CRRT：严重脓毒症与MODS(邱海波)课件

CRRT

SeveresepsisandMODS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CRRT

SeveresepsisandMODS邱海1.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.PossiblewaystoincreasemediatorsclearanceCurrentopinioninCRRT1.CRRTvsIRRTCurrentopinioModeofRRT

differencesamongcontinentsBellomo,etal.2001UnderstandingRenalReplacementTherapyandAcuteRenalFailureintheICU(TheB.E.S.Tkidneystudy)ModeofRRT

differencesamongRetrospectivecohortstudyPatswithARFandrequireddialysisbetweenApril1,1996,andMarch31,19992ICUinCanada.N=261CRRT对ARF肾功能恢复的影响

－CRRT促进肾功能恢复CRRTIHDPAPACHEII2725.10.10BaselineSCr1361800.002MAPBeforeRRT74.787.2<0.001HospMortality71.9%42.2%<0.01Renalrecoveryinhosp80.0%62.5%0.06DurationofRRT14.7d14.5d0.91Costperweek(Can$)3486-51171341Survivor(Costpery)No-RRTRRT$11,192$73,273CritCareMed2003;31:449–455RetrospectivecohortstudyCRRIHDvsCRRTICURRTn=116RRTforoverdosen=7Pre-existingCRFn=16ICURRTforARF/MOFn=66InitialCRRTn=66InitialIHDn=28JackaMJ,IvancinovaX,GibneyRTN.CanJAnaesth2005;52:327-332IHDvsCRRTICURRTRRTforoverMunnsetal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?Munnsetal观察危重急性肾衰竭患者为什么CRRT促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=0.001NEnglJMed2002;346:305-310为什么CRRT有助于肾脏功能的恢复？？160patswithARF:DailyvseEffectofRRTdoseonrecoveryofrenalfunction?P=NSRoncoCetal.

EffectsofdifferentdosesinCVVHonoutcomesofARF:AprospectiveRCT20ml/h/kg35/ml/kg/h45ml/kg/h95%92%

90%N=425SurvivalLancet2000;356:26-30EffectofRRTdoseonrecoveryCRRTvsIRRTonreturnofrenalfunctionOnmortalityCRRTvsIRRTMortality:

WhichisbetterCRRTorIHD?Swzrtz.RD.

ComparingcontinuousHFwithHDinpatientswithsevereARF

AmJKidney1999;34:424-432Mehti.RL.

CollaborativeGroupforTreatmentofARFinICU:ARCTofcontinuousversusIHDforARF.

KidneyInt2001;60:1154-63KellumJA.

ContinuousversusintermittentRRT.Ameta-analysis.IntensiveCareMed2002;162:197-202

Conclusion:ThereisnoconclusiveevidencetosupportthesuperiorityofCRRTvsIHD.BothtechniquesarecomplimentaryMortality:

WhichisbetterCRRCRRTvsIRRT对危重病患者的影响

－CRRT可降低危重病患者病死率Qualityscore5:definitelyequalCRRTvsIRRT对危重病患者的影响

－CRRT可降低CRRTvsIRRT对危重病患者的影响

－CRRT可降低危重病患者病死率Hospitalmortality:CRRTwasassociatedwithareducedriskofhospitaldeathinthesixstudiesinwhichbaselineseverityofillnesswassimilar

RR0.48,0.34–0.69,p<0.0005IntensiveCareMed,2002,28:29-37CRRTvsIRRT对危重病患者的影响

－CRRT可降低1.CRRTvsIRRT2.EarlyvslateCRRT

3.Highvsnormalflow4.PossiblewaystoincreasemediatorsclearanceCurrentopinioninCRRT1.CRRTvsIRRTCurrentopinio1989－1997：100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,1999,25:805-8131989－1997：100例创伤后ARF早期－后期CRRT对早期－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,1999,25:805-813OutcomeEarlystart39%survivalLatestart20%survival早期－后期CRRT对危重病患者的影响

－早期或预防性CRRTEarlyvs.LateRRTRCT(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.CritCareMed30:2205-2211,2002Earlyvs.LateRRTRCT(n=106)DoseandTimingofCVVHinARFBoumanCS,etal.CriticalCareMed2002;30:2205-221174.3%68.8%75.0%0%20%40%60%80%100%28-DaySurvivalLV-LateLV-EarlyHV-EarlyTreatmentGroupn=35SOFA10.3±2.8n=36SOFA10.6±1.9n=35SOFA10.1±2.2DoseandTimingofCVVHinARF1.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.PossiblewaystoincreasemediatorsclearanceCurrentopinioninCRRT1.CRRTvsIRRTCurrentopinioHigh-volumehemofilitration(HVHF)RoncoCetal.

