1
MINISTRY OF EDUCATION
MINISTRY OF NATIONAL
AND TRAINING
DEFENCE
MEDICAL MILITARY UNIVERSITY
THUY HUYNH THI NGOC
EVALUATE THE TREATMENT RESULTS OF SUPPORTING PATIENTS
WITH MULTIPLE ORGAN FAILURE BY PRE-AND-POST-DILUTION
CONTINUOUS VENO-VENOUS HEMOFILTRATION
Speciality:
Internal Medicine
Code:
972 01 07
ABSTRACT OF MEDICAL DOCTORAL THESIS
HA NOI - 2019
THE THESIS WAS COMPLETED AT
MEDICAL MILITARY UNIVERSITY
The scientific instructors:
Ass.Prof. VINH HOANG TRUNG, PhD
HUY DO QUOC, PhD
Reviewer 1: Prof. TAM VO, PhD
Reviewer 2: Ass.Prof. CHI NGUYEN VAN, PhD
Reviewer 3: Ass.Prof. MANH BUI VAN, PhD
2
The thesis will be judged by the board of examiners of Medical Military University
At: ………… o’clock, … / … / 2019
The thesis can be found at:
- National Library of Vietnam
- Medical Military University’s Library
LIST OF PUBLICATIONS RELATED TO THE THESIS
1. Thuy Huynh Thi Ngoc, Vinh Hoang Trung, Huy Do Quoc (2018), "Khảo sát một số đặc điểm lâm
sàng, cận lâm sàng của bệnh nhân suy đa tạng tại Bệnh viện Nhân dân 115", Journal ofMedical
Military,43(6): 60-67.
2. Thuy Huynh Thi Ngoc, Vinh Hoang Trung, Huy Do Quoc (2018), "Evaluate the change of some
parameters in patients with multiple organ failure supported by continuous renal replacement
therapy", Journal ofMedical Military,43(7):130-138.
INTRODUCTION
OVERVIEW
Multiple organ failure (MOF) is the common desease in ICU with complex
injured mechanisms and high mortality, from 22% for 1 failured organ, up to
83% for ≥ 4 failured ones. The more number and severity of organ failure, the
higher mortality rate, therefore the treatment objective is supporting organ
function to reduce the severity of each injured organ and preventing
complications until restored organ function. Continuous renal replacement
therapy (CRRT) is a blood purification through the outer body circulation on the
basis of replacing impaired renal function and removing inflammatory
mediators by diffusion, hemofiltration, convection and adsorption. Convection
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can remove large amounts of solutes if the water flow accross the membrane is
strong enough. In CRRT, this quality is optimized by using the replacement
fluid infused before the filter(predilution), or after the filter (postdilution).
When the replacement fluid infused afterthe filter, solutes concentration are
increased within the membrane filter so that the filter efficiency is increased but
the filter easily clotted. Pre-dilution reduces the viscosity of the blood as it
travels through the filter so it can prolong the life of the filter but the solubility
of the solute decreases. As recommended by ADQI (Acute Dialysis Quality
Initiative), the two methods can be combined by pre-and-post-dilution. Many
domestic and international studies have applied the pre-and-post-dilution
hemofiltration in patients with MOF and reported the efficacy in decreasing
severity of organ failure and death, however, there were a few topics compared
dilution methodsand the efficiency between predilution or postdilution are still
controversial. For the above reasons, we do the research "Evaluate the treatment
results of supportingpatients with multiple organ failure by pre-and-postdilution continuous veno-venuous hemofiltration".
1. Objectives:
The study was conducted in patients diagnosed with multiple organ failure
at the ICU, People's Hospital 115, with two objectives:
1.1. Survey the clinical, subclinical characteristics of patients with multiple
organ failure having acute kidney injury, indicated CRRT in ICU, People's
Hospital 115.
1.2. Evaluate the treatment results of supporting patients with MOF by pre-andpost-dilution compared with post-dilution continuous veno-venous
hemofiltration.
