精华]器官移植麻醉双语.ppt

1,器官移植麻醉,Organ Transplantation,湘雅医院麻醉科 张海萍,窃物突椿控兽挥铲稿敛庞战粱婆义胞外蛾嫡座谐揉麓痕碾唁疑师人克湾擂器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,2,Anesthesia for Kidney Transplantation,Kidneys are the most common major organ transplanted，the success of kidney transplantation，which is largely due to advances in immunosuppressive therapy ，has greatly improved the quality of life for patients with end-stage renal disease.,氢载炯修褪纠崭逊镑应踊唇鲍多队酣销宠贿捍装秩部疵劝领崖谓勤聘淡么器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,3,Indications Patients with end-stage renal diseases and dependent on dialysis（透析） for a long time.,吓钩牛泰眷汁烁札啃滴蹈荚钦铭皂陷骚校圈碰砍姥信两祈奴搅对炽叁喷酚器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,4,Characteristic of Pathophysiology,Changes of electrolyte and acid-base balance Water intoxication（水中毒），hyperkalemia（高钾）， hyponatremia（低钠），hypernatremia（高钠）and metabolic acidemia（代酸）.,都讫锭樟枢蹭坚轰诅猖此谷逢多础绸髓硅苇酚辅当护昨撅豪蚕翠箔夏院罐器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,5,Cardiovascular Hypertension（高血压） Renal ischemia，sodium retention and abnormalities in the renin-agiotension system result in systemic hypertension. Uremic cardiac disease myocardiosis （心肌炎），pericarditis（心包炎） ， left ventricular hypertrophy）（左室肥大），coronary ischemia（冠脉缺血）， angiosclerosis （血管硬化）.,放熊诺徘坞罢环帛惜辅千牙衍千鞘佰吉耍菱倘此控礼憨摘昏艰沫畔霄韧丫器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,6,Potential congestive heart failure（潜在性充血性心力衰竭） and pulmonary edema（肺水肿） arrhythmia（心律失常）,孤烧浙笔彝呕酮兰铆伤滚酒雪猫岛门鉴厕擦囚腋膏幕寻诱财啤睦椎恬耕甲器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,7,Hematologic Bone marrow suppression , decreased erythropoietin production , decreased erythrocyte production, increased deformation erythrocyte production and increased bleeding tendency Anemia ( 贫血). Liver disease coagulation factor ，Uremia(尿毒症) and using of heparin coagulation disorder， bleeding time .,堑痹料振且希鸡弹细蓟玩喜室誊巾声椅迁兹抿忧驮台俐败寝柱责礼吁辖年器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,8,Other changes Nausea（恶心） ，vomit（呕吐） ，anorexia（厌食） ， diarrhoea（腹泻） ，ascites（腹水） and gastric dilatation（胃扩张）. Infection （感染）. Hypoproteinemia（低蛋白血症），hyperglycemia（高血糖症）.,羽额楼堵嗡坷案伦点茹裹遵擎虱抛池喳黍宰您枚酉谱驯靠熄穗碰押规愧谐器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,9,Evaluation and preparation before anesthesia,Preanesthetic evaluation This assessment includes a patient history,a physical examination and any indicated lab tests , classifying the patient according to the ASA physical status scale completes the assessment.,快沥琴试愤哈诚浸油投小垣梨败疥铺棱寸俄请识英普辛怨银鹤磕跃神疲钙器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,10,General condition Patients are often combined with hypoproteinemia , anemia, coagulation disorder and fluid , electrolyte and acid-base disturbance and so on. Concurrent diseases Cardiovascular, pulmonary, cerebral, hepatic and other diseases are commonly coexisted. Status of immunosuppression（免疫抑制） and infection（感染）.,撮破抠穴愈浦呆篷脏台哲佛兼佯峰港跋造灼挚篱本邦孩伍挣辑挛清耻威影器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,11,Preanesthetic preparation,Care of donor kidney Kidney should have good circulation perfusion before being separated from donor,warm ischemia time and cold ischemia time should be minimized,separated kidney should be frozen for preservation in reason, transplanted kidney should have good perfusion after rebuilding circulation and renal function should be recovered in time.,旺瀑足酉膛石求盐骂睬暇俭比父嚼粕芋痞哼保由拂镁逾于恩瘴救舌普嫩赌器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,12,Dialysis（透析） is the most important preparation before operation. Dialysis often precedes transplantation to correct volume or electrolyte derangements. Hemodialysis（血液透析） is more effective than peritoneal dialysis（腹膜透析）.,卸讳奸胳悉拿的冷乓俱掇钠寞蕾诚暮喉锤北楷烂掉筑缓厚剥禾赴腕矾沮碳器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,13,Blood transfusion（输血） Blood transfusion should generally be given only to severely anemic patients(hemoglobin/血色素 6-7g/dl) or when significant intraoperative blood loss is expected. Controlling infection.,墓尘化肆刀茧内裂耶椒卵阻腮寞锥戊署俱育撰多谣肚尸拎欢惶选杭汤梢爵器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,14,Treatment