Renal-replacement-Strategies-in-the-ICU课件.ppt

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1、Renal replacement Strategies in the ICUChest 2007;132/1379-1388IntroductionoSelon les tudes lincidence de linsuffisance rnale(IRn)en ranimation varie de 5 20%oIRn augmente la morbimortalit des patients de ranimation oIRn associe une dfaillance multiviscrale:90%de mortalitDeux techniquesDeux grands p

2、rincipesoHmodialyse:Gradient de concentration ncessite une concentration leve,PM(5000 Da),dbit sang levoHmofiltration:gradient de pression:PM(30 000 Da),Pression transmembranaireTimingoCratininmie seuil pour linstitution dune puration extra-rnale?Pas de consensus clairoPas dindication l EER prophyla

3、ctiqueBauer M,Marzi I,Ziegenfuss T,et al.Prophylactic hemofiltration in severely traumatized patients:effects on posttraumatic organ dysfunction syndrome.Intensive Care Med 2001;27:376383 Cole L,Bellomo R,Hart G,et al.A phase II randomized,controlled trial of continuous hemofiltration in sepsis.Crit

4、 Care Med 2002;30:100106oEER prcoce?Pas de diffrence de survie J28 mais peu de patients atteints de sepsisBouman CSC,Oudemans-van Straaten HM,Tijssen JGP,et al.Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with

5、 acute renal failure:a prospective,randomized trial.Crit Care Med 2002;30:22052211Dose d puration extra-rnaleoHemofiltration:haut dbit+35ml/kg/j Ronco C,Bellomo R,Homel P,et al.Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure:a prospective rando

6、mised trial.Lancet 2000;356:2630oHmodialyse:3 4h,quotidienne+Schiffl H,Lang SM,Fischer R.Daily hemodialysis and the outcome of acute renal failure.N Engl J Med 2002;346:305310Tolrance hmodynamiqueoLhmofiltration avait la rputation davoir une meilleure stabilit hmodynamiqueoMais amlioration hmodynami

7、que de lhmodialyse depuis:-Augmentation du temps d dialyse-Dialyse quotidienne-Connexion blanche-Refroidissement des bains de dialyse-Bain de dialyse forte concentration de sodium Schortgen F,Soubrier N,Delclaux C,et al.Hemodynamic tolerance of intermittent hemodialysis in critically ill patients:us

8、efulness of practice guidelines.Am J Respir Crit Care Med 2000;162:197202Mthodes continues/discontinues:rsultats long termePas de diffrence en terme de survie 60 jours Vinsonneau C,Camus C,Combes A,et al.Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failu

9、re in patients with multiple-organ dysfunction syndrome:a multicentre randomised trial.Lancet 2006;368:379385Inflammation et Epuration Extra rnaleoHypothse:Epuration des cytokines?Mais-Seule une petite partie de ces molecules sont limines-Adsorption plutot que puration-Elimination des molcules pro m

10、ais aussi anti-inflammatoiresDe Vriese AS,Vanholder R,Pascual M,et al.Can inflammatory mediators be removed fficiently by continuous renal replacement techniques.Intensive Care Med 1999;25:903910Silvester W.Mediator removal with CRRT:complement and cytokines.Am J Kidney Dis 1997;30:3843 De Vriese AS

11、,Colardyn F,Philippe J,et al.Cytokine removal during continuous hemofiltration in septic patients.J Am Soc Nephrol 1999;10:846853Hmofiltration pratique(1)oKT dialyse nJugulaire Dt 15cm,nJugulaire G 20cm,nFmoral 25cm 13 14 FoBobine nHF12 si debit 4500ml/hoVerrou hparin des voies du KT si dialyse pas

12、branche immdiatement(100ui/ml)AlarmesoPression artrielle basse ou pression veineuse leve:Modifier position du KT central,diminuer dbit sangoPression Trans-membranaire et Pression Pr filtre leves:Coagulation Filtre,RinceroPression Trans-membranaire leve et Pression Pr filtre Normale:diminuer dbit sang(dbit trop haut pour le filtre)