ICU中的血液净化指南之我见

,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,*,ICU,中的血液净化指南之我见,Contents,Introduction,1,Type of therapy,2,Timing of CRRT,3,Dose of CRRT,4,Conclusions,5,6,Introduction,Methods of extracorporeal renal replacement therapy(RRT)have been used for the supportive treatment of AKI for over 60 years.,CRRT for the critically ill patient with ARF was introduced in 1977 by Kramer et al.,Since then,many studies have reported on CRRT in the critically ill.,Klin Wochenschr 1977;55:1121-1122.,Introduction,But for several reasons comparison among studies is difficult:,Various treatment modalities have been applied in heterogeneous populations.,Differences in clinical setting and underlying molecular biological mechanisms that initiate and maintain ARF.,Furthermore,more than 35 definitions of ARF.,Practice patterns vary widely between individual centers.,Up to now,there are,no standard guidelines,for the application of CRRT in critically ill patients.,Curr Opin Crit Care 2002;8:509-514.,Introduction,The RIFLE Classification for acute renal failure,Crit Care 2004;8:R204-R212.,Introduction,Conclusions:,More then 200 different definitions of ARF and about 90 RRT start criteria were reported.Oliguria and RIFLE were the most frequent criteria used to define ARF.RIFLE criteria might show a clinical impact on future daily practice and research.,Different RRT techniques are available in most centers,but a general lack of treatment dose standardization is noted by our survey.,Non-renal indications to RRT still need to find a definitive role in routine practice.,Nephrol Dial Transplant(2006)21:690696,In the past,the interaction between nephrology and intensive care was minimal.,Today,there is continuous interaction with several moments of high interaction due to common patients and complex syndromes,and much of the treatment of AKI has moved from the renal ward into ICUs.,Introduction,Contrib Nephrol.Basel,Karger,2010(166):13,Contents,Introduction,1,Type of therapy,2,Timing of CRRT,3,Dose or intensity of CRRT,4,Conclusions,5,6,Type of therapy,Classification of blood purification in critical care(BPCC)technology,PMX=polymyxin-B immobilized fiber;PMMA=polymethylmethacrylate;,PAN=polyacrylonitrile;PEPA=polyether polymer alloy,Contrib Nephrol.Basel,Karger,2010(166):1120,Type of therapy,As a continuous therapy,CRRT can be rapidly tailored to changes in a patients clinical condition during critical illness,Blood purification in critical care,Contrib Nephrol.Basel,Karger,2010(166):1120,HDF=hemodiafiltration,Type of therapy,These advantages have contributed to the widespread uptake of CRRT as the first-choice RRT in ICUs throughout Australia,Japan and Europe.,In these regions,CRRT is usually initiated and managed within the ICU,with RRT being integrated with other aspects of the management of critical illness,Nat.Rev.Nephrol.2010:6:521529.,Type of therapy,In north America,however,traditional structures of ICU management favor an open-ICU approach:,Within this model,RRT is usually prescribed by a nephrologist in the ICU and is initiated by a dialysis nurse,In this environment,IHD has the advantage of requiring only daily or alternate-day attendance by the renal team,Conversely,the relative labor costs of providing CRRT are increased,an effect that is compounded by the larger fixed costs and higher consumable requirements of CRRT,These logistic factors have led to a preference for IHD over CRRT being maintained in ICUs that use the north American.,Nat.Rev.Nephrol.2010:6:521529.,Type of therapy,Clinical studies of CRRT in the ICU,The diversity of clinical approaches to the treatment of AKI in the ICU is illustrated by the results of the BEST Kidney study,The multinational epidemiological study of RRT practice in the ICU,Study documented the treatment of AKI in 1,738 patients in 54 ICUs on five continents,Nat.Rev.Nephrol.2010:6:521529.,Type of therapy,BEST study results,CRRT was the most common choice of initial RRT treatment,with 80%of patients on CRRT;,IHD use was mostly restricted to ICUs in north and south America,where it was used as initial therapy in 3040%of patients,while,by contrast,CRRT is used first in 100%of ICUs in Australia.,Among patients receiving CRRT,however,marked variation in the modality,intensity,timing was observed,Making it difficult to compare outcomes between patients on CRRT and those on IHD,Nat.Rev.Nephrol.2010:6:521529.,Type of therapy,Nat.Rev.Nephrol.2010:6:521529.,有些研究表明在,ICU,不稳定的患者中应用,IHD,也不会存在明显的问题,有,RCTs,并没有显示出,CRRT,优于,IHD,Type of therapy,Kidney Int 2009,76:422-427.,BMC Nephrol 2010,11:32.,Nephrol Dial Transplant 2009,24:512-518.,Lancet 2006,368:379-385.,对于依赖血管活性药物的,AKI,患者，,CRRT,才是最适合的；,依赖血管活性药物的,AKI,患者将来接受长期透析的几率,CRRT,间断性治疗；,AKI,的急性期推荐应用,CRRT,，尤其是对于严重血流动力学不稳定、需大量清除液体以便于进行更有效药物治疗的患者。,Crit Care Med 2008,36:610-617.,Kidney Int 20