器官移植麻醉双语.ppt

1,器官移植麻醉,OrganTransplantation,湘雅医院麻醉科张海萍,2,AnesthesiaforKidneyTransplantation,Kidneysarethemostcommonmajororgantransplanted，thesuccessofkidneytransplantation，whichislargelyduetoadvancesinimmunosuppressivetherapy，hasgreatlyimprovedthequalityoflifeforpatientswithend-stagerenaldisease.,3,IndicationsPatientswithend-stagerenaldiseasesanddependentondialysis（透析）foralongtime.,4,CharacteristicofPathophysiology,Changesofelectrolyteandacid-basebalanceWaterintoxication（水中毒），hyperkalemia（高钾），hyponatremia（低钠），hypernatremia（高钠）andmetabolicacidemia（代酸）.,5,CardiovascularHypertension（高血压）Renalischemia，sodiumretentionandabnormalitiesintherenin-agiotensionsystemresultinsystemichypertension.Uremiccardiacdiseasemyocardiosis（心肌炎），pericarditis（心包炎），leftventricularhypertrophy）（左室肥大），coronaryischemia（冠脉缺血），angiosclerosis（血管硬化）.,6,Potentialcongestiveheartfailure（潜在性充血性心力衰竭）andpulmonaryedema（肺水肿）arrhythmia（心律失常）,7,HematologicBonemarrowsuppression,decreasederythropoietinproduction,decreasederythrocyteproduction,increaseddeformationerythrocyteproductionandincreasedbleedingtendencyAnemia(贫血).Liverdiseasecoagulationfactor，Uremia(尿毒症)andusingofheparincoagulationdisorder，bleedingtime.,8,OtherchangesNausea（恶心），vomit（呕吐），anorexia（厌食），diarrhoea（腹泻），ascites（腹水）andgastricdilatation（胃扩张）.Infection（感染）.Hypoproteinemia（低蛋白血症），hyperglycemia（高血糖症）.,9,Evaluationandpreparationbeforeanesthesia,PreanestheticevaluationThisassessmentincludesapatienthistory,aphysicalexaminationandanyindicatedlabtests,classifyingthepatientaccordingtotheASAphysicalstatusscalecompletestheassessment.,10,GeneralconditionPatientsareoftencombinedwithhypoproteinemia,anemia,coagulationdisorderandfluid,electrolyteandacid-basedisturbanceandsoon.ConcurrentdiseasesCardiovascular,pulmonary,cerebral,hepaticandotherdiseasesarecommonlycoexisted.Statusofimmunosuppression（免疫抑制）andinfection（感染）.,11,Preanestheticpreparation,CareofdonorkidneyKidneyshouldhavegoodcirculationperfusionbeforebeingseparatedfromdonor,warmischemiatimeandcoldischemiatimeshouldbeminimized,separatedkidneyshouldbefrozenforpreservationinreason,transplantedkidneyshouldhavegoodperfusionafterrebuildingcirculationandrenalfunctionshouldberecoveredintime.,12,Dialysis（透析）isthemostimportantpreparationbeforeoperation.Dialysisoftenprecedestransplantationtocorrectvolumeorelectrolytederangements.Hemodialysis（血液透析）ismoreeffectivethanperitonealdialysis（腹膜透析）.,13,Bloodtransfusion（输血）Bloodtransfusionshouldgenerallybegivenonlytoseverelyanemicpatients(hemoglobin/血色素6-7g/dl)orwhensignificantintraoperativebloodlossisexpected.Controllinginfection.,14,Treatmentofcomplication（Hypertension,cardiacfunction,fluid,electrolyteandacid-basedisturbanceandsoon）Fasting（禁食）Premedication（术前用药）Protectionofarteriesandveinsfistula,15,Principlesofanesthesiamanagement,PrinciplesofanestheticschosenAnestheticsnotprimarilydependentonrenalexcretionforelimination，nonephrotoxicity（肾毒性）andhavingshortdurationofactionshouldbeused.,16,VenousanestheticsPropofol（异丙酚）,Fentanyl（芬太尼）,Midazolum（咪达唑仑）,Etomidate（依托咪酯）andsmalldosesofSodiumpentothal（硫喷妥钠）areoftenused.InhalationalanestheticsIsoflurane（异氟烷）,Enflurane（安氟烷）,Nitrousoxide（笑气）,Desflurane(地氟烷)andsevoflurane（七氟烷）areoftenused，methoxyflurane（甲氧氟烷）isforbiddenbecauseofitsnephrotoxicity.,17,MusclerelaxantsAtracurium（阿曲库铵）,Rocuronium（罗库溴铵）andVecuronium（维库溴铵）areoftenused，dontusesuccinylcholine（琥珀胆碱）.LocalasnestheticsLidocaine,Bupivacaine,RupivacaineandDicaineareoftenused，noticetoxicityreactionsinducedbyexcessiveoflocalanesthetics,dontuseepinephrine（肾上腺素）.,18,PostoperativeanalgesicsDolantin,tramal,fortanoryn,PCEA.ChoiceofanesthesiaPrinciplesNopain,musclerelaxed,sedationperfectly,vitalsignsstable,nocomplications.,19,20,ContinuousepiduralanesthesiaforkidneytransplantationisoftenusedinChinanow.Choiceofpuncturesites,T11-12orT12L1，L2-3orL3-4.,21,AdvantageHavinggoodmusclerelaxation，avoidingsideeffectsofmusclerelaxants.Avoidingpulmonaryinfectioninducedbyendotrachealintubation.Avoidingdepressiontorespirationandcirculationiftheblockleveliswellcontrolled.,22,DisadvantageMentalstress,Epiduralhemorrhage（出血）andhematoma（血肿）(directpressureandischemiatospinalcord),Circulationandrespirationdepression(iftheblocklevelisinadequatecontrolled).,23,Generalanesthesiacombinedintravenousandinhalationalanesthesiaisoftenused.Combinedspinalandepiduralanesthesia,24,IntraoperativemonitoringandanestheticmanagementMonitoringIncludesECG,Bloodpressure,SPO2,Temperature,Electrolyte,Bloodgasanalysisandurinaryoutput，monitoringdirectintra-arterialbloodpressureandCVPifitisnecessary.,25,AnestheticmanagementPreventionandcureofhypotensionPreventionandcureofhypertensionMonitoringserumkaliumUrinaryoutputDrugs,26,Venousroad15%Glucose250ml/ivbydripDXM75mg/ivbydrip(3060)5%Glucose250ml/ivbydripLasilix（速尿）80mgivwhenstartingtoanastomoserenalartery20%Mannitol（甘露醇）250mlivbydvip(fast)assoonasbloodvesselisanastomosed,27,5%Glucose250ml/ivbydvipDXM75mg/ivbydrip(3060)5%Glucose250ml/ivbydvip0.9%NS250ml/ivbydvip10%kclivwhenpatienthasdiuresis（多尿）,28,Venousroad2BloodtransfusionshouldbegivenandDopamine23g/kg.minivbydripwhenitisnecessarytoenhance1020mmHgofpressurebeforerebuildingcirculation.Maintenanceofintravenousfluidsisdecidedbyanesthetist.,29,PostoperativemanagementSterilizeAvoidanoxia，preventandcurerespiratoryairwaycomplicationsRecovert