CRRT嚴(yán)重膿毒癥與MODS(邱海波)課件

1、CRRT CRRT Severe sepsis and Severe sepsis and MODSMODS邱海波邱海波東南大學(xué)附屬中大醫(yī)院東南大學(xué)附屬中大醫(yī)院ICU東南大學(xué)急診東南大學(xué)急診(jzhn)與危重醫(yī)學(xué)研究所與危重醫(yī)學(xué)研究所第一頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)1. CRRT vs IRRT2. Early vs late CRRT 3. High vs normal flow4.Current opinion in CRRT Current opinion in CRRT 第二頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)Mode of RRT diff

2、erences among continentsBellomo, et al. 2001Understanding Renal Replacement Therapy and Acute Renal Failure in the ICU (The B.E.S.T kidney study)第三頁，共四十四頁。 Retrospective cohort study Pats with ARF and required dialysis between April 1,1996, and March 31, 1999 2 ICU in Canada. N=261CRRT對(duì)對(duì)ARF腎功能恢復(fù)腎功能恢

3、復(fù)(huf)的影響的影響CRRTCRRT促進(jìn)腎功能恢復(fù)促進(jìn)腎功能恢復(fù)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

4、2003; 31:449 455第四頁，共四十四頁。IHD vs CRRTICU RRTn=116 RRT for overdosen=7Pre-existing CRFn=16ICU RRT for ARF/MOFn=66Initial CRRTn=66Initial IHDn=28Jacka MJ, Ivancinova X, Gibney RTN. Can J Anaesth 2005;52:327-332第五頁，共四十四頁。 Munns et al觀察危重急性腎衰竭患者 IHD CRRT CCr下降25%7% 尿量下降50%10% 鈉排泄分?jǐn)?shù)下降46%12%腎功能下降的原因: IHD平

5、均動(dòng)脈(dngmi)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) 為什么為什么CRRT促進(jìn)促進(jìn)(cjn)(cjn)腎功能恢復(fù)腎功能恢復(fù)? ?第六頁，共四十四頁。 160 pats with ARF: Daily vs every-other-160 pats with ARF: Daily vs every-other-day IHDday IHD Mean Mean ultrafiltration volumeultrafiltration volumeDaily: 1.2 Daily: 1.2 0.5 L 0.5 L Every-other-day: 3.5 Ev

6、ery-other-day: 3.5 0.3 L (P 0.001). 0.3 L (P 0.001). HypotensionHypotension 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-ot

7、her-day:16 Every-other-day:16 6 Days P = 0.001 6 Days P = 0.001N Engl J Med 2002; 346:305-310為什么為什么CRRTCRRT有助于腎臟功能有助于腎臟功能(gngnng)(gngnng)的恢復(fù)？的恢復(fù)？第七頁，共四十四頁。Effect of Effect of RRT doseRRT dose on recovery of on recovery of renal function?renal function?P = NS Ronco C et al. Effects of different doses

8、 in CVVH on outcomes of ARF:A prospective RCT20ml/h/kg 35/ml/kg/h45ml/kg/h95% 92% 90%N=425SurvivalLancet 2000; 356: 26 -30第八頁，共四十四頁。lCRRT vs IRRTon return of renal functionOn mortality第九頁，共四十四頁。Mortality:Which is better CRRT or IHD?Swzrtz. RD. Comparing continuous HF with HD in patients with severe

9、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

10、e evidence to support the superiority of CRRT vs IHD. Both techniques are complimentary第十頁，共四十四頁。CRRT vs IRRT對(duì)危重病患者對(duì)危重病患者(hunzh)的影響的影響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第十一頁，共四十四頁。CRRT vs IRRT對(duì)危重病患者對(duì)危重病患者(hunzh)的影響的影響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 asso

11、ciated with a reduced risk of hospital death in the six studies in which baseline severity of illness was similar RR 0.48, 0.340.69, p0.0005 Intensive Care Med, 2002, 28: 29-37第十二頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)1. CRRT vs IRRT2. Early vs late CRRT 3. High vs normal flow4.Current opinion in CRRT Current o

