crrt严重脓毒症与mods邱海波.pptx

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1、1.CRRT vs IRRT2.Early vs late CRRT 3.High vs normal flow4.Possible ways to increase mediators clearanceCurrent opinion in CRRT Current opinion in CRRT 第1页/共43页Mode of RRT differences among continentsBellomo,et al.2001Understanding Renal Replacement Therapy and Acute Renal Failure in the ICU(The B.E.

2、S.T kidney study)第2页/共43页Retrospective cohort study Pats with ARF and required dialysis between April 1,1996,and March 31,19992 ICU in Canada.N=261CRRT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CRRTIHDPAPACHE II2725.10.10Baseline SCr1361800.002MAP Before RRT74.787.20.001Hosp Mortality71.9%42.2%0.01R

3、enal recovery 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IHD vs CRRTICURRTn=116RRTforoverdosen=7Pre-existingCRFn=16ICURRTforARF/MOFn=66InitialCRRTn=66InitialIHDn=28JackaMJ,Ivancino

4、vaX,GibneyRTN.CanJAnaesth2005;52:327-332第4页/共43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?第5页/共43页160 pats with ARF:Daily vs every-other-day IHD160 pats with ARF:Daily vs every-other-day IHDMean Mean u

5、ltrafiltration volumeultrafiltration volumeDaily:1.2 0.5 L Daily:1.2 0.5 L Every-other-day:3.5 0.3 L(P 0.001).Every-other-day:3.5 0.3 L(P 0.001).HypotensionHypotension occurred in occurred in Daily:5 2%Daily:5 2%Every-other-day:25 5%(P 0.001)Every-other-day:25 5%(P 0.001)Time to recovery of renal fu

6、nction Time to recovery of renal function Daily:9 2 days Daily:9 2 days NEnglJMed2002;346:305-310为什么CRRTCRRT有助于肾脏功能的恢复？第6页/共43页Effect of Effect of RRT doseRRT dose on on recovery of renal function?recovery of renal function?P=NSRonco C et al.Effects of different doses in CVVH on outcomes of ARF:A pr

7、ospective RCT20ml/h/kg 35/ml/kg/h45ml/kg/h95%92%90%N=425SurvivalLancet 2000;356:26-30第7页/共43页lCRRT vs IRRTon return of renal functionOn mortality第8页/共43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.Col

8、laborative 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 tec

9、hniques are complimentary第9页/共43页CRRT vs IRRT对危重病患者的影响CRRT可降低危重病患者病死率nQuality score 5:definitely equal第10页/共43页CRRT vs IRRT对危重病患者的影响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

10、,0.340.69,p0.0005 Intensive Care Med,2002,28:29-37第11页/共43页1.CRRT vs IRRT2.Early vs late CRRT 3.High vs normal flow4.Possible ways to increase mediators clearanceCurrent opinion in CRRT Current opinion in CRRT 第12页/共43页19891997：100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

11、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n生存率明显差异Gettings LG.Intensive Care Med,1999,25:805-813OutcomeOutcomeEarlystart39%survivalEarlystart39%survivalLatestart20%survivalLatestart20%survival第14页/共43页Early vs.Late RRTRC

12、T(n=106)Oliguria(30cc/hr)refractorytohigh-dosefurosemide(500mgover6hrs)Randomizedto3groups:Early(12h)high-volumehemofiltration(n=35;72-96L/24h)Early(5060 ml/kg/hrOR:60 L/d including net ultrafiltration in continuous hemofiltration mode第27页/共43页q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)血流血流动力学和细胞因子的

13、影响动力学和细胞因子的影响q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)(AN69m2)或或8h CVVH(1L/h)(AN69m2)q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和液体平衡无差和液体平衡无差异异维持维持MAP70mmHg，HVHF组组NE剂量显著低于剂量显著低于CVVHNEug/min高流量血滤在感染性休克患者中的作高流量血滤在感染性休克患者中的作用用HV

14、HF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第28页/共43页Mean Norepinephrine DoseMean C3a concentrationMean C5a concentration第29页/共43页Effect of HVHF on mortalityOudemans-van Straaten Hm et al,Intens Care Med 1999;25:814-821.Oudemans-van Straaten Hm et al,Intens Care Med 1999

