CRRT：严重脓毒症与MODS(邱海波)VIP免费

CRRTSeveresepsisandMODS邱海波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1.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.PPossiblewaystoincreaseossiblewaystoincreasemediatorsclearancemediatorsclearanceCurrentopinioninCRRTModeofRRTdifferencesamongcontinents0%20%40%60%80%100%AsiaAustraliaEuropeNorthAmericaSouthAmericaContinuousIntermittentOtherBellomo,etal.2001UnderstandingRenalReplacementTherapyandAcuteRenalFailureintheICU(TheB.E.S.Tkidneystudy)•Retrospectivecohortstudy•PatswithARFandrequireddialysisbetweenApril1,1996,andMarch31,1999•2ICUinCanada.•N=261CRRT对ARF肾功能恢复的影响－CRRT促进肾功能恢复CRRTIHDPAPACHEII2725.10.10BaselineSCr1361800.002MAPBeforeRRT74.787.2<0.001HospMortality71.9%42.2%<0.01Renalrecoveryinhosp80.0%62.5%0.06DurationofRRT14.7d14.5d0.91Costperweek(Can$)3486-51171341Survivor(Costpery)No-RRTRRT$11,192$73,273CritCareMed2003;31:449–455IHDvsCRRTICURRTn=116RRTforoverdosen=7Pre-existingCRFn=16ICURRTforARF/MOFn=66InitialCRRTn=66InitialIHDn=28JackaMJ,IvancinovaX,GibneyRTN.CanJAnaesth2005;52:327-332•Munnsetal观察危重急性肾衰竭患者IHDCRRT•CCr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CRRT促进肾功能恢复?•160patswithARF:Dailyvsevery-other-dayIHD•Meanultrafiltrationvolume–Daily:1.2±0.5L–Every-other-day:3.5±0.3L(P<0.001).•Hypotensionoccurredin–Daily:5±2%–Every-other-day:25±5%(P<0.001)•Timetorecoveryofrenalfunction–Daily:9±2days–Every-other-day:16±6DaysP=0.001NEnglJMed2002;346:305-310为什么CRRT有助于肾脏功能的恢复？？EffectofRRTdoseonrecoveryofrenalfunction?P=NS•RoncoCetal.EffectsofdifferentdosesinCVVHonoutcomesofARF:AprospectiveRCT20ml/h/kg35/ml/kg/h45ml/kg/h95%92%90%N=425SurvivalLancet2000;356:26-30CRRTvsIRRTonreturnofrenalfunctionOnmortalityMortality:WhichisbetterCRRTorIHD?Swzrtz.RD.ComparingcontinuousHFwithHDinpatientswithsevereARFAmJKidney1999;34:424-432Mehti.RL.CollaborativeGroupforTreatmentofARFinICU:ARCTofcontinuousversusIHDforARF.KidneyInt2001;60:1154-63KellumJA.ContinuousversusintermittentRRT.Ameta-analysis.IntensiveCareMed2002;162:197-202Conclusion:ThereisnoconclusiveevidencetosupportthesuperiorityofCRRTvsIHD.BothtechniquesarecomplimentaryCRRTvsIRRT对危重病患者的影响－CRRT可降低危重病患者病死率Qualityscore5:definitelyequalCRRTvsIRRT对危重病患者的影响－CRRT可降低危重病患者病死率Hospitalmortality:CRRTwasassociatedwithareducedriskofhospitaldeathinthesixstudiesinwhichbaselineseverityofillnesswassimilarRR0.48,0.34–0.69,p<0.0005IntensiveCareMed,2002,28:29-371.CRRTvsIRRT2.EarlyvslateCRRT3.Highvsnormalflow4.PPossiblewaystoincreaseossiblewaystoincreasemediatorsclearancemediatorsclearanceCurrentopinioninCRRT•1989－1997：100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CRRT对危重病患者的影响－早期或预防性CRRT可降低ARF患者病死率GettingsLG.IntensiveCareMed,1999,25:805-813早期－后期CRRT对危重病患者的影响－早期或预防性CRRT可降低ARF患者病死率生存率－明显差异GettingsLG.IntensiveCareMed,1999,25:805-813OutcomeOutcomeEarlystart39%survivalEarlystart39%survivalLatestart20%survivalLatestart20%survivalEarlyvs.LateRRT•RCT(n=106)•Oliguria(<30cc/hr)refractorytohigh-dosefurosemide(500mgover6hrs)•Randomizedto3groups:–Early(<12h)high-volumehemofiltration(n=35;...