12、pinion in CRRT 第十三頁，共四十四頁。 19891997：100例創(chuàng)傷(chungshng)后ARF 早期后期的臨界：BUN 60mg/dl 兩組病人創(chuàng)傷評(píng)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早期后期(huq)CRRT對(duì)危重病患者的影響對(duì)危重病患者的影響早期或預(yù)防性早期或預(yù)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第十四頁，共四十四頁。早期后期早期后期(huq)CRRT對(duì)危重病患者的影對(duì)危重病患者的影響響早期或預(yù)防性早期或預(yù)防性CRRT可降低可降

13、低ARF患者病死率患者病死率n生存率明顯生存率明顯(mngxin)差異差異Gettings LG. Intensive Care Med, 1999, 25: 805-813第十五頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)Early vs. Late RRT RCT (n =106) Oliguria ( 30cc/hr) refractory to high-dose furosemide (500mg over 6hrs) Randomized to 3 groups: Early (12h) high-volume hemofiltration (n=35; 72-96L/2

14、4 h) Early ( 5060 ml/kg/hr OR: 60 L/d including net ultrafiltration in continuous hemofiltration mode第二十八頁，共四十四頁。q目的：目的：評(píng)估高流量血濾對(duì)感染性休克患者評(píng)估高流量血濾對(duì)感染性休克患者(n-11)血流動(dòng)力學(xué)和細(xì)胞血流動(dòng)力學(xué)和細(xì)胞因子的影響因子的影響q方法：方法：隨機(jī)隨機(jī)cross-over試驗(yàn)，患者隨機(jī)接受試驗(yàn)，患者隨機(jī)接受8h HVHF (6L/h) (AN69濾器，濾器，1.6m2)或或8h CVVH (1L/h) (AN69濾器，濾器，1.2m2)q檢測(cè)指標(biāo)：檢測(cè)指標(biāo)：血流

15、動(dòng)力學(xué)、去甲腎上腺素需要量、血清血流動(dòng)力學(xué)、去甲腎上腺素需要量、血清C3a、C5a、IL-2、IL-8、IL-10和和TNF的含量的含量(hnling)HVHF組與組與CVVH組組CVP、CI、 PAWP和液體平衡無差異和液體平衡無差異維持維持MAP70mmHg，HVHF組組NE劑量顯著低于劑量顯著低于CVVHNE劑量分別降低劑量分別降低10.5ug/min和和1.0ug/min P=0.02高流量高流量(liling)血濾在感染性休克患者中的作血濾在感染性休克患者中的作用用HVHF顯著降低感染性休克顯著降低感染性休克NE用量用量Cole L, et al. Intensive Care Me

16、d, 2001, 27: 978-986第二十九頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)Mean Norepinephrine DoseMean C3a concentrationMean C5a concentration第三十頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)第三十一頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)HV-CVVHHV-CVVH明顯改善感染性休克明顯改善感染性休克(xik)(xik)預(yù)后預(yù)后46.0%46.0%75.0%75.0%70.5%70.5%65.0%65.0%0%0%20%20%40%40%60%60%80%80%100%10

17、0%HV-CVVHHHV-CVVHHSOFA-SOFA-PredictedPredictedLOD-LOD-predictedpredictedMODS-MODS-predictedpredictedMortality (%)Mortality (%)第三十二頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)脈沖式高容量血液脈沖式高容量血液(xuy)濾過濾過 (Pulse HVHF) 極高容量很難維持24h以上，而且(r qi)對(duì)溶質(zhì)動(dòng)力學(xué)無明顯改進(jìn) Ranco提出了脈沖式高容量血液濾過Seminars in Dialysis, 2006, 19(1): 69-746420PulseL/h

18、第三十三頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)第三十四頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)HVHF- As 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 No

19、n-R (NE and lactate levels at 6h after PHVHF)Intensive Care Med (2006) 32:713722第三十五頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)第三十六頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)第三十七頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)第三十八頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)第三十九頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)第四十頁，共四十四頁。CRRT嚴(yán)重膿毒癥與MODS(邱海波)CVVH + CVVH + 血漿吸附對(duì)感染性休克血漿吸附對(duì)感染性休克(xik)(xik)血流動(dòng)力學(xué)的影響血流動(dòng)力學(xué)的影響Hemodynamic response to coupledHemodynamic response to coupledplasmafiltration-adsorption in human septic shockplasmafiltration-adsorption in human septic shockN=12 mechanically ventilated pats with septic shockInterve