15、;25:814-821.*=Madrid ARF score*=Madrid ARF score第30页/共43页HV-CVVHHV-CVVH明显改善感染性休克预明显改善感染性休克预后后第31页/共43页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):69-746420PulseL/h第32页/共43页第33页/共43页HVHF-As salvage therapyin severe septic shockObjectives:To evalu

16、ate the effect PHVHF(12-h)in reversing progressive refractory hypotension in pats with sshockN=20 sshock pats with NE 0.3 g/kg.min and and lactic acidosisResponders vs Non-R(NE and lactate levels at 6h after PHVHF)IntensiveCareMed(2006)32:713722第34页/共43页Higher Uf volumesHigher Uf volumes Higher memb

17、raneHigher membrane cut-off cut-offPermeabilityConvectionGrootendorst AF et al,1992Grootendorst AF et al,1992Bellomo R et al,1998Bellomo R et al,1998Leese T et al.1987Leese T et al.1987Berlot G et al.1997Berlot G et al.1997促进介质清除/遏制炎症反应的可能途径1 12 2第35页/共43页Efficacy of membrane pore size on morbidity

18、and mortality in an immature swine model of Staph.Aureus induced sepsisJames R.Matson,Crit Care Med,26:730-737,1998James R.Matson,Crit Care Med,26:730-737,1998 Cut-offCut-off100 KD100 KD第36页/共43页Higher Uf volumesHigher Uf volumes Higher membraneHigher membrane cut-off cut-offPermeabilityConvectionGr

19、ootendorst AF et al,1992Grootendorst AF et al,1992Bellomo R et al,1998Bellomo R et al,1998Leese T et al.1987Leese T et al.1987Berlot G et al.1997Berlot G et al.19971 12 2 Use of sorbents inUse of sorbents in c combination therapiesombination therapiesAdsorptionRonco C Ronco C et al.19 et al.199999Te

20、tta CTetta C et al.et al.200120013 3促进介质清除/遏制炎症反应的可能途径第37页/共43页SorbenSorbent tCoupled plasmafiltration-adsorption,by regenerating Coupled plasmafiltration-adsorption,by regenerating the plasmafiltrate,avoids unwanted losses,avoids the the plasmafiltrate,avoids unwanted losses,avoids the contact of R

21、BC,WBC and platelets with the sorbent,contact of RBC,WBC and platelets with the sorbent,and prevents treatment induced thrombocytopenia.and prevents treatment induced thrombocytopenia.HemodiafilterHemodiafilterPlasmafilterPlasmafilter DialysateDialysate30 ml/min30 ml/minPlasmafilterPlasmafilter20 ml

22、/min20 ml/min100-200 ml/min100-200 ml/min第38页/共43页CPFA:Hemodynamics and Biological EffectsNANAMAPMAPat 10 hours of treatment versus baselineat 10 hours of treatment versus baselineD D-Norepinephrine Dose Norepinephrine Dose and and D D+MAPMAP 0 0 2020 4040 6060 8080100100%TNF Prod.TNF Prod.Phagocyto

23、sisPhagocytosisD D Monocyte TNF production Monocyte TNF production and Phagocytic Capacityand Phagocytic Capacity 0 0 2020 4040 6060 80801001000 0 50500 0 1001000 0 1501500 0%at 10 hours of treatment versus baselineat 10 hours of treatment versus baseline pg/mlpg/ml5 5第39页/共43页CVVH+CVVH+血浆吸附对感染性休克血流

24、动力学的影血浆吸附对感染性休克血流动力学的影响响Hemodynamic response to coupledHemodynamic response to coupledplasmafiltration-adsorption in human septic plasmafiltration-adsorption in human septic shockshockN=12 mechanicallyventilatedpatswithsepticshockIntervention:Amedianof10consecutivesessions(prescribedtreatmenttime:10

25、h/session;deliveredduration:8.431.37h/min)ofcoupledplasmafiltration-adsorptionIntensive Care Med(2003)29:703708第40页/共43页CRRT in ICUCRRT in ICUEarly 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 patsWWay to increase mediators clearance:ay to increase mediators clearance:PHVHF vs CPFAPHVHF vs CPFA第41页/共43页Thanks for you attention第42页/共43页感谢您的观看！第43页/共43页