医学资料小儿先天性心脏病术后的肾脏替代性治疗课件.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 Ultrafiltration