EER quand, comment - JIVD - AER · EER quand, comment ? ... Yevgeniy Gitelman, Jennie Lin, Dan Negoianu, Chirag R Parikh, Peter P Reese, Richard Urbani, Barry Fuchs Dialysis

EER quand, comment ? Pr. Nicolas Lerolle Département de réanima5on médicale et médecine hyperbare

Duration of hypotension before initiation of effective antimicrobialtherapy is the critical determinant of survival in human septic shock*

Anand Kumar, MD; Daniel Roberts, MD; Kenneth E. Wood, DO; Bruce Light, MD; Joseph E. Parrillo, MD;Satendra Sharma, MD; Robert Suppes, BSc; Daniel Feinstein, MD; Sergio Zanotti, MD; Leo Taiberg, MD;David Gurka, MD; Aseem Kumar, PhD; Mary Cheang, MSc

on. (Crit Care Med 2006; 34:1589 1596)Y WORDS: sepsis; antimicrobial; timing; de

EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT OF SEVERE SEPSIS AND SEPTIC SHOCK

E

MANUEL

R

IVERS

, M.D., M.P.H., B

RYANT

N

GUYEN

, M.D., S

UZANNE

H

AVSTAD

, M.A., J

ULIE

R

ESSLER

, B.S., A

LEXANDRIA

M

UZZIN

, B.S., B

ERNHARD

K

NOBLICH

, M.D., E

DWARD

P

ETERSON

, P

H

.D.,

AND

M

ICHAEL

T

OMLANOVICH

, M.D.,

FOR

THE

E

ARLY

G

OAL

-D

IRECTED

T

HERAPY

C

OLLABORATIVE

G

ROUP

*

<8 mm Hg

Supplemental oxygen ±endotracheal intubation and

mechanical ventilation

Central venous andarterial catheterization

Sedation, paralysis(if intubated),

or both

CVP

MAP

ScvO2

Goalsachieved

Hospital admission

Crystalloid

Colloid

Vasoactive agents

Transfusion of red cells until hematocrit »30%

Inotropic agents

<65 mm Hg

>90 mm Hg

8–12 mm Hg

»65 and «90 mm Hg

No

Yes

<70%<70%

»70%

»70%

1368

·

N Engl J Med, Vol. 345, No. 19

·

November 8, 2001

·

www.nejm.org

Randomization(N=221)

Noninvasive ventilation(N=114)

Standard medical therapy(N=107)

Crossover to noninvasive ventilation (N=28)

Reintubation(N=55)

No reintubation(N=59)

Reintubation(N=51)


Reintubation(N=7)


Death(N=21)

Death(N=7)

Death(N=11)

Death(N=4)

Death(N=1)

Death(N=2)

Noninvasive Positive-Pressure Ventilation for Respiratory Failure after Extubation

Andrés Esteban, M.D., Ph.D., Fernando Frutos-Vivar, M.D., Niall D. Ferguson, M.D., Yaseen Arabi, M.D.,

Carlos Apezteguía, M.D., Marco González, M.D., Scott K. Epstein, M.D., Nicholas S. Hill, M.D., Stefano Nava, M.D., Marco-Antonio Soares, M.D.,

Gabriel D’Empaire, M.D., Inmaculada Alía, M.D., and Antonio Anzueto, M.D.

N Engl J Med 2004;350:2452-60.

Copyright © 2004 Massachusetts Medical Society.