2. The urgency of the topic
CRRT is a technique that has been used in Vietnam for more than 10 years
and is now considered an effective tool to support the patients with multiple
organ failure. Continuous veno-venous hemofiltration (CVVH) - one of many
methods of CRRT - can eliminate water and inlammatory mediators by using
the replacement fluid infused before or after the filter. Any dilution mode brings
the benefit to patients, but each mode has advantages and disadvantages. In
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2002, ADQI (Acute Dialysis Quality Initiative) recommended applying preand-post-dilution in order to get the efficiency as well as to limitdisadvantages
of each mode. This method has been applied in many domestic and international
studies in supporting the function of organs. However, there are some issues
that have not been addressed in many studies, such as how muchthe purifying
solutes between post-dilution and pre-and-post-dilution is likely to be? Are
there differences in supporting the function of organs? and which mode can
extend the filter lifetime? We conducted a prospective, intervention and followup study using two different dilution modes in supporting patients with multiple
organ failure to answer the above questions.
3. The contributions of the thesis
The thesis contributes further the clinical, subclinical characteristics and
the role of pre-and-post-dilution CVVH in supporting patients with MOF.
Data from the research showed that bacterial infection was the leading cause
of multiple organ failure (77.9%). Patients had 2-6 injured organs when
being admitted to the study, 4 organs accounted for the highest proportion
(51.9%). Type of injured organ included: kidney 100%, respiratory 97.4%,
cardiovascular 89.6%, and the lowest rate was acute liver failure19.5%.
Showed the common picture of MOF's clinical and subclinical
characteristics with 59.8% of oliguria/anuria; used one vasoconstrictor
(70.1%); and required mechanical ventilation (70.7%). Almost patients had
metabolic acidosis and hypoxia; very high level of inflammatory markers,
especially Il-6 > 90 times and TNF- approximately increased 5 times.
Proved the role of continuous veno-venous hemofiltration (CVVH) in
patients with MOF: increased MAP from the 24h after intervention (p <
0,05); gradually improved the renal function during treatment (p < 0,001);
improved the metabolic acidosis from the 72h after intervention (p < 0,01);
improved the respiratory oxygenation after 48h of intervention (p <
0,01);decreased plasma level of cytokins after CVVH (p < 0,01); and
decreased the severity of organ failure through the improving of the SOFA
score during treatment (p < 0,01).
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Comparing with post-dilution, the pre-and-post-dilution CVVH had better
ability in improving: the renal function (the plasma level of creatinin was
lower at 72h after intervention, p < 0,05); the metabolic acidosis (HCO3decreased at 72h after intervention, p < 0,01). It also had higher ability in
purifying TNF- (p < 0,01) and prolonging the filter lifetime (33,8 ± 11,8h vs
28,2 ± 11,7h; p < 0,05).
4. The structure of the thesis
The thesis consists of 131 pages; excluding the Introduction, Conclusions,
and Recommendations, the thesis consists of 4 chapters: chapter 1- Literature
review: 34 pages, chapter 2- Subjects and methods: 23 pages, chapter 3:
Results: 33 pages, chapter 4- Discussion: 34 pages. The thesis has 53 tables, 2
diagram, 3 pictures, 10 charts. The thesis used 135 references.
Chapter 1: LITERATURE REVIEW
1.1.
Overview on MOF
Multiple organ failure (MOF) is the common desease in ICU with at least
two dysfunctional organs. MOF is formed by many causes with complex
pathophysiology. The main factors include: immune response, tissue hypoxia,
apoptosis, "two-hit" phenomenon; and the system inflammatory response is the
best important factor. The MOF clinical manifestations are the combination of
many dysfunctional organs, consist of cardiovascular, lung, kidney, liver,
coagulation and central nervous system (CNS).There are many testing and
diagnostic image need to perform early and repeat many times for diagnosis,
follow-up and treatment. Early or late organ failure depends on desease's nature.
For the patients having organ failure after the few days of admittinng to
hospital, that is usually related to severe infection or surgery. The time to
identify MOF is also different in research and patients, but its common point is
the longer stay in hospital and the higher mortality rate in patients with late
organ failure.
