嚴(yán)重膿毒癥與mods.ppt

CRRT Severe sepsis and MODS,邱海波 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,1. CRRT vs IRRT 2. Early vs late CRRT 3. High vs normal flow 4.Possible ways to increase mediators clearance,Current opinion in CRRT,Mode of RRT differences among continents,Bellomo, et al. 2019,Understanding 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=261,CRRT對(duì)ARF腎功能恢復(fù)的影響 CRRT促進(jìn)腎功能恢復(fù),Crit Care Med 2019; 31:449 455,IHD vs CRRT,ICU RRT n=116,RRT for overdose n=7,Pre-existing CRF n=16,ICU RRT for ARF/MOF n=66,Initial CRRT n=66,Initial IHD n=28,Jacka 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?jǐn)?shù)下降 46% 12% 腎功能下降的原因: IHD平均動(dòng)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CRRT促進(jìn)腎功能恢復(fù)?,160 pats with ARF: Daily vs every-other-day IHD Mean ultrafiltration volume Daily: 1.2 0.5 L Every-other-day: 3.5 0.3 L (P 0.001). Hypotension occurred in Daily: 5 2% Every-other-day: 25 5% (P 0.001) Time to recovery of renal function Daily: 9 2 days Every-other-day:16 6 Days P = 0.001,N Engl J Med 2019; 346:305-310,為什么CRRT有助于腎臟功能的恢復(fù)？,Effect of RRT dose on recovery of renal function?,P = NS,Ronco C et al. Effects of different doses in CVVH on outcomes of ARF:A prospective RCT,Lancet 2000; 356: 26 -30,CRRT vs IRRT on return of renal function On mortality,Mortality: Which is better CRRT or IHD?,Swzrtz. RD. Comparing continuous HF with HD in patients with severe ARF Am J Kidney 2019; 34: 424 - 432 Mehti. RL. Collaborative Group for Treatment of ARF in ICU:A RCT of continuous versus IHD for ARF. Kidney Int 2019; 60: 1154 - 63 Kellum 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 complimentary,CRRT vs IRRT對(duì)危重病患者的影響 CRRT可降低危重病患者病死率,Quality score 5: definitely equal,CRRT vs IRRT對(duì)危重病患者的影響 CRRT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, 2019, 28: 29-37,1. CRRT vs IRRT 2. Early vs late CRRT 3. High vs normal flow 4.Possible ways to increase mediators clearance,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(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CRRT對(duì)危重病患者的影響 早期或預(yù)防性CRRT可降低ARF患者病死率,Gettings LG. Intensive Care Med, 2019, 25: 805-813,早期后期CRRT對(duì)危重病患者的影響 早期或預(yù)防性CRRT可降低ARF患者病死率,生存率明顯差異,Gettings LG. Intensive Care Med, 2019, 25: 805-813,Outcome Early start 39% survival Late start 20% survival,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/24 h) Early (12h) low-volume hemofiltration (n=35; 24-36L/24 h) Late low-volume hemofiltration (n=36; 24-36 L/24 h),Bouman et al. Crit Care Med 30:2205-2211, 2019,Dose and Timing of CVVH in ARF,Bouman CS, et al. Critical Care Med 2019; 30:2205-2211,74.3%,68.8%,75.0%,0%,20%,40%,60%,80%,100%,28-Day Survival,LV-Late,LV-Early,HV-Early,Treatment Group,n=35 SOFA 10.32.8,n=36 SOFA 10.61.9,n=35 SOFA 10.12.2,1. CRRT vs IRRT 2. Early vs late CRRT 3. High vs normal flow 4.Possible ways to increase mediators clearance,Current opinion in CRRT,High-volume hemofilitration (HVHF),Ronco C et al. Effects of different doses in CVVH on outcomes of ARF:A prospective RCT,Lancet 2000; 356: 26 -30,RCT of HVHF in Septic Shock,5919 ICU admissions,Oliguric ARF N=248,Non-oliguric ARF N=130,Not randomized in study N=142,Randomized In study N-106,EHV n=35,ELV n=35,LLV n=36,Hemofiltration n=352,No hemofiltration N=6,Bouman CS et al. Effects of early high-volume CVVH on survival and recovery of renal function in IC patients with ARF. Crit Care Med 2019; 30: 2205 (n=106),EHV 74.3%,LLV 75%,ELV 68.8%,ELV= Early low vol hemofiltration=1-1.5 L/hr LLV= Late low vol