小兒先天性心臟病術后的腎臟替代性治療課件

小兒先天性心臟病術后的腎臟替代性治療Acuterenalfailure小兒先天性心臟病術後重要的合併癥發(fā)生率:高達32.8%(1.6-32.8%)死亡率:20-79%(~50%)Riskfactors

ThedurationofCPBHighRACHS-1scorePost-oplowcardiacoutputNeedforcirculatoryarrestComplexcardiaclesionsYoungagePost-opcentralvenoushypertensionPost-opuseofepinephrineorisoprenalineManagementDiureticTherapyInotropicAgentsRenalReplacementTherapy

PeritonealDialysis

ProphylacticPDHemofiltration

CVVHIndicationofRRT1.Anuriaoroliguria(<1ml/kg/h)>4hoursdespiteintervention2.Creatinine>75mol/L(0.85mg/dL)3.IncreasedCreatininelevelwith:ClinicalsignsoffluidoverloadHyperkalemia:SerumK+>5.5mmol/LPersistentacidosisLowcardiacoutputsyndromePeritonealDialysis

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 eritonealDialysisAchieveanegativefluidbalanceMeannumberofinotropicagentsImprovedmeanairwaypressureandalveolar-arterial

oxygengradientsProphylacticPD(預防性腹膜透析)

combinationofPDwithperioperativeultrafiltration

ImprovedoxygenationindexandlungmechanicsEffectiveinprovidingtherequiredpostoperativenegativefluidbalanceMaintainingthelevelofurea-creatininewithinacertainrangeProphylacticPD(預防性腹膜透析)IncreaseinmyocardialcontractilityaccountedforbyadecreaseinmyocardialwallvolumeormyocardialedemaPost-operativeProphylacticPDMethod:Neonateandinfants(n=756,age0-1)Allunderwentperiopertaiveultrafiltration186/756(24.6%)“highrisk”patientsrequiredPDResults:23/186(12.3%)ofpPD,23/756(3%)ofalldevelopedARF4/23died,MortalityofARF17.3%4/186(2.15%ofallp`tunderwentoperation)Alkanetal.PostoperativeProphylacticPeritonealDialysisinNeonatesandInfantsAfterComplexCongenitalCardiacSurgeryASAIOJournal2006;52:693–697HemofiltrationsuperiortoPDdueto:BetterfluidremovalSuperiordecreaseofBUN/CreHowever:RelativelyhighmortalityinhemofiltrationduetoslowerinitiationofRRTHesitationdueto:newtechniquevascularaccessAnticoagulationComparsionPeritonealDialysisHemofiltrationWellstudiedFewerReportsMortality~30%~50%AccessPeritonealcatheterVascularaccessAnticoagulationNotneededHeparinFluidRemovalEffectiveMoreefficientBUN/CreNon-significantSignificantReductionComplications1.Peritonitis2.Catheterfailure/leakage3.e-imbalanceHemorrhage/thrombosis2.e-imbalanceIncomplexcongenitalheartcase

PeritonealDialysis

+PerioperativeUltrafiltration

EffectiveinprovidingtherequiredpostoperativenegativefluidbalanceThankyouforyourattention!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