Hémo2iltration

•  C Ronco Lancet 2000 •  425 pa5ents de réanima5on •  Réinjec5on 20 ml/kg/h vs 35 vs 45 •  Survie J15 après fin hémofiltra5on

RESEARCH Open Access

A comparison of early versus late initiation ofrenal replacement therapy in critically ill patientswith acute kidney injury: a systematic review andmeta-analysisConstantine J Karvellas1, Maha R Farhat2, Imran Sajjad3, Simon S Mogensen4, Alexander A Leung5, Ron Wald6,Sean M Bagshaw1*

Karvellas et al. Critical Care 2011, 15:R72http://ccforum.com/content/15/1/R72

louise

Continuous venovenous haemodiafi ltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trialChristophe Vinsonneau, Christophe Camus, Alain Combes, Marie Alyette Costa de Beauregard, Kada Klouche, Thierry Boulain, Jean-Louis Pallot, Jean-Daniel Chiche, Pierre Taupin, Paul Landais, Jean-François Dhainaut, for the Hemodiafe Study Group*

00

0·2

0·4

0·6

0·8

1·0

10 20 30 40 50 60

Surv

ival

(%)

Time (days)

CVVHDFIHD

Lancet 2006; 368: 379–85

High-volume versus standard-volumehaemofiltration for septic shock patientswith acute kidney injury (IVOIRE study):a multicentre randomized controlled trial

Intensive Care Med (2013) 39:1535–1546DOI 10.1007/s00134-013-2967-z ORIGINAL

Early High-Volume Hemofiltration versus Standard Care forPost–Cardiac Surgery ShockThe HEROICS StudyAlain Combes1, Nicolas Brechot1, Julien Amour2, Nathalie Cozic3, Guillaume Lebreton4, Catherine Guidon5,Elie Zogheib6, Jean-Claude Thiranos7, Jean-Christophe Rigal8, Olivier Bastien9, Hamina Benhaoua10, Bernard Abry11,Alexandre Ouattara12, Jean-Louis Trouillet1, Alain Mallet3, Jean Chastre1, Pascal Leprince4, and Charles-Edouard Luyt1

Am J Respir Crit Care Med Vol 192, Iss 10, pp 1179–1190, Nov 15, 2015

C i ht © 2015 b th A i Th i S i t

0

20

40

60

80

100

Follow-up (days)

Pro

babi

lity

of s

urvi

val (

%)

Standard Care

P = 0.72 by log-rank test

Early HVHF

100 20 30 40 50 60 70 80 90

•  TT intensif : CVVHDF 35 ml/kg/h ou IHD/SLD quo5dien

•  TT non intensif :20 ml/kg/h ou IHD/SLED 2j

Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury

The VA/NIH Acute Renal Failure Trial Network*

1.0

0.8

0.6

0.4

0.2

0.00 10 20 30 40 50 605 15 25 35 45 55

Intensive therapy

Less-intensive therapy

N Engl J Med 2008;359:7-20.Copyright © 2008 Massachusetts Medical Society.

Effects of early high-volume continuous venovenous hemofiltrationon survival and recovery of renal function in intensive carepatients with acute renal failure: A prospective, randomized trial

Catherine S. C. Bouman, MD; Heleen M. Oudemans-van Straaten, MD, PhD; Jan G. P. Tijssen, MD, PhD;Durk F. Zandstra, MD, PhD; Jozef Kesecioglu, MD, PhD

Crit Care Med 2002 Vol. 30, No. 10

Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit

Stéphane Gaudry, M.D., David Hajage, M.D., Fréderique Schortgen, M.D.,

T h e n e w e ngl a nd j o u r na l o f m e dic i n e

KDIGO 3 Créat > 300% Créat > 354 µM Oligurie 24h Anurie 12h

•  Urée > 40 mM •  K> 6 mM ; > 5.5 mM après traitement •  pH<7.15 (métabolique) •  OAP résistant aux diuré5ques + oliguria > 72h

