严重脓毒症与MODSppt课件.ppt

CRRTSeveresepsisandMODS 2 1 CRRTvsIRRT2 EarlyvslateCRRT3 Highvsnormalflow4 Possiblewaystoincreasemediatorsclearance CurrentopinioninCRRT 3 ModeofRRTdifferencesamongcontinents Bellomo etal 2001 UnderstandingRenalReplacementTherapyandAcuteRenalFailureintheICU TheB E S Tkidneystudy RetrospectivecohortstudyPatswithARFandrequireddialysisbetweenApril1 1996 andMarch31 19992ICUinCanada N 261 CRRT对ARF肾功能恢复的影响 CRRT促进肾功能恢复 CritCareMed2003 31 449 455 IHDvsCRRT ICURRTn 116 RRTforoverdosen 7 Pre existingCRFn 16 ICURRTforARF MOFn 66 InitialCRRTn 66 InitialIHDn 28 JackaMJ IvancinovaX GibneyRTN CanJAnaesth2005 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 2 0 5LEvery other day 3 5 0 3L P 0 001 HypotensionoccurredinDaily 5 2 Every other day 25 5 P 0 001 TimetorecoveryofrenalfunctionDaily 9 2daysEvery other day 16 6DaysP 0 001 NEnglJMed2002 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 ComparingcontinuousHFwithHDinpatientswithsevereARFAmJKidney1999 34 424 432Mehti RL CollaborativeGroupforTreatmentofARFinICU ARCTofcontinuousversusIHDforARF KidneyInt2001 60 1154 63KellumJA ContinuousversusintermittentRRT Ameta analysis IntensiveCareMed2002 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 34 0 69 p 0 0005 IntensiveCareMed 2002 28 29 37 13 1 CRRTvsIRRT2 EarlyvslateCRRT3 Highvsnormalflow4 Possiblewaystoincreasemediatorsclearance CurrentopinioninCRRT 1989 1997 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 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 GettingsLG IntensiveCareMed 1999 25 805 813 OutcomeEarlystart39 survivalLatestart20 survival 16 Earlyvs LateRRT RCT n 106 Oliguria 30cc hr refractorytohigh dosefurosemide 500mgover6hrs Randomizedto3groups Early 12h high volumehemofiltration n 35 72 96L 24h Early 12h low volumehemofiltration n 35 24 36L 24h Latelow volumehemofiltration n 36 24 36L 24h Boumanetal CritCareMed30 2205 2211 2002 17 DoseandTimingofCVVHinARF BoumanCS etal CriticalCareMed2002 30 2205 2211 74 3 68 8 75 0 0 20 40 60 80 100 28 DaySurvival LV Late LV Early HV Early TreatmentGroup n 35SOFA10 3 2 8 n 36SOFA10 6 1 9 n 35SOFA10 1 2 2 18 1 CRRTvsIRRT2 EarlyvslateCRRT3 Highvsnormalflow4 Possiblewaystoincreasemediatorsclearance CurrentopinioninCRRT High volumehemofilitration HVHF RoncoCetal EffectsofdifferentdosesinCVVHonoutcomesofARF AprospectiveRCT Lancet2000 356 26 30 RCTofHVHFinSepticShock 5919ICUadmissions OliguricARFN 248 Non oliguricARFN 130 NotrandomizedinstudyN 142 RandomizedInstudyN 106 EHVn 35 ELVn 35 LLVn 36 Hemofiltrationn 352 NohemofiltrationN 6 BoumanCSetal Effectsofearlyhigh volumeCVVHonsurvivalandrecoveryofrenalfunctioninICpatientswithARF CritCareMed2002 30 2205 n 106 EHV74 3 LLV75 ELV68 8 ELV Earlylowvolhemofiltration 1 1 5L hrLLV Latelowvolhemofiltration 1 1 5L hrEHV Earlyhighvolhemofiltration 3 4L hr Early within12hoursofdiagnosisofsepticshock Survival