crrt：严重脓毒症与mods(邱海波)

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1、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.PossiblewaystoincreasemediatorsclearanceCurrentopinioninCRRTModeofRRTdifferencesamongcontinentsBellomo,etal.2001UnderstandingRenalReplacementTherapyandAcuteRenalFailureintheIC

2、U(TheB.E.S.Tkidneystudy)RetrospectivecohortstudyPatswithARFandrequireddialysisbetweenApril1,1996,andMarch31,19992ICUinCanada.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%<0.01Renalrecoveryinhos

3、p80.0%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.CanJ

4、Anaesth2005;52:327-332Munnsetal观察危重急性肾衰竭患者IHDCRRTCCr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-dayIHDMeanultrafiltrationvolumeDaily:1.2±0.5LEvery-other-day:3.5±0.3L(P<0.001).Hypotensionoccurr

5、edinDaily:5±2%Every-other-day:25±5%(P<0.001)TimetorecoveryofrenalfunctionDaily:9±2daysEvery-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=NSRoncoCetal.EffectsofdifferentdosesinCVVHonoutcomesofARF:AprospectiveRCT2

6、0ml/h/kg35/ml/kg/h45ml/kg/h95%92%90%N=425SurvivalLancet2000;356:26-30CRRTvsIRRTonreturnofrenalfunctionOnmortalityMortality:WhichisbetterCRRTorIHD?Swzrtz.RD.ComparingcontinuousHFwithHDinpatientswithsevereARFAmJKidney1999;34:424-432Mehti.RL.CollaborativeGroupforTreatmentofARFinI

7、CU: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

8、重病患者病死率Qualityscore5:definitelyequalCRRTvsIRRT对危重病患者的影