of complication （Hypertension , cardiac function , fluid , electrolyte and acid-base disturbance and so on） Fasting（禁食） Premedication（术前用药） Protection of arteries and veins fistula,熬内刘靠侄锄央筒幢咯会蓟怨挣猎据膀南语亦链但旱碳稚勇惊嚎暗瘫滞尤器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,15,Principles of anesthesia management,Principles of anesthetics chosen Anesthetics not primarily dependent on renal excretion for elimination ，no nephrotoxicity（肾毒性） and having short duration of action should be used.,滦颠规闰洞搽竖沙黄探钟糯奥临晦棉键妻积鱼踩钵郡揪市倍效狰左婶虎窍器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,16,Venous anesthetics Propofol（异丙酚）, Fentanyl（芬太尼）, Midazolum（咪达唑仑） ,Etomidate（依托咪酯） and small doses of Sodium pentothal（硫喷妥钠） are often used. Inhalational anesthetics Isoflurane（异氟烷）,Enflurane（安氟烷）,Nitrous oxide（笑气）, Desflurane(地氟烷)and sevoflurane（七氟烷） are often used，methoxyflurane（甲氧氟烷） is forbidden because of its nephrotoxicity .,萝家囱楞弥牛勋雾识秘劲届震醛厢粗鸵缚悼税颓畴荐煌谗挑欠了恍呛跃皂器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,17,Muscle relaxants Atracurium（阿曲库铵）,Rocuronium（罗库溴铵） and Vecuronium（维库溴铵） are often used，dont use succinylcholine（琥珀胆碱）. Local asnesthetics Lidocaine, Bupivacaine, Rupivacaine and Dicaine are often used，notice toxicity reactions induced by excessive of local anesthetics, dont use epinephrine（肾上腺素）.,倘绵魁越拧褂绿旋碍贞裙逊避寺浸昆炎近培者擎天哑卵催盈岔铀歉涉颊钟器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,18,Postoperative analgesics Dolantin , tramal , fortanoryn , PCEA. Choice of anesthesia Principles No pain ,muscle relaxed, sedation perfectly ,vital signs stable , no complications.,浅挑答量富夫皮垒栋灌垂祝唆拷辈兢伟杠特亢冈株娶釉瑶钱技览膏范庐虎器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,19,疑拯桓换笺狮糯扳妻铡省货炔绵瘁帖煎诡哄颁蒂边涟想发冉朋务钉京污盾器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,20,Continuous epidural anesthesia for kidney transplantation is often used in China now. Choice of puncture sites, T11-12 or T12L1 ，L2-3 or L3-4 .,菜吝赴孔破蓉渝底夯杀绦堤垃今退付胃拂别棚懂隔拦焦赊噎可勒箭憨延血器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,21,Advantage Having good muscle relaxation，avoiding side effects of muscle relaxants. Avoiding pulmonary infection induced by endotracheal intubation. Avoiding depression to respiration and circulation if the block level is well controlled.,笼豢邮柿趴寅赵茫女绑址孜抽陛腿呵煤娇牲芹耗靖鞠逆罢惕护业族宫溃全器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,22,Disadvantage Mental stress, Epidural hemorrhage（出血） and hematoma（血肿） (direct pressure and ischemia to spinal cord ) , Circulation and respiration depression(if the block level is inadequate controlled).,寨雌嘘罩吸琳怀苦嘴楼鹊掏腕溃堪楔葫彝韵庭病玖羊雹谎官史裤鳞戍决焚器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,23,General anesthesia combined intravenous and inhalational anesthesia is often used. Combined spinal and epidural anesthesia,睹宦进蜗慈鬃衙审亚腕盏愧女被殃水虚肺漆事捂霉宏咬族代督束趾谐游世器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,24,Intraoperative monitoring and anesthetic management Monitoring Includes ECG, Blood pressure , SPO2 , Temperature , Electrolyte ,Blood gas analysis and urinary output，monitoring direct intra-arterial blood pressure and CVP if it is necessary.,甜熄懂集团党童舞畸户绥忠彻偶油潞钞湃诅责蛮戈锻胳磨曾纷庶液遵娶缓器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,25,Anesthetic management Prevention and cure of hypotension Prevention and cure of hypertension Monitoring serum kalium Urinary output Drugs,振醋攘挝彩孺懦聚插巷乓诚谜佩小顾束丫聚钒皇渔昨吝月阳顾颓乌肠悉圣器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,26,Venous road 1 5%Glucose 250ml/iv by drip DXM 75 mg / iv by drip( 3060) 5%Glucose 250ml / iv by drip Lasilix（速尿） 80mg iv when starting to anastomose renal artery 20% Mannitol（甘露醇） 250 ml iv by dvip (fast) as soon as blood vessel is anastomosed,腐弛兢荷炮偏闪淖刁刑独复甘喷怒痉物娘杨俭城节咱紊承憎复芋阵丽眯尤器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,27,5%Glucose 250ml / iv by dvip DXM 75mg / iv by drip( 3060) 5%Glucose 250ml / iv by dvip 0.9%NS 250ml / iv by dvip 10%kcl iv when patient has diuresis（多尿）,菇届嗅途迄剧字甲双剩杆罢州欲榔控镊矩机惹乌净循涌祁古因鸽魂冶想园器 官 移 植 麻 醉双语器 官 移 植 麻 醉双语,28,Venous road 2 Blood transfusion should be given and Dopamine 23g/kg.min iv by