03 Perioperative Renal Failure In Cardiac Surgery
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  • 3/6 sudden onset of VT was noted. CPCR was done. Asystole was noted. Then AAD.

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  • 1. SICU Case Discussion— Perioperative Renal Failure in Cardiac Surgery Intern 許惠晴 Resident 李惠琴 醫師 V.S. 張家昇 主任
  • 2.
    • Name: 莊先生
    • Age: 82
    • Sex: male
    • Chart No.: 16448408
    • Date of admission: 2008/03/04
    Basic Data
  • 3. Present Illness
    • Sudden onset of upper back pain since 3 AM
    • Intolerable pain without radiation  brought to 埔基 H.  CT: aortic dissection  experienced bilateral legs numbness and right leg weakness  transferred to our hospital
    • On admission: severe back pain; not able to move his right leg; bedside doppler failed to sense blood flow over bilateral dorsal pedis, bilateral popliteal and right femoral artery.
  • 4. Present Illness
    • Leg CTA: 1) Aortic dissection at lower abdominal aorta, 2) PAOD of both lower limb from bilateral external iliac arteries
    • Type B aortic dissection was diagnosed  sent to OR
  • 5. Past History
    • RCC, pT2N1M0 s/p R't radical nephrectomy + hilar lymph node excision + R't adrenalectomy on 96/10/02
    • 3V-CAD s/p PTCA + stent to RCA
    • Complete AV block s/p TPM in 96/08
    • Chronic renal failure
    • Hypertension
    • Gout
  • 6. Lab data on 2008/03/04
    • RBC Hb HCT PLT.
    • 3.41 9.9 29.4 143
    • WBC Seg Lymph Mono. Baso. Eos.
    • 9.07 87 8.9 2.4 0.1 0.9
    • GPT Bil-T Glu-AC
    • 14 0.55 166
    • BUN CREA NA K eGFR
    • 40 2.57 136 5.1 19.4
  • 7.
    • Operative Method
    • Right axillo-femoral; femoral-femoral bypass
    • Operative Findings
    • no pulsation of rt’ common femoral artery
    • dissection with intramural hematoma over lt’ common femoral artery
    • equal artery pressure over bilateral subclavian artery
  • 8.
    • Hyperkalemia(K:6.5) and oliguria were noted at OR
    • ABG: PH 7.36, PaO2 274.5, PaCO2 38.6, HCO3 22.4, O2 sat 100.0%
    • Acute renal failure  Consult nephrologist for CVVH
  • 9. Perioperative Renal Failure in Cardiac Surgery
  • 10. Incidence of Peri-operative ARF
    • occurs in up to 30% of all patients who undergo cardiac surgery, dialysis occurs in approximately 1%
    • 7% after abdominal aortic reconstruction
    • 3% after elective infrarenal aortic reconstruction, mortality greater than 40%
    • Acute tubular necrosis accounts for nearly all renal dysfunction and failure after aortic reconstruction.
    • The degree of preoperative renal insufficiency remains the strongest predictor of postoperative renal dysfunction.
  • 11.
    • Acute perioperative renal failure is most likely to occur in patients who have renal insufficiency before surgery, are older than 60 years, and have preoperative left ventricular dysfunction
  • 12.  
  • 13.  
  • 14. General Measures to Prevent ARF
    • Optimization of systemic hemodynamics—
    • maintenance of intravascular volume  the most effective means of renal protection
    • Hemodynamic monitoring
    • Avoid over-hydration
    • Avoid nephrotoxin
    • Use isosmolar contrast agents
  • 15. Pharmacologic Intervention to Prevent ARF after Cardiac Surgery
    • Increase renal blood flow— low dose dopamine, fenoldopam
    • Induce natriuresis—ANP, mannitol, diuretics
    • Block inflammation—Pentoxifylline, N-acetylcysteine
    • Other—Clonidine, diltiazem, prophylactic hemodialysis
  • 16.
    • Loop diuretics and low-dose dopamine (1 to 3 μg/kg/min) have been advocated to protect the kidneys by increasing renal blood flow and urine  failed to show benefit
  • 17. Fenoldopam mesylate
    • A selective dopamine type 1 agonist that preferentially dilates renal and splanchnic vascular beds; has shown some early promise as a renal-protective agent .
    • causes natriuresis and increases renal blood flow and urine output
  • 18. Atrial natriuretic peptide
    • anaritide
    • increases natriuresis by increasing GFR as well as by inhibiting sodium reabsorption by the medullary collecting duct
    • significant reduction in the incidence of dialysis at day 21 after the start of treatment (low rate, prolonged infusion)
  • 19. Mannitol
    • to induce an osmotic diuresis
    • improves renal cortical blood flow
    • reduce ischemia-induced renal vascular endothelial cell edema and vascular congestion
    • acting as a scavenger of free radicals
    • decreasing renin secretion
    • increasing renal prostaglandin synthesis
  • 20. N-acetylcysteine (N-AC)
    • shown to block inflammation and oxidant stress in cardiac surgery patient
    • may hold promise as a simple, nontoxic protective measure
    • Not proven yet.
  • 21. Prophylactic hemodialysis
    • Single study
    • Creatinine > 2.5 mg/dl
    • Perioperative prophylactic dialysis vs. Dialysis only when postoperative ARF that indicated the procedure
    • Mortality: 4.8 vs.30.4%
    •  Need more study
  • 22. Inh. Sym. tone Inh. Inflamm Prevent vasospasm
  • 23. Continuous Renal Replacement Therapy
    • Arteriovenous: external shunt, without the absolute need of a blood pump
    • Venovenous: catheter, require a blood pump
    • CVVH: hemofiltration; removal of fluid and waste occur by entirely by convection or bulk flow, transmembrane pressure governs the amount of fluid and dissolved waste being ultrafiltered across the membrane
  • 24. Continuous renal replacement therapy(CRRT) Yes RF/D Yes Continuous venovenous hemodiafiltration(CVVHDF) Yes D Yes Continuous venovenous hemodialysis(CVVHD) Yes RF Yes Continuous venovenous hemofiltration(CVVH) No RF/D No Continuous arterio venous hemodiafiltration(CAVHDF) No D No Continuous arterio venous hemodialysis(CAVHD) Yes None Yes/no Slow continuous ultrafiltration (SCUF) Intraoperative Use Replacement Fluid (RF)/Dialysate (D) Blood Pump Renal Replacement Therapy
  • 25. Thanks for your attention!!
  • 26. Reference
    • Brenner & Rector's The Kidney, 7th ed.
    • Miller's Anesthesia, 6th ed.
    • Acute Kidney Injury Associated with Cardiac Surgery, Mitchell H. Rosner, Clin J Am Soc Nephrol 1: 19–32, 2006.