crrt在严重感染中应用.ppt

定义 发病机制 治疗 -CRRT治疗,内容提要,定 义,定 义,Sepsis =Infection+SIRS Severe sepsis =Sepsis + organ function Septic shock =Sepsis + hypotension,损伤 SIRS Sepsis severe sepsis (septic shock) MODS MOF,感染的全过程,infection,院内感染发生率,普通病房中病人: 6-17% ICU病人：25-40%,重症感染与MODS,重症感染常并发MODS 心、肺、肾、肝、脑等器官发生单一器官衰竭死亡率是20 随器官衰竭数量增加，死亡率逐渐上升，合并4个器官衰竭患者死亡率达100,Deitch EA. Surg Clin N Am, 1999, 79: 1471-88,Rangel-Frausto, M, et al. JAMA, 1995, 273:117-123,感染与重症感染对患者预后的影响,MODS对患者预后的影响,定义 发病机制 治疗 -CRRT治疗,内容提要,炎症反应学说,重症感染至感染性休克和MODS的发病机制,The acute inflammatory response A complex series of cellular, immune and metabolic responses which have evolved to be protective and promote repair processes Stimuli of inflammation Infection Burns Toxins Pancreatitis Surgery Malignancy Trauma Poisoning Ischaemia/reperfusion,Inflammatory mediator release,Albumin,Injury，infection,H2O,NaCl,Systemic capillary leak,参与SIRS和MODS的可溶性介质,概述 发病机制 治疗 -CRRT治疗,内容提要,重症感染和感染性休克的治疗,感染病灶的引流 早期合理的抗生素应用 改善器官灌注 器官功能支持 炎症调控-血液滤过治疗,重症感染的治疗转归,肾脏替代治疗,CVVH通过对流清除中小分子炎症介质(30-40KD)，另外还有滤过膜的吸附作用,CRRT在重症感染和感染性休克中的作用,重症感染和感染性休克部分主要炎症介质的分子量,CVVH对重症感染炎症介质的影响,目的： CVVH对重症感染炎症介质的清除 方法： 检测患者与健康志愿者血滤开始(t0)与血滤60min (t60)滤器前(afferent)滤器后(efferent)与超滤液中炎症介质的浓度。滤器为金宝FH66D，聚酰胺膜，超滤率2L/h,Hoffmann JN, et al. Kidney International, 1995, 48: 1563-1570,CVVH对重症感染炎症介质的影响,*与t0相比，P0.01，c没有检测到,CVVH对重症感染炎症介质的影响,Hoffmann JN, et al. Kidney International, 1995, 48: 1563-1570,聚酰胺膜具有较好的生物相容性，不刺激机体产生大量的炎症介质 CVVH可以部分清除IL-1，IL-8，C3a和C5a CVVH对炎症介质的清除作用除与炎症介质的分子量有关外，还与炎症介质的蛋白结合率、活性状态、跨膜压等有关 CVVH对血滤前后炎症介质浓度无显著影响，可能与CVVH超滤率较低导致的清除效率低有关,CVVH对重症感染炎症介质的影响,Hoffmann JN, et al. Kidney International, 1995, 48: 1563-1570,滤器膜对各种炎症介质的影响,低流量CRRT对重症感染和感染性休克疗效的影响,Low -flow hemofiltration,低流量CVVH在重症感染中的临床应用,目的：探讨CVVH对重症感染部分炎症 介质和器官功能的影响 随机、控制研究 24例早期重症感染或感染性休克患者 随机进行48hCVVH(2L/h，AN69膜，1.2m2) 或不进行CVVH,Bellomo R, et al. CCM, 2002, 30: 100-106,C3a和C5a的变化,低流量CVVH在重症感染中的临床应用,IL-6和IL-8的变化,低流量CVVH在重症感染中的临床应用,IL-10和TNF的变化,低流量CVVH在重症感染中的临床应用,低流量CVVH在重症感染中的临床应用,低流量CVVH在重症感染中的临床应用,血管活性药物的应用时间,机械通气时间,低流量CVVH在重症感染中的临床应用,ICU住院时间,低流量CVVH不显著改善重症感染 和感染性休克动物与患者的血流动 力学状态和预后,Object: evaluate hemodynamic and kinetics of TNF, IL1 and IL6 in septic shock patients and ARF undergoing CVVHF over 24-hour Methods: 11 Patients, AN69 , blood flow rate 240 mL/min and UF 1.650.33 L/h. MAP, PVR, SVR, CO before and after 2h, 4h, 6h, 12h and 24 h of CVVHF. the pre- and postfilter lines and ultrafiltrate samples collected for the of TNF, IL-1 and IL6,CVVH improves hemodynamics in septic shock without modifying TNF* and IL6 plasma concentrations,Klouche K, et al. J NEPHROL 2002; 15: 150-157,血流动力学结果,氧代谢结果,低流量CVVH部分改善感染 性休克患者血流动力学状态,高流量CRRT对重症感染和感染性休克疗效的影响,CVVH不同治疗量对内毒素休克狗血流动力学的影响,动物模型：LPS静脉注射复制感染性休克狗模型 分组： 对照组(A)：内毒素休克组 CVVH1组(B)：CVVH3l/h 270min(0.7m2聚砜膜滤器， 40KD) CVVH2组(C)：CVVH3l/h 150min+6l/h 120min 观察指标：MAP、MPAP、CO、SVR、PVR、SV、LVSWI、Lac、肝动脉血流量,Rogiers P, et al. Crit Care Med, 1999, 27: 1848-1855,CVVH不同治疗量对内毒素休克狗血流动力学的影响,CVVH不同治疗量对内毒素休克狗血流动力学的影响,CVVH不同治疗量对内毒素休克狗血流动力学的影响,CVVH不同治疗量对内毒素休克狗血流动力学的影响,CVVH 