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AcuteRenal急性腎衰KarlJandrey,DVM,MAS,DACVECCSecondInternationalPractitionersSymposiumOctober27-31,Oki7yrFSBurmese2PresentingComplaint:主訴：生HistoryofPresenting現(xiàn)病 ynotedweakness明顯的虛25%ofnormal正?；顒恿康?Environment環(huán)Multi-cathouseholdNoknowntoxinsIndooronlyPastPertinentChronic,frequent 慢性頻繁的打Chronic,intermittentcough慢性間歇性咳Previousradiographs:bronchiolarPhysicalDullmentation,T=99.7,P=180,R=Weight=ODcornealhaze,laterallimbalDelayedskinturgorPainfulAbdomenAsymmetrickidneys5-6cmR,3cmL)兩腎尺寸不Problem問題列AcuteAbdomenDehydation8%脫水ODDermoid右眼皮樣囊StepOne:FixShock,ifOptimizeIV

ErasePre-renalpartStepTwo:Fixany第二步：糾正脫OptimizeIS

ErasePre-renalcauses,part2Step3a:Maintain步驟3a：維持灌注CVP≠中心靜脈壓壓UOP=Renal腎臟灌注Renalperfusion≠≠尿滲透Step3b:MonitorUrine步驟3b：監(jiān)測PreloadCVP

UOP CVPCVP決定因Venomotor 靜脈舒張的程Intrathoracic Rightatrial 右心房功Volumeofbloodincranialvena顱內(nèi)靜脈血容FluidIVFluid 靜脈輸Isotonic 10ml/kgover5-10minutes10ml/kg超過5-End-pointsof(Renal)腎臟功能恢復(fù)的檢測Sixperfusion 六個灌注參 動態(tài)血CVP中心頸靜脈UOP尿腎毒Ethyleneglycol乙二Lilies百合Melamine-cyanuric Rx處方NSAIDS AmphotericinB兩性霉素CisplatinEthyleneGlycol–乙二醇EGmetabolizedtomoretoxicOxalicacidbindsCrystalsdepositinthekidneys→晶體沉積在腎臟→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燈EGPhasesofClinical乙二 臨床癥狀的不同階First:1-12Ataxia,drunkenbehavior,andSecond:12-36Normaltovomitingand由正常發(fā)展 和嗜Third:Toxicmetabolitesofethyleneglycolcause乙二 產(chǎn)物導(dǎo)致急性腎Oftenexposureisknown edEthyleneGycol乙二 ：診Serumethyleneglycoltest乙烯乙二 檢測試劑Orgys→ase+ →HighAGmetabolicHighosmolalgapOxalatecrystalluriaAbdominalultrasounddiffuse,intenselyhyperechoic彌散的 腎臟回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逆轉(zhuǎn)腎后性原Ureteral輸尿 梗 導(dǎo)Doublecheck 確 的通封閉式尿液收集系Urethral梗水，電解質(zhì)，酸解平Paincontrol,sedation,疼痛管理 ，麻Urethral導(dǎo) 監(jiān)Ins/Outs輸入量/EKGManagementof~~IV<Volumeexpansion,Dextrose6.0-TranslocatesK+&K+HReg.InsulinK+movesintracellularK+>Cardioprotective臟RaisesthresholdpotentialExcitable直接作用于可興奮IfeelmuchIfeelmuch-70-90EffectsofHyperkalemiaon高鉀血癥對心電圖的影Establishadequateurine確保足夠的排尿Adequatepreloadtothekidneys首先足夠的腎 考慮利尿 利尿藥的替代RememberRemember-Therestorationofurineoutputdoesnotequatetofunctionalrenalrecovery.記住–尿量恢復(fù)不等于腎臟功能恢復(fù)Cr:18.5→BUN:218→

Diuretic利尿劑的使Renal 擴(kuò)張腎血Loopdiuretic髓袢利尿Na+-K+-2Cl-Na+-K+-2Cl-1-5mg/kg?1.0mg/kg/hrCRI固定速率輸Responsewithin10-15Mannitol甘露Osmoticdiuretic滲透性利0.5gm/kgIVover201.0mg/kg/min.CRI恒Netfreewater凈自由水丟高滲多巴 多巴1-5mcg/kg/minIVCanincreaseto20可以增加到Watchfor&stim.觀察&Increasedafferentdilation Combinewith 聯(lián)合用Cr=BUN=

Oki+19Oki19個月Howdoweknowifweneedadvanced我們怎樣知道是否需要進(jìn)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%)通過高滲Dwelltime30min.停留Watch Toxins:EG,aspirin,AG,毒素：乙二醇，阿司匹林，銀，鉀Peritoneal腹膜透析Peritoneal腹膜40warm高滲hypertonicdialysate

Unresponsive Dangerousfluidoverload DialyzableintoxicationsStepbyStep