hemofiltration=1-1.5 L/hr EHV= Early high vol hemofiltration=3-4 L/hr,Early=within 12 hours of diagnosis of septic shock,Survival %,No difference renal recovery or 28-d mortality,160 pats with ARF: Daily vs every-other-day ID,N Engl J Med 2019; 346:305-310,Survival vs dialysis dose in IHD,CRRT: Impact on outcomes,Severity of Disease,Survival rate %,High Dose (CRRT),Low Dose (IHD),The Cleveland Clinic Observation,100,90,80,70,60,50,40,30,20,10,0,ATN (n=1260),Multi-center RCT in the USA. Patients with ARF randomized to: Intensive Management Strategy: If hemodynamically stable (SOFA CVS score: 0-2) IHD 6-times/week (target Kt/V =1.2-1.4/session) If hemodynamically unstable (SOFA CVS score: 3-4) CVVHDF at 35 ml/kg/hr or SLED 6-times/week (target Kt/V = 1.2-1.4/session) Conventional Management Strategy: If hemodynamically stable (SOFA CVS score: 0-2) IHD 3-times/week (target Kt/V =1.2-1.4/session); If hemodynamically unstable (SOFA CVS score: 3-4) CVVHDF at 20 ml/kg/hr or SLED 3-times/week (target Kt/V = 1.2-1.4/session),RENAL,Multicenter RCT (centers = 35) N= 1500 Australia and New Zealand 25 ml/kg/hr vs. 40 ml/kg/hr of CVVHDF Outcome: all cause mortality at 90 days Currently under way,1. CRRT vs IRRT 2. Early vs late CRRT 3. High vs normal flow 4.Possible ways to increase mediators clearance,Current opinion in CRRT,Higher Uf volumes,Convection,Grootendorst AF et al , 1992 Bellomo R et al, 2019,1,促進(jìn)介質(zhì)清除/遏制炎癥反應(yīng)的可能途徑,HVHF,HVHF: An ultrafiltration rate 5060 ml/kg/hr OR: 60 L/d including net ultrafiltration in continuous hemofiltration mode,目的：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)胞因子的影響 方法：隨機(jī)cross-over試驗(yàn)，患者隨機(jī)接受8h HVHF (6L/h) (AN69濾器，1.6m2)或8h CVVH (1L/h) (AN69濾器，1.2m2) 檢測(cè)指標(biāo)：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TNF的含量 HVHF組與CVVH組CVP、CI、 PAWP和液體平衡無差異 維持MAP70mmHg，HVHF組NE劑量顯著低于CVVH NE劑量分別降低10.5ug/min和1.0ug/min P=0.02,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NE用量,Cole L, et al. Intensive Care Med, 2019, 27: 978-986,Mean Norepinephrine Dose,Mean C3a concentration,Mean C5a concentration,Effect of HVHF on mortality,Oudemans-van Straaten Hm et al, Intens Care Med 2019;25:814-821.,*=Madrid ARF score,HV-CVVH明顯改善感染性休克預(yù)后,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(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, 2019, 19(1): 69-74,HVHF- As salvage therapy in severe septic shock,Objectives: To evaluate the effect PHVHF (12-h) in 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) 32:713722,Higher Uf volumes,Higher membrane cut-off,Permeability,Convection,Grootendorst AF et al , 1992 Bellomo R et al, 2019,Leese T et al. 1987 Berlot G et al. 2019,促進(jìn)介質(zhì)清除/遏制炎癥反應(yīng)的可能途徑,1,2,Efficacy of membrane pore size on morbidity and mortality in an immature swine model of Staph. Aureus induced sepsis James R. Matson, Crit Care Med, 26: 730-737, 2019,Cut-off 100 KD,Higher Uf volumes,Higher membrane cut-off,Permeability,Convection,Grootendorst AF et al , 1992 Bellomo R et al, 2019,Leese T et al. 1987 Berlot G et al. 2019,1,2,Use of sorbents in combination therapies,Adsorption,Ronco C et al. 1999 Tetta C et al. 2019,3,促進(jìn)介質(zhì)清除/遏制炎癥反應(yīng)的可能途徑,Coupled plasmafiltration-adsorption, by regenerating the plasmafiltrate, avoids unwanted losses, avoids the contact of RBC, WBC and platelets with the sorbent, and prevents treatment induced thrombocytopenia.,Hemodiafilter,Plasmafilter,Dialysate 30 ml/min,Plasmafilter,20 ml/min,100-200 ml/min,CPFA: Hemodynamics and Biological Effects,P 0.01,NA,MAP,