crrt严重脓毒症与mods邱海波实用教案

1、1. CRRT vs IRRT2. Early vs late CRRT 3. High vs normal flow4.Current opinion in CRRT Current opinion in CRRT 第1页/共43页第一页，共44页。Mode of RRT differences among continentsBellomo, et al. 2001Understanding Renal Replacement Therapy and Acute Renal Failure in the ICU (The B.E.S.T kidney study)第2页/共43页第二页，共

2、44页。 Retrospective cohort study Pats with ARF and required dialysis between April 1,1996, and March 31, 1999 2 ICU in Canada. N=261CRRT对对ARF肾功能恢复肾功能恢复(huf)的影响的影响CRRT促进肾功能恢复促进肾功能恢复(huf)CRRTIHDPAPACHE II2725.10.10Baseline SCr1361800.002MAP Before RRT74.787.20.001Hosp Mortality71.9%42.2%0.01Renal recov

3、ery in hosp80.0%62.5%0.06Duration of RRT14.7d14.5d0.91Cost per week (Can $)3486-51171341Survivor (Cost per y) No-RRT RRT $11,192 $73,273Crit Care Med 2003; 31:449 455第3页/共43页第三页，共44页。IHD vs CRRTICU RRTn=116 RRT for overdosen=7Pre-existing CRFn=16ICU RRT for ARF/MOFn=66Initial CRRTn=66Initial IHDn=28

4、Jacka MJ, Ivancinova X, Gibney RTN. Can J Anaesth 2005;52:327-332第4页/共43页第四页，共44页。 Munns et al观察危重急性肾衰竭患者 IHD CRRT CCr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(snshng)，延迟急性肾衰竭肾功能的恢复 为什么为什么CRRT促进促进(cjn)肾功能肾功能恢复恢复?第5页/共43页第五页，共44页。 160 pats with ARF: Daily vs every-other-

5、day IHD160 pats with ARF: Daily vs every-other-day IHD Mean Mean ultrafiltration volumeultrafiltration volume Daily: 1.2 Daily: 1.2 0.5 L 0.5 L Every-other-day: 3.5 Every-other-day: 3.5 0.3 L (P 0.001). 0.3 L (P 0.001). HypotensionHypotension occurred in occurred in Daily: 5 Daily: 5 2% 2% Every-oth

6、er-day: 25 Every-other-day: 25 5% (P 0.001) 5% (P 0.001) Time to recovery of renal function Time to recovery of renal function Daily: 9 Daily: 9 2 days 2 days N Engl J Med 2002; 346:305-310为什么CRRTCRRT有助于肾脏(shnzng)(shnzng)功能的恢复？第6页/共43页第六页，共44页。Effect of Effect of RRT doseRRT dose on on recovery of r

7、enal function?recovery of renal function?P = NS Ronco C et al. Effects of different doses in CVVH on outcomes of ARF:A prospective RCT20ml/h/kg 35/ml/kg/h45ml/kg/h95% 92% 90%N=425SurvivalLancet 2000; 356: 26 -30第7页/共43页第七页，共44页。lCRRT vs IRRTon return of renal functionOn mortality第8页/共43页第八页，共44页。Mor

8、tality: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 inte

9、rmittent 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第9页/共43页第九页，共44页。CRRT vs IRRT对危重病患者的影响(yngxing)CRRT可降低危重病患者病死率nQuality score 5: definitely equal第10页/共43页第十页，共

10、44页。CRRT vs IRRT对危重病患者(hunzh)的影响CRRT可降低危重病患者(hunzh)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第11页/共43页第十一页，共44页。1. CRRT vs IRRT2. E

11、arly vs late CRRT 3. High vs normal flow4.Current opinion in CRRT Current opinion in CRRT 第12页/共43页第十二页，共44页。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(ninlng)、性别和创伤分布均无差异早期后期(huq)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第13页/共43页第十三页，共44

12、页。早期(zoq)后期CRRT对危重病患者的影响早期(zoq)或预防性CRRT可降低ARF患者病死率n生存率明显(mngxin)差异Gettings LG. Intensive Care Med, 1999, 25: 805-813第14页/共43页第十四页，共44页。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 hemofiltrati

13、on (n=35; 72-96L/24 h) Early ( 5060 ml/kg/hr OR: 60 L/d including net ultrafiltration in continuous hemofiltration mode第27页/共43页第二十七页，共44页。q目的目的(md)：评估高流量血滤对感染性休克患者：评估高流量血滤对感染性休克患者(n-11)血血流动力学和细胞因子的影响流动力学和细胞因子的影响q方法：随机方法：随机cross-over试验，患者随机接受试验，患者随机接受8h HVHF (6L/h) (AN69m2)或或8h CVVH (1L/h) (AN69m2)q

14、检测指标：血流动力学、去甲肾上腺素需要量、血清检测指标：血流动力学、去甲肾上腺素需要量、血清C3a、C5a、IL-2、IL-8、IL-10和和TNF的含量的含量qHVHF组与组与CVVH组组CVP、CI、 PAWP和液体平衡无差异和液体平衡无差异q维持维持MAP70mmHg，HVHF组组NE剂量显著低于剂量显著低于CVVHqNEug/min高流量血滤在感染性休克患者中的作用(zuyng)HVHF显著降低感染性休克NE用量Cole L, et al. Intensive Care Med, 2001, 27: 978-986第28页/共43页第二十八页，共44页。Mean Norepinephr

15、ine DoseMean C3a concentrationMean C5a concentration第29页/共43页第二十九页，共44页。第30页/共43页第三十页，共44页。HV-CVVHHV-CVVH明显改善感染性休克明显改善感染性休克(xik)(xik)预后预后第31页/共43页第三十一页，共44页。脉冲式高容量血液(xuy)滤过 (Pulse HVHF) 极高容量很难维持24h以上，而且对溶质(rngzh)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): 69-746420PulseL/h第32页/共43页

16、第三十二页，共44页。第33页/共43页第三十三页，共44页。HVHF- As salvage therapyin severe septic shockObjectives: To evaluate the effect PHVHF (12-h) in reversing progressive refractory hypotension in pats with sshock N=20 sshock pats with NE 0.3 g/kg.min and and lactic acidosisResponders vs Non-R (NE and lactate levels at

17、6h after PHVHF)Intensive Care Med (2006) 32:713722第34页/共43页第三十四页，共44页。第35页/共43页第三十五页，共44页。第36页/共43页第三十六页，共44页。第37页/共43页第三十七页，共44页。第38页/共43页第三十八页，共44页。第39页/共43页第三十九页，共44页。CVVH + CVVH + 血浆吸附血浆吸附(xf)(xf)对感染性休克血流动力学的影对感染性休克血流动力学的影响响Hemodynamic response to coupledHemodynamic response to coupledplasmafilt

18、ration-adsorption in human septic plasmafiltration-adsorption in human septic shockshock N=12 mechanically ventilated pats with septic shock Intervention: A median of 10 consecutive sessions (prescribed treatment time: 10 h/session; delivered duration: 8.431.37 h/min) of coupled plasmafiltration-adsorptionIntensive Care Med (2003) 29:703708第40页/共43页第四十页，共44页。CRRT in ICUCRRT in ICU Early CRRT: 改善创伤合并改善创伤合并ARF患者的预后患者的预后 CRRTvs IRRT： CRRT可能促进肾脏功能恢复可能促进肾脏功能恢复(huf) 可能降低危重病人的病死率可能降低危重病人的病死率 Use 45 ml/kg.min for CVVH for septic shock pats Way to increase mediators clearance: PHVHF vs CPFA第41页/共4