CRRT：严重脓毒症与MODS(邱海波).ppt

CRRT CRRT Severe sepsis and Severe sepsis and MODSMODS 邱海波邱海波 东南大学附属中大医院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东南大学急诊与危重医学研究所 1.CRRT vs IRRT 2.Early vs late CRRT 3.High vs normal flow 4.Possible ways to increase mediators clearance Current opinion in CRRT Current opinion in CRRT Mode of RRT differences among continents 0%20%40%60%80%100%AsiaAustraliaEuropeNorthAmericaSouthAmericaContinuousIntermittentOtherBellomo,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 31,1999 2 ICU in Canada.N=261 CRRT对对ARF肾功能恢复的影响肾功能恢复的影响 CRRTCRRT促进肾功能恢复促进肾功能恢复 CRRT IHD P APACHE II 27 25.1 0.10 Baseline SCr 136 180 0.002 MAP Before RRT 74.7 87.2 0.001 Hosp Mortality 71.9%42.2%0.01 Renal recovery in hosp 80.0%62.5%0.06 Duration of RRT 14.7d 14.5d 0.91 Cost per week(Can$)3486-5117 1341 Survivor(Cost per y)No-RRT RRT$11,192$73,273 Crit Care Med 2003;31:449 455 IHD vs CRRT ICU RRT n=116 RRT for overdose n=7 Pre-existing CRF n=16 ICU RRT for ARF/MOF n=66 Initial CRRT n=66 Initial IHD n=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 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，延迟急性肾衰竭肾功能的恢复 为什么为什么CRRT促进肾功能恢复促进肾功能恢复?160 pats with ARF:Daily vs every160 pats with ARF:Daily vs every-otherother-day IHDday IHD Mean Mean ultrafiltration volumeultrafiltration volume Daily:1.2 Daily:1.2 0.5 L 0.5 L EveryEvery-otherother-day:3.5 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%EveryEvery-otherother-day:25 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 EveryEvery-otherother-day:16 day:16 6 Days P=0.0016 Days P=0.001 N Engl J Med 2002;346:305-310 为什么为什么CRRTCRRT有助于肾脏功能的恢复？有助于肾脏功能的恢复？Effect of Effect of RRT doseRRT dose on recovery on recovery of renal function?of renal function?P=NS Ronco C et al.Effects of different doses in CVVH on outcomes of ARF:A prospective RCT 20ml/h/kg 35/ml/kg/h 45ml/kg/h 95%92%90%N=425 Survival Lancet 2000;356:26-30 CRRT vs IRRT on return of renal function On mortality Mortality:Which is better CRRT or IHD?Swzrtz.RD.Comparing continuous HF with HD in patients with severe ARF Am J Kidney 1999;34:424-432 Mehti.RL.Collaborative Group for Treatment of ARF in ICU:A RCT of continuous versus IHD for ARF.Kidney Int 2001;60:1154-63 Kellum 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对危重病患者的影响 CRRT可降低危重病患者病死率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对危重病患者的影响 CRRT可降低危重病患者病死率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 IRRT 2.Early vs late CRRT 3.High vs normal flow 4.Possible ways to increase mediators clearance Current opinion in CRRT 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 早期后期早期后期CRRT对危重病患者的影响对危重病患者的影响 早期或预防性早期或预防性CRRT可降低可降低ARF患者病死率患者病死率 Gettings LG.Intensive Care Med,1999,25:805-813 早期后期早期后期CRRT对危重病患者的影响对危重病患者的影响 早期或预防性早期或预防性CRRT可降低可降低ARF患者病死率患者病死率 生存率明显差异生存率明显差异 Gettings LG.Intensive Care Med,1999,25:805-813 Outcome Early 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/hr OR:60 L/d including net ultrafiltration in continuous hemofiltration mode 目的：目的：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)血流动力血流动力学和细胞因子的影响学和细胞因子的影响 方法：方法：随机随机cross-over试验，患者随机接受试验，患者随机接受8h HVHF(6L/h)(AN69滤器，滤器，1.6m2)或或8h CVVH(1L/h)(AN69滤器，滤器，1.2m2)检测指标：检测指标：血流动力学、去甲肾上腺素需要量、血清血流动力学、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 HVHF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 维持维持MAP70mmHg，HVHF组组NE剂量显著低于剂量显著低于CVVH NE剂量分别降低剂量分别降低10.5ug/min和和1.0ug/min P=0.02 高流量血滤在感染性休克患者中的作用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显著降低感染性休克NE用量用量 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 020406080AllCardiacsurgicalOther surgicalCardiacMedicalMortality(%)PredictedObservedOudemans-van Straaten Hm et al,Intens Care Med 1999;25:814-821.*=Madrid ARF score HVHV-CVVHCVVH明显改善感染性休克预后明显改善感染性休克预后 46.0%46.0%75.0%75.0%70.5%70.5%65.0%65.0%0%0%20%20%40%40%60%60%80%80%100%100%HV-CVVHHHV-CVVHHSOFA-SOFA-PredictedPredictedLOD-LOD-predictedpredictedMODS-MODS-predictedpredictedMortality(%)Mortality(%)脉冲式高容量血液滤过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 6 4 2 0 Pulse L/h HVHF-A