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CPFA - Coupled Plasma Filtration Adsorption La risposta mirata alla SEPSI

CPFA - Coupled Plasma Filtration Adsorption La risposta mirata alla SEPSI. Marco POZZATO Struttura Complessa di Nefrologia e Dialisi (Direttore: Dr. F. Quarello) Ospedale S. Giovanni Bosco - Torino. Casi di sepsi. NEJM 348:1546 (2003). Dialysate Recycling. Poisoning treatment. ‘80s.

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CPFA - Coupled Plasma Filtration Adsorption La risposta mirata alla SEPSI

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  1. CPFA -Coupled Plasma Filtration AdsorptionLa risposta mirata alla SEPSI Marco POZZATO Struttura Complessa di Nefrologia e Dialisi (Direttore: Dr. F. Quarello) Ospedale S. Giovanni Bosco - Torino

  2. Casi di sepsi NEJM 348:1546 (2003)

  3. Dialysate Recycling Poisoning treatment ‘80s Sorbent Plasma filtrate regeneration Ultrafiltrate regeneration ‘90s Coupled plasma filtration-adsorption Hemodiafiltration

  4. SORBENTI • granuli, sfere o piccoli cilindri • diametri variabili da pochi µm a circa 1 cm con superfici variabili da 300 a 1200 m2/g • dimensioni dei pori come macropori (50 nm), mesopori (2-50 nm), micropori (<2 nm) • geometrie differenti al fine di rendere l’adsorbimento da parzialmente a molto selettivo

  5. Tipi di sorbenti nella pratica clinica Sorbenti Trattamento Non Selettivi • Hemoperfusion • Hemodiafiltration • Coupled plasma filtration adsorption (CPFA) • Hemodiadsorption • Charcoal coated / uncoated. • Uncharged resins (Amberlite XAD-7) • Hydrophobic resins • Powdered sorbent Selettivi • Regenerative push-pull pheresis • Polystyrene-derivative fibers • Macroporous cellulosic beads • Macroporous cellulosic beads • Microphere-based detoxification system • Engineered matrices: Polymyxin-B • Engineered matrices: Polyethyleneimine

  6. Inquadramento SIRS, SEPSI, MOF INFEZIONE SIRS SEPSI SEPSI GRAVE MOF SHOCK SETTICO

  7. Inquadramento SIRS, SEPSI, MOF • SIRS • Temperatura corporea > 38°C o <36°C • Frequenza cardiaca > 90 bpm • Frequenza respiratoria > 20 • Leucocitosi >12000 • Leucopenia <4000 • Mutamenti omeostasi

  8. Inquadramento SIRS, SEPSI, MOF • SEPSI • Infiammazione sistemica • Alterazioni della coagulazione • Fibrinolisi • Disfunzione endoteliale • Trombosi microvascolare

  9. Inquadramento SIRS, SEPSI, MOF • SEPSI • Alterazione coscienza • Confusione mentale e/o psicosi • Ipotensione (PAS <90) • Tachicardia (FC >100) • PaO2 < 70 • SaO2 < 90% • PaO2/FiO2 < 300 • Aumento CVP e PAOP • Oliguria, anuria, aumento ritentivi • Indice di shock: FC/PAS <0.9

  10. MULTIPLE ORGAN DISFUNCTION Infezione /Trauma SIRS SEPSI SEPSI GRAVE ipoperfusione SHOCK SETTICO

  11. Volume 345:1368-1377 November 8, 2001 Number 19 Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock Emanuel Rivers, M.D., M.P.H., Bryant Nguyen, M.D., Suzanne Havstad, M.A., Julie Ressler, B.S., Alexandria Muzzin, B.S., Bernhard Knoblich, M.D., Edward Peterson, Ph.D., Michael Tomlanovich, M.D., for the Early Goal-Directed Therapy Collaborative Group

  12. SEPSI: DEA flow-chart

  13. Sepsi: Protocollo di Trattamento Precoce

  14. Sepsi: Mortalità

  15. Sepsi: Organi e Apparati interessati

  16. Sepsi: danno d’organo

  17. Epidemiologia dell’IRA • 5-7% di tutti i pazienti ospedalizzati • 40-50% necessitano di dialisi • 40-90% di mortalità nei soggetti sottoposti a trattamento dialitico Himmelfarb J. J Am Soc Nephrol 1998;9:257-66

  18. Trattato di NEFROLOGIA (1995). A. Vercellone, G. Piccoli, GP. Segoloni, P. Stratta Insufficienza Renale Acuta PRE-RENALE PARENCHIMALE POST-RENALE necrosi tubulare acuta patologia vascolare nefrite interstiziale acuta GN acuta The Lancet vol. 365, January 29, 2005, p. 417-430

  19. RIFLE Criteria for Acute Renal Dysfunction Urine Output Criteria GFR Criteria* Increased Cr x 1.5 or GFR decrease > 25% UO < .5 ml/kg/h x 6 hr High Sensitivity Risk Increased Cr x 2 or GFR decrease > 50% UO < .5 ml/kg/h x 12 hr Injury Increased Cr x 3 or GFR dec >75% or Cr 4 mg/dl (Acute rise of 0.5 mg/dl) UO < .3 ml/kg/h x 24hr or Anuria x 12 hrs High Specificity Failure Persistent ARF** = complete loss of renal function > 4weeks Loss End Stage Renal Disease (>3 months) ESRD

  20. IRA: incidenza nella sepsi SEPSI 19% SEPSI SEVERA 23% SHOCK SETTICO 51% Rangel-Frausto JAMA 1995; 273:117-23

  21. N Engl J Med 348;2 www.nejm.org january 9, 2003 Richard S. Hotchkiss et Irene E. Karl

  22. MORTALITÀ Mortalità % N° di organi interessati Chertow GM. et al, Arch Int Med 1995

  23. GiViTI

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