crrt：嚴重膿毒癥與mods邱海波課件

CRRT

SeveresepsisandMODS邱海波ICU1.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.PossiblewaystoincreasemediatorsclearanceCurrentopinioninCRRTModeofRRT

differencesamongcontinentsBellomo,etal.2001UnderstandingRenalReplacementTherapyandAcuteRenalFailureintheICU(TheB.E.S.Tkidneystudy)IHDvsCRRTICURRTn=116RRTforoverdosen=7Pre-existingCRFn=16ICURRTforARF/MOFn=66InitialCRRTn=66InitialIHDn=28JackaMJ,IvancinovaX,GibneyRTN.CanJAnaesth2005;52:327-332Munnsetal觀察危重急性腎衰竭患者

IHDCRRTCCr下降 25% 7%尿量下降 50%

10%鈉排泄分數下降 46% 12%腎功能下降的原因:IHD平均動脈壓下降，導致腎臟低灌注，加重腎臟缺血性損傷，延遲急性腎衰竭腎功能的恢復為什么CRRT促進腎功能恢復?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為什么CRRT有助于腎臟功能的恢復？？CRRTvsIRRTonreturnofrenalfunctionOnmortalityMortality:

WhichisbetterCRRTorIHD?Swzrtz.RD.

ComparingcontinuousHFwithHDinpatientswithsevereARF

AmJKidney1999;34:424-432Mehti.RL.

CollaborativeGroupforTreatmentofARFinICU:ARCTofcontinuousversusIHDforARF.

KidneyInt2001;60:1154-63KellumJA.

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

Conclusion:ThereisnoconclusiveevidencetosupportthesuperiorityofCRRTvsIHD.BothtechniquesarecomplimentaryCRRTvsIRRT對危重病患者的影響

－CRRT可降低危重病患者病死率Qualityscore5:definitelyequal1.CRRTvsIRRT2.EarlyvslateCRRT

3.Highvsnormalflow4.PossiblewaystoincreasemediatorsclearanceCurrentopinioninCRRT1989－1997：100例創(chuàng)傷后ARF早期－后期的臨界：BUN60mg/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)傷分布均無差異早期－后期CRRT對危重病患者的影響

－早期或預防性CRRT可降低ARF患者病死率GettingsLG.IntensiveCareMed,1999,25:805-813早期－后期CRRT對危重病患者的影響

－早期或預防性CRRT可降低ARF患者病死率生存率－明顯差異GettingsLG.IntensiveCareMed,1999,25:805-813OutcomeEarlystart39%survivalLatestart20%survivalDoseandTimingofCVVHinARFBoumanCS,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±2.21.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.PossiblewaystoincreasemediatorsclearanceCurrentopinioninCRRTHigh-volumehemofilitration(HVHF)RoncoCetal.

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

58%N=425SurvivalLancet2000;356:26-30EHV74.3%LLV75%ELV68.8%ELV=Earlylowvolhemofiltration=1-1.5L/hrLLV=Latelowvolhemofiltration=1-1.5L/hrEHV=Earlyhighvolhemofiltration=3-4L/hrEarly=within12hoursofdiagnosisofsepticshockSurvival%Nodifference

renalrecoveryor28-dmortality

160patswithARF:Dailyvsevery-other-dayIDNEnglJMed2002;346:305-310SurvivalvsdialysisdoseinIHDCRRT:ImpactonoutcomesSeverityofDiseaseSurvivalrate%HighDose(CRRT)LowDose(IHD)TheClevelandClinicObservation1009080706050403020100RENALMulticenterRCT(centers=35)N=1500AustraliaandNewZealand25ml/kg/hrvs.40ml/kg/hrofCVVHDFOutcome:allcausemortalityat90daysCurrentlyunderway1.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.PossiblewaystoincreasemediatorsclearanceCurrentopinioninCRRT目的：評估高流量血濾對感染性休克患者(n-11)血流動力學和細胞因子的影響方法：隨機cross-over試驗，患者隨機接受8hHVHF(6L/h)(AN69濾器，1.6m2)或8hCVVH(1L/h)(AN69濾器，1.2m2)檢測指標：血流動力學、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MAP>70mmHg，HVHF組NE劑量顯著低于CVVHNE劑量分別降低10.5ug/min和1.0ug/minP=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ColeL,etal.IntensiveCareMed,2001,27:978-986MeanNorepinephrineDoseMeanC3aconcentrationMeanC5aconcentrationEffectofHVHFonmortalityOudemans-vanStraatenHmetal,IntensCareMed1999;25:814-821.*=MadridARFscoreHV-CVVH明顯改善感染性休克預后脈沖式高容量血液濾過

(PulseHVHF)極高容量很難維持24h以上，而且對溶質動力學無明顯改進Ranco提出了脈沖式高容量血液濾過SeminarsinDialysis,2006,19(1):69-746420PulseL/hHVHF---Assalvagetherapy

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

Highermembranecut-offPermeabilityConvectionGrootendorstAFetal,1992BellomoRetal,1998LeeseTetal.1987BerlotGetal.1997促進介質清除/遏制炎癥反應的可能途徑12EfficacyofmembraneporesizeonmorbidityandmortalityinanimmatureswinemodelofStaph.AureusinducedsepsisJamesR.Matson,CritCareMed,26:730-737,1998

Cut-off100KDHigherUfvolumes

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

UseofsorbentsincombinationtherapiesAdsorptionRoncoCetal.1999TettaCetal.20013促進介質清除/遏制炎癥反應的可能途徑SorbentCoupledplasmafiltration-adsorption,byregeneratingtheplasmafiltrate,avoidsunwantedlosses,avoidsthecontactofRBC,WBCandplateletswiththesorbent,andpreventstreatmentinducedthrombocytopenia.HemodiafilterPlasmafilter

Dialysate30ml/minPlasmafilter20ml/min100-200ml/minCPFA:HemodynamicsandBiologicalEffectsP<0.01NAMAPat10hoursoftreatmentversusbaselineD-NorepinephrineDoseandD+MAP

0

20

40

60

80100%P<0.01TNFProd.PhagocytosisD

MonocyteTNFproductionandPhagocyticCapacity

0

20

40

60

80100P<0