不同容量连续性肾脏替代治疗严重腹腔感染对比研究

目的:探讨治疗严重腹腔感染的最佳连续性肾脏替代治疗(CRRT)血液滤过容量。方法:56例严重腹腔感染患者分别进行常规容量、大容量持续CRRT治疗,CRRT治疗前、治疗后4h、12h、24h、36h、48h、72h检测血浆肿瘤坏死因子-α(TNF-α)、白介素-6(IL-6)水平及降钙素原(PCT)水平、统计ICU入住时间、机械通气时间及日均医疗费用,评价卫生经济学。结果:大容量组持续CRRT治疗后4hTNFα-、IL-6水平开始下降直至48h,其后下降水平不大,降钙素原在持续CRRT治疗后4h下降,维持至72h,大容量组入住ICU时间4.3±0.6d,机械通气时间36.3±0.8h,短于常规容量组,日均医疗费用无差异。结论:大容量CRRT能有效清除炎症介质,控制感染较常规容量好,效益/费用比更好。     

应用血浆灌流吸附联合血液滤过技术治疗重症肝炎的临床探讨

目的探讨非生物型人工肝技术血浆灌流吸附加血液滤过疗法(PPA HF)(PlasmaperfusionAdsorption Hemofiltration)治疗各种原因所致重症肝炎肝衰竭的临床疗效和安全性.方法天津市第三中心医院肾病中心15例不同病因重症肝炎患者应用PPA HF人工肝技术进行38例次治疗,比较治疗前后患者生化指标肝功能、凝血酶原时间、血氨及临床症状改善程度及观察治疗不良反应对临床疗效和安全性评价.结果患者在治疗后意识障碍、黄疸、乏力、恶心、呕吐、腹胀、纳差等症状明显改善,食欲增加,血清总胆红素、直接胆红素、血氨分别较前下降了32.4%、46.1%、63.8%.血浆白蛋白、转氨酶、肾功能较前好转,凝血酶原时间由治疗前(20.61±12.26)%上升为(31.18±9.06)%上升了47.65%,出血倾向得到纠正.血白细胞、血小板及电解质水平无明显变化.未发生出血、休克、过敏等并发症,患者耐受好.结论(PPA HF)人工肝技术可显著改善各种原因引起的重症肝炎肝衰竭患者临床症状及生化指标,安全性好,无明显不良反应,近期疗效显著.可作为支持治疗、外科手术和肝移植的术前过渡治疗手段.     

Circuit Life Versus Bleeding Risk: The Impact of Achieved Activated Partial Thromboplastin Time Versus Achieved Filtration Fraction

Whilst prolonging hemofilter (circuit) life, heparin increases bleeding risk. The impact of achieved activated partial thromboplastin time (APTT) on circuit life and bleeding risk has not been assessed in a modern critically ill cohort. Lowering filtration fraction may be an alternative means of prolonging circuit life, but is often overlooked in critical care. An observational study of 309 consecutive circuits in a general intensive care unit was conducted using a wide target APTT range. Multilevel modeling was used to predict circuit life and bleeding according to achieved APTT and filtration fraction. Independent predictors of circuit failure (i.e. unplanned ending of treatment) included filtration fraction (P < 0.001, HR 1.07 per 1% increase), peak APTT (P < 0.001, HR 0.8 per 10 s increase or 0.3 APTR increase) and baseline PT (P = 0.014, HR 0.91 for every 50% increase). The only significant predictor of bleeding was peak APTT (P = 0.017, OR 1.05 per 10 s increase). Every 10 s APTT increase was associated with a 20% reduction in circuit failure, but a 5% increase in hemorrhage. A 3% reduction in filtration fraction was associated with the same improvement in circuit life as a 10 s increase in APTT. Increasing APTT prolongs circuit life but carries a substantial risk of bleeding even in modern practice. Filtration fraction has a large impact on circuit life in the critically ill: a 3% reduction in filtration fraction, e.g. by increasing blood flow or delivering some of the clearance via dialysis, would be expected to reduce circuit failure as much as a 10 s increase in APTT.     