Many authors mentioned the diagnostic critiria of MOF, but the Textbook
of Critical Care (2011) used SOFA score for evaluating MOF in 6 organs,
includingcardiovascular, lung, kidney, liver, coagulation and central nervous
system (CNS). In 2004, the nephrologist purposed the RIFLE criteria to discribe
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three levels of acute renal impairement (Risk, Injury, Failure) and two clinical
outcomes (Loss and End-stage kidney desease) for more early diagnosis and
treatment the acute kidney injury in order to impove outcome and to decrease
mortality rate. The American Association for the Study of Liver Desease
(AASLD) accepted definition of the acute liver failure, included an INR ≥ 1,5;
and any degree of mental alteration (encephalopathy) in a patient without
presisting cirrhosis and with an illness of < 26 weeks duration.
1.2. Therapy methods
Although having many progresses in treatment of MOF, but the mortality
rate is still very high. That's why need to combine many intensively
simultaneous methods; consist of interventing promoted factors and organs
dysfunction, as well as supporting organ function by CRRT. This is a method
that can replace renal impairement amd eliminate inflammatory mediators by
using the replacement fluid infused before or after the filter. According to the
dialysis experts - Ronco and Bellomo - postdilution is a completely convection
mode. When the replacement fluid infusedafterthe filter, solutes concentration
are increased within the membrane filter so that the filter efficiency is increased
but the filter easily clotted. Pre-dilution reduces the viscosity of the blood as it
travels through the filter so it can prolong the life of the filter but the solubility
of the solute decreases. Besides, it requires large amounts ofreplacement fluidas
well as the high blood flowrate to get the same efficacy as postdilution.
1.3. Domestic and international studies on MOF
In research of Elizabeth in 2001 with 249 patients stayed in ICU, the infection
rate was 22%.Zarbock et al in the ELAIN randomized controlled trial
publishedin 2016 in 231 patients, reported that earlycomparedwith delayed
initiation of renal replacement therapyreduced mortality over the first 90 days.
Research ofBoussekey et al, ultrafiltrate flow was delivered prefilterin one-third
and postfilter in two-thirds of thepatients, results showed that high volume
hemofiltration decreasedvasopressor requirement and tendedto increase urine
output in septicshock patients with renal failure.Research ofGuang-Ming Chen
also used pre-and-post-dilution hemofiltration, reported that CRRT treatment
combined with conventional treatment resulted in ahigher hospital-discharge
rate, a greater increase in platelets, a greater decrease in WBC,neutrophils, and
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greaterimprovement of organ dysfunction thanconventional treatment used
alone. In the IVOIRE trial -a prospective,randomized, doubleblined,multicentre
clinical trial conducted in 137 patients with septic shock complicated by AKI,
applied pre-and-post-dilution hemofiltration. researchers concluded that this
method improve haemodynamic profile, respiratory oxygenation and
organfunction. The filter lifetime was 45.7h in predilution and 16.1h in
postdilution, but creatinin clearance in postdilution was higher (45 ml/minute
versus 33 ml/minute) in a study of Van der Voort et al.
In Vietnam, there were many trials reported about the clinical, subclinical
characterristics of MOF in many groups of age, such as Duyen Le Thi My, Vinh
Nguyen Xuan, Tien Nguyen Minh, Tuyet le Thi Diem. Somes studies used preand-post-dilution hemofiltration to evaluate the efficiency of CRRT in patients
with MOF: Hai Truong Ngoc (2008), Quang Hoang Van (2009), Thang Vu
Dinh (2011). Study was achieved the State Award of Binh Nguyen Gia et al
(2013) also used pre-and-post-dilution hemofiltration in 65 patients with MOF
and showed that CRRT help to improve haemodynamic profile, metabolic
acidosis, respiratory oxygenation and to purify cytokins; howevwe, the
mortality was still very high (67.7%) and mean organ failure was 3,12 ± 0,96.
In general, although domestic and international studies have not evaluated
many clinical and subclinical parameters of organ failure; but almost all of them
supported the role of CRRT in patients with MOF. However, dialysis methods
differed in lots of parameters such as blood flow rate, total quantity of
replacement fluid, dilution mode, and effectiveness between pre-versus-post
dilution. Thus, the problem that needs to be answered is: beside the ability to
clear for solutes, the pre-and-post-dilutioncan help to extend the filter lifetime
when comparing with the post-dilutionway or not?
Chapter 2.
SUBJECTS AND METHODS
2.1. Subjects
A prospective, intervention and follow-up studywith the total of 77patients
diagnosed with MOF, admitted toICU - People's Hospital 115, Ho Chi Minh
City from February 2014 to February 2016.