EffectsofdifferentdosesinCVVHonoutcomesofARF:AprospectiveRCT20ml/h/kg35/ml/kg/h45ml/kg/h41%57%

58%N=425SurvivalLancet2000;356:26-30High-volumehemofilitration(HRCTofHVHFinSepticShock5919ICUadmissionsOliguricARFN=248Non-oliguricARFN=130NotrandomizedinstudyN=142RandomizedInstudyN-106EHVn=35ELVn=35LLVn=36Hemofiltrationn=352NohemofiltrationN=6BoumanCSetal.

Effectsofearlyhigh-volumeCVVHonsurvivalandrecoveryofrenalfunctioninICpatientswithARF.

CritCareMed2002;30:2205(n=106)RCTofHVHFinSepticShock591EHV74.3%LLV75%ELV68.8%ELV=Earlylowvolhemofiltration=1-1.5L/hrLLV=Latelowvolhemofiltration=1-1.5L/hrEHV=Earlyhighvolhemofiltration=3-4L/hrEarly=within12hoursofdiagnosisofsepticshockSurvival%Nodifference

renalrecoveryor28-dmortality

EHV74.3%LLV75%ELV68.8%ELV=160patswithARF:Dailyvsevery-other-dayIDNEnglJMed2002;346:305-310SurvivalvsdialysisdoseinIHD160patswithARF:DailyvseCRRT:ImpactonoutcomesSeverityofDiseaseSurvivalrate%HighDose(CRRT)LowDose(IHD)TheClevelandClinicObservation1009080706050403020100CRRT:ImpactonoutcomesSeveriATN(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)ATN(n=1260)Multi-centerRCTiRENALMulticenterRCT(centers=35)N=1500AustraliaandNewZealand25ml/kg/hrvs.40ml/kg/hrofCVVHDFOutcome:allcausemortalityat90daysCurrentlyunderwayRENALMulticenterRCT(centers1.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.PossiblewaystoincreasemediatorsclearanceCurrentopinioninCRRT1.CRRTvsIRRTCurrentopinioHigherUfvolumesConvectionGrootendorstAFetal,1992BellomoRetal,19981促进介质清除/遏制炎症反应的可能途径HigherUfvolumesConvectionGrHVHFHVHF:Anultrafiltrationrate>50–60ml/kg/hrOR:60L/dincludingnetultrafiltrationincontinuoushemofiltrationmodeHVHFHVHF: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MeanNorepinephrineDoseMeanC3aconcentrationMeanC5aconcentrationMeanNorepinephrineDoseMeanCEffectofHVHFonmortalityOudemans-vanStraatenHmetal,IntensCareMed1999;25:814-821.*=MadridARFscoreEffectofHVHFonmortalityOudHV-CVVH明显改善感染性休克预后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,2006,19(1):69-746420PulseL/h脉冲式高容量血液滤过

(PulseHVHF)极高容量很难CRRT：严重脓毒症与MODS(邱海波)课件HVHF---Assalvagetherapy

inseveresepticshockObjectives:ToevaluatetheeffectPHVHF(12-h)inreversingprogressiverefractoryhypotensioninpatswithsshockN=20sshockpatswithNE>0.3μg/kg.minandandlacticacidosisRespondersvsNon-R(NEandlactatelevelsat6hafterPHVHF)IntensiveCareMed(2006)32:713–722HVHF---Assalvagetherapy

inHigherUfvolumes

Highermembranecut-offPermeabilityConvectionGrootendorstAFetal,1992BellomoRetal,1998LeeseTetal.1987BerlotGetal.1997促进介质清除/遏制炎症反应的可能途径12HigherUfvolumesHighermEfficacyofmembraneporesizeonmorbidityandmortalityinanimmatureswinemodelofStaph.AureusinducedsepsisJamesR.Matson,CritCareMed,26:730-737,1998

Cut-off100KDEfficacyofmembraneporesizeHigherUfvolumes

Highermembranecut-offPermeabilityConvectionGrootendorstAFetal,1992BellomoRetal,1998LeeseTetal.1987BerlotGetal.199712

UseofsorbentsincombinationtherapiesAdsorptionRoncoCetal.1999TettaCetal.20013促进介质清除/遏制炎症反应的可能途径HigherUfvolumesHighermSorbentCoupledplasmafiltration-adsorption,byregeneratingtheplasmafiltrate,avoidsunwantedlosses,avoidsthecontact