crrt：嚴重膿毒癥與mods邱海波ppt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)急診與危重醫(yī)學(xué)研究所東南大學(xué)急診與危重醫(yī)學(xué)研究所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 Mode of RRT differences among conti

2、nentsBellomo, et al. 2019Understanding Renal Replacement Therapy and Acute Renal Failure in the ICU (The B.E.S.T kidney study) Retrospective cohort study Pats with ARF and required dialysis between April 1,2019, and March 31, 2019 2 ICU in Canada. N=261CRRT對對ARF腎功能恢復(fù)的影響腎功能恢復(fù)的影響CRRT促進腎功能恢復(fù)促進腎功能恢復(fù)CRRT

3、IHDPAPACHE 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 2019; 31:449 455IHD vs CRRTICU RRTn=1

4、16 RRT for overdosen=7Pre-existing CRFn=16ICU RRT for ARF/MOFn=66Initial CRRTn=66Initial IHDn=28Jacka MJ, Ivancinova X, Gibney RTN. Can J Anaesth 2019;52:327-332 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% 鈉排泄分數(shù)下降46%12% 腎功能下降的原因: IHD平均動脈壓下降，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促進腎功能恢復(fù)

5、促進腎功能恢復(fù)? 160 pats with ARF: Daily vs every-other-160 pats with ARF: Daily vs every-other-day IHDday IHD Mean ultrafiltration volumeMean ultrafiltration volume Daily: 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). Hypotension occurred in Hypoten

6、sion 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 = 0.001N Engl J Med 2019; 3

7、46:305-310為什么為什么CRRTCRRT有助于腎臟功能的恢復(fù)？有助于腎臟功能的恢復(fù)？Effect of RRT dose on recovery Effect of RRT dose on recovery of renal function?of renal function?P = NS Ronco 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% 90%N=425SurvivalLancet 200

8、0; 356: 26 -30lCRRT vs IRRTlon return of renal functionlOn mortalityMortality:Which is better CRRT or IHD?Swzrtz. RD. Comparing continuous HF with HD in patients with severe ARF Am J Kidney 2019; 34: 424 - 432Mehti. RL. Collaborative Group for Treatment of ARF in ICU:A RCT of continuous versus IHD f

9、or ARF. Kidney Int 2019; 60: 1154 - 63Kellum JA. Continuous versus intermittent RRT. A meta-analysis. Intensive Care Med 2019; 162: 197- 202 Conclusion :There is no conclusive evidence to support the superiority of CRRT vs IHD. Both techniques are complimentaryCRRT vs IRRT對危重病患者的影響對危重病患者的影響CRRT可降低危重

10、病患者病死率可降低危重病患者病死率nQuality score 5: definitely equalCRRT vs IRRT對危重病患者的影響對危重病患者的影響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 associated 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,

11、2019, 28: 29-371. 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 19892019：100例創(chuàng)傷后ARF 早期后期的臨界：BUN 60mg/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早期后期CRRT對危重病患者的影響對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

12、者患者病死率病死率Gettings LG. Intensive Care Med, 2019, 25: 805-813早期后期早期后期CRRT對危重病患者的影響對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患者患者病死率病死率n生存率明顯差異生存率明顯差異Gettings LG. Intensive Care Med, 2019, 25: 805-813Early vs. Late RRT RCT (n =106) Oliguria ( 30cc/hr) refractory to high-dose furosemide (500mg over 6hrs) Random

13、ized to 3 groups: Early (12h) high-volume hemofiltration (n=35; 72-96L/24 h) Early ( 5060 ml/kg/hr OR: 60 L/d including net ultrafiltration in continuous hemofiltration modeq目的：評估高流量血濾對感染性休克患者目的：評估高流量血濾對感染性休克患者(n-11)血流動力血流動力學(xué)和細胞因子的影響學(xué)和細胞因子的影響q方法：隨機方法：隨機cross-over試驗，患者隨機接受試驗，患者隨機接受8h HVHF (6L/h) (AN6

14、9濾器，濾器，1.6m2)或或8h CVVH (1L/h) (AN69濾器，濾器，1.2m2)q檢測指標(biāo)：血流動力學(xué)、去甲腎上腺素需要量、血清檢測指標(biāo)：血流動力學(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qHVHF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q維持維持MAP70mmHg，HVHF組組NE劑量顯著低于劑量顯著低于CVVHqNE劑量分別降低劑量分別降低10.5ug/min和和1.0ug/min P=0.02高流量血濾在感染性休克患者中的作用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

15、顯著降低感染性休克NE用量用量Cole L, et al. Intensive Care Med, 2019, 27: 978-986Mean Norepinephrine DoseMean C3a concentrationMean C5a concentrationHV-CVVHHV-CVVH明顯改善感染性休克預(yù)后明顯改善感染性休克預(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%100%HV-CVVHHHV-CVVHHSOFA-SOFA-PredictedPredictedLOD-LOD-p

16、redictedpredictedMODS-MODS-predictedpredictedMortality (%)Mortality (%)脈沖式高容量血液濾過脈沖式高容量血液濾過 (Pulse HVHF) 極高容量很難維持24h以上，而且對溶質(zhì)動力學(xué)無明顯改進 Ranco提出了脈沖式高容量血液濾過Seminars in Dialysis, 2019, 19(1): 69-746420PulseL/hHVHF- As salvage therapyin severe septic shock Objectives: To evaluate the effect PHVHF (12-h) in

17、 reversing progressive refractory hypotension in pats with sshock N=20 sshock pats with NE 0.3 g/kg.min and and lactic acidosis Responders vs Non-R (NE and lactate levels at 6h after PHVHF)Intensive Care Med (2019) 32:713722CVVH + CVVH + 血漿吸附對感染性休克血流動力學(xué)的影響血漿吸附對感染性休克血流動力學(xué)的影響Hemodynamic response to co

18、upledHemodynamic response to coupledplasmafiltration-adsorption in human septic plasmafiltration-adsorption in human septic shockshock N=12 mechanically ventilated pats with septic shock Intervention: A median of 10 consecutive sessions (prescribed treatment time: 10 h/session; delivered duration: 8.431.37 h/min) of coupled plasmafiltration-adsor