尿毒症患者冠状动脉旁路移植术后的过渡性床旁连续性肾脏替代治疗观察

Transitional bedside continuous renal replacement therapy for uremic patients after coronary artery bypass grafting

目的观察尿毒症合并冠心病患者冠状动脉旁路移植术(CABG)后过渡性床旁连续性肾脏替代治疗(CRRT)的治疗效果。方法收集2008年1月至2016年12月上海交通大学附属新华医院心胸外科28例实施冠状动脉旁路移植术的尿毒症透析患者资料,其中2例行体外循环下CABG,其余26例均行非体外循环下CABG。所有患者术后予CRRT逐渐过渡至维持性血液透析(MHD)治疗。收集并统计分析手术前后相关指标。结果所有患者均顺利完成手术,并术后早期即进行了床旁CRRT,平均首次CRRT时间为术后(18.6±5.4)h。其中26例患者行3次CRRT后过渡至MHD治疗;1例患者行7次CRRT后再过渡至MHD治疗;1例患者CRRT期间过渡治疗失败,并于术后第10天并发多脏器功能不全死亡。CRRT平均持续时间为(7.8±5.4)d;气管插管拔管时间为(3.8±3.3)d,监护室滞留时间平均为(8.8±4.3)d;其中血小板低于60×109/L有9例(32.1%);术后心包、纵隔引流管引流量超过500 ml有5例;胸腔引流超过500 ml有4例;术后并发房颤有10例;术后严重感染有3例。除1例死亡病例,其余27例均成功过渡至普通病房行MHD治疗。结论床旁CRRT过渡MHD治疗是尿毒症透析患者行CABG术后一种安全有效的过渡办法。

Objective To observe the therapeutic effects of bedside continuous renal replacement therapy（CRRT） after coronary artery bypass grafting（CABG） in uremic patients with coronary heart disease. M ethods The data were collected from 2 8 uremic dialysis patients undergoing CABG from January 2008 to December 2016 in Xinhua Hospital Affiliated to Shanghai Jiao Tong University. Two of them underwent CABG under cardiopulmonary bypass,and the remaining 2 6 patients underwent CABG under off-pump. All of them were given the CRRT treatment to gradually convent to maintenance hemodialysis（MHD） treatment. Results All patients completed the surgery successfully,and CRRT was performed early after the surgery. The average first CRRT time was postoperative（1 8. 6 ± 5. 4） h. Twenty-six patients underwent 3 times of CRRT before MHD treatment and 1 patient underwent 7 times of CRRT before MHD. One patient had failed during CRRT and died of multiple organ dysfunction on the 1 0 th day after surgery. The average duration of CRRT was（7. 8 ± 5. 4） days. The extubation time of the tracheal intubation was（3. 8 ± 3. 3） days. The mean retention time of ICU was（8. 8 ± 4. 3） days. Nine cases（32. 1%） had the level of platelets below 60 × 10^9/L. Postoperative pericardial and mediastinal drainage exceeded 5 0 0 mL in 5 cases and chest drainage exceeded 5 0 0 mL in 4 cases. Ten cases got atrial fibrillation and 3 cases got serious infection after surgery. Except 1 case of death,the remaining 2 7 patients were successfully transferred back to conventional MHD treatment. Conclusions Bedside CRRT is a safe and effective transitional approach to MHD treatment for dialysis patients undergoing CABG surgery.