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 IRRT2. Early vs late CRRT 3. High vs normal flow4.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, 19992 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 RRTn=116,RRT for overdosen=7,Pre-existing CRFn=16,ICU RRT for ARF/MOFn=66,Initial CRRTn=66,Initial IHDn=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 CRRTCCr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 IHDMean ultrafiltration volumeDaily: 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 IRRTon return of renal functionOn 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 - 432Mehti. RL. Collaborative Group for Treatment of ARF in ICU:A RCT of continuous versus IHD for ARF. Kidney Int 2001; 60: 1154 - 63Kellum 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 IRRT2. Early vs late CRRT 3. High vs normal flow4.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,OutcomeEarly 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 ( 5060 ml/kg/hrOR: 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CVVHNE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 therapyin severe septic shock,Objectives: To evaluate the effect PHVHF (12-h) in reversing progressive refractory hypotension in pats with sshockN=20 sshock pats with NE 0.3 g/kg.min and and lactic acidosisResponders 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 , 1992Bellomo R et al, 1998,Leese T et al. 1987Berlot 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 sepsisJames R. Matson, Crit Care Med, 26: 730-737, 1998,Cut-off100 KD,Higher Uf volumes,Higher membrane cut-off,Permeability,Convection,Grootendorst AF et al , 1992Bellomo R et al, 1998,Leese T et al. 1987Berlot G et al. 1997,1,2,Use of sorbents in combination therapies,Adsorption,Ronco C et al. 1999Tetta 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,Dialysate30 ml/min,Plasmafilter,20 ml/min,100-200 ml/min,CPFA: Hemodynamics and Biological Effects,P 0.01,NA,MAP,at 10 hours of treatment versus baseline,D- Norepinephrine Dose and D+ MAP,0,20,40,60,80,100,%,P 0.01,TNF Prod.,Phagocytosis,D Monocyte TNF production and Phagocytic Capacity,P 0.01,0,500,1000,1500,%,at 10 hours of treatment versus baseline,pg/ml,P 0.05,CVVH + 血浆吸附对感染性休克血流动力学的影响Hemodynamic response to coupledplasmafiltration-adsorption in human septic shock,N=12 mechanically ventilated pats with septic shockIntervention: A median of 10 consecutive sessions (prescribed treatment time: 10 h/session; delivered duration: 8.