医学专题一CRRT：严重脓毒症与MODS(邱海波).ppt

《医学专题一CRRT：严重脓毒症与MODS(邱海波).ppt》由会员分享，可在线阅读，更多相关《医学专题一CRRT：严重脓毒症与MODS(邱海波).ppt（44页珍藏版）》请在淘文阁 - 分享文档赚钱的网站上搜索。

1、CRRT CRRT Severe sepsis and Severe sepsis and MODSMODS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东南大学急诊东南大学急诊(jzhn)与危重医学研究所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 clearanceCurrent opinion in CRRT Current opinion in CRRT 第二页，共四十四页。ModeofRRTdif

2、ferencesamongcontinentsBellomo,et al.2001Understanding 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=261CRRT对对ARF肾功能恢复肾功能恢复(huf)的影响

3、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%0.01Renal 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;31:449 455

4、第四页，共四十四页。IHDvsCRRTICURRTn=116RRTforoverdosen=7Pre-existingCRFn=16ICURRTforARF/MOFn=66InitialCRRTn=66InitialIHDn=28JackaMJ,IvancinovaX,GibneyRTN.CanJAnaesth2005;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

5、的恢复 为什么为什么CRRT促进促进(cjn)(cjn)肾功能恢复肾功能恢复?第六页，共四十四页。160 pats with ARF:Daily vs every-other-160 pats with ARF:Daily vs every-other-day IHDday IHDMean Mean ultrafiltration volumeultrafiltration volumeDaily:1.2 Daily:1.2 0.5 L 0.5 L Every-other-day:3.5 Every-other-day:3.5 0.3 L(P 0.001).0.3 L(P 0.001).Hyp

6、otensionHypotension occurred in occurred in Daily:5 Daily:5 2%2%Every-other-day:25 Every-other-day:25 5%(P 0.001)5%(P 0.001)Time to recovery of renal function Time to recovery of renal function Daily:9 Daily:9 2 days 2 days Every-other-day:16 Every-other-day:16 6 Days P=0.001 6 Days P=0.001NEnglJMed

7、2002;346:305-310为什么为什么CRRTCRRT有助于肾脏功能有助于肾脏功能(gngnng)(gngnng)的恢复？的恢复？第七页，共四十四页。Effect of Effect of RRT doseRRT dose on recovery on recovery of renal function?of renal function?P=NSRonco C et al.Effects of different doses in CVVH on outcomes of ARF:A prospective RCT20ml/h/kg 35/ml/kg/h45ml/kg/h95%92%9

8、0%N=425SurvivalLancet 2000;356:26-30第八页，共四十四页。lCRRT 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:

9、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 IR

10、RT对危重病患者对危重病患者(hunzh)的影响的影响CRRT可降低危重病患者病死率可降低危重病患者病死率nQuality score 5:definitely equal第十一页，共四十四页。CRRT vs IRRT对危重病患者对危重病患者(hunzh)的影响的影响CRRT可降低危重病患者病死率可降低危重病患者病死率Hospital mortality:CRRT was associated with a reduced risk of hospital death in the six studies in which baseline severity of illness was si

11、milar 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 clearanceCurrent opinion in CRRT 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：BUN60mg/dl两组病人创伤评分、GCS、发生休

12、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(huq)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Gettings LG.Intensive Care Med,1999,25:805-813第十四页，共四十四页。早期后期早期后期(huq)CRRT对危重病患者的影对危重病患者的影响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生存率明显生存率明显(mngxin)差异差异Gettings LG.Intensive Care Med,1999,25:805-813OutcomeEarlysta

13、rt39%survivalEarlystart39%survivalLatestart20%survival第十五页，共四十四页。Early vs.Late RRTRCT(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

14、hemofiltration mode第二十八页，共四十四页。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)血流动力学和细胞血流动力学和细胞因子的影响因子的影响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)(AN69滤器，滤器，1.6m2)或或8h CVVH(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(hnling)HVHF组与组与CV

15、VH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/min P=0.02高流量高流量(liling)血滤在感染性休克患者中的作血滤在感染性休克患者中的作用用HVHF显著降低感染性休克显著降低感染性休克NE用量用量Cole L,et al.Intensive Care Med,2001,27:978-986第二十九页，共四十四页。Mean Norepinephrine DoseMean C3a concentrationMean C5a conce

