CRRT严重脓毒症与MODS邱海波.ppt
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CRRT严重脓毒症与MODS邱海波.ppt
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CRRTCRRTSeveresepsisandSeveresepsisandMODSMODS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.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.PossiblewaystoincreasemediatorsclearanceCurrentopinioninCRRTCurrentopinioninCRRTModeofRRTdifferencesamongcontinentsBellomo,etal.2001UnderstandingRenalReplacementTherapyandAcuteRenalFailureintheICU(TheB.E.S.Tkidneystudy)RetrospectivecohortstudyPatswithARFandrequireddialysisbetweenApril1,1996,andMarch31,19992ICUinCanada.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CRRTIHDPAPACHEII2725.10.10BaselineSCr1361800.002MAPBeforeRRT74.787.20.001HospMortality71.9%42.2%0.01Renalrecoveryinhosp80.0%62.5%0.06DurationofRRT14.7d14.5d0.91Costperweek(Can$)3486-51171341Survivor(Costpery)No-RRTRRT$11,192$73,273CritCareMed2003;31:
449455IHDvsCRRTICURRTn=116RRTforoverdosen=7Pre-existingCRFn=16ICURRTforARF/MOFn=66InitialCRRTn=66InitialIHDn=28JackaMJ,IvancinovaX,GibneyRTN.CanJAnaesth2005;52:
327-332Munnsetal观察危重急性肾衰竭患者IHDCRRTCCr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?
160patswithARF:
160patswithARF:
DailyDailyvsvsevery-other-every-other-dayIHDdayIHDMeanMeanultrafiltrationultrafiltrationvolumevolumeDaily:
1.2Daily:
1.20.5L0.5LEvery-other-day:
3.5Every-other-day:
3.50.3L(0.3L(PP0.001).0.001).HypotensionHypotensionoccurredinoccurredinDaily:
5Daily:
52%2%Every-other-day:
25Every-other-day:
255%(5%(PP0.001)0.001)TimetorecoveryofrenalfunctionTimetorecoveryofrenalfunctionDaily:
9Daily:
92days2daysEvery-other-day:
16Every-other-day:
166Days6DaysPP=0.001=0.001NEnglJMed2002;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?
EffectofEffectofRRTdoseRRTdoseonrecoveryonrecoveryofrenalfunction?
ofrenalfunction?
P=NSRoncoCetal.EffectsofdifferentdosesinCVVHonoutcomesofARF:
AprospectiveRCT20ml/h/kg35/ml/kg/h45ml/kg/h95%92%90%N=425SurvivalLancet2000;356:
26-30lCRRTvsIRRTonreturnofrenalfunctionOnmortalityMortality:
WhichisbetterCRRTorIHD?
Swzrtz.RD.ComparingcontinuousHFwithHDinpatientswithsevereARFAmJKidney1999;34:
424-432Mehti.RL.CollaborativeGroupforTreatmentofARFinICU:
ARCTofcontinuousversusIHDforARF.KidneyInt2001;60:
1154-63KellumJA.ContinuousversusintermittentRRT.Ameta-analysis.IntensiveCareMed2002;162:
197-202Conclusion:
ThereisnoconclusiveevidencetosupportthesuperiorityofCRRTvsIHD.BothtechniquesarecomplimentaryCRRTvsIRRT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nQualityscore5:
definitelyequalCRRTvsIRRT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Hospitalmortality:
CRRTwasassociatedwithareducedriskofhospitaldeathinthesixstudiesinwhichbaselineseverityofillnesswassimilarRR0.48,0.340.69,p0.0005IntensiveCareMed,2002,28:
29-371.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.PossiblewaystoincreasemediatorsclearanceCurrentopinioninCRRTCurrentopinioninCRRT19891997:
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GettingsLG.IntensiveCareMed,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n生存率明显差异生存率明显差异GettingsLG.IntensiveCareMed,1999,25:
805-813OutcomeOutcomeEarlystart39%survivalEarlystart39%survivalLatestart20%survivalLatestart20%survivalEarlyvs.LateRRTRCT(n=106)Oliguria(30cc/hr)refractorytohigh-dosefurosemide(500mgover6hrs)Randomizedto3groups:
Early(12h)high-volumehemofiltration(n=35;72-96L/24h)Early(5060ml/kg/hrOR:
60L/dincludingnetultrafiltrationincontinuoushemofiltrationmodeq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8hHVHF(6L/h)(AN69滤器,滤器,1.6m2)或或8hCVVH(1L/h)(AN69滤器,滤器,1.2m2)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CVVHNE剂量分别降低剂量分别降低10.5ug/min和和1.0ug/minP=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ColeL,etal.IntensiveCareMed,2001,27:
978-986MeanNorepinephrineDoseMeanC3aconcentrationMeanC5aconcentrationEffectofHVHFonmortalityOudemans-vanOudemans-vanStraatenStraatenHmHmetetal,al,IntensIntensCareCareMedMed1999;25:
814-821.1999;25:
814-821.*=MadridARFscore*=MadridARFscoreHV-CVVHHV-CVVH明显改善感染性休克预后明显改善感染性休克预后脉冲式高容量血液滤过脉冲式高容量血液滤过(PulseHVHF)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SeminarsinDialysis,2006,19
(1):
69-746420PulseL/hHVHF-AssalvagetherapyinseveresepticshockObjectives:
ToevaluatetheeffectPHVHF(12-h)inreversingprogressiverefractoryhypotensioninpatswithsshockN=20sshockpatswithNE0.3g/kg.minandandlacticacidosisRespondersvsNon-R(NEandlactatelevelsat6hafterPHVHF)IntensiveCareMed(2006)32:
713722HigherHigherUfUfvolumesvolumesHighermembraneHighermembranecut-offcut-offPermeabilit
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- CRRT 严重 脓毒症 MODS 海波