* The inclusion criteria: patients defined MOF according to SOFA score
with 6 organs:cardiovascular, lung, kidney, liver, coagulation and central
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nervous system (CNS). Organ dysfunction is when SOFA score ≥ 2 or having
one of three approaches: a single variable that reflects a physiologic
derangement, ora single variable that reflects a therapeutic intervention in
response to a physiologic derangement, ora combination of variables that in
their own right define a syndrome. And having acute kidney injury (AKI)
according to RIFLE criteria: plasma creatinine increases by 2 times the baseline
(creatinine concentration in the previous 7 days), or urine volume < 0.5
mL/kg/hr for 12 hours.
* The exclusion criteria: MOF without AKI. Death within 24 hours
admiited to ICU. Have no enough subclinical data for evaluateing and follow-up
the organ function. Have indication for surgical intervention but no effective
treatment. Have severe end-stage disease such as decompensated cirrhosis,
metastatic cancer. Patients are pregnant.
2.2. Procedures
After admitting to ICU, the patients who met the inclusion criteria and the
exclusion criteria will be consulted in the study.All patients were only accepted
to the study after the patient's legal representative (family) agreed to dialysis
and made a commitment in the form of the hospital.Patients will be screened for
theantecedent history, laboratory tests for diagnosis and treatment according to
the regimens at ICU.
The patients will be randomized by blocks, each block involved for 10 with
software R.3.3.3. From the first 8 blocks, we collected a total of 77 patients in
both groups (03 patients were excluded due to mortality within 24 hours after
enrollment in ICU), including 41 patients in the group 1 (pre-and-post-dilution
hemofiltration) and 36 patients in group 2 (post-dilution hemofiltration).In
addition to initial treatment and resuscitation regimens, patients are supported
by CRRT with in two dilution modes.
Each patient has been requestedthe following data:
* The clinical features of the MOF included: reasons for hospitalization,
transfered place, associated diseases, edema, 24-hour urine output, conscious
state, heart rate, mean arterial pressure (MAP), vasopressor requirement,
respiratory rate, dyspnea, cyanosis,respiratory support, ECG and SpO2.
* Examination and folow-up:
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+ Doing laboratory tests to diagnose MOF according to the SOFA score,
including parameters: cell blood count, INR, aPTT, ure, creatinin, electrolyte,
AST, ALT, total Bilirubin, direct Bilirubin, plasma lactat, CRP, arterial blood
gas (ABG).
+ Right before and after the end of the first CRRT, we collected two
blood samples for measuring plasma level of IL-6 and TNF-. These samples
will be centrifuged to extract serum and taken to test in Hoa Hao Hospital.
+Clinical and subclinical data were collected during treatment and CRRT,
with attention given to admission, prior to CRRT (T0), after 24 hours (T24),
after 48 hours (T48), after 72 hours (T72) and at the end of the study.
* Initial resuscitation and treatment of organ failure:
+ Solving the resource of infection by drainage abscess focus, surgery,
eliminate of necrotic tissue, removal of drainage tube (if necessary).
Sterilization and regular check of airway control, bedside lift, sucking. Using
intravenous antibiotics in the first hour of recognition of severe infection or
septic shock. Insert intravasculardevice and early administration of crystalloids
if suspecting the patient has decreased volume. When patient have been in
hypotension, vasopressor therapy initially to target a mean arterial pressure
(MAP) ≥ 65 mm Hg.
+ Acute respiratory failure: objectives are SpO2 ≥ 92% or PaO2 ≥ 60mmHg
(with ARDS: maintain SpO2 ≥ 88%, PaO2 ≥ 58mmHg) by oxygen therapy or
mechanical ventilation.
+ Cardiovascular dysfunction: objectives are to maintain systolic blood
pressure ≥ 90mmHg or MAP ≥ 65mmHg by administration of fluids and
vasopressors.
+ Acute kidney injury: fluid therapy to maintain stable blood pressure and
to prevent pre-renal failure. Use blood purification techniques to treat severe
acure renal failure.
