医学交流课件：肾功能不全患者的麻醉

1、 Anesthesia and Kidney Failure Anesthesia for Patients with Kidney Failure Anesthesia and Kidney Failure Contents Preoperative Considerations Intraoperative Considerations Anesthesia and Kidney Failure Preoperative Considerations-Acute Kidney Failure Acute Kidney Failure Deterioration in renal funct

2、ion Waste products Toxins Widespread organ dysfunction Anesthesia and Kidney Failure Preoperative Considerations-Acute Kidney Failure Classified as prerenal,renal, and postrenal Prerenal: acute decrease in renal perfusion Renal: underlying renal disease, renal ischemia, or nephrotoxins Postrenal: ur

3、inary tract obstruction or disruption. Anesthesia and Kidney Failure Acute Kidney Failure Both prerenal and postrenal forms of kidney failure are readily reversible in their initial stages but with time progress to intrinsic kidney failure. Preoperative Considerations-Acute Kidney Failure Anesthesia

4、 and Kidney Failure Management priorities in patients with acute kidney failure Anesthesia and Kidney Failure Preoperative Considerations-End-Stage Renal Disease The most common causes Hypertensive nephrosclerosis Diabetic nephropathy Chronic glomerulonephritis Polycystic kidney disease Anesthesia a

5、nd Kidney Failure Preoperative Considerations- Manifestations of Kidney Failure Anesthesia and Kidney Failure Complications of hemodialysis The majority of patients who do not undergo renal transplantation receive hemodialysis three times per week, and there are complications directly related to hem

6、odialysis itself Anesthesia and Kidney Failure Drugs accumulation in patients with renal impairment. Anesthesia and Kidney Failure The systemic effects of kidney failure mandate a thorough evaluation of the patient. Optimal perioperative management is dependent on dialysis. Preoperative Consideratio

7、ns-Preoperative Evaluation Anesthesia and Kidney Failure Preoperative dialysis on the day of surgery or on the previous day is typical. Preoperative Considerations-Preoperative Evaluation Anesthesia and Kidney Failure Cardiac and respiratory function Fluid overload or hypovolemia(weights) Hemodynami

8、c data Arterial blood gas Eelectrocardiogram(hyperkalemia or ischemia, conduction block, and ventricular hypertrophy. hypocalcemia) Preoperative red blood cell transfusions Lab tests Preoperative Considerations-Preoperative Evaluation Anesthesia and Kidney Failure Reduced doses of a benzodiazepine o

9、r an opioid H2 blocker or proton pump inhibitor Metoclopramide Antihypertensive agentsshould be continued until the time of surgery Others Preoperative Considerations- Premedication Anesthesia and Kidney Failure Intraoperative considerations-Monitoring Increased risk of perioperative complications B

10、ecause of the risk of thrombosis, blood pressure should not be measured by a cuff on an arm with an arteriovenous fistula Intraarterial blood pressure monitoring in poorly controlled hypertension,regardless of the procedure Anesthesia and Kidney Failure Intraoperative considerations-Induction Rapid-

11、sequence induction Dose of the induction agent (hypovolemia) Propofol, 12 mg/kg, or etomidate, 0.20.4 mg/kg opioid, blocker (esmolol), or lidocaine Succinylcholine, 1.5 mg/kg. Vecuronium (0.1 mg/kg) or cisatracurium (0.15mg/ kg), or propofollidocaine induction without a relaxant, may be considered f

12、or intubation in patients with hyperkalemia. Anesthesia and Kidney Failure Intraoperative considerations-Anesthesia Maintenance Control hypertension with minimal deleterious effect on cardiac output v Avoid or cautously use Nitrous oxide Meperidine is not an ideal choice(metabolite normeperidine) Mo

13、rphine may be used, but some prolongation of its effects should be expected. Anesthesia and Kidney Failure Intraoperative considerations-Anesthesia Maintenance Prevent hypercarbia Respiratory acidosis exacerbate preexisting acidemia severe circulatory depression Dangerously increase serum potassium

14、concentration Respiratory alkalosis Shifts the hemoglobin dissociation curve to the left Can exacerbate preexisting hypocalcemia Reduce cerebral blood flow. Anesthesia and Kidney Failure Intraoperative considerations-Fluid Therapy Lactated Ringers injection is best avoided in hyperkalemic patients Normal saline may be used instead. Glucose-free solutions Colloid or packed red blood cells Allogeneic blood transfusion Anesthesia and Kidney Failure Summary Preoperative Evaluation A thorough eva