Nodifferencerenalrecoveryor28 dmortality 22 160patswithARF Dailyvsevery other dayID NEnglJMed2002 346 305 310 SurvivalvsdialysisdoseinIHD 23 CRRT Impactonoutcomes SeverityofDisease Survivalrate HighDose CRRT LowDose IHD TheClevelandClinicObservation 100 90 80 70 60 50 40 30 20 10 0 24 ATN n 1260 Multi centerRCTintheUSA PatientswithARFrandomizedto IntensiveManagementStrategy Ifhemodynamicallystable SOFACVSscore 0 2 IHD6 times week targetKt V 1 2 1 4 session Ifhemodynamicallyunstable SOFACVSscore 3 4 CVVHDFat35ml kg hrorSLED6 times week targetKt V 1 2 1 4 session ConventionalManagementStrategy Ifhemodynamicallystable SOFACVSscore 0 2 IHD3 times week targetKt V 1 2 1 4 session Ifhemodynamicallyunstable SOFACVSscore 3 4 CVVHDFat20ml kg hrorSLED3 times week targetKt V 1 2 1 4 session 25 RENAL MulticenterRCT centers 35 N 1500AustraliaandNewZealand25ml kg hrvs 40ml kg hrofCVVHDFOutcome allcausemortalityat90daysCurrentlyunderway 26 1 CRRTvsIRRT2 EarlyvslateCRRT3 Highvsnormalflow4 Possiblewaystoincreasemediatorsclearance CurrentopinioninCRRT 27 HigherUfvolumes Convection GrootendorstAFetal 1992BellomoRetal 1998 1 促进介质清除 遏制炎症反应的可能途径 28 HVHF HVHF Anultrafiltrationrate 50 60ml kg hrOR 60L dincludingnetultrafiltrationincontinuoushemofiltrationmode 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8hHVHF 6L h AN69滤器 1 6m2 或8hCVVH 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MAP 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 2001 27 978 986 30 MeanNorepinephrineDose MeanC3aconcentration MeanC5aconcentration 31 EffectofHVHFonmortality Oudemans vanStraatenHmetal IntensCareMed1999 25 814 821 MadridARFscore 32 HV CVVH明显改善感染性休克预后 33 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 2006 19 1 69 74 34 35 HVHF Assalvagetherapyinseveresepticshock Objectives ToevaluatetheeffectPHVHF 12 h inreversingprogressiverefractoryhypotensioninpatswithsshockN 20sshockpatswithNE 0 3 g kg minandandlacticacidosisRespondersvsNon R NEandlactatelevelsat6hafterPHVHF IntensiveCareMed 2006 32 713 722 36 HigherUfvolumes Highermembranecut off Permeability Convection GrootendorstAFetal 1992BellomoRetal 1998 LeeseTetal 1987BerlotGetal 1997 促进介质清除 遏制炎症反应的可能途径 1 2 37 EfficacyofmembraneporesizeonmorbidityandmortalityinanimmatureswinemodelofStaph AureusinducedsepsisJamesR Matson CritCareMed 26 730 737 1998 Cut off100KD 38 HigherUfvolumes Highermembranecut off Permeability Convection GrootendorstAFetal 1992BellomoRetal 1998 LeeseTetal 1987BerlotGetal 1997 1 2 Useofsorbentsincombinationtherapies Adsorption RoncoCetal 1999TettaCetal 2001 3 促进介质清除 遏制炎症反应的可能途径 39 Coupledplasmafiltration adsorption byregeneratingtheplasmafiltrate avoidsunwantedlosses avoidsthecontactofRBC WBCandplateletswiththesorbent andpreventstreatmentinducedthrombocytopenia Hemodiafilter Plasmafilter Dialysate30ml min Plasmafilter 20ml min 100 200ml min 40 CPFA HemodynamicsandBiologicalEffects P 0 0