AnestheticConcernsforthePatientWithRenaland…在肾脏和患者的麻醉问题…课件

1、AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Anesthetic Concerns for the Patient With Renal and Hepatic Disease R4 AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题 Advanced renal or hepatic diseaseSystemic disease processes, affecting multiple organ systems.Fundamental defect in prote

2、in metabolismhyperammonemia or elevated BUN(markers for other circulating byproducts of protein metabolism).Defective ion transport across cell membranes, resulting in intracellular sodium and water accumulation.Imply abnormal handling of anesthetic drugs, multiorgan dysfunction, general debility, a

3、nd specific problem associated with replacement therapy and transplantation.- A challenge to anesthegiologists. AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Systemic Manifestations of Renal and Hepatic DiseaseAnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题 Chronic renal failure(1)Flu

4、id and acid-base imbalanceDialysis : control metabolic acidosis, hyperkalemia, and CHF.In anuric patients,Only fluid loss is insensible(500ml/day)Excessive sodium intake - edema, hypertension.Excessive water intake - hyponatremia.In polyuric CRF,Urine output is normal, but concentrating ability is a

5、bsent.Acute fluid loss - hypovolemia.A moderate anion gap acidosisCompensated by chronic respiratory alkalosis.Buffer base is depleted.Shock, diarrhea, or hypercatabolism(sepsis, trauma, steroid therapy).Profound metabolic acidosis. AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Electrolyte i

6、mbalanceExtracellular potassiumMaintained in narrow range(3.5 to 5.0 mEq/l).Active intracellular transport by a sodium ATP pump at the cell membrane.Clinical and ECG manifestations of hyperkalemia(or hypokalemia) depend on potassium flux rather than the serum concentration.Catabolic stress, acidosis

7、, potassium-sparing diuretics, erythrocyte transfusionRapid, life-threatening hyperkalemia.HypermagnesemiaMuscle weakness, susceptibility to muscle relaxants.HypomagnesemiaAssociated with hypokalemia, ventricular irritability.AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题HyperphosphatemiaInc

8、reased bone deposition of calcium and hypocalcemia.Decreased renal synthesis of vitamin D.HypocalcemiaSecondary hyperparathyroidism and bone resorption.The syndrome of renal osteodystrophy.Treatment : vitamin D, calcium salts, phosphate binders(aluminium hydroxide), dietary phosphate restriction.Hyp

9、ophosphatemia( 15 minutes).Impaired platelet aggregation.d/t defective endothelial release of von Willebrand factor-factor VIII complex. AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Impaired metabolic and immune functionHyperglycemia, hypertriglyceridemiaperipheral insulin resistance and de

10、creased lipoprotein lipase activity in tein malnutrition(kwashiorkor, hypoalbuminemic malnutrition)dietary protein restriction, chronic albuminuria.Protein loss via CAPD(10 to 20 g/dl, 30 to 40 g/dl with peritonitis).Hypoalbuminemia, lowered colloid oncotic pressureperipheral edema, pulmon

11、ary edema.Impaired leukocyte chemotaxis and immunoglobulin responsesnosocomial or oppportunistic infection.Depleted lean body mass and catabolic effects of uremia.wound dehiscence, fistulas, bed sores. AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Gastrointestinal dysfunction (Uremic enterop

12、athy)Anorexia, hiccups, nausea, vomiting.Autonomic neuropathydelays gastric emptying.Regurgitation and aspiration during anesthetic induction.Peptic ulcerup to 25% in CRF patients.Hepatitis B and Chigh incidence in patients on chronic hemodialysis.often anicteric or in a carrier state. AnestheticCon

13、cernsforthePatientWithRenaland在肾脏和患者的麻醉问题Neurologic dysfunctionDepend on the acuity of uremia.Personality changes, drowsiness, asterexis, myoclonus, seizures.Major surgery, gastrointestinal bleeding, infectionprecipitate acute encephalopathy.Lifetime hospital dependence passive-aggressive, depressed

14、, manipulative, and churlish.Uremic distal sensorimotor neuropathya marker for autonomic neuropathy.orthostatic hypotension, impaired circulatory response to anesthesia, delayed gastric emptying.silent myocardial ischemia(without angina). AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题 Chroni

15、c liver disease Ascites, fluid, and electrolyte imbalanceHypoalbuminemia, portal hypertensioninduce ascites and intravascular hypovolemia.secondary hyperaldosteronism(sodium and water retention, potassium excretion): hypokalemic metabolic alkalosis, generalized edema(anasarca), progressive ascites.A

16、sciteselevates diaphragm, decreases FRC.increase intraabdominal pressure, decreases venous return and renal blood flow.Spontaneous bacterial peritonitis(10% of patients). resistance to loop diuretics.exacervate intravascular hypovolemia and hypokalemia, worsen hepatic perfusion.spironolactone(specif

17、ic aldosteron antagonist): choice. AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Metabolic alkalosisworsens hepatic encephalopathy.Extracellular hydrogen ion concentration , ammonium(NH4+) is converted to ammonia(NH3), crosses lipid membrane(nonionic diffusion trapping).Treatmentpotassium ch

18、loride with careful volume repletion.Refractory alkalosis corrected by central venous infusion of dilute(0.1N) hydrochloric acid. Gastrointestinal dysfunctionPotential for active viral hepatitis(A,C,D).Delayed gastric emptyingrisk of regurgitation and aspiration during induction.Patients with portal

19、 hypertensionrisk of massive bleeding from esophageal or gastric varices.Risk of peptic ulcer disease(bleeding source). AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Hepatorenal syndromeAny degree of renal insufficiency that occurs in the presence of liver failure.A specific form of vasomoto

