严重脓毒症与mods.ppt

CRRTSeveresepsisandMODS,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.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.Possiblewaystoincreasemediatorsclearance,CurrentopinioninCRRT,ModeofRRTdifferencesamongcontinents,Bellomo,etal.2019,UnderstandingRenalReplacementTherapyandAcuteRenalFailureintheICU(TheB.E.S.Tkidneystudy),RetrospectivecohortstudyPatswithARFandrequireddialysisbetweenApril1,2019,andMarch31,20192ICUinCanada.N=261,CRRT对ARF肾功能恢复的影响CRRT促进肾功能恢复,CritCareMed2019;31:449455,IHDvsCRRT,ICURRTn=116,RRTforoverdosen=7,Pre-existingCRFn=16,ICURRTforARF/MOFn=66,InitialCRRTn=66,InitialIHDn=28,JackaMJ,IvancinovaX,GibneyRTN.CanJAnaesth2019;52:327-332,Munnsetal观察危重急性肾衰竭患者IHDCRRTCCr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?,160patswithARF:Dailyvsevery-other-dayIHDMeanultrafiltrationvolumeDaily:1.20.5LEvery-other-day:3.50.3L(P0.001).HypotensionoccurredinDaily:52%Every-other-day:255%(P0.001)TimetorecoveryofrenalfunctionDaily:92daysEvery-other-day:166DaysP=0.001,NEnglJMed2019;346:305-310,为什么CRRT有助于肾脏功能的恢复？,EffectofRRTdoseonrecoveryofrenalfunction?,P=NS,RoncoCetal.EffectsofdifferentdosesinCVVHonoutcomesofARF:AprospectiveRCT,Lancet2000;356:26-30,CRRTvsIRRTonreturnofrenalfunctionOnmortality,Mortality:WhichisbetterCRRTorIHD?,Swzrtz.RD.ComparingcontinuousHFwithHDinpatientswithsevereARFAmJKidney2019;34:424-432Mehti.RL.CollaborativeGroupforTreatmentofARFinICU:ARCTofcontinuousversusIHDforARF.KidneyInt2019;60:1154-63KellumJA.ContinuousversusintermittentRRT.Ameta-analysis.IntensiveCareMed2019;162:197-202,Conclusion:ThereisnoconclusiveevidencetosupportthesuperiorityofCRRTvsIHD.Bothtechniquesarecomplimentary,CRRTvsIRRT对危重病患者的影响CRRT可降低危重病患者病死率,Qualityscore5:definitelyequal,CRRTvsIRRT对危重病患者的影响CRRT可降低危重病患者病死率,Hospitalmortality:CRRTwasassociatedwithareducedriskofhospitaldeathinthesixstudiesinwhichbaselineseverityofillnesswassimilarRR0.48,0.340.69,p0.0005,IntensiveCareMed,2019,28:29-37,1.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.Possiblewaystoincreasemediatorsclearance,CurrentopinioninCRRT,19892019：100例创伤后ARF早期后期的临界：BUN60mg/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,GettingsLG.IntensiveCareMed,2019,25:805-813,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,GettingsLG.IntensiveCareMed,2019,25:805-813,OutcomeEarlystart39%survivalLatestart20%survival,Earlyvs.LateRRT,RCT(n=106)Oliguria(30cc/hr)refractorytohigh-dosefurosemide(500mgover6hrs)Randomizedto3groups:Early(70mmHg，HVHF组NE剂量显著低于CVVHNE剂量分别降低10.5ug/min和1.0ug/minP=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,ColeL,etal.IntensiveCareMed,2019,27:978-986,MeanNorepinephrineDose,MeanC3aconcentration,MeanC5aconcentration,EffectofHVHFonmortality,Oudemans-vanStraatenHmetal,IntensCareMed2019;25:814-821.,*=MadridARFscore,HV-CVVH明显改善感染性休克预后,脉冲式高容量血液滤过(PulseHVHF),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,SeminarsinDialysis,2019,19(1):69-74,HVHF-Assalvagetherapyinseveresepticshock,Objectives:ToevaluatetheeffectPHVHF(12-h)inreversingprogressiverefractoryhypotensioninpatswithsshockN=20sshockpatswithNE0.3g/kg.minandandlacticacidosisRespondersvsNon-R(NEandlactatelevelsat6hafterPHVHF),IntensiveCareMed(2019)32:713722,HigherUfvolumes,Highermembranecut-off,Permeability,Convection,GrootendorstAFetal,1992BellomoRetal,2019,LeeseTetal.1987BerlotGetal.2019,促进介质清除/遏制炎症反应的可能途径,1,2,EfficacyofmembraneporesizeonmorbidityandmortalityinanimmatureswinemodelofStaph.AureusinducedsepsisJamesR.Matson,CritCareMed,26:730-737,2019,Cut-off100KD,HigherUfvolumes,Highermembranecut-off,Permeability,Convection,GrootendorstAFetal,1992BellomoRetal,2019,LeeseTetal.1987BerlotGetal.2019,1,2,Useofsorbentsincombinationtherapies,Adsorption,RoncoCetal.1999TettaCetal.2019,3,促进介质清除/遏制炎症反应的可能途径,Coupledplasmafiltration-adsorption,byregeneratingtheplasmafiltrate,avoidsunwantedlosses,avoidsthecontactofRBC,WBCandplateletswiththesorbent,andpreventstreatmentinducedthrombocytopenia.,Hemodiafilter,Plasmafilter,Dialysate30ml/min,Plasmafilter,20ml/min,100-200ml/min,CPFA:HemodynamicsandBiologicalEffects,P0.01,NA,MAP,at10hoursoftreatmentversusbaseline,D-NorepinephrineDoseandD+MAP,0,20,40,60,80,100,%,P0.01,TNFProd.,Phagocytosis,DMonocyteTNFproductionandPhagocyticCapacity,P0.01,0,500,1000,1500,%,at10hoursoftreatmentversusbaseline,pg/ml,P0.05,CVVH+血浆吸附对感染性休克血流动力学的影响Hemodynamicresponsetocoupledplasmafiltration-adsorptioninhumansepticshock,N=12mechanicallyventilatedpatswithsepticshockIntervention:Amedianof10consecutivesessions(prescribedtreatmenttime:10h/session;deliveredduration:8.431.37h/min)ofcouple