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.
  • 03 Perioperative Renal Failure In Cardiac Surgery

    1. 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. 2. <ul><li>Name: 莊先生 </li></ul><ul><li>Age: 82 </li></ul><ul><li>Sex: male </li></ul><ul><li>Chart No.: 16448408 </li></ul><ul><li>Date of admission: 2008/03/04 </li></ul>Basic Data
    3. 3. Present Illness <ul><li>Sudden onset of upper back pain since 3 AM </li></ul><ul><li>Intolerable pain without radiation  brought to 埔基 H.  CT: aortic dissection  experienced bilateral legs numbness and right leg weakness  transferred to our hospital </li></ul><ul><li>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. </li></ul>
    4. 4. Present Illness <ul><li>Leg CTA: 1) Aortic dissection at lower abdominal aorta, 2) PAOD of both lower limb from bilateral external iliac arteries </li></ul><ul><li>Type B aortic dissection was diagnosed  sent to OR </li></ul>
    5. 5. Past History <ul><li>RCC, pT2N1M0 s/p R't radical nephrectomy + hilar lymph node excision + R't adrenalectomy on 96/10/02 </li></ul><ul><li>3V-CAD s/p PTCA + stent to RCA </li></ul><ul><li>Complete AV block s/p TPM in 96/08 </li></ul><ul><li>Chronic renal failure </li></ul><ul><li>Hypertension </li></ul><ul><li>Gout </li></ul>
    6. 6. Lab data on 2008/03/04 <ul><li>RBC Hb HCT PLT. </li></ul><ul><li>3.41 9.9 29.4 143 </li></ul><ul><li>WBC Seg Lymph Mono. Baso. Eos. </li></ul><ul><li>9.07 87 8.9 2.4 0.1 0.9 </li></ul><ul><li>GPT Bil-T Glu-AC </li></ul><ul><li>14 0.55 166 </li></ul><ul><li>BUN CREA NA K eGFR </li></ul><ul><li>40 2.57 136 5.1 19.4 </li></ul>
    7. 7. <ul><li>Operative Method </li></ul><ul><li>Right axillo-femoral; femoral-femoral bypass </li></ul><ul><li>Operative Findings </li></ul><ul><li>no pulsation of rt’ common femoral artery </li></ul><ul><li>dissection with intramural hematoma over lt’ common femoral artery </li></ul><ul><li>equal artery pressure over bilateral subclavian artery </li></ul>
    8. 8. <ul><li>Hyperkalemia(K:6.5) and oliguria were noted at OR </li></ul><ul><li>ABG: PH 7.36, PaO2 274.5, PaCO2 38.6, HCO3 22.4, O2 sat 100.0% </li></ul><ul><li>Acute renal failure  Consult nephrologist for CVVH </li></ul>
    9. 9. Perioperative Renal Failure in Cardiac Surgery
    10. 10. Incidence of Peri-operative ARF <ul><li>occurs in up to 30% of all patients who undergo cardiac surgery, dialysis occurs in approximately 1% </li></ul><ul><li>7% after abdominal aortic reconstruction </li></ul><ul><li>3% after elective infrarenal aortic reconstruction, mortality greater than 40% </li></ul><ul><li>Acute tubular necrosis accounts for nearly all renal dysfunction and failure after aortic reconstruction. </li></ul><ul><li>The degree of preoperative renal insufficiency remains the strongest predictor of postoperative renal dysfunction. </li></ul>
    11. 11. <ul><li>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 </li></ul>
    12. 14. General Measures to Prevent ARF <ul><li>Optimization of systemic hemodynamics— </li></ul><ul><li>maintenance of intravascular volume  the most effective means of renal protection </li></ul><ul><li>Hemodynamic monitoring </li></ul><ul><li>Avoid over-hydration </li></ul><ul><li>Avoid nephrotoxin </li></ul><ul><li>Use isosmolar contrast agents </li></ul>
    13. 15. Pharmacologic Intervention to Prevent ARF after Cardiac Surgery <ul><li>Increase renal blood flow— low dose dopamine, fenoldopam </li></ul><ul><li>Induce natriuresis—ANP, mannitol, diuretics </li></ul><ul><li>Block inflammation—Pentoxifylline, N-acetylcysteine </li></ul><ul><li>Other—Clonidine, diltiazem, prophylactic hemodialysis </li></ul>
    14. 16. <ul><li>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 </li></ul>
    15. 17. Fenoldopam mesylate <ul><li>A selective dopamine type 1 agonist that preferentially dilates renal and splanchnic vascular beds; has shown some early promise as a renal-protective agent . </li></ul><ul><li>causes natriuresis and increases renal blood flow and urine output </li></ul>
    16. 18. Atrial natriuretic peptide <ul><li>anaritide </li></ul><ul><li>increases natriuresis by increasing GFR as well as by inhibiting sodium reabsorption by the medullary collecting duct </li></ul><ul><li>significant reduction in the incidence of dialysis at day 21 after the start of treatment (low rate, prolonged infusion) </li></ul>
    17. 19. Mannitol <ul><li>to induce an osmotic diuresis </li></ul><ul><li>improves renal cortical blood flow </li></ul><ul><li>reduce ischemia-induced renal vascular endothelial cell edema and vascular congestion </li></ul><ul><li>acting as a scavenger of free radicals </li></ul><ul><li>decreasing renin secretion </li></ul><ul><li>increasing renal prostaglandin synthesis </li></ul>
    18. 20. N-acetylcysteine (N-AC) <ul><li>shown to block inflammation and oxidant stress in cardiac surgery patient </li></ul><ul><li>may hold promise as a simple, nontoxic protective measure </li></ul><ul><li>Not proven yet. </li></ul>
    19. 21. Prophylactic hemodialysis <ul><li>Single study </li></ul><ul><li>Creatinine > 2.5 mg/dl </li></ul><ul><li>Perioperative prophylactic dialysis vs. Dialysis only when postoperative ARF that indicated the procedure </li></ul><ul><li>Mortality: 4.8 vs.30.4% </li></ul><ul><li> Need more study </li></ul>
    20. 22. Inh. Sym. tone Inh. Inflamm Prevent vasospasm
    21. 23. Continuous Renal Replacement Therapy <ul><li>Arteriovenous: external shunt, without the absolute need of a blood pump </li></ul><ul><li>Venovenous: catheter, require a blood pump </li></ul><ul><li>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 </li></ul>
    22. 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
    23. 25. Thanks for your attention!!
    24. 26. Reference <ul><li>Brenner & Rector's The Kidney, 7th ed. </li></ul><ul><li>Miller's Anesthesia, 6th ed. </li></ul><ul><li>Acute Kidney Injury Associated with Cardiac Surgery, Mitchell H. Rosner, Clin J Am Soc Nephrol 1: 19–32, 2006. </li></ul>