1、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
2、 or isoprenaline,Management Diuretic Therapy Inotropic Agents Renal Replacement TherapyPeritoneal DialysisProphylactic PDHemofiltrationCVVH,Indication of RRT1. Anuria or oliguria ( 4 hours despite intervention 2. Creatinine 75 mol/L (0.85 mg/dL) 3. Increased Creatinine level with: Clinical signs of
3、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
4、帶離人體,P eritoneal DialysisAchieve 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 provi
5、ding 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,Method: Neonate
6、 and infants (n=756, age 0-1) All underwent periopertaive ultrafiltration 186/756 (24.6%) “high risk” patients required PD Results: 23/186 (12.3%) of pPD, 23/756 (3%) of all developed ARF 4/23 died, Mortality of ARF 17.3% 4/186(2.15% of all pt underwent operation),Alkan et al. Postoperative Prophyla
7、ctic Peritoneal Dialysis in Neonates and Infants After Complex Congenital Cardiac Surgery ASAIO Journal 2006; 52: 693697,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 RRTHesitati
8、on due to: new technique vascular access Anticoagulation,Comparsion,In complex congenital heart casePeritoneal Dialysis+ Perioperative UltrafiltrationEffective in providing the required postoperative negative fluid balance,Thank you for your attention!,Ultrafiltation,血液在人工腎臟透析器中,因幫浦推動而產生壓力,另外透析液流動或人為製造出負的壓力。如果血中壓力為100 mmHg,透析液壓力為負150 mmHg,此時總共即有250 mmHg的跨膜壓力(transmembranous pressure, TMP),將血液中的水份伴有些大份子尿毒溶質,經由此種拉力移出人體血液,而由透析液帶走。此种情形即叫超過濾(Ultrafiltation)。,