Meta-Analysis of Ultrafiltration versus Diuretics Treatment Option for Overload Volume Reduction in Patients with Acute Decompensated Heart Failure

Introduction

Although diuretics are mainly used for the treatment of acute decompensated heart failure (ADHF), inadequate responses and complications have led to the use of extracorporeal ultrafiltration (UF) as an alternative strategy for reducing volume overloads in patients with ADHF.

Objective

The aim of our study is to perform meta-analysis of the results obtained from studies on extracorporeal venous ultrafiltration and compare them with those of standard diuretic treatment for overload volume reduction in acute decompensated heart failure.

Methods

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were systematically searched using a pre‑specified criterion. Pooled estimates of outcomes after 48 h (weight change, serum creatinine level, and all-cause mortality) were computed using random effect models. Pooled weighted mean differences were calculated for weight loss and change in creatinine level, whereas a pooled risk ratio was used for the analysis of binary all-cause mortality outcome.

Results

A total of nine studies, involving 613 patients, met the eligibility criteria. The mean weight loss in patients who underwent UF therapy was 1.78 kg [95% Confidence Interval (CI): −2.65 to −0.91 kg; p < 0.001) more than those who received standard diuretic therapy. The post-intervention creatinine level, however, was not significantly different (mean change = −0.25 mg/dL; 95% CI: −0.56 to 0.06 mg/dL; p = 0.112). The risk of all-cause mortality persisted in patients treated with UF compared with patients treated with standard diuretics (Pooled RR = 1.00; 95% CI: 0.64–1.56; p = 0.993).

Conclusion

Compared with standard diuretic therapy, UF treatment for overload volume reduction in individuals suffering from ADHF, resulted in significant reduction of body weight within 48 h. However, no significant decrease of serum creatinine level or reduction of all-cause mortality was observed.     

Extracorporeal Treatment for Septic Patients: New Adsorption Technologies and Their Clinical Application

Abstract: Many kinds of blood purifying technologies have been applied to the treatment of critically ill patients since 1979 when plasma exchange with hollow fiber membranes was developed. These technologies have been applied not only to the removal of toxic substances, but also to the treatment of objective diseases and the removal of the factors relating to the associated inflammation. This article briefly summarizes these methods and their efficacies for critically ill patients, especially those with severe sepsis. Attempts have been made to remove endotoxin, the main cause of sepsis from the circulation, using polymyxin B‐immobilized fiber, charcoal hemoperfusion, and plasma or whole blood exchange. Attempts have also been made to remove proinflammatory cytokines, eicosanoids, and coagulative factors from the circulation in the human body. Continuous hemofiltration or hemodiafiltration is representative technology. The efficacy of these methods has been established, but several issues remain unresolved. All methods of the treatment of severe sepsis are discussed with reference to treatment indications, efficacy, and outcome parameters. In particular, the clinical results of endotoxin removal with polymyxin B‐immobilized fiber are summarized in this article.     

连续性血液净化对重症急性胰腺炎患者胃黏膜酸度的影响

目的观察连续性血液净化(CBP)对重症急性胰腺炎(SAP)患者胃黏膜酸度的影响。方法选择SAP患者20例,随机分为CBP治疗组和非CBP治疗对照组各10例,两组均在治疗前、治疗第2天、4天和6天测定其胃黏膜pH值(pHi)及动脉血乳酸值。结果两组患者初始pHi均值均偏低,CBP组患者治疗后第4天和第6天pHi水平较治疗前明显升高,且差异有显著性(分别为P<0.05和P<0.01),对照组治疗前后pHi水平未见显著改变。两组间比较,治疗第4天和第6天,CBP组pHi水平显著高于对照组(分别为P<0.05和P<0.01)。CBP组在治疗第2天乳酸值即开始显著下降(P<0.05),治疗第6天乳酸值下降最为显著(P<0.01);对照组治疗前后乳酸值无显著改变(P>0.05);与对照组比较,治疗后第2天和第4天CBP组乳酸水平显著降低(P<0.05),第6天降低最为明显(P<0.01)。结论应用CBP治疗可提高SAP患者pHi,并降低患者乳酸代谢水平,改善患者胃肠道的微循环灌注及氧合。     

