肾功能不全病人手术的麻醉课件

肾功能不全病人手术的麻醉1肾功能不全急性肾功能不全各种原因引起肾功能急骤、进行性减退出现的临床综合征慢性肾功能不全指所有原发病或继发性慢性肾脏疾病所致进行性肾功能损害所出现的一系列症状或代谢紊乱组成的临床综合征2肾功能评估serum

creatinineinsensitivereadily

available

clinical

data3慢性肾脏疾病CKD2002

National

Kidney

Foundation–Kidney

DiseaseOutcomes

Quality

Initiative

(NKFK/DOQI)4肾功能减退分期肾贮备力下降期（肾功能不全代偿期）Ccr >

50%氮质血症期（肾功能不全失代偿期）Ccr

25-50%sCr <

221µmol/L肾功能衰竭期尿毒症早期Ccr

10-25%sCr 221-

442

µmol/L终末期肾病尿毒症晚期Ccr

<10%sCr >

442µmol/L5流行病学NHANES

IIIstage

2

CKD3%

of

the

adult

population

in

the

USA≥stage

3

CKD4.7%ESRD

receiving

chronic

dialysis

in

USA↑

3–5%

/y45.6%

of

chronic

dialysis

patients>

65

y6病因学Diabetic

nephropathymost

common

cause

,

>40%Hypertensive

nephrosclerosisbidirectional

relationship

between

BP

and

renal

diseaseGlomerular

diseasenephroticnephriticInterstitial

diseases

of

the

kidneyVascular

diseases

of

the

kidneyInherited

kidney

diseases7Systemic

ManifestationsofRenal

Disease8麻醉前评估——系统回顾Systemic

disease

processesaffecting

multiple

organ

systems基本代谢受影响麻醉药物的异常作用，多器官功能不全，替代治疗以及移植相关的特殊问题等等A

challenge

toanesthesiologists9系统回顾——水和酸碱平衡紊乱无尿患者只有不感失水(500ml/day)钠摄入过量–edema,hypertension水摄入过量–hyponatremia多尿患者尿浓缩功能障碍急性失水–hypovolemia代谢性酸中毒代偿性呼吸性碱中毒Shock,

diarrhea,

orhypercatabolism

(sepsis,

trauma,

steroid

therapy)→

Profound

metabolic

acidosis10症

系细统胞回外钾顾——电解质紊乱Maintained

in

narrow

range(3.5

to

5.0

mmol/L)高钾血症（or低钾血症）临床和ECG

表现更取决于钾流量

高分解代谢,酸中毒保钾利尿剂输注RBC→

急速致命的高钾血高镁血症肌无力,对肌松药敏感低镁血症Associated

with

hypokalemia,

ventricular

irritability11系统回顾——电解质紊乱高磷血症骨钙沉积增加，低钙血症肾合成vitD

减少低钙血症继发性甲旁亢，骨质吸收肾性骨营养不良综合征低磷血症过度透析，氢氧化铝治疗,or

TPN磷耗竭综合征

对肌松药敏感性增加,机械通气撤机困难, CNS

功能障碍12系统回顾——心血管系统高血压左室高电压(向心性or

非对称性)高脂血症加速动脉粥样硬化贫血和AV

分流血流动力学：高排低阻循环储备受损心肌缺血尿毒症性心包炎，心包填塞心功能不全13系统回顾——呼吸系统放射的对称型蝴蝶状阴影早期肺活量减低，限制性通气障碍和氧弥散能力下降气促，代偿代谢性酸中毒尿毒症性肺胸片：以肺门为中心向两侧病理：肺水肿肺毛细血管通透性增加PCWP增加尿毒症性胸膜炎14系统回顾——血液系统15贫血正细胞正色素性贫血肾生成EPO减少骨髓抑制RBC寿命缩短胃肠道慢性失血尿毒症性凝血病血小板功能异常出血时间延长血小板凝集功能受损血栓形成倾向动静脉内瘘易阻塞系统回顾——代谢和免疫系统16高血糖，高甘油三酯血症外周胰岛素抵抗，脂蛋白脂酶活性降低蛋白质营养不良(kwashiorkor,

hypoalbuminemic

malnutrition)蛋白饮食限制，长期蛋白尿CAPD蛋白丢失(经腹膜10-40

g/dl)低蛋白血症，低胶体渗透压周围组织水肿，肺水肿淋巴细胞趋化性和免疫球蛋白反应性受损易感染尿毒症分解代谢效应伤口不愈，瘘，褥疮系统回顾——消化系统表现最早、最突出厌食，呃逆，恶心，呕吐自主神经系统病变胃排空延迟麻醉诱导易反流误吸消化道溃疡up

to

25%

in

CRFpatientsHepatitis

B

and

Chigh

incidence

in

patients

on

chronic

hemodialysis

常anicteric

or

in

a

carrierstate17系统回顾——神经系统

神经纤维脱髓鞘变18中枢神经系统早期为功能抑制淡漠，疲劳，记忆力减退加重记忆力，判断力，定向力，计算力障碍欣快感，抑郁症，妄想，幻觉，扑翼样震颤嗜睡，昏迷周围神经病变下肢不安综合征下肢疼痛，灼痛，痛觉过敏，运动后消失肢体无力，步态不稳，深肌腱反射减退运动障碍自主神经功能障碍体位性低血压，发汗障碍，神经源性膀胱，早泄病理改变麻醉前评估The

cause

of

CRF,

complicated

systemic

disease,the

other

manifestations

of

the

diseaseDaily

urine

output,

type

of

dialysis,

recent

treatment麻醉前评估——心血管系统Anaesthesia

for

renal

transplant:

