2022年医学专题—CRRT：严重脓毒症与MODS(邱海波)(1).ppt

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(jzhn)与危重医学研究所,第一页，共四十四页。,1.CRRT vs IRRT2.Early vs late CRRT 3.High vs normal flow4.Possible ways to increase mediators clearance,Current opinion in CRRT,第二页，共四十四页。,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),第三页，共四十四页。,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(huf)的影响CRRT促进肾功能恢复,Crit Care Med 2003;31:449 455,第四页，共四十四页。,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,第五页，共四十四页。,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(dngmi)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(cjn)肾功能恢复?,第六页，共四十四页。,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(gngnng)的恢复？,第七页，共四十四页。,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,第八页，共四十四页。,CRRT vs IRRTon return of renal functionOn mortality,第九页，共四十四页。,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,第十页，共四十四页。,CRRT vs IRRT对危重病患者(hunzh)的影响CRRT可降低危重病患者病死率,Quality score 5:definitely equal,第十一页，共四十四页。,CRRT vs IRRT对危重病患者(hunzh)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,第十二页，共四十四页。,1.CRRT vs IRRT2.Early vs late CRRT 3.High vs normal flow4.Possible ways to increase mediators clearance,Current opinion in CRRT,第十三页，共四十四页。,19891997：100例创伤(chungshng)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(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,第十四页，共四十四页。,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,生存率明显(mngxin)差异,Gettings LG.Intensive Care Med,1999,25:805-813,OutcomeEarly start 39%survival Late start 20%survival,第十五页，共四十四页。,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 hemofiltration(n=35;72-96L/24 h)Early(12h)low-volume hemofiltration(n=35;24-36L/24 h)Late low-volume hemofiltration(n=36;24-36 L/24 h),Bouman et al.Crit Care Med 30:2205-2211,2002,第十六页，共四十四页。,Dose and Timing of CVVH in ARF,Bouman CS,et al.Critical Care Med 2002;30:2205-2211,74.3%,68.8%,75.0%,0%,20%,40%,60%,80%,100%,28-Day Survival,LV-Late,LV-Early,HV-Early,Treatment Group,n=35SOFA10.32.8,n=36SOFA10.61.9,n=35SOFA10.12.2,第十七页，共四十四页。,1.CRRT vs IRRT2.Early vs late CRRT 3.High vs normal flow4.Possible ways to increase mediators clearance,Current opinion in CRRT,第十八页，共四十四页。,High-volume hemofilitration(HVHF),Ronco C et al.Effects of different doses in CVVH on outcomes of ARF:A prospective RCT,Lancet 2000;356:26-30,第十九页，共四十四页。,RCT of HVHF in Septic Shock,5919 ICUadmissions,Oliguric ARFN=248,Non-oliguric ARFN=130,Not randomized in studyN=142,RandomizedIn studyN-106,EHVn=35,ELVn=35,LLVn=36,Hemofiltrationn=352,No hemofiltrationN=6,Bouman CS et al.Effects of early high-volume CVVH on survival and recovery of renal function in IC patients with ARF.Crit Care Med 2002;30:2205(n=106),第二十页，共四十四页。,EHV 74.3%,LLV 75%,ELV 68.8%,ELV=Early low vol hemofiltration=1-1.5 L/hrLLV=Late low vol hemofiltration=1-1.5 L/hrEHV=Early high vol hemofiltration=3-4 L/hr,Early=within 12 hours of diagnosis of septic shock,Survival%,No difference renal recovery or 28-d mortality,第二十一页，共四十四页。,160 pats with ARF:Daily vs every-other-day ID,N Engl J Med 2002;346:305-310,Survival vs dialysis dose in IHD,第二十二页，共四十四页。,CRRT:Impact on outcomes,Severity of Disease,Survival rate%,High Dose(CRRT),Low Dose(IHD),The Cleveland Clinic Observation,100,90,80,70,60,50,40,30,20,10,0,第二十三页，共四十四页。,ATN(n=1260),Multi-center RCT in the USA.Patients with ARF randomized to:Intensive Management Strategy:If hemodynamically stable(SOFA CVS score:0-2)IHD 6-times/week(target Kt/V=1.2-1.4/session)If hemodynamically unstable(SOFA CVS score:3-4)CVVHDF at 35 ml/kg/hr or SLED 6-times/week(target Kt/V=1.2-1.4/session)Conventional Management Strategy:If h