肾功能不全患者心脏手术的围术期管理

Perioperative period treatment for patients with renal dysfunction underwent cardiac surgery

目的:总结肾功能不全患者心脏手术围手术期管理的临床经验。方法:对1998年8月至2009年3月中国医科大学第一医院院收治的24例(其中18例为冠心病,4例为风湿性心脏病,1例为主动脉瓣病变合并冠心病,1例为二尖瓣病变合并冠心病)合并肾功能不全患者心脏手术围术期治疗进行总结。结果:18例冠心病患者中10例在体外循环下完成手术,8例在非体外循环下完成手术。2例风湿性心脏病患者行双瓣置换术,2例行二尖瓣置换术。1例行冠状动脉旁路移植术加主动脉瓣置换术,1例行冠状动脉旁路移植加二尖瓣置换术。术后均进行连续性肾脏替代疗法(CRRT),透析6h后患者心率、中心静脉压、肌酐和尿素氮较未透析时明显下降(P<0.05),而平均动脉压、动脉血氧分压较未透析时明显升高(P<0.05)。围术期3例患者死亡,3例患者放弃治疗,其余18例患者中有5例改为内科规律透析治疗,10例患者肾功能恢复到术前水平出院后尿量恢复未再透析治疗,术后随访(28.5±25.4)个月,心脏症状均消失,生存质量明显提高。结论:CRRT是肾功能不全患者心脏术后围术期治疗的重要手段。

Objective To summarize the experience about perioperative period treatment for patients with renal dysfunction underwent cardiac surgery. Methods 24 patients （18 cases of coronary heart disease, 4 cases of rheumatic valve disease, 1 case of aortic valve disease with coronary heart disease, 1 case of mitral valve disease with coronary heart disease ） with renal dysfunction were underwent perioperative period treatment of cardiac surgeries. The clinical data were summarized. Results Ten of the 18 patients with cardiac heat disease underwent on-pump coronary artery bypass and the other 8 accepted off-pump operations. Two of the 4 patients with rheumatic heart disease underwent double-valve replacement and the other 2 accepted mitral valve replacement. One patient underwent coronary artery bypass grafting and aortic valve replacement. Another patient underwent coronary artery bypass grafting and mitral valve replacement. Continous renal replacement therapy （CRRT） was performed for all patients. HR, CVP, creatinine and BUN significantly decreased after 6-hour CRRT （P 〈 0.05）, while MAP and PaO2 significantly increased （P 〈 0.05）. Three patients died in perioperational period and 3 patients gave up for non-medical reasons. Five of the rest 18 patients received regular dialysis treatment. Ten of the rest 18 patients stop dialysis treatment when their renal function returned to preoperative levels and urine volume recovered. Postoperation follow-up period was （28.5 -± 25.4） months. All patients were asymptomatic and life qualities remarkably improved. Conclusion CRRT can be an important procedure in the periopeartive treatment for patients with renal dysfunction underwent cardiac surgery.