20、r nephropathysevere prerenal oliguria, low urine sodium(10mEq/l), progressive azotemia.Severe obstructive jaundice(total bilirubin8mg/dl) or liver failurebile salts bind to endotoxin in the gut, access into the portal circulation.Endotoxin enters into the systemic circulation and induces renal vasoc

21、onstriction.Renal tubular water and sodium retention.Acute tubular necrosisdirect nephrotoxic effect of endotoxin.Variceal bleeding with hemorrhagic shock- ischemic tubular necrosis.AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Hyperdynamic circulationA fixed low systemic vascular resistance

22、.countless tiny arteriovenous shunts in the skin(spider nevi, palmar erythema), GI tract and lung.Chronic low systemic arterial pressure.Impaired circulatory reserve hypovolemia, sepsis, myocardial ischemia decompensation and shock. Respiratory failureHepatopulmonary syndromehypoxemia refractory to

23、increased inspired oxygen fraction in patients with advanced liver disease.By intrapulmonary shunting through the arteriovenous anstomoses. Reactive or fixed pulmonary hypertension.Aspiration risk(in hepatic encephalopathy).High risk for perioperative pulmonary complications. AnestheticConcernsforth

24、ePatientWithRenaland在肾脏和患者的麻醉问题Hematologic abnormalities.Factor VII deficiencyImpaired hepatic synthesis, impaired vitamin K absorption.Prolongation of prothrombin time.marker of hepatic synthetic dysfunction.Thrombocytopeniaplatelet count 50,000 to 75,000/mm3.Hypersplenism in portal hypertension, a

25、cute GI bleeding or DIC.Factor V deficiencya sensitive marker of acute liver dysfunction.used after liver transplantation.Dysfibrinogenemia(in advanced liver disease).Anemiaacute or chronic blood loss, malnutrition, bone marrow suppression.Chronic alcoholism : macrocytic anemia. AnestheticConcernsfo

26、rthePatientWithRenaland在肾脏和患者的麻醉问题Nutritional-metabolic problemsLoss of glycogenesis(hepatic glycogen synthesis)Poikiloglycemic(regulated by exogenous administration)Hypoglycemia(blood glucose 26%).Only to treat acute blood loss, for patients with cardiopulmonary disease undergoing major surgery.Tra

27、nsfusion shoud be administered during dialysis only(risk of hypervolemia and hyperkalemia).Causes immunosuppression, increase the infection risk. Human recombinant erythropoietinAt a dose of 50 to 75 IU/kg subcutaneously three times weekly.Normalizes the hematocrit concentration.Decrease the require

28、ment for erythrocyte transfusion, decrease hospitalization, cardiovascular mortality(30%), improve the quality of life.Adverse effects.Hypertension, increase the risk for arteriovenous graft thrombosis. AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Treatment of platelet dysfunctionbleeding t

29、ime 15minutes.A synthetic analogue of arginine vasopressin(DDAVP)stimulates endothelial release of von Willebrand factor VIII.0.3 g/kg, IV, over 20 minutes at least 30 minutes before anticipated bleeding.vasodilator effects induce hypotension in hypovolemic patient.TachyphylaxisCryoprecipitatecontai

30、ns von Willebrand factor VIII.Critically ill patient on catecholamine inotropic agents(induce endothelial release of factor VIII) are best served than DDAVP. AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Operative preparationSedative or opiod premedication minimized or avoided.Aspiration pro

31、phylaxisanticholinergic agents, H2 blockers, metoclopramide, sodium bicitrate.BP cuffs or arterial catheters should be avoided on the arm with an AV fistula or shunt.Do not place a urinary catheter in anuric or oliguric patients(ascending infection).Fracture and joint injury in patient with renal os

32、teodystrophy.Active warming devices(prevent hypothermia).AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Anesthetic planning and managementRegional anesthesiaNot contraindicated if coagulopathy is corrected.Increase risk of hypotension(autonomic neuropathy), and site infection.General anesthes

33、iaAt induction : aspiration precautions, preoxygenation, preinduction fluid load(250 to 1000 ml).SuccinylcholineNot contraindicated if serum potassium 3 seconds above control, not corrected with vitamin K.AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Preoperative preparationHepatic failureDr

34、ain tense ascites before surgery.Performed with caution because of the risk of hypovolemia, hypotension, and liver injury.spironolactone(aldosterone antagonist)Exacerbate hyperkalemia in the presence of ARF.Should be discontinued 3 to 4 days before surgery.parenteral vitamin K and FFPCorrect factor

35、VII deficiency and prolonged prothrombin time.Treatment of encephalopathyProtein restriction, lactulose, neomycin. Protection of hepatorenal syndrome(in patients with end stage liver disease)Ensure adequate preoperative hydration.Pharmacological renal protection(low dose dopamine, furosemide, fenold

36、opam). AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Transjugular intrahepatic portosystemic shuntIn patients for orthotopic liver transplantation. Decompresses portal system, relieves severe ascites, decrease the risk of variceal bleeding, improves renal perfusion and hepatorenal syndrome.R

37、isks : bleeding, acute heart failure d/t sudden increase in right atrial filling, endotoxemia, encephalopathy. AnestheticConcernsforthePatientWithRenaland在肾脏和患者的麻醉问题Anesthetic planning and managementRegional anesthesiaHelp to preserve hepatic blood flow if bp and cardiac output is maintained.Should

38、not use in the presence of coagulopathy, ascites, encephalopathy.Drug handlingpharmacokinetics.Large volume of distribution and impaired hepatic elimination.Loading dose requirement may be high, but emergence is delayed.Doses of all sedative drugs should be decreased.CisatracuriumMetabolism is independent of liver function.Neuromuscula