ICU中的血液净化治疗（55页）.ppt

Short Term-Very HVHF Patrick Honore et al. (Crit Care Med 2000; 28: 3581-3587) 20 patients in severe refractory septic shock 20例严重的难以控制的感染中毒性休克病人 4 hours of HVHF (blood flow 450 ml/min, 1.6 m2 Fresenius polysulfone filter, bicarbonate buffer, post-dilution, UF rate 8750 ml/hr) 4小时HVHF（血流450ml/min,1.6m2多聚砜膜，后置换，UF＝8750ml/hr） Approx. small solute clearance: 116ml/kg/hr 小分子物质的清除率≈116ml/kg/hr Results 11 responders (rapid increase in CI, MVSO2, pH7.3 and 50% reduction in adrenaline dose) 11例有反应的病人 9 of 11 responders survived Responders weighed less : 66 vs. 83 kg 有反应的病人体重较无反应者体重偏轻 Responders got more UF: 132 ml/kg/min vs. 107 ml/kg/min 那么有反应的病人UF则要高于无反应者 Responders were treated earlier: 6.5 vs. 13.8 hrs 同时也发现，有反应的病人治疗要早于无反应者 Comments注解 但这一试验本身存在问题： No controls No randomization No predefined criteria of response 没有预先制定有反应组的诊断标准 However..... Provocative study 研究是具有煽动性的 Findings consistent with expectations 与期望的结果一致 Conclusions We have no consensus definition for the term “HVHF” but we have several phase I studies suggesting that “more” UF might be better. 我们没有关于高容量血滤的一致定义，但是我们已经从一些一期临床试验报道中看到，UF越大，疗效越好 We have limited understanding of mechanisms, dose and duration, however, and no markers like urea 我们对于其机制的了解非常有限，剂量，时间，而且我们除了尿素没有任何可以取而代之的指标 This is a promising and exciting area of research. We now need a phase II trial. 这是一个非常有前途和令人兴奋的领域。我们现在需要进行的是二期临床试验 Why not plasma exchange?为什么不选择血浆置换？ Fresh frozen plasma (FFP) is available in limited amounts FFP的数量非常有限 If done continuously, after a while one is removing the FFP given 如果持续进行，在很短的时间内就会耗竭所有的血浆 FFP contains many of the proteins we want to remove. Intermittent therapy is unlikely to be enough FFP中含有很多我们希望清除的蛋白。间断的治疗未必充足 No effect in Phase Ib trial (Reeves et al. Crit Care Med 1999; 27: 2096-2104) 从如下一b期临床试验中反应的结果是无效的 Why Coupled Plasma Filtration Adsorption (CPFA)?为什么选择联合血浆滤过黏附 All plasma becomes available for “purification” 体内所有的血浆都变得可以用于净化治疗 Therapy can be continuous 治疗可以持续 No interaction between cells and adsorptive