Recent

developments

and

recommendations.Current

Anaesthesia

&

Critical

Care

(2008)

19,

247–253按心脏病人非心脏手术麻醉术前流程评估长期药物治疗史20麻醉前评估——心血管系统21麻醉前评估——心血管系统22术前准备——透析血液透析controls

the

manifestations

of

ARF(fluid

overload,

acidosis,hyperkalemia,

acute

uremia)不能完全纠正血小板病变或逆转肾性骨营养不良和神经病变Preoperative

dialysis

12–24

h

before

surgeryEffects

of

recent

dialysis液体不足和重分布到血管外致血管内容量不足电解质紊乱，尤其是低钾血症血透治疗时全身肝素化后的残留抗凝作用23术前准备——透析腹膜透析provides

hemodynamic

stability

but

not

effective

inhypermetabolic

statesAbdominal

distension

compromise

perioperativepulmonary

function腹部手术改为血透直至腹部伤口愈合24术前准备——血液系统25术前输血Not

indicated

for

patients

with

a

stable

Hct

>

26%适应症急性出血，心肺疾病患者行重大手术Transfusion

during

dialysis

only

(risk

of

hypervolemiaandhyperkalemia)Causes

immunosuppression,

increase

the

infection

riskHuman

recombinant

erythropoietin肾病导致的慢性贫血非常有效The

response

to

rHuEPO

takes

2–6weeks50

-

75

IU/kg

subcutaneously

three

times

weekly不良反应高血压,增加动静脉内瘘血栓形成风险术前准备Sedative

or

opiod

premedicationminimized

or

avoidedBP

cuffs

or

arterial

catheters

should

be

avoided

on

thearm

with

an

AV

fistula

or

shuntActive

warming

devices

(prevent

hypothermia)26Pharmacologic

Effectsof

Renal

Failure27肾功能不全对药物的影响——静脉药物Drugs

with

increased

unbound

fraction

inhypoalbuminemia硫喷妥钠，美索比妥，地西泮↓

20

-50%Drugs

that

depend

predominantly

on

renal

elimination

加拉明，箭毒，地高辛，青霉素，先锋霉素，氨基糖苷类，万古霉素，环孢素A负荷量(—)，维持量↓

↓28肾功能不全对药物的影响——静脉药物Drugs

depend

in

part

on

renal

elimination抗胆碱能药物和胆碱能药物泮库溴铵, 哌库溴铵, 杜什库铵米力农，氨力农苯巴比妥，抑肽酶氨基己酸，氨甲环酸维持量↓

30-50%29肾功能不全对药物的影响——静脉药物Drugs

with

active

metabolites

that

are

eliminatedby

thekidneysExert

a

prolonged

effect

in

CRFThe

parent

drugs

should

be

avoided

or

maintenancedoses

must

be

↓30-50%30肾功能不全对药物的影响——吸入麻醉药31Nephrotoxic

effects长时间的甲氧氟烷麻醉可导致多尿性肾衰肾毒性与氟化物代谢产物相关与氟化物血浆峰值浓度及使用时间直接相关Enflurane只在肾毒性、肝毒性或者酶诱导剂的情况下产生肾损害Compound

Aa

metabolite

produced

by

the

interaction

of

sevoflurane

withoutdated

sodalime

when

fresh

gas

flows

are

<

2

L/minPerioperativeManagement32麻醉规划与管理——术中33Summary

of

perioperative

considerationsAnaesthetic

options

–

GA,

RA

or

LAAirway

managementVascular

accessFluid

and

electrolyte

managementBlood

transfusionImmune

function

and

antibiotic

prophylaxisSteroid

supplementation麻醉规划与管理——术中34Regional

anesthesiaNot

contraindicated

if

coagulopathy

iscorrectedIncrease

risk

of

hypotension

(autonomic

neuropathy)and

siteinfectionGeneral

anesthesiaAt

induction

:

aspiration

precautions,preoxygenation,SuccinylcholineNot

contraindicated

if

serum

K<

5.0

mEq/l,

haddialysis

within

24hs麻醉规划与管理——术中35nondepolarizing

agentspancuronium

and

pipecuronium

—

be

avoidedmivacurium

andcisatracuriumMetabolized

independent

of

renal

eliminationvecuronium

androcuronium —okIncrease

mechanical

minute

ventilationCompensate

chronic

metabolic

acidosisIn

anuric

patientsMaintenance

fluid

kept

in

minimal,

fluid

losses

must

be

fullyreplaced麻醉规划与管理——术后苏醒36苏醒延迟，持续神经肌肉阻滞，呕吐，误吸 高血压，呼吸抑制，肺水肿In

patient

with

chronic

metabolic

acidosisopioid-induced

respiratorydepressionCause