16、ntration第三十页，共四十四页。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;25:814-821.*=Madrid ARF score*=Madrid ARF score第三十一页，共四十四页。HV-CVVHHV-CVVH明显改善感染性休克明显改善感染性休克(xik)(xik)预后预后第三十二页，共四十四页。脉冲式高容量血液脉冲式高容量血液(xuy)滤

17、过滤过(Pulse HVHF)极高容量很难维持24h以上，而且(rqi)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第三十三页，共四十四页。第三十四页，共四十四页。HVHF-As salvage therapyin severe septic shockObjectives:To evaluate the effect PHVHF(12-h)in reversing progressive refractory hypotension in pats with sshockN=20

18、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第三十五页，共四十四页。Higher Uf volumes Higher membrane cut-offPermeabilityConvectionGrootendorst AF et al,1992Grootendorst AF et al,1992Bellomo R et al,1998Bellom

19、o R et al,1998Leese T et al.1987Leese T et al.1987Berlot G et al.1997Berlot G et al.1997促进介质清除促进介质清除/遏制炎症反应遏制炎症反应(fnyng)(fnyng)(fnyng)(fnyng)的可能途径的可能途径12 2第三十六页，共四十四页。Efficacy of membrane pore size on morbidity and mortality in an immature swine model of Staph.Aureus induced sepsisJames R.Matson,Cri

20、t Care Med,26:730-737,1998James R.Matson,Crit Care Med,26:730-737,1998 Cut-offCut-off100 KD100 KD第三十七页，共四十四页。Higher Uf volumes Higher membraneHigher membrane cut-offPermeabilityConvectionGrootendorst AF et al,1992Grootendorst AF et al,1992Bellomo R et al,1998Bellomo R et al,1998Leese T et al.1987Lee

21、se T et al.1987Berlot G et al.1997Berlot G et al.199712 Use of sorbents inUse of sorbents in combination therapiesAdsorptionRonco C Ronco C et al.19 et al.199999Tetta CTetta C et al.et al.200120013促进介质促进介质(jizh)(jizh)(jizh)(jizh)清除清除/遏制炎症反应的可能途径遏制炎症反应的可能途径第三十八页，共四十四页。SorbentCoupled plasmafiltration-

22、adsorption,by regenerating the plasmafiltrate,avoids unwanted losses,avoids the contact of RBC,WBC and platelets with the sorbent,and prevents treatment induced thrombocytopenia.HemodiafilterPlasmafilterPlasmafilter DialysateDialysate30 ml/min30 ml/minPlasmafilterPlasmafilter20 ml/min20 ml/min100-20

23、0 ml/min100-200 ml/min第三十九页，共四十四页。CPFA:Hemodynamics and Biological EffectsP 0.01P 0.01NANAMAPMAPat 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%P 0.01P 0.01TNF Prod.TNF Prod.P

24、hagocytosisPhagocytosisD D Monocyte TNF production and Monocyte TNF production and Phagocytic CapacityPhagocytic Capacity 0 0 2020 4040 6060 8080100100P 0.01P 0.010 0 50500 0 1001000 0 1501500 0%at 10 hours of treatment versus baselineat 10 hours of treatment versus baseline pg/mlpg/mlP 0.0P 0.05 5第

25、四十页，共四十四页。CVVH+CVVH+血浆吸附对感染性休克血浆吸附对感染性休克(xik)(xik)血流动力学的影响血流动力学的影响Hemodynamic response to coupledHemodynamic response to coupledplasmafiltration-adsorption in human septic shockplasmafiltration-adsorption in human septic shockN=12 mechanicallyventilatedpatswithsepticshockIntervention:Amedianof10cons

26、ecutivesessions(prescribedtreatmenttime:10h/session;deliveredduration:8.431.37h/min)ofcoupledplasmafiltration-adsorptionIntensive Care Med(2003)29:703708第四十一页，共四十四页。CRRT in ICUCRRT in ICUEarly CRRT:改善创伤改善创伤(chungshng)合并合并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

27、 ml/kg.min for CVVH for septic shock patsWay to increase mediators clearance:ay to increase mediators clearance:PHVHF vs CPFA第四十二页，共四十四页。Thanks for you attention第四十三页，共四十四页。内容(nirng)总结CRRT Severe sepsis and MODS。CRRT对ARF肾功能恢复的影响CRRT促进肾功能恢复。35/ml/kg/h。45ml/kg/h。两组病人创伤评分、GCS、发生休克(xik)的比例、年龄、性别和创伤分布均无差异。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。24-36L/24 h)。可能降低危重病人的病死率第四十四页，共四十四页。