CRRT：嚴(yán)重膿毒癥與MODS(邱海波)

1、CRRT Severe sepsis and MODS邱海波東南大學(xué)附屬中大醫(yī)院ICU東南大學(xué)急診與危重醫(yī)學(xué)研究所1. CRRT vs IRRT2. Early vs late CRRT 3. High vs normal flow4.Possible ways to increase mediators clearanceCurrent opinion in CRRT Mode of RRT differences among continentsBellomo, et al. 2001Understanding Renal Replacement Therapy and Acute Ren

2、al 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, 19992 ICU in Canada.N=261CRRT對ARF腎功能恢復(fù)的影響CRRT促進腎功能恢復(fù)CRRTIHDPAPACHE II2725.10.10Baseline SCr1361800.002MAP Before RRT74.787.20.001Hosp Mortality71.9%42.2%

3、0.01Renal 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 455IHD vs CRRTICU RRTn=116 RRT for overdosen=7Pre-existing CRFn=16ICU RRT for ARF/MOFn=66Initial CRRTn=66Initial IHDn=28Ja

4、cka MJ, Ivancinova X, Gibney RTN. Can J Anaesth 2005;52:327-332Munns et al觀察危重急性腎衰竭患者 IHD CRRTCCr下降25%7%尿量下降50%10%鈉排泄分數(shù)下降46%12%腎功能下降的原因: IHD平均動脈壓下降，導(dǎo)致腎臟低灌注，加重腎臟缺血性損傷，延遲急性腎衰竭腎功能的恢復(fù) 為什么CRRT促進腎功能恢復(fù)?160 pats with ARF: Daily vs every-other-day IHDMean ultrafiltration volumeDaily: 1.2 0.5 L Every-other-da

5、y: 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 = 0.001N Engl J Med 2002; 346:305-310為什么CRRT有助于腎臟功能的恢復(fù)？Effect of RRT dose on recovery of renal function?P = NSRonco C et al. Effec

6、ts 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 -30CRRT vs IRRTon return of renal functionOn mortalityMortality:Which is better CRRT or IHD?Swzrtz. RD. Comparing continuous HF with HD in patients with severe

7、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 conclusiv

8、e evidence to support the superiority of CRRT vs IHD. Both techniques are complimentaryCRRT vs IRRT對危重病患者的影響CRRT可降低危重病患者病死率Quality score 5: definitely equalCRRT vs IRRT對危重病患者的影響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 bas

9、eline severity of illness was similar RR 0.48, 0.340.69, p0.0005 Intensive Care Med, 2002, 28: 29-371. CRRT vs IRRT2. Early vs late CRRT 3. High vs normal flow4.Possible ways to increase mediators clearanceCurrent opinion in CRRT 19891997：100例創(chuàng)傷后ARF早期后期的臨界：BUN 60mg/dl兩組病人創(chuàng)傷評分、GCS、發(fā)生休克的比例、年齡、性別和創(chuàng)傷分布均

10、無差異早期后期CRRT對危重病患者的影響早期或預(yù)防性CRRT可降低ARF患者病死率Gettings LG. Intensive Care Med, 1999, 25: 805-813早期后期CRRT對危重病患者的影響早期或預(yù)防性CRRT可降低ARF患者病死率生存率明顯差異Gettings LG. Intensive Care Med, 1999, 25: 805-813OutcomeEarly start 39% survival Late start 20% survivalEarly vs. Late RRTRCT (n =106)Oliguria ( 30cc/hr) refractor

11、y 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/hrOR: 60 L/d including net ultrafiltration in continuous hemofiltration mode目的：評估高流量血濾對感染性休克患者(n-11)血流動力學(xué)和細胞因子的影響方法：隨機cross-over試驗，患者隨機接受8h HVHF (6L/h) (AN

12、69濾器，1.6m2)或8h CVVH (1L/h) (AN69濾器，1.2m2)檢測指標(biāo)：血流動力學(xué)、去甲腎上腺素需要量、血清C3a、C5a、IL-2、IL-8、IL-10和TNF的含量HVHF組與CVVH組CVP、CI、 PAWP和液體平衡無差異維持MAP70mmHg，HVHF組NE劑量顯著低于CVVHNE劑量分別降低10.5ug/min和1.0ug/min P=0.02高流量血濾在感染性休克患者中的作用HVHF顯著降低感染性休克NE用量Cole L, et al. Intensive Care Med, 2001, 27: 978-986Mean Norepinephrine DoseM

13、ean C3a concentrationMean C5a concentrationEffect of HVHF on mortalityOudemans-van Straaten Hm et al, Intens Care Med 1999;25:814-821. *=Madrid ARF scoreHV-CVVH明顯改善感染性休克預(yù)后脈沖式高容量血液濾過 (Pulse HVHF)極高容量很難維持24h以上，而且對溶質(zhì)動力學(xué)無明顯改進Ranco提出了脈沖式高容量血液濾過Seminars in Dialysis, 2006, 19(1): 69-746420PulseL/hHVHF- As

14、salvage therapyin severe septic shockObjectives: To evaluate 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)Intensive Care Med (2006)

15、32:713722Higher Uf volumes Higher membrane cut-offPermeabilityConvectionGrootendorst AF et al , 1992Bellomo R et al, 1998Leese T et al. 1987Berlot G et al. 1997促進介質(zhì)清除/遏制炎癥反應(yīng)的可能途徑12Efficacy of membrane pore size on morbidity and mortality in an immature swine model of Staph. Aureus induced sepsisJame

16、s R. Matson, Crit Care Med, 26: 730-737, 1998 Cut-off100 KDHigher Uf volumes Higher membrane cut-offPermeabilityConvectionGrootendorst AF et al , 1992Bellomo R et al, 1998Leese T et al. 1987Berlot G et al. 199712 Use of sorbents in combination therapiesAdsorptionRonco C et al. 1999Tetta C et al. 200

17、13促進介質(zhì)清除/遏制炎癥反應(yīng)的可能途徑SorbentCoupled plasmafiltration-adsorption, by regenerating the plasmafiltrate, avoids unwanted losses, avoids the contact of RBC, WBC and platelets with the sorbent, and prevents treatment induced thrombocytopenia. HemodiafilterPlasmafilter Dialysate30 ml/minPlasmafilter20 ml/min100-200 ml/minCPFA: Hemodynamics and Biological EffectsP 0.01NAMAPat 10 hours of treatment