+ Red blood cell transfusion occurs only when hemoglobinconcentration
decreases to<7.0 g/dL to target a hemoglobin concentration of 7.0–9.0 g/dL in
adults. Administer platelets when counts are <10,000/mm3.
+ Continuous or intermittent sedation be minimized in mechanically
ventilated sepsis patients. Neuromuscular blocking agents (NMBAs) be avoided
10
if possible in the septic patient without ARDS due to the risk of
prolongedneuromuscular blockade following discontinuation.
2.3 Continuous renal replacement therapy
* Follow these steps: insert the catheter into the femoral vein or internal
jugular vein. Put the wire system and filter into the machine. Priming filter with
Natrichloride 9% together with heparin. Set the cycle between the machine and
the patient. Dialysis during the day, when the filter clotted: stop and replace the
other filter if the patient still have indicated.
* Parameters: CVVH mode, blood flow rate 120-150 mL/minute,
replacement flow rate30-40ml/kg/h (study group: pre-and-post-dilution, control
group: post-dilution), the ratio of dilution: 50% pre-dilutionand 50%postdilution, change no more 10% in the other dialysis.For patients without high
bleeding risk and without contraindications for heparin, systemic heparin was
used with a dose of 20-25 UI/kg and followed by 5-15 UI/kg/h.
* Follow-up during dialysis: heart rate, blood pressure, temperature, ECG,
SpO2 every hour; daily input and output bilan; coagulation (aPTT, INR), blood
glucose and electrolyte every 4-6 hours; monitor the alarm on the machine for
solving timely; monitor the catheter to prevent slipping or twisting; and monitor
the complications that may be encountered during dialysis.
2.4. Data analysis
The data were analyzed and processed using SPSS version 22. The
qualitative variables were expressed in percentages. Using χ2 test (corrected
Fisher 'exact test as appropriate)to compare two ratios. T test was used to
compare the mean and paired-samples T test for evaluating changes of
parameters between intervals. For non-standard variables, two medians were
compared and the Mann-Whitney test assessed the difference between the two
groups and the Wilcoxon test assessed the difference between before and after
intervention.
The statistically significant threshold is p <0.05.
2.5. The ethical aspect of the thesis
The study was approved by the Science Council of People's Hospital 115.
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All patients were only admitted to the study after the patient's legal
representative (family) agreed to CRRT and made a commitment in the form
of a hospital.
The legal representative of the patient may request withdrawal from the
study at any time and will be unconditionally approved.
PhD student have responsibility to pay for the test sent to other lab center,
patients' relatives do not pay extra.
The study will also be stopped immediately if there are any risk relating to
the technique and/or therapeutic options associated with dialysis.
The collected data will be only used in the study and in the diagnosis and
treatment of the patient, all patient information will be kept confidentially
according to current regulations.
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77 patiets wit MOF iedicatid for CRRT
Ask for aeticidiet istory
Clieical ixamieatoe
Subclieical tists
Triatmiet of causis aed orgae dysfuectoe
Pri-aed-post dilutoe CVVH
(Group 1, e = 41)
Post-dilutoe CVVH
(Group 2, e = 36)
CONCLUSION 1
CONCLUSION 2
cal, subclieical c aractiristcs of patiets
T i triatmiet
wit MOF
risults
avieg
of supporteg
acuti kideiy
patiets
iejury.wit MOF by pri-aed-post-d
RECOMMENDATIONS
13
Chapter 3: RESULTS
3.1. General characteristics of the research subjects
Table 3.1. General characteristics of the patients
77
Total number
Average age (year)
67,1 ± 17,2
Male/Female
32/45
SOFA score
12,2 ± 2,4
APACHE II score
28,6 ± 5,8
Average number of organ failure
3,96 ± 0,78
Time from diagnosis to CRRT
9,6 ± 10,8
Mortality rate
71,4%
The ratio of patients with chronic deseases was 66.2%. Hypertension was
the highest (37.7%), chronic liver desease was the lowest (5.2%).
The patients diagnosed MOF within 24h after admitting to ICU had the
highest rate (84.4%), from 48h to < 72h was the lowest (1.3%).
3.2. Clinical and subclinical characteristics of MOF
3.2.1. The main causes of MOF
There was 4 main causes promoted MOF with the different rates: infection
had the highest rate (77.9%), hemorrhage shock with the lowest rate (1.3%).