3L/h显著改善感染性休克狗CO和SV，但对动脉血压无明显改善 与CVVH 3L/h相比，6L/h显著改善感染性休克狗动脉血压和左心室做功指数,对象：33例难治的感染性休克和MODS患者 HVHF方法：置换液量108L/24h，滤器面积2.3m2 结果：HVHF4h后 MAP从8.40.94KPa上升至10.3 2.3KPa PaO2/FiO2从10.1 2.0KPa升至11.8 3.0KPa 患者存活率无显著改变,HVHF对感染性休克和MODS的影响,Bellomo R, et al. Kidney Int, 1998, 53(S66):S182.,STHVH on hemodynamics and outcome in intractable circulatory failure patients resulting from septic shock,Objective: evaluate effects of STHVH on hemodynamics, metabolic , 28-day survival in refractory septic patients shock Design: Prospective, interventional Patients: 20 with intractable septic shock, who had failed to respond to conventional therapy Interventions: STHVH 4-hr 35 L of ultrafiltrate and neutral fluid balance is maintained Subsequent CVVH continued for at least 4 days (1.6m2，聚砜膜，35KD),Patrick M, et al. CCM. 2000, 28:3581-3587,Measure : CI, SVR, PVR, DO2, SvO2, pHa, and lactate Therapeutic endpoints STHVH: a) 2 hrs, 50% increase in CI b) 2 hrs, 25% increase in SvO2 c) 4 hrs, increase in pHa to 7.3 d) 4 hrs, 50% reduction in EP “responders” : attained four goals (11 of 20) “nonresponders” : did not (9 of 20),Results,Base : age, APACHE II, predicted risk of death, SAPS II, epinephrine requirement no differences,Twenty-Eight-Day Survival : 9 of 11 responder survived 9 nonresponders died by T24 Body weight : responders (66.28.4)kg nonresponders (82.613.4)kg, (p .0031) Ultrafiltrate : responders (0.530.07)L/kg nonresponders (0.430.07)L/kg, (p .0031) Delay time : responders 6.5 hrs nonresponders 13.8 hrs (p .01) Responder was associated with : delay time, body weight, and ultrafiltrate dose,Results,STHVH may be of major therapeutic value in the treatment of intractable septic shock Early initiation of therapy and adequate dose may improve hemodynamic and metabolic responses and 28-day survival,目的： 评估高流量血滤对感染性休克患者血流动力学和细胞因子的影响 方法： 随机cross-over试验， 11例患者随机接受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,高流量血滤在感染性休克患者中的作用,Bellomo R, et al. Intensive Care Med, 2001, 27: 978-986,结果： HVHF组与CVVH组期间CVP、CI、 PAWP和 液体平衡均无显著差异 C3a, C5a, IL-10在治疗 2 h内均显著降低， C3a 和C5a在 HVHF期间降低更为明显 (p 70mmHg，HVHF组去甲肾上腺素需 要量显著低于CVVH组(分别较血滤前降低10.5 ug/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,Bellomo R, et al. Inten Care Med, 2001, 27: 978-986,高流量血滤部分清除感染性休克患者血清中补体成分，显著降低患者去甲肾上腺素的用量,Impact of high volume hemofiltration on hemodynamic disturbance and outcome during septic shock,Study design : 24 patients with septic shock, with dysfunction of more than two organs HVCVVH : ultrafiltration rate between 40 ml/kg/hr and 60 ml/kg/hr for 96hours Primary end point : mortality at 28 days,All patients, increase in hemodynamic parameters was statistically significant(p0.05) With a significant decrease in norepinephrine doses (p 0.05). The predicted 28 day mortality by severity scores was more than 70% The mortality in the hemofiltration group was 46% (p 0.075),ASAIO Journal. 50(1):102-9, 2004 Jan-Feb,不同时期、流量血滤对伴呼吸循环衰竭的少尿急性肾衰患者的影响,随机、控制双中心研究 患者分组： EHV组：出现少尿前开始，超滤率72-96L/24h ELV组：出现少尿前开始，