恢复？,Effect of RRT dose on recovery of renal function?,P = NS,Ronco C et al. Effects of different doses in CVVH on outcomes of ARF:A prospective RCT,Lancet 2000; 356: 26 -30,CRRT vs IRRT on return of renal function On mortality,Mortality: Which is better CRRT or IHD?,Swzrtz. RD. Comparing continuous HF with HD in patients with severe ARF Am J Kidney 1999; 34: 424 - 432 Mehti. RL. Collaborative Group for Treatment of ARF in ICU:A RCT of continuous versus IHD for ARF. Kidney Int 2001; 60: 1154 - 63 Kellum JA. Continuous versus intermittent RRT. A meta-analysis. Intensive Care Med 2002; 162: 197- 202,Conclusion :There is no conclusive evidence to support the superiority of CRRT vs IHD. Both techniques are complimentary,CRRT vs IRRT对危重病患者的影响 CRRT可降低危重病患者病死率,Quality score 5: definitely equal,CRRT vs IRRT对危重病患者的影响 CRRT可降低危重病患者病死率,Hospital mortality: CRRT 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: 29-37,1. CRRT vs IRRT 2. Early vs late CRRT 3. High vs normal flow 4.Possible ways to increase mediators clearance,Current opinion in CRRT,19891997：100例创伤后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CRRT对危重病患者的影响 早期或预防性CRRT可降低ARF患者病死率,Gettings LG. Intensive Care Med, 1999, 25: 805-813,早期后期CRRT对危重病患者的影响 早期或预防性CRRT可降低ARF患者病死率,生存率明显差异,Gettings LG. Intensive Care Med, 1999, 25: 805-813,Outcome Early start 39% survival Late start 20% survival,Early 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 (12h) low-volume hemofiltration (n=35; 24-36L/24 h) Late low-volume hemofiltration (n=36; 24-36 L/24 h),Bouman et al. Crit Care Med 30:2205-2211, 2002,Dose and Timing of CVVH in ARF,Bouman CS, et al. Critical Care Med 2002; 30:2205-2211,74.3%,68.8%,75.0%,0%,20%,40%,60%,80%,100%,28-Day Survival,LV-Late,LV-Early,HV-Early,Treatment Group,n=35 SOFA 10.32.8,n=36 SOFA 10.61.9,n=35 SOFA 10.12.2,1. CRRT vs IRRT 2. Early vs late CRRT 3. High vs normal flow 4.Possible ways to increase mediators clearance,Current opinion in CRRT,High-volume hemofilitration (HVHF),Ronco C et al. Effects of different doses in CVVH on outcomes of ARF:A prospective RCT,Lancet 2000; 356: 26 -30,RCT of HVHF in Septic Shock,5919 ICU admissions,Oliguric ARF N=248,Non-oliguric ARF N=130,Not randomized in study N=142,Randomized In study N-106,EHV n=35,ELV n=35,LLV n=36,Hemofiltration n=352,No hemofiltration N=6,Bouman CS et al. Effects of early high-volume CVVH on survival and recovery of renal function in IC patients with ARF. Crit Care Med 2002; 30: 2205 (n=106),EHV 74.3%,LLV 75%,ELV 68.8%,ELV= Early low vol hemofiltration=1-1.5 L/hr LLV= Late low vol hemofiltration=1-1.5 L/hr EHV= Early high vol hemofiltration=3-4 L/hr,Early=within 12 hours of diagnosis of septic shock,Survival %,No difference renal recovery or 28-d mortality,160 pats with ARF: Daily vs every-other-day ID,N Engl J Med 2002; 346:305-310,Survival vs dialysis dose in IHD,CRRT: Impact on outcomes,Severity of Disease,Survival rate %,High Dose (CRRT),Low Dose (IHD),The Cleveland Clinic Observation,100,90,80,70,60,50,40,30,20,10,0,ATN (n=1260),Multi-center RCT in the USA. Patients with ARF randomized to: Intensive Management Strategy: If hemodynamically stable (SOFA CVS score: 0-2) IHD 6-times/week (target Kt/V =1.2-1.4/session) If hemodynamically unstable (SOFA CVS score: 3-4) CVVHDF at 35 ml/kg/hr or SLED 6-times/week (target Kt/V = 1.2-1.4/session) Conventional Management Strategy: If hemodynamically stable (SOFA CVS score: 0-2) IHD 3-times/week (target Kt/V =1.2-1.4/session); If hemodynamically unstable (SOFA CVS score: 3-4) CVVHDF at 20 ml/kg/hr or SLED 3-times/week (target Kt/V = 1.2-1.4/session),RENAL,Multicenter RCT (centers = 35) N= 1500 Australia and New Zealand 25 ml/kg/hr vs. 40 ml/kg/hr of CVVHDF Outcome: all cause mortality at 90 days Currently under way,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,Higher Uf volumes,Convection,Grootendorst AF et al , 1992 Bellomo R et al, 1998,1,促进介质清除/遏制炎症反应的可能途径,HVHF,HVHF: An ultrafiltration rate 5060 ml/kg/hr OR: 60 L/d including net ultrafiltration in continuous hemofiltration mode,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 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) 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 mortality,Oudemans-van Straaten Hm et al, Intens Care Med 1999;25:814-821.,*=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,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 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/遏制炎症反应的可能途径,1,2,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,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/遏制炎症反应的可能途径,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.,Hemodiafilter,Plasmafilter,Dialysate 30 ml/min,Plasmafilter,20 ml/min,100-200 ml/min,CPFA: Hemodynamics and Biological Eff