In patients with infection, respiratory was the highest (58.3%), and
gastrointestical tract was the second one (28.3%).
3.2.2. Number and type of MOF
Patients in the study injured from 2 to 6 organs, 4 organs failure had the
highest rate (54.5%), impairement of 2 organs and 6 organs was the same with
the lowest rate (2.6%).
All of patients had acute kidney injury, and then was respiratory failure
(97.4%), cardiovascular dysfunction (89,6%). Liver injurryhad the lowest rate
(19.5%).
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3.2.3. Some clinical and subclinical characteristics
In patients with AKI, anuria and oliguria were reported in 59.8% of the
patients, and 13% had hypertension. All patients with respiratory failure
haddyspnea; 45.5% had tachypnea and 70.7% needed mechanical ventilation.
Tachycardia occured in 84.62% and 70.1% used a vasopressors in patients with
cardiovascular damage. For patients with CNS injury, the lowest Glasgow score
was 3 points prior to intervention. Most patients with coagulopathy and aPTT
are within the safe range that allowed us to use heparin in CRRT.
Most patients hadleukocytosis and anemia pre-dialysis, mean white blood
cell count was 18.3 ± 10.9 K/μL and average hemoglobin concentration was
11.3 ± 2.8 g/dL.
Patients with metabolic acidosis and hypoxia prior to intervention, with an
average pH of 7.27 ± 0.12; HCO3-median concentration was 16.2 ± 5.4 mmol/L
and PaO2/FiO2 ratio was 181.7 ± 146.1.
Serum creatinine concentration was 3.5 ± 1.9 mg/dL, ure concentration was
106.7 ± 60.7 mg/dL. Inflammatory markers were elevated with mean values of
151.9 ± 106.3 mg/L. The median value of IL-6 was 659.9 pg/mL and that of
TNF- was 37.3 pg/mL, it means that the concentration of IL-6 increased >90
times and TNF-increased nearly 5 times by the baseline.
3.3. The treatment results
3.3.1. The patients' number during treatment
Table 3.2The patients' number during research
Time
Gr1 (n=41)
Gr2 (n=36)
p
T0 (n, %)
41 (100)
36 (100)
>0.05
T24 (n, %)
41 (100)
36 (100)
> 0.05
T48 (n, %)
37 (90.2)
31 (86.1)
> 0.05
T72 (n, %)
31 (75.6)
27 (75)
> 0.05
15
No patients died in the first 24 hours after intervention. The
patients'number started to decrease from the time of T48 (group 1 had 37
patients, group 2 had 31 patients). By the time of T72, Gr1 had 31 patients, Gr2
had 27 patients.
3.3.2.Effects on blood pressure
Table 3.3. The change of MAP in research intervals of the 2 groups
MAP
Gr1
Gr2
n
X ± SD
p
n
X ± SD
p
T24 - T0
41
12.8 ± 30.1
< 0.05
36
13.8 ± 30.5
< 0.05
T48 - T0
37
14.6 ± 28.7
< 0.01
31
17.4 ± 27.1
< 0.01
T72 - T0
31
14.0 ± 34.2
< 0.05
27
16.8 ± 31.8
< 0.05
* Paired-samles T test: at the time ofT48 (GR1 had 37 patients, Gr2 had 31
patients), at the time of T72 (Gr1 had 31 patients, Gr2 had 27 patients), so that
the patients' number was the same at T0.
MAP in 2 groups improved from the time of T24 after intervention (p < 0.05).
3.3.3. Effects on renal function
Table 3.4. The change of serum creatinine concentration at the evaluated times
between the 2 group2
Creatinin
Gr1 (n=41)
PGr2 (n=36)
p
n
X±SD
n
X± SD
T0
41
3.4 ± 2.2
36
3.6 ± 1.7
> 0.05
T24
41
2.1 ± 1.6
36
2.5 ± 1.8
> 0.05
T48
37
1.9 ± 1.2
31
2.0 ± 1.6
> 0.05
T72
31
1.3 ± 0.6
27
1.9 ± 1.2
< 0.05
Creatinine concentration in Gr1 decreased> 50% after 72 hours of CRRT
and was significantly lower than in Gr2.
