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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东南大学急诊与危重医学研究所东南大学急诊与危重医学研究所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 ModeofRRTdifferencesamongcontinents
2、Bellomo, et al. 2001UnderstandingRenalReplacementTherapyandAcuteRenalFailureintheICU(TheB.E.S.Tkidneystudy)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肾功能恢复的影响肾功能恢复的影响CRRTCRRT促进肾功能恢复促进肾功能恢复CRRTIHDPAPACHE II2725.
3、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 455IHDvsCRRTICURRTn=116RRTforoverdosen=7Pre
4、-existingCRFn=16ICURRTforARF/MOFn=66InitialCRRTn=66InitialIHDn=28JackaMJ,IvancinovaX,GibneyRTN.CanJAnaesth2005;52:327-332Munns 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的恢复 为什么为什么CRRT促进肾功能恢复促进肾功能恢复? ?160 pats with ARF: 160 pats with AR
5、F: Daily Daily vsvs every-other- every-other-day IHDday IHDMean Mean ultrafiltrationultrafiltration volume 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 (0.3 L (P P 0.001).0.001).HypotensionHypotension occurred in occurred in Daily: 5 Daily: 5 2% 2% Every-ot
6、her-day: 25 Every-other-day: 25 5% (5% (P P 0.001) 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 6 Days P P = 0.001= 0.001NEnglJMed2002;346:305-310为什么为什么CRRTCRRT有助于肾脏功能的恢复？有助于肾脏功能的恢复？Effect of
7、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% 90%N=425SurvivalLancet 2000; 356: 26 -30lCRRT vs IRRTon return of renal functionOn m
8、ortalityMortality: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:A RCT of continuous versus IHD for ARF. Kidney Int 2001; 60: 1154 - 63Kellum JA. Continuous
9、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 complimentaryCRRT vs IRRT对危重病患者的影响对危重病患者的影响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 equalCRRT vs I
10、RRT对危重病患者的影响对危重病患者的影响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 similar RR 0.48, 0.340.69, p0.0005 Intensive Care Med, 2002, 28: 29-371. CRRT vs IRRT2. Early vs late CRRT 3. High
11、vs normal flow4.Possible ways to increase mediators clearanceCurrent opinion in CRRT Current opinion in CRRT 19891997：100例创伤后ARF早期后期的临界：BUN60mg/dl两组病人创伤评分、GCS、发生休克的比例、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早期后期
12、早期后期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n生存率明显差异生存率明显差异Gettings LG. Intensive Care Med, 1999, 25: 805-813OutcomeOutcomeEarlystart39%survivalEarlystart39%survivalLatestart20%survivalLatestart20%survivalEarly vs. Late RRTRCT(n=106)Oliguria(30cc/hr)refractorytohigh-dosefurosemide(5
13、00mgover6hrs)Randomizedto3groups:Early(12h)high-volumehemofiltration(n=35;72-96L/24h)Early( 5060 ml/kg/hrOR: 60 L/d including net ultrafiltration in continuous hemofiltration modeq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)血流动力血流动力学和细胞因子的影响学和细胞因子的影响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
14、) (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HVHF组与组与CVVH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高流量血滤在感染性休克患者中的作用高流量血滤在感染性休克患者中的作用HVHF显著降低感染
15、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: 978-986Mean Norepinephrine DoseMean C3a concentrationMean C5a concentrationEffect of HVHF on mortalityOudemans-vanOudemans-van StraatenStraaten Hm Hm et et al, al, IntensIntens Care Care MedMed 1999;25:814-821. 1999;25:814-821. *=Madrid
16、ARF score*=Madrid ARF scoreHV-CVVHHV-CVVH明显改善感染性休克预后明显改善感染性休克预后脉冲式高容量血液滤过脉冲式高容量血液滤过 (Pulse HVHF)极高容量很难维持24h以上，而且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/hHVHF- As salvage therapyin severe septic shockObjectives: To evaluate the effect PHVHF (12-h) in reversing
17、progressive refractory hypotension in pats with sshockN=20 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)32:713722Higher Higher UfUf volumes volumes Higher membraneHigher membrane cut-off cut-offPermeability
18、ConvectionGrootendorstGrootendorst AF et al , 1992 AF et al , 1992BellomoBellomo R et al, 1998 R et al, 1998LeeseLeese T et al. 1987 T et al. 1987BerlotBerlot G et al. 1997 G et al. 1997促进介质清除促进介质清除/ /遏制炎症反应的可能途径遏制炎症反应的可能途径1 12 2Efficacy of membrane pore size on morbidity and mortality in an immatur
19、e swine model of Staph. Aureus induced sepsisJames R. Matson, James R. Matson, CritCrit Care Med, 26: 730-737, 1998 Care Med, 26: 730-737, 1998 Cut-offCut-off100 KD100 KDHigher Higher UfUf volumes volumes Higher membraneHigher membrane cut-off cut-offPermeabilityConvectionGrootendorstGrootendorst AF
20、 et al , 1992 AF et al , 1992BellomoBellomo R et al, 1998 R et al, 1998LeeseLeese T et al. 1987 T et al. 1987BerlotBerlot G et al. 1997 G et al. 19971 12 2 UseUse of of sorbentssorbents in in c combinationombination therapiestherapiesAdsorptionRonco C Ronco C et al. 19 et al. 199999Tetta CTetta C et
21、 al. et al. 200120013 3促进介质清除促进介质清除/ /遏制炎症反应的可能途径遏制炎症反应的可能途径SorbenSorbent tCoupled Coupled plasmafiltrationplasmafiltration-adsorption, by regenerating -adsorption, by regenerating the the plasmafiltrateplasmafiltrate, avoids unwanted losses, avoids the , avoids unwanted losses, avoids the contact o
22、f RBC, WBC and platelets with the contact of RBC, WBC and platelets with the sorbentsorbent, , and prevents treatment induced thrombocytopenia. and prevents treatment induced thrombocytopenia. HemodiafilterHemodiafilterPlasmafilterPlasmafilter DialysateDialysate30 ml/min30 ml/minPlasmafilterPlasmafi
23、lter20 ml/min20 ml/min100-200 ml/min100-200 ml/minCPFA: Hemodynamics and Biological EffectsP 0.01P 0.01NANAMAPMAPat 10 hours of treatment versus baselineat 10 hours of treatment versus baselineD D- - NorepinephrineNorepinephrine Dose Dose and and D D+ + MAPMAP 0 0 2020 4040 6060 8080100100%P 0.01P 0
24、.01TNF TNF ProdProd. . PhagocytosisPhagocytosisD D MonocyteMonocyte TNF production TNF production and and PhagocyticPhagocytic CapacityCapacity 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
25、pg/ml/mlP 0.0P 0.05 5CVVH + CVVH + 血浆吸附对感染性休克血流动力学的影响血浆吸附对感染性休克血流动力学的影响HemodynamicHemodynamic response to coupled response to coupledplasmafiltrationplasmafiltration-adsorption in human septic shock-adsorption in human septic shockN=12 mechanicallyventilatedpatswithsepticshockIntervention: Amedianof
26、10consecutivesessions(prescribedtreatmenttime:10h/session;deliveredduration:8.431.37h/min)ofcoupledplasmafiltration-adsorptionIntensive Care Med (2003) 29:703708CRRT in ICUCRRT in ICUEarly CRRT: 改善创伤合并改善创伤合并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 ml/kg.min for CVVH for septic shock patsWWay to increase mediators clearance:ay to increase mediators clearance:PHVHF PHVHF vsvs CPFA CPFAThanks for you attention