EER immédiate Adente

Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit

Stéphane Gaudry, M.D., David Hajage, M.D., Fréderique Schortgen, M.D.,

T h e n e w e ngl a nd j o u r na l o f m e dic i n e

Prop

ortio

n Fr

ee fr

om R

enal

-R

epla

cem

ent T

hera

py

1.0

0.8

0.9

0.7

0.6

0.4

0.3

0.1

0.5

0.2

0.00 1 2 3 4 6 28

Days

P<0.001

5 247 8 12 16 20

Early strategy

Delayed strategy

Prob

abili

ty o

f Ade

quat

e U

rine

Out

put w

ithN

o N

eed

for

Ren

al-R

epla

cem

ent T

hera

py

1.0

0.8

0.9

0.7

0.6

0.4

0.3

0.1

0.5

0.2

0.00 7 14 21 28

Days

P<0.001

Early strategy

Delayed strategy

Mortalité Jamais EER 37.1% EER précoce 48.5% EER tardive 68,1%

57h

Ven5lé 85% Vasopresseur 85%

Effect of Early vs Delayed Initiation of Renal ReplacementTherapy onMortality in Critically Ill PatientsWith Acute Kidney InjuryThe ELAIN Randomized Clinical TrialAlexander Zarbock, MD; John A. Kellum, MD; Christoph Schmidt, MD; Hugo Van Aken, MD; Carola Wempe, PhD;

Original Investigation | CARING FORTHE CRITICALLY ILL PATIENT

JAMA. doi:10.1001/jama.2016.5828Published online May 22, 2016.


Time from KDIGO 2 to RRT,median (Q1, Q3), h

6.0(4.0, 7.0)

25.5(18.8, 40.3)

Early(n = 112)

Delayed(n = 119)

108 112

KDIGO 2 Créat > 200% Oligurie 12h

+ pNGAL>150 ng/mL

KDIGO 3 K>6, Mg >4 mM Urée > 35 mM





Time from KDIGO 2 to RRT,median (Q1, Q3), h

6.0(4.0, 7.0)

25.5(18.8, 40.3)

Early(n = 112)

Delayed(n = 119)

108 112

KDIGO 2 Créat > 200% Oligurie 12h

+ pNGAL>150 ng/mL

KDIGO 3 K>6, Mg >4 mM Urée > 35 mM

Un seul centre

43% chirurgie cardiaque 37% chirurgie diges5ve




100

80

60

40

20

00 10 20 30 40 50 60 70 80 90

Ove

rall

Mor

talit

y Pr

obab

ility

, %

Days Since Randomization

Early RRT

Delayed RRT

Inverse normal log-rank test, P = .03; HR = 0.66 (95% CI, 0.45-0.97)

Hospital stay, median (Q1, Q3), dn 51(31, 74)

82(67, >90)

<.001 −37(−� to −19.5)

D ti f h i l til ti 125 5 181 0 002 60 0

Early(n = 112)

Delayed(n = 119)

PValue

AbsoluteDifference, %(95% CI)

Durée CVVH 25j

9j 3 pts !

Hemodynamic Tolerance of Intermit tent Hemodialysis in Crit ically Ill Pat ients

Usefulness of Practice Guidelines

FRÉDÉRIQUE SCHORTGEN, NADINE SOUBRIER, CHRISTOPHE DELCLAUX, MARIE THUONG, EMMANUELLE GIROU,CHRISTIAN BRUN-BUISSON, FRANÇOIS LEMAIRE, and LAURENT BROCHARD

Service de Réanimation Médicale, Unité d’Hygiène et de Prévention de l’infection, Hôpital Henri Mondor, AP-HP, Créteil, France

Am J Respir Crit Care Med Vol 162. pp 197–202, 2000Internet address: www.atsjournals.org

Nicolas LerolleDominique NochyEmmanuel GuerotPatrick BrunevalJean-Yves FagonJean-Luc DiehlGary Hill

Histopathology of septic shock induced acutekidney injury: apoptosis and leukocyticinfiltration

Intensive Care Med (2010) 36:471–478DOI 10.1007/s00134-009-1723-x ORIGINAL

RRT (yes = 1; no = 0)

