CRRT在严重感染中应用new

东南大学附属中大医院危重病医学科郭凤梅,CRRT在 重症感染和感染性休克中的应用,定义发病机制治疗 -CRRT治疗,内容提要,定 义,定 义,Sepsis =Infection+SIRSSevere sepsis =Sepsis + organ functionSeptic 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 responseA complex series of cellular, immune and metabolic responses which have evolved to be protective and promote repair processesStimuli 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，P7.3 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 shockEarly 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 organsHVCVVH : 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，超滤率24-36L/24h LLV组：出现少尿后开始，超滤率24-36L/24h (1.9m2纤维素三醋酸脂中空纤维膜)比较指标：28天生存率、ICU与住院生存率,Bouman CSC, et al. CCM, 2002, 30: 2205-2211,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,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,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,Renal replacement,背景：Severe sepsis 和septic shock合并急性肾功能衰竭患者，推荐采用持续性静脉-静脉血液滤过或间歇血液透析进行肾脏替代治疗，其中血流动力学不稳定的患者采用持续血液滤过更有利于液体管理推荐级别：B级,Guidelines for the Managenment of Severe Sepsis and Septic Shock Intensive Care Med 2004, 30: 536-555,总 结,SIRS在重症