医学资料小儿先天性心脏病术后的肾脏替代性治疗ppt课件

小兒先天性心臟病術後的腎臟替代性治療,ECMO技術員 崔思純,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 ( 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,Method: Neonate 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 Prophylactic 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 RRT Hesitation due to: new technique vascular access Anticoagulation,Comparsion,In complex congenital heart case Peritoneal Dialysis + Perioperative Ultrafiltration Effective 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