Ra P

‘‘Common’’ tubular injury lesionsTubular brush border lossc 0.58 0.008Tubular proximal necrosisc 0.46 0.05Tubular distal necrosisc 0.51 0.03Tubular luminal cytoplasmic debrisc 0.57 0.01‘‘Very severe’’ injury lesionsTubular cytoplasmic degenerationc 0.27 0.25Cellular detachment from TBMc,d 0.36 0.12Capillary congestionc 0.12 0.62

Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trialF Perry Wilson, Michael Shashaty, Jeff rey Testani, Iram Aqeel, Yuliya Borovskiy, Susan S Ellenberg, Harold I Feldman, Hilda Fernandez, Yevgeniy Gitelman, Jennie Lin, Dan Negoianu, Chirag R Parikh, Peter P Reese, Richard Urbani, Barry Fuchs

Lancet 2015; 385: 1966–74

1201 assigned to alert group1169 received allocated intervention

32 did not receive allocated intervention 32 text page not received

23 664 screened

21 271 excluded2539 <18 years 4749 <2 creatinine values

716 first creatinine ≥4·0 mg/dL 54 ESRD ICD-9 code at admission

1359 admitted to observation or hospice 157 unable to determine provider

11 697 no acute kidney injury detected

2393 randomised

1192 assigned to and received usual care group

1201 analysed 1192 analysed

‘‘[Initials], [Room Number], has been identifi ed as having acute kidney injury (AKI) based upon the latest creatinine value. Please take appropriate diagnostic and therapeutic measures. THIS ALERT DOES NOT FIRE FOR ALL PATIENTS WITH AKI. For more information, please visit [internal study website].’’


Lancet 2015; 385: 1966–74

Medical intensive care unit (n=278)

Renal consult

Dialysis

Death

Death or dialysis

Medical ward (n=1044)

Renal consult

Dialysis

Death

Death or dialysis

Surgical intensive care unit (n=444)

Renal consult

Dialysis

Death

Death or dialysis

Surgical ward (n=627)

Renal consult

Dialysis

Death

Death or dialysis

1·38 (0·68–2·85)

1·41 (0·72–2·81)

0·85 (0·50–1·47)

1·07 (0·64–1·77)

0·68 (0·43–1·05)

0·96 (0·55–1·68)

0·96 (0·54–1·69)

0·95 (0·62–1·46)

1·19 (0·69–2·05)

0·90 (0·51–1·59)

1·11 (0·64–1·93)

0·94 (0·59–1·51)

2·29 (1·22–4·44)

2·49 (1·02–6·67)

2·07 (0·77–6·13)

2·51 (1·17–5·73)

Events, n (%) Odds ratio (95% CI)

0·34

0·29

0·55

0·79

0·06

0·87

0·87

0·80

0·51

0·70

0·68

0·79

0·01

0·03

0·12

0·01

p value

Alert group (n=1201)

Usual care group (n=1192)

Favours alert Favours usual care

0·25 0·5

24 (17%)

27 (19%)

40 (29%)

58 (41%)

41 (8%)

29 (6%)

28 (5%)

50 (10%)

38 (17%)

30 (13%)

36 (16%)

49 (22%)

36 (12%)

19 (6%)

14 (5%)

26 (8%)

18 (13%)

20 (15%)

44 (32%)

55 (40%)

58 (11%)

30 (6%)

29 (6%)

52 (10%)

32 (15%)

32 (15%)

32 (15%)

50 (23%)

17 (5%)

8 (3%)

7 (2%)

11 (4%)

21 4


Lancet 2015; 385: 1966–74

Medical intensive care unit (n=278)

Renal consult

Dialysis

Death

Death or dialysis

Medical ward (n=1044)

Renal consult

Dialysis

Death

Death or dialysis

Surgical intensive care unit (n=444)

Renal consult

Dialysis

Death

Death or dialysis

Surgical ward (n=627)

Renal consult

Dialysis

Death

Death or dialysis

1·38 (0·68–2·85)