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Table 3.5. The change of creatinine concentration in research intervals
of the 2 groups
Gr1
Gr2
Creatinin
n
X ± SD
p
n
X ± SD
p
T24 - T0
41
1.2 ± 1.3
< 0.001
36
1.0 ± 1.4
< 0.001
T48 - T0
37
1.5 ± 1.6
< 0.001
31
1.5 ± 1.7
< 0.001
T72 - T0
31
2.3 ± 2.3
< 0.001
27
1.6 ± 1.5
< 0.001
Creatinine concentration in both groups was gradually decreased during
treatment, statistically significant from the time of T24 after intervention (p <
0.001).
3.3.4. Effects on metabolic and respiratory oxygenation
Table 3.6. The change of HCO3-concentration in research intervals
of the 2 groups
Gr1
HCO3
Gr2
-
n
X ± SD
p
n
X ± SD
p
T24 - T0
41
1.2 ± 5.1
> 0.05
36
0.2 ± 4.4
> 0.05
T48 - T0
37
2.3 ± 7.1
> 0.05
31
2.2 ± 5.4
> 0.05
T72 - T0
31
3.3 ± 6.3
< 0.01
27
2.4 ± 6.4
> 0.05
In group 1, HCO3- concentration statistically improved from the time of
T72 after intervention (p < 0.01).However, the improvement of HCO3concentration in Gr2 was not significant during the first 72 hours (p > 0.05).
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Table 3.7. The change of paO2/FiO2ratioin research intervals
of the 2 groups
Gr1
Gr2
paO2/FiO2
n
X ± SD
p
n
X ± SD
p
T24 - T0
41
44.3 ± 214.5
> 0.05
36
108.9 ± 233.7
< 0.01
T48 - T0
37
142.7 ± 259.9
< 0.01
31
104.0 ± 208.6
< 0.01
T72 - T0
31
162.4 ± 269.5
< 0.01
27
194.9 ± 269.0
< 0.01
PaO2/FiO2 ratio of patients in Gr1 statistically improved after 48 hours of
intervention(p < 0.01), while the improvement in Gr2 happened from 24 hours
after intervention (p < 0.01).
3.3.5. Purification of cytokins
Table 3.8. The change of serum IL-6 và TNF-α before and after CRRT
Chỉ số
Gr1
Gr2
n
Median
n
Median
Before-After
41
703.3
36
480.8
p
41
< 0.001
36
< 0.001
Before-After
24
6.6
24
(-) 7.3
p
24
< 0.01
24
> 0.05
IL-6 (pg/mL)
TNF-α (pg/mL)
*Using Wilcoxin test for evaluating the difference between before and after CRRT
(Some blood samples were failed while transport, no full enough of TNF-α).
SerumIL-6 concentration significantly decreased in both groups, while
TNF-αconcentration only statistically decreased in group 1 (p < 0.01).
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3.3.6. The common results
Table 3.9. Mechanical ventilation time, days in ICU and mortality rate
of the 2 groups
Parameters
Total
(n = 77)
gr1
(n=41)
PN2
(n=36)
p
Mechanical ventilation time
(days)
7.4 ± 8.3
5.9 ± 5.3
9.1 ± 10.7
> 0.05
Days in ICU
9.5 ± 8.7
8.2 ± 6.0
10.9 ± 10.9
> 0.05
Mortality rate
(n, %)
55 (71.4%)
29 (70.7%)
26 (72.2%)
> 0.05
\
There was not different between 2 groups about above parameters.
3.3.7. Evaluate some technical data and side-effects during CRRT
Table 3.10. Some technical paremeters related to CRRT
Thông số
PN1 (n=41)
PN2 (n=36)
p
Time of starting CRRT (hour)
7.7 ± 6.8
11.7 ± 13.8
> 0.05
Numbers of CRRT
1.9 ± 1.3
1.5 ± 0.7
> 0.05
373.78 ± 105.62
408.1 ± 104.7
> 0,05
Transmembrane Pressure-TMP
at the end of CRRT (mmHg)
387.9 ± 45.8
379.5 ± 33.1
> 0.05
Average filter lifetime (hour)
33.8 ± 11.8
28.2 ± 11.7
< 0.05
Replacement volume (ml/kg/h)
36.7 ± 4.1
37.9 ± 5.1
> 0.05
Mean dose of heparin (UI/h)
Average filter lifetime in group1 was significantly longer than that in group
2 (p < 0.05).The other parameters were similar in the 2 groups.
