Transcript Diapositive 1

Prise en charge de l'IRA au
cours du sepsis
" Quelle place pour
l’hémofiltration continue ? "
Bertrand Souweine Clermont-Ferrand
Acute renal failure in ICU
Uchino S, JAMA 05
oliguria <200 ml/12 h or BUN=30 or need for RRT; 1738 / 29269 (5.7%) patients
ICU mortality = 52%
hospital mortality = 60%
Acute renal failure in ICU
Uchino S, JAMA 05
ICU mortality = 52%
hospital mortality = 60%
oliguria <200 ml/12 h or BUN=30 or need for RRT; 1738 / 29269 (5.7%) patients
CVVH
CVVHD
53%
34%
Uchino BEST Study ICM 07
to waste
Blood In
(from patient)
QUF = CH O x PTM x S
replacement
Solution
2
Blood Out
(to patient)
LOW PRESS
HIGH PRESS
(Convection)
Christaki, Cur Opin Crit Care 08
CVVHF
• Primary therapeutic goal:
– Convective removal of water and electrolytes
– Management of intravascular volume
– higher clearance of middle and large molecular
weight solutes
• Blood Flow rate = 150 ml/min (10 – 180)
• UF rate ranges 20-35 ml/kg/h (> 100)
• Requires replacement solution to drive convection
• No dialysate
CVVHF as renal support in
septic acute renal failure
Arm
Global survival
Sepsis group survival
20 ml/kg/h
41%
25%
35 ml/kg/h
57%
18%
45 ml/kg/h
58%
47%
Ronco C, Lancet 00
48 patients
270 filters
Median filter life = 15.0 h (8.9-26.1)
Median down time = 3.0 h (1.0-8.3) per day
in patients with septic acute renal failre
CVVHF is probably not less effective than IHD as renal
support
a-35 ml/kg/h of UF rate is required
think of down time and perhaps prescribe a higher
CVVHF doses (45 ml/kg/h) to deliver at less 35 ml/kg/h
Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.
CVVHF
from renal support
to sepsis support
Annane D, Lancet 05
Mi
M=DxC
Blood In
(from patient)
MUF
Repl.
Solution
Mads
Blood Out
(to patient)
MO
CLHF = S x Quf
TdM = Mi-MO
Membrane permeability (cut-off…)
Molecular weight of the substance
Free substance or protein bound
Hemofiltration and immunomodulation
Honore PM, CCI 03
C3a
IL-6
IL-10
C5a
IL-8
TNF
4/12 DC dans chaque bras
CVVHF for sepsis support
renal dose is no sufficient to improve survival
Cole L, CCM 02
cytokine
TNF
IL-1
IL-6
IL-10
TNF
CS
<0.2
0.07-0.40
0.1-0.8
0
<0.01
< 20%
< 25%
< 25%
0
< 20%
clairance extra-corporelle
CLHF = S x Quf
De Vriese AS, JASN 1999
10 patients with CVVH cross over study
QB = 100 ml/min, UF rate = 25.4 +/- 0.7 ml/min followed by
QB = 200 ml/min, UF rate = 44.3 +/- 1.5 ml/min
change of filter
change of filter
cytokine removal was highest 1 hour after the start of CVHHF and after the change
the effect increases when increasing in UF rate
the inhibitors were remove at the same extend as the inflammatory cytokines
no clinical impact
De Vriese AS, JASN 1999
Pulse high volume hemofiltration
delay time (hrs)
non survivors
survivors
20 patients with refractory septic shock
4-hr HVHF followed by standard CVVH
HVHF, QB=450 ml/mn + 35-L UF volume
CVVH, UF volume = 24-L/day
Honore PM, CCM 00
Pulse HVVHF and vasopressor requirements
15 patients with severe sepsis/septic shock
8-hrs HVHF (85 ml/kg) followed by 16-hrs LVHF (35 ml/kg)
observed 28-days mortality of 47% vs Predicted of 68%
Ratanarat R, Crit Care 03
Pulse HVVHF QUF=100 ml/kg/h in 20 patients
with septic shock
mortality (SMR) = 0.6; 2/11 in responders vs 6/9 in non responders
response to HVHF was the only predictor of survival
Cornejo, ICM 06
Piccini, ICM 06
HVHF decreases vasopressor requirements in septic shock
Short lived physiological effect
randomized cross over study,
11 patients with septic shock and MOF
either 8 h of CVVH (2l/h) or 8 h of HVHF (6l/h)
Cole L, ICM
01
Early HVHF in ARF with shock
RCT in 106 cardiac surgery patients
with MV + shock + ARF
causes of death :
cardiac failure = 55.6%
septic shock = 6.7%
low mortality rate
delay time between admission and HF
in early groups >1.5 days
no sufficient statistical power to
demonstrate equivalence
Bouman CSC, CCM 02
N. Renal Replacement
Grade B
There is no current evidence to support the use of continuous venovenous
hemofiltration for the treatment of sepsis independent of renal replacement
needs.
PA < -150 mmHg
QUF = CH O x PTM x S
2
 QUF :  PTM
QB : 250 ml/mn
abord vx, volémie…
Ratio UF/[QB x (1-hte)]
pré / post / mixte
PUF < -150 mmHg
P
R
I
S
M
A
P
R
I
S
M
A
P
R
I
S
M
A
Pharmacokinetic data
of AB for 70 kg patient
receiving CVVHF 35
ml/kg/h
clinically significant if >0.25
Bouman
LOADING DOSE IS UNAFFECTED
BY CVVHF
since loading dose mainly depends on the VD and not
on the elimination
VD affected by
TBW,
Protein binding,
tissue perfusion,
lipid solubility,
pH gradient,
active transport
MAINTENANCE DOSE
FrCVVHF >0.25
requires dosage increase in comparison with renal
failure
concentration dependent ABs :
shorten dosing interval maintained fixed dosage)
IntervalCVVHF = Tanuric x (1 - FrCVVHF)
time-dependent Abs
Doseanuric
dose CVVHF =
1-FrCVVHF
Conventional CVVH is associated
with a broad spectrum of metabolic
side effects, including: the loss of
amino acids such as glutamine,
water-soluble vitamin, minerals, and
antioxidants
amino acid losses
approximatively
10-15 g /day
approximatively
3 g /day
Amino acid losses during CRRT
• depend upon the rate of ultrafiltration and free serum
amino acid levels
• losses approximatively 10-15 g per day
• 10% to 13% loss of the total amount infused [1]
• AA losses largely vary from one AA to another :
- 1.5% of AA supply for glutamate
- 11.6% for tyrosine during CVVH [2].
- glutamine accounted for 33% of AA loss [3].
1-Bellomo R. Am J Kidney Dis 1993
2-Davies SP et al. Crit Care Med 1991
3-Novák I et al. Artif Organs 1997
Seabra AJKD 08
CVVHF during sepsis
is only indicated for renal support
must be started without delay
requires an UF rate of 45 ml/kg/hr
physician must take into account the down time
to prescribe the CVHHF dose