1·41 (0·72–2·81)

0·85 (0·50–1·47)

1·07 (0·64–1·77)

0·68 (0·43–1·05)

0·96 (0·55–1·68)

0·96 (0·54–1·69)

0·95 (0·62–1·46)

1·19 (0·69–2·05)

0·90 (0·51–1·59)

1·11 (0·64–1·93)

0·94 (0·59–1·51)

2·29 (1·22–4·44)

2·49 (1·02–6·67)

2·07 (0·77–6·13)

2·51 (1·17–5·73)

Events, n (%) Odds ratio (95% CI)

0·34

0·29

0·55

0·79

0·06

0·87

0·87

0·80

0·51

0·70

0·68

0·79

0·01

0·03

0·12

0·01

p value

Alert group (n=1201)

Usual care group (n=1192)

Favours alert Favours usual care

0·25 0·5

24 (17%)

27 (19%)

40 (29%)

58 (41%)

41 (8%)

29 (6%)

28 (5%)

50 (10%)

38 (17%)

30 (13%)

36 (16%)

49 (22%)

36 (12%)

19 (6%)

14 (5%)

26 (8%)

18 (13%)

20 (15%)

44 (32%)

55 (40%)

58 (11%)

30 (6%)

29 (6%)

52 (10%)

32 (15%)

32 (15%)

32 (15%)

50 (23%)

17 (5%)

8 (3%)

7 (2%)

11 (4%)

21 4

Impact of continuous venovenous hemofiltration on organ failureduring the early phase of severe sepsis: A randomized controlledtrial*

Didier Payen, MD, PhD; Joaquim Mateo, MD; Jean Marc Cavaillon, PhD; Francois Fraisse, MD;Christian Floriot, MD; Eric Vicaut, MD, PhD; for the Hemofiltration and Sepsis Group of the College Nationalde Reanimation et de Medecine d’Urgence des Hopitaux extra-Universitaires

Figure 3. Kaplan-Meier curves for time to death

is. (Crit Care Med 2009; 37:803–810septic shock; hemofiltration; cyt

Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults

Yaseen M. Arabi, M.D., Abdulaziz S. Aldawood, M.D., Samir H. Haddad, M.D., Hasan M. Al-Dorzi, M.D., Hani M. Tamim, M.P.H., Ph.D., Gwynne Jones, M.D.,

Sangeeta Mehta, M.D., Lauralyn McIntyre, M.D., Othman Solaiman, M.D., Maram H. Sakkijha, R.D., Musharaf Sadat, M.B., B.S., and Lara Afesh, M.S.N.,

for the PermiT Trial Group*

Prob

abili

ty o

f Sur

viva

l1.0

0.8

0.9

0.7

0.6

0.4

0.3

0.1

0.5

0.2

0.00 20 60 1008040 120 140 160 180

Days

P=0.43 by log-rank test

Permissive underfeeding

Standard feeding

N Engl J Med 2015;372:2398-408.DOI: 10.1056/NEJMoa1502826

• Pas de rela5on dose / effet

•  Tôt ou tard peu importe

• Pourrait augmenter la mortalité/morbidité chez certains pa5ents

• Pas de rela5on dose / effet

•  Tôt ou tard peu importe

• Pourrait augmenter la mortalité/morbidité chez certains pa5ents

Que traite-‐t-‐on avec l’épura5on extra-‐rénale aiguë?

Que traite-‐t-‐on avec l’épura5on extra-‐rénale aiguë?

K pH

Surcharge Urée > 35 mM

Intensive Care Med (2013) 39:987–997DOI 10.1007/s00134-013-2864-5

HDI vs. CVVH : long terme

Documents

EER quand, comment - JIVD - AER · EER quand, comment ? ... Yevgeniy Gitelman, Jennie Lin, Dan Negoianu, Chirag R Parikh, Peter P Reese, Richard Urbani, Barry Fuchs Dialysis