器官移植麻醉双语ppt课件

1、湘雅医院麻醉科湘雅医院麻醉科 张海萍张海萍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.uInd

2、icationsu P a t i e n t s w i t h e n d - s t a g e r e n a l d i s e a s e s a n d dependent on dialysis透析透析 for a long time.u Characteristic of Pathophysiology Changes of electrolyte and acid-base balance Wa t e r i n t o x i c a t i o n 水 中 毒 ， 水 中 毒 ，hyperkalemia高钾，高钾， hyponatremia低低钠 ，钠 ， h y p

3、 e r n a t re m i a 高 钠 高 钠 a n d metabolic acidemia代酸代酸. Cardiovascular Hypertension高血压高血压 Renal ischemia，sodium retention and abnormalities in the renin-agiotension system result in systemic hypertension. U r e m i c c a r d i a c d i s e a s e myocardiosis 心肌炎，心肌炎，pericarditis心包炎心包炎 ， left ventri

4、cular hypertrophy左室左室肥大，肥大，coronary ischemia冠冠脉缺血，脉缺血， angiosclerosis 血管血管硬化硬化.Potential congestive heart failure潜在性充血性心力衰竭潜在性充血性心力衰竭 and pulmonary edema肺水肺水肿肿 arrhythmia心律失常心律失常 Hematologic Bone marrow suppression , d e c r e a s e d e r y t h r o p o i e t i n production , decreased erythrocyte pr

5、oduction, increased deformation erythrocyte production and increased bleeding tendency Anemia 贫血贫血. Liver disease coagulation factor ，Uremia尿毒症尿毒症 and using of heparin coagulation disorder， bleeding time . Other changes Nausea恶心恶心 ，vomit呕呕吐吐 ，anorexia厌食厌食 ， diarrhoea腹泻腹泻 ，ascites腹腹水水 and gastric dil

6、atation胃扩胃扩张张. Infection 感染感染. Hypoproteinemia低蛋白血症，低蛋白血症，hyperglycemia高血糖症高血糖症.u Evaluation and preparation before anesthesia Preanesthetic evaluation This assessment includes a p a t i e n t h i s t o r y, a p h y s i c a l examination and any indicated lab tests , classifying the patient accordin

7、g to the ASA physical status scale completes the assessment. General condition Patients are often combined with hypoproteinemia , anemia, coagulation disorder and fluid , e l e c t r o l y t e a n d a c i d - b a s e d i s t u r b a n c e a n d s o o n . C o n c u r r e n t d i s e a s e s C a r d i

8、 o v a s c u l a r , pulmonary, cerebral, hepatic and other diseases are commonly coexisted. Status of immunosuppression免疫免疫抑制抑制 and infection感染感染.Preanesthetic preparation Care of donor kidney Kidney should have good circulation perfusion before being separated from donor,warm ischemia time and col

9、d 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. Di a l y s i s 透 析 透 析 i s t h e m o s t important preparation before operatio

10、n. Dialysis often precedes transplantation to correct volume or electrolyte derangements. Hemodialysis血液透析血液透析 is more effective than peritoneal dialysis腹腹膜透析膜透析. Blood transfusion输血输血 Blood transfusion should generally be given only to severely anemic patientshemoglobin/血色素血色素 6-7g/dl or when signi

11、ficant intraoperative blood loss is expected. Controlling infection. Treatment of complication Hypertension , cardiac function , fluid , electrolyte and acid-base disturbance and so onFasting禁食禁食Premedication术前用药术前用药Protection of arteries and veins fistulauPrinciples of anesthesia management Princip

12、les of anesthetics chosen Anesthetics not primarily dependent on renal excretion for elimination ，no nephrotoxicity肾毒性肾毒性 and having short duration of action should be used. Venous anesthetics Propofol异丙酚异丙酚, Fentanyl芬太芬太尼 尼 , M i d a z o l u m 咪 达 唑 咪 达 唑仑仑 ,Etomidate依托咪酯依托咪酯 and small doses of Sod

13、ium pentothal硫喷妥钠硫喷妥钠 are often used. Inhalational anesthetics Isoflurane异氟烷异氟烷,Enflurane安安氟烷氟烷,Nitrous oxide笑气笑气, D e s f l u r a n e 地 氟 烷 地 氟 烷 a n d sevoflurane七氟烷七氟烷 are often used，methoxyflurane甲氧氟烷甲氧氟烷 is forbidden because of its nephrotoxicity . Muscle relaxants Atracurium阿曲阿曲库铵库铵,Rocuronium

14、罗库溴铵罗库溴铵 and Vecuronium维库溴铵维库溴铵 are often used，dont use succinylcholine琥琥珀胆碱珀胆碱. Local asnesthetics Lidocaine, Bupivacaine, Rupivacaine and Dicaine are often used，notice toxicity reactions induced by excessive of local anesthetics, dont use epinephrine肾上腺素肾上腺素. Postoperative analgesics Dolantin , tr

15、amal , fortanoryn , PCEA. Choice of anesthesia Principles No pain ,muscle relaxed, sedation perfectly ,vital signs stable , no complications. 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 . Advantage Havi

16、ng 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. Disadvantage Mental stress, Epidural hemorrhage出血出血 and hematoma血肿血肿 direct

17、pressure and ischemia to spinal cord , Ci rcul ati on and respi rati on depressionif the block level is inadequate controlled. General anesthesia combined intravenous and inhalational anesthesia is often used. Combined spinal and epidural anesthesia Intraoperative monitoring and anesthetic managemen

18、t 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. Anesthetic management Prevention and cure of hypotension Prevention and cure of hypertension Monitoring seru

19、m kalium Urinary output Drugs 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 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多尿多尿 Venous r