icu中的血液凈化指南之我見(jiàn)(完整版)
【正文】 ica, where it was used as initial therapy in 30–40% 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 pare outes between patients on CRRT and those on IHD Nat. Rev. Nephrol. 2024:6:521–529. 第十四頁(yè)，共四十二頁(yè)。 Timing of CRRT ? 目前廣為接受的 Septic AKI開(kāi)始 RRT時(shí)機(jī)，尤其是在 septic shock 時(shí)： RIFLE injury stage (or AKIN stage 2) ? but consensus on this topic awaits results from largescale RCTs. 第二十一頁(yè)，共四十二頁(yè)。 Dose or intensity of CRRT ? 而關(guān)于 nonseptic AKI 的治療劑量， RENAL研究得到了一個(gè)明確的答案 : Randomized Evaluation of Normal versus Augmented Levels (RENAL) study: ? no beneficial effect of CVVHDF at 40 ml/kg/h pared with 25 ml/kg/h. ? Therefore, current consensus suggests a hemofiltration dose of 25 ml/kg/h in nonseptic AKI with no additional benefit from a dose increase. N Engl J Med 2024, 361:16271638. 第二十九頁(yè)，共四十二頁(yè)。 RRT in ICU: Preference ?2. The patient`s cardiovascular status ? CRRT causes less rapid fluid shifts and is the preferred option if there is any degree of cardiovascular instability. ?3. The availability of resources ?CRRT is more labour intensive and more expensive than IHD ?Availability of equipment may dictate the form of RRT 第三十四頁(yè)，共四十二頁(yè)。 內(nèi)容總結(jié) ICU中的血液凈化指南之我見(jiàn)。 AKI的急性期推薦應(yīng)用 CRRT，尤其是對(duì)于嚴(yán)重血流動(dòng)力學(xué)不穩(wěn)定、需大量去除液體以便于進(jìn)行更有效藥物治療的患者。 許多問(wèn)題懸而未決 第三十六頁(yè)，共四十二頁(yè)。 ? 但實(shí)際中由于存在可預(yù)測(cè)的〔 bags change, nursing...〕和不可預(yù)測(cè)的〔 surgery, clotting...〕治療中斷，意味著劑量要在 3035 ml/kg/h； ? Septic AKI患者的治療劑量目前仍存在爭(zhēng)議，一些小的前瞻隨機(jī)研究說(shuō)明高劑量的血液濾過(guò)是有益的。 Timing of CRRT ? When initiation of RRT is considered, it is important to realize that: ? the consequences of ureamic toxicity, metabolic acidosis and/or fluid overload are likely to be more severe in the critically ill patient. ? Moreover, renal function is unlikely to recover within a short period during persistent and severe failure of other ans. ? Furthermore, various inflammatory mediators are cleared by the kidney. 第二十三頁(yè)，共四十二頁(yè)。 ? 有些研究說(shuō)明在 ICU不穩(wěn)定的患者中應(yīng)用 IHD也不會(huì)存在明顯的問(wèn)題 , 有RCTs并沒(méi)有顯示出 CRRT優(yōu)于 IHD Type of therapy Kidney Int 2024,76:422427. BMC Nephrol 2024, 11:32. Nephrol Dial Transplant 2024, 24:512518. Lancet 2024,368:379385. ? 對(duì)于依賴血管活性藥物的 AKI患者， CRRT才是最適合的； ? 依賴血管活性藥物的 AKI患者將來(lái)接受長(zhǎng)期透析的幾率 CRRT 間斷性治療； ? AKI的急性期推薦應(yīng)用 CRRT，尤其是對(duì)于嚴(yán)重血流動(dòng)力學(xué)不穩(wěn)定、需大量去除液體以便于進(jìn)行更有效藥物治療的患者。 PEPA = polyether polymer alloy Contrib Nephrol. Basel, Karger, 2024(166):11–20 第九頁(yè)，共四十二頁(yè)。 Introduction ? The RIFLE Classification for acute renal failure Crit Care 2024。 Contents Intro
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