Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock The HEROICS Study

被引：92

作者：

Combes, Alain ^{[1
]}

Brechot, Nicolas ^{[1
]}

Amour, Julien ^{[2
]}

Cozic, Nathalie ^{[3
]}

Lebreton, Guillaume ^{[4
]}

Guidon, Catherine ^{[5
]}

Zogheib, Die ^{[6
]}

Thiranos, Jean-Claude ^{[7
]}

Rigai, Jean-Christophe ^{[8
]}

Bastien, Olivier ^{[9
]}

Benhaoua, Hamina ^{[10
]}

Abry, Bernard ^{[11
]}

Ouattara, Alexandre ^{[12
,13
]}

Trouillet, Jean-Louis ^{[1
]}

Mallet, Alain ^{[3
]}

Chastre, Jean ^{[1
]}

Leprince, Pascal ^{[4
]}

Luyt, Charles-Edouard ^{[1
]}

机构：

[1] Univ Paris 06, Hop Pitie Salpetriere, Assistance Publ Hop Paris, Med Surg Intens Care Unit,Inst Cardiometab & Nutr, Paris, France

[2] Univ Paris 06, Hop Pitie Salpetriere, Assistance Publ Hop Paris, Anesthesiol & Crit Care Med Dept,Inst Cardiometab, Paris, France

[3] Univ Paris 06, Hop Pitie Salpetriere, Assistance Publ Hop Paris, Unite Rech Clin,Inst Cardiometab & Nutr, Paris, France

[4] Univ Paris 06, Hop Pitie Salpetriere, Assistance Publ Hop Paris, Cardiac Surg Dept,Inst Cardiometab & Nutr, Paris, France

[5] CHU La Timone, Anesthesiol & Crit Care Med Dept, Marseille, France

[6] Univ Picardie Jules Verne, Amiens Univ Hosp, Anesthesiol & Crit Care Med Dept, INSERM,U1088, Amiens, France

[7] CHU Strasbourg, Anesthesiol & Crit Care Med Dept, F-67000 Strasbourg, France

[8] CHU Nantes, Dept Anesthesiol & Reanimat, F-44035 Nantes 01, France

[9] CHU Lyon, Anesthesiol & Crit Care Med Dept, Lyon, France

[10] CHU Toulouse, Anesthesiol & Crit Care Med Dept, Toulouse, France

[11] Clin Jacques Cartier, Anesthesiol & Crit Care Med Dept, Massy, France

[12] CHU Bordeaux, Dept Anesthesia & Crit Care 2, Pessac, France

[13] Univ Bordeaux, Adaptat Cardiovasc Ischem, U1034, Pessac, France

来源：

AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE | 2015年 / 192卷 / 10期

关键词：

cardiac surgery; high-volume hemofiltration; mortality; randomized controlled trial; CONTINUOUS VENOVENOUS HEMOFILTRATION; RENAL-REPLACEMENT THERAPY; ACUTE KIDNEY INJURY; CRITICALLY-ILL PATIENTS; CORONARY-ARTERY-BYPASS; SYSTEMIC INFLAMMATORY RESPONSE; RANDOMIZED CONTROLLED-TRIAL; CARDIOPULMONARY BYPASS; SEPTIC SHOCK; OUTPUT SYNDROME;

D O I：

10.1164/rccm.201503-0516OC

中图分类号：

R4 [临床医学];

学科分类号：

1002 ; 100602 ;

摘要：

Rationale: Post-cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence. Objectives: To determine whether early HVHF decreases all-cause mortality 30 days after randomization. Methods: This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3-24 hours post-cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury. Measurements and Main Results: On Day 30,40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64-1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors' Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia. Conclusions: For patients with post-cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury.

引用

页码：1179 / 1190

页数：12

共 51 条

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