Nakayama Y, Sakata R, Ueyama K, Ura M, Kamohara K, Mabuni K, Arai Y
Department of Cardiovascular Surgery, Kumamoto Chu-oh Hospital, Japan.
Nihon Kyobu Geka Gakkai Zasshi. 1997 Oct;45(10):1661-6.
From July 1988 through August 1996, 54 patients with chronic renal failure (CRF) on maintenance dialysis (50 hemodialysis = HD, and 4 continuous ambulatory peritoneal dialysis) have undergone some sort of surgical procedure requiring the use of extra corporeal circulation (ECC); 42 patients underwent isolated coronary artery bypass grafting (CABG), 8 valve replacement, 3 combined procedures and 1 correction of a congenital heart defect. The protocol called for maintenance dialysis on the day before surgery, large volume hemofiltration (HF) during the ECC period, postoperative K+ management with dextrose-insulin if required, and resumption of whatever preoperative maintenance dialysis 24 hours after the operative procedure. The mean diafiltrate volume of HF was 7963 +/- 2688 ml which was replaced with 6342 +/- 2748 ml. No patient required emergency HD before the resumption of the maintenance dialysis, although in 40% of the early patients HD was added on the second postoperative day. However as experience was gained, in the latter 60% of patients resumption of maintenance dialysis (HD 3 times a week) was thought to be sufficient. The incidence of calcification in patients with CRF is higher not only of involved coronary artery segments (4.5 +/- 2.3 segments; AHA coronary classification) than its counterpart without CRF, but also of the ascending aorta which mandated modifications of the technique in 6 patients (operation under ventricular fibrillation, cannulation access other than ascending aorta). The use of arterial in situ conduits for CABG was also thought to be advantageous, and the left internal thoracic artery combined to the gastro-epiploic artery was used in 11 patients (26.2%). Four patients died) (7.4%): 2 from arrhythmia, one from intestinal necrosis and one from multiple cerebral infarction. Thus we conclude that the outlined protocol is quite effective in controlling fluid and electrolyte balance in patients on maintenance dialysis allowing to undertake surgical procedures requiring the use of extra corporeal circulation relatively safely.
从1988年7月至1996年8月，54例接受维持性透析的慢性肾衰竭（CRF）患者（50例血液透析 = HD，4例持续性非卧床腹膜透析）接受了某种需要使用体外循环（ECC）的外科手术；42例患者接受了单纯冠状动脉旁路移植术（CABG），8例进行了瓣膜置换，3例进行了联合手术，1例进行了先天性心脏缺陷矫正。方案要求在手术前一天进行维持性透析，在ECC期间进行大容量血液滤过（HF），必要时用葡萄糖 - 胰岛素进行术后钾管理，并在手术24小时后恢复术前的任何维持性透析。HF的平均置换液量为7963±2688 ml，用6342±2748 ml进行置换。在恢复维持性透析前，没有患者需要紧急HD，尽管在早期患者中有40%在术后第二天增加了HD。然而，随着经验的积累，认为在后期60%的患者中恢复维持性透析（每周3次HD）就足够了。CRF患者的钙化发生率不仅在所累及的冠状动脉节段（4.5±2.3节段；美国心脏协会冠状动脉分类）高于无CRF的患者，而且升主动脉的钙化发生率也更高，这使得6例患者的技术需要改进（在心室颤动下手术，采用升主动脉以外的插管途径）。用于CABG的原位动脉血管也被认为是有利的，11例患者（26.2%）使用了左胸廓内动脉联合胃网膜动脉。4例患者死亡（7.4%）：2例死于心律失常，1例死于肠坏死，1例死于多发性脑梗死。因此，我们得出结论，所述方案在控制维持性透析患者的液体和电解质平衡方面非常有效，能够相对安全地进行需要使用体外循环的外科手术。