19
Table 3.11. Some comlications during CRRT
Comlications
Gr1 (n=41)
Gr2 (n=36)
p
n
%
n
%
1
2.4
0
0
> 0.05
Hemorrhage
Hematome due to
wrong insert in artery
Thrombocytopenia
1
2.4
0
0
> 0.05
15
36.6
8
22.2
> 0.05
Hypokalimia
28
68.3
22
61.1
> 0.05
Glycemia
5
12.2
3
8.3
> 0.05
Hemolysis
0
0
0
0
Membrane rupture
0
0
0
0
Death while CRRT
0
0
0
0
There was not different between 2 groups about above parameters.
Chapter 4: DISCUSSION
4.1. The common characteristics of research subjects
Patients in the study had a mean age (67.1 ± 17.2 years) and a chronic
disease rate of 66.2%. Several studies have shown a link between morbidity and
mortality with age; the higher the age are, the greater the death is, especially in
patients> 65 years. The increased incidence of chronic disease is costly to
individuals and community. When chronic illnesses become an acute severe
exacerbation, it may constitute a major cause of death. In our study, the majority
of patients manifested MOF within 24 hours of entering the ICU (84.4%) and
58.4% of patients were transferred from other hospitals to our ICU. The basic
responsibility of the ICUs is to treat severe patients being transfered from the
other departments or hospitals, so the mortality rate of patients who are treated
in ICU is usually very high.In addition, the higher the severity as well as the
number of organ failure are, the higher the mortality is. Our study found that the
mean SOFA score was 12.2 ± 2.4 and the mean APACHE II score was 28.6 ±
5.8. Besides, the mean number of organ failure before intervention was 3.96 ±
0.78. Thus, the patients in our study had severe prognosis and the overall
mortality rate is quite high, 71.4%.
20
4.2. Clinical and subclinical characteristics of MOF
Clinical andsubclinical characteristics of patients with MOR were very
diverse; related to the cause, characteristics and severity of each organ failure.
The four most common causes in ICUs were bacterial infection, shock, acute
pancreatitis and poisoning. Infection in our study was highest (77.9%) and
respiratory infection was also highest (58.3%).
In severe patients, any organ can be damaged even if the organ is not the
original disease. Our study showed that the patients injured from 2 to 6 organs,
4 simultaneous organs accounted for the highest proportion (51.9%). The higher
the number of organ failure, the higher the risk of death.
In the study, 100% of patients had AKI with 59.8% of patients presented
anuria and oliguria. Respiratory tract infection are common early appears in
patients with MOF, the rate of respiratory failure in our study was 97.4%. All
patients with respiratory tract injuries exhibited dyspnea and needed oxygen
support, with the rate of mechanical ventilation was 70.7%.Cardiovascular
system damage can be caused by a variety of causes and depending on the
degree of dysfunction in the heart, blood vessels and circulatory volume of the
patient, clinical manifestations may be cool-clammy skin, peripheral
hypoperfusion, hypotension, arrhythmias.Our results showed that 89.6% of
patients had cardiovascular damage with MAP<70 mmHg and tachycardia was
84.62%. Patients with CNS lesions were 63.6% with an average Glawgow score
of 8.9 ± 2.9 and Glasgow with a lowest score of 3 points. Thus, the clinical
manifestations of patients with MOF in our study are varied.
To the subclinical characteristics, our study noted that the majority of
patients had leukocytosis with an average white blood cells of 18.3 ± 10.9
K/μL. Leukocytes play an important role in fighting off pathogens, but
excessive activation causes tissue damage and aggressive chemicals. In
addition, the majority of patients had anemia with a Hb value of 11.3 ± 2.8
g/dL. Anemia plays an important role in the treatment and prognosis. If patients
need blood transfusion, they maybe in high risk for sepsis.
Biochemical findings suggested that creatinine concentration was 3.5 ± 1.9
mg/dL. Most patients were transferred from other hospitals and other
departments to the ICU, so the level of acute kidney failure was worse than
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