[HSF] postop hepatorenal insufficiency

[Nasser F. Abou'Seada]

Prasanna
would you elaborate more on your dasage of vasopressin ?
how far in permessive hypercapnoea are you ready to go for?
do you calculate / add a volume for dead space when caculating the tidal
volume to be given ?

incidentally, what is your protocol for ARDS ?

NFA


On 5/9/07, prasannasimha <prasannasimha at gmail.com> wrote:
>
> Erdinc,
> I did not get what you exactly want to manage. I would probably continue
> CVVHor Peritoneal dialysis.(Even if you are not doing PD keep the
> peritoneal catheter to drain to keep intra-abdominal pressure and hence
> trans renal and trans hepatic perfusion pressures adequate) low) Add
> phenobarbitone and also oral Agar Agar and lactulose. I would continue
> mannitol  and would also consider rapidly getting down on the pO2 - my
> preference is to ventilate at 6-7 ml /Kg Tidal volume and increase PEEP
> and keep I;E ratio 1:1 and get the FIO2 down as rapidly to 40 %. You can
> use permissive hypercapnea and repeated open lung manueuevers to get the
> FIO2 up and adjust PEEP to keep the lungs "open" at the lowest FIO2.You
> are dealing with  a post CPB post transfusion hepatorenal dysfunction
> and I think you would not want ARDS to add to it.I would not paralyze
> him but just sedate him.
> I would get him off "renal dopamine" and if anything start low dose
> Vasopressin - 0.0003 U/Kg min in fact the ANZICS trial has actually
> shown a worse outcome with renal dopamine and I am convincing myself to
> stop using it and I have actually switched at times to very low dose
> vasopressin which causes efferent renal arteriolar constriction and thus
> increases GFR.
> Prasanna
> erdinç naseri wrote:
> > Opinion requested,
> > 37 y/o male Bicuspid aorta and root 5 cm,ascending aorta 5.3 cm,Mitral
> regurg,EF 15-20%
> > OPerated:aortic button modification of bentall+ mitral ring
> annuloplasty,Continous antegrade cold hyperkalemic blood crpl for most of
> the operation,weaned from CPB with IABP( inserted in the 3.rd trial for
> weaning) and high dose inotropic support(CPB time 230 minutes).Moderate
> oozing from the root( no bioglue) and unfortunately mechanical failure of
> the only CATS(autotransfusion) available.+ units of FFP and 4 units of whole
> blood( Htc 21 when weaned from CPB)packed with sponges and closure of the
> skin and taken to ICU.gradual weaning from inotrops in 20 hours.
> > Postop1.st day morning:Creatinin 1.4,AST470,ALT 290,ABG perfect
> > Open in the ICU and took the sponges and culture of mediastinum
> .uneventful and finished in 20 minutes.
> > Repeat lab on evening:CRE 3.2,AST 4900 ALT9048,INR2.1,ABG:PO2 67(FIO2
> %70),Left atrial pressure 18 mmHg,BP 110/80( no inotrops),renal shut down in
> hours and unremitting fever( despite everything).Stared peritoneal dialysis
> but doesnt work. started CVVHDF( good function)
> > POstop 2.nd day( today):hemodynamics stable( no inotropes),Dopamine(3
> micro),PO2 70(FIO2 %80,pressure support ventilation) still oliguric(40 cc/6
> hrs),Cre 3.8,AST 1270,ALT5342,He is awake but sedated and paralysed.nogrowth in cultures
> > erdinc
> >
> >
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-- 
Nasser  F.  Abou'Seada,
MB,ChB,MD,FRCSEd,ChM,ChD C/Th,
FICS,FISCVS,FSSRCTS,FHMS,MESC