小儿先天性心脏病术后的肾脏替代性治疗精品课件.ppt

小兒先天性心臟病術後的腎臟替代性治療 Acute renal failure 小兒先天性心臟病術後重要的合併症 發生率:高達32.8%(1.6-32.8%) 死亡率: 20-79% (~50% ) Risk factors The duration of CPB High RACHS-1 score Post-op low cardiac output Need for circulatory arrest Complex cardiac lesions Young age Post-op central venous hypertension Post-op use of epinephrine or isoprenaline Management Diuretic Therapy Inotropic Agents Renal Replacement Therapy Peritoneal Dialysis Prophylactic PD Hemofiltration CVVH Indication of RRT 1. Anuria or oliguria (1ml/kg/h) 4 hours despite intervention 2. Creatinine 75 ?mol/L (0.85 mg/dL) 3. Increased Creatinine level with: Clinical signs of fluid overload Hyperkalemia: Serum K+ 5.5 mmol/L Persistent acidosis Low cardiac output syndrome Peritoneal Dialysis 利用人體天然的半透膜---腹膜來進行淨化 ,利用腹膜來代替腎臟功能,經由透析藥水的使用移除體內水分與廢物 Hemodialysis 經由半透膜的兩端血液及透析液中的分子,經濃度的差異而互相產生自由擴散的現象叫做透析作用 ,可使血液中的尿毒分子,得以經透析液帶出體外 Ultrafiltration 在透析液邊加上負壓(抽吸的拉力),則會使血液中的水份大量的移到透析液中,而帶離人體 P eritoneal Dialysis Achieve a negative fluid balance Mean number of inotropic agents Improved mean airway pressure and alveolar-arterial oxygen gradients Prophylactic PD(預防性腹膜透析) combination of PD with perioperative ultrafiltration Improved oxygenation index and lung mechanics Effective in providing the required postoperative negative fluid balance Maintaining the level of urea-creatinine within a certain range Prophylactic PD(預防性腹膜透析) Increase in myocardial contractility accounted for by a decrease in myocardial wall volume or myocardial edema Post-operative Prophylactic PD Hemofiltration superior to PD due to: Better fluid removal Superior decrease of BUN/Cre However: Relatively high mortality in hemofiltration due to slower initiation of RRT Hesitation due to: new technique vascular access Anticoagulation Comparsion In complex congenital heart case Peritoneal Dialysis + Perioperative Ultrafiltr