内容教案成果

AcuteRenal急性肾衰KarlJandrey,DVM,MAS,DACVECCSecondInternationalPractitionersSymposiumOctober27-31,Oki7yrFSBurmese2PresentingComplaint:主诉：生HistoryofPresenting现病 ynotedweakness明显的虚25%ofnormal正常活动量的?Environment环Multi-cathouseholdNoknowntoxinsIndooronlyPastPertinentChronic,frequent 慢性频繁的打Chronic,intermittentcough慢性间歇性咳Previousradiographs:bronchiolarPhysicalDullmentation,T=99.7,P=180,R=Weight=ODcornealhaze,laterallimbalDelayedskinturgorPainfulAbdomenAsymmetrickidneys5-6cmR,3cmL)两肾尺寸不Problem问题列AcuteAbdomenDehydation8%脱水ODDermoid右眼皮样囊StepOne:FixShock,ifOptimizeIV

ErasePre-renalpartStepTwo:Fixany第二步：纠正脱OptimizeIS

ErasePre-renalcauses,part2Step3a:Maintain步骤3a：维持灌注CVP≠中心静脉压压UOP=Renal肾脏灌注Renalperfusion≠≠尿渗透Step3b:MonitorUrine步骤3b：监测PreloadCVP

UOP CVPCVP决定因Venomotor 静脉舒张的程Intrathoracic Rightatrial 右心房功Volumeofbloodincranialvena颅内静脉血容FluidIVFluid 静脉输Isotonic 10ml/kgover5-10minutes10ml/kg超过5-End-pointsof(Renal)肾脏功能恢复的检测Sixperfusion 六个灌注参 动态血CVP中心颈静脉UOP尿肾毒Ethyleneglycol乙二Lilies百合Melamine-cyanuric Rx处方NSAIDS AmphotericinB两性霉素CisplatinEthyleneGlycol–乙二醇EGmetabolizedtomoretoxicOxalicacidbindsCrystalsdepositinthekidneys→晶体沉积在肾脏→急性Minimumlethaldose:最小致死4.4mL/kginthe 1.4mL/kginthe EthyleneGlycol–乙二醇–病理生EthyleneGlycol–乙二醇BloodEGPOC ChemistryPanelBloodgasOsmolalgapUrinalysisAbdominalWood’slamp灯EGPhasesofClinical乙二 临床症状的不同阶First:1-12Ataxia,drunkenbehavior,andSecond:12-36Normaltovomitingand由正常发展 和嗜Third:Toxicmetabolitesofethyleneglycolcause乙二 产物导致急性肾Oftenexposureisknown edEthyleneGycol乙二 ：诊Serumethyleneglycoltest乙烯乙二 检测试剂Orgys→ase+ →HighAGmetabolicHighosmolalgapOxalatecrystalluriaAbdominalultrasounddiffuse,intenselyhyperechoic弥散的 肾脏回EthyeleGlycol乙二 的治DecontaminationHemo/Peritoneal 4-methylpyrazole(4-MP,Dogs:20mg/kgIVthen15mg/kgq12hthen5mg/kgEthanol(20%)Dogs/Cats:5.5ml/kgIVq4-6hx5thenq6-8hxReversethePost-renal逆转肾后性原Ureteral输尿 梗 导Doublecheck 确 的通封闭式尿液收集系Urethral梗水，电解质，酸解平Paincontrol,sedation,疼痛管理 ，麻Urethral导 监Ins/Outs输入量/EKGManagementof~~IV<Volumeexpansion,Dextrose6.0-TranslocatesK+&K+HReg.InsulinK+movesintracellularK+>Cardioprotective脏RaisesthresholdpotentialExcitable直接作用于可兴奋IfeelmuchIfeelmuch-70-90EffectsofHyperkalemiaon高钾血症对心电图的影Establishadequateurine确保足够的排尿Adequatepreloadtothekidneys首先足够的肾 考虑利尿 利尿药的替代RememberRemember-Therestorationofurineoutputdoesnotequatetofunctionalrenalrecovery.记住–尿量恢复不等于肾脏功能恢复Cr:18.5→BUN:218→

Diuretic利尿剂的使Renal 扩张肾血Loopdiuretic髓袢利尿Na+-K+-2Cl-Na+-K+-2Cl-1-5mg/kg•1.0mg/kg/hrCRI固定速率输Responsewithin10-15Mannitol甘露Osmoticdiuretic渗透性利0.5gm/kgIVover201.0mg/kg/min.CRI恒Netfreewater净自由水丢高渗多巴 多巴1-5mcg/kg/minIVCanincreaseto20可以增加到Watchfor&stim.观察&Increasedafferentdilation Combinewith 联合用Cr=BUN=

Oki+19Oki19个月Howdoweknowifweneedadvanced我们怎样知道是否需要进一步的治透Peritoneal 腹膜透Hemodialysis血液透Peritoneal腹膜透Peritoneal 腹膜透析Strictaseptic Hypertonicviadextrose1.5-4.5%)通过高渗Dwelltime30min.停留Watch Toxins:EG,aspirin,AG,毒素：乙二醇，阿司匹林，银，钾Peritoneal腹膜透析Peritoneal腹膜40warm高渗hypertonicdialysate

Unresponsive Dangerousfluidoverload DialyzableintoxicationsStepbyStep