Endotoxin and Cytokine Removal in Sepsis

Abstract: Sespis, the leading cause of mortality in intensive care units, is a complex series of interrelated effects caused by the overproduction of multiple mediators and their unrestrained biological activity. Both proinflammatory and antiinflammatory mediators participate in the high complexity of sepsis and explain the failure of specific therapies to improve survival. Continuous extracorporeal therapies have been proposed as therapeutic options and as tools for blood purification in sepsis. Along these lines and in order to achieve higher clearances and mass removal rates, we studied the effects of plasmafiltration coupled with adsorption and provided in vitro and in vivo evidence that adsoprtion of multiple cytokines, activated complement components, and lipid mediators such as the platelet‐activating factor occurs. We also showed that such treatment may lead to improved survival in a rabbit model of sepsis and to improved hemodynamics, reduced norepinephrine dose, and restoration of near‐to‐normal responsiveness of blood leukocytes to endotoxin in humans. It is anticipated that treatment of plasma, as a modular device to conventional hemofiltration, may pave the way to innovative approaches in the extracorporeal treatment of septic patients.     

Timing for Initiation of Continuous Renal Replacement Therapy in Patients With Septic Shock and Acute Kidney Injury

The optimal timing for renal replacement therapy initiation in septic acute kidney injury (AKI) remains controversial. This study investigates the impact of early versus late initiation of continuous renal replacement therapy (CRRT) on organ dysfunction among patients with septic shock and AKI. Patients were dichotomized into “early” (simplified RIFLE Risk) or “late” (simplified RIFLE Injury or Failure) CRRT initiation. Patients with chronic kidney disease stage 5 or those on long‐term dialysis were excluded. Organ dysfunction was quantified by Sequential Organ Failure Assessment (SOFA) score. From January 2008 to June 2011, 120 patients fulfilled the inclusion criteria. Thirty‐one (26%) underwent “early” while 89 (74%) had “late” CRRT. No significant difference was noted between groups on improvement of total SOFA/non‐renal SOFA score or noradrenaline equivalent in the first 24 and 48 h after CRRT initiation. Dialysis requirement and mortality (at 28 days, 3 months and 6 months) did not differ. In conclusion, improvement of non‐renal SOFA score 48 h after CRRT correlated with SOFA score on CRRT initiation (P = 0.040) and APACHE IV risk of death (P = 0.000), but not estimated glomerular filtration rate on CRRT initiation (P = 0.377). Improvement of non‐renal SOFA score correlated with SOFA score on CRRT initiation and APACHE IV risk of death. However, this retrospective review cannot identify any significant clinical benefit of early CRRT initiation in patients presenting with septic shock and AKI.     

Operating characteristics of pediatric continuous arteriovenous hemofiltration in an animal model

Continuous arteriovenous hemofiltration (CAVH) is an increasingly popular technique in the care of critically ill children. The operating characteristics of the available circuits are largely unknown. Prior to introducing CAVH into our pediatric intensive care unit, we investigated the performance of three CAVH circuits: CAVH with postfilter dilution, CAVH with prefilter dilution (CAVH_pre) and CAVH with dialysis counterflow. Using a neonatal lamb model, we measured filter blood flow (Q_B), ultrafiltrate rate (Q_U), arterial, venous and ultrafiltrate compartment pressure, oncotic pressure, plus urea levels in blood and ultrafiltrate fluid for the three CAVH circuit designs. Transmembrane pressure and urea clearance were calculated for various values of Q_B after varying a clamp on the arterial side of the circuit. The major finding, applicable to all circuits, was the wide variability of Q_B. Constant attention was required in order to obtain a consistent Q_B. Fluid clearance was effective with all three circuits. Urea clearance averaged 5–10 ml/min and was principally dependent on Q_U and independent of Q_B. The addition of dialysis counterflow did not increase urea clearance. The most convenient circuit we tested was CAVH_pre, but the problem of unstable Q_B is common to all unpumped arteriovenous filtrate circuits. It is a major limiting factor in the practical application of this technology to critically ill children.