器官移植麻醉双语.pptx

1湘雅医院麻醉科湘雅医院麻醉科 张海萍张海萍2Anesthesia for Kidney TransplantationKidneys 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.3uIndications Patients with end-stage renal diseases and dependent on dialysis（透透析）析）for a long time.4uCharacteristic of Pathophysiology Changes of electrolyte and acid-base balance Water intoxication（水水中中毒毒），hyperkalemia（高高 钾钾），hyponatremia（低低 钠钠），hypernatremia（高高 钠钠）and metabolic acidemia（代酸）（代酸）.5 Cardiovascular Hypertension（高高血血压压）Renal ischemia，sodium retention and abnormalities in the renin-agiotension system result in systemic hypertension.Uremic cardiac disease myocardiosis（心心肌肌 炎炎），pericarditis（心心 包包 炎炎），left ventricular hypertrophy）（左左 室室 肥肥 大大），coronary ischemia（冠冠 脉脉 缺缺 血血），angiosclerosis（血管硬化）（血管硬化）.6Potentialcongestiveheartfailure（潜在性充血性心力衰竭）（潜在性充血性心力衰竭）andpulmonaryedema（肺水（肺水肿）肿）arrhythmia（心律失常）（心律失常）7 Hematologic Bone marrow suppression,decreased erythropoietin production,decreased erythrocyte production,increased deformation erythrocyte production and increased bleeding tendency Anemia(贫血贫血).Liver disease coagulation factor，Uremia(尿尿毒毒症症)and using of heparin coagulation disorder，bleeding time .8 Other changes Nausea（恶恶心心），vomit（呕呕吐吐），anorexia（厌厌食食），diarrhoea（腹腹泻泻），ascites（腹腹 水水）and gastric dilatation（胃扩张）（胃扩张）.Infection（感染）（感染）.Hypoproteinemia（低低 蛋蛋 白白 血血 症症），hyperglycemia（高血糖症）（高血糖症）.9u Evaluation and preparation before anesthesia Preanesthetic evaluation This assessment includes a patient history,a physical examination and any indicated lab tests,classifying the patient according to the ASA physical status scale completes the assessment.10General condition Patients are often combined with hypoproteinemia,anemia,coagulation disorder and fluid,electrolyte and acid-base disturbance and so on.Concurrent diseases Cardiovascular,pulmonary,cerebral,hepatic and other diseases are commonly coexisted.Status of immunosuppression（免免疫疫抑抑制制）and infection（感染）（感染）.11Preanesthetic preparationCare of donor kidney Kidney should have good circulation perfusion before being separated from donor,warm ischemia time and cold 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.12Dialysis（透透 析析）is the most important preparation before operation.Dialysis often precedes transplantation to correct volume or electrolyte derangements.Hemodialysis（血血液液透透析析）is more effective than peritoneal dialysis（腹腹膜膜透析）透析）.13 Blood transfusion（输输血血）Blood transfusion should generally be given only to severely anemic patients(hemoglobin/血血色色素素 6-7g/dl)or when significant intraoperative blood loss is expected.Controlling infection.14Treatment of complication（Hypertension,cardiac function ,fluid,electrolyte and acid-base disturbance and so on）Fasting（禁食）（禁食）Premedication（术前用药）（术前用药）Protection of arteries and veins fistula15uPrinciples of anesthesia managementPrinciples of anesthetics chosen Anesthetics not primarily dependent on renal excretion for elimination，no nephrotoxicity（肾肾 毒毒 性性）and having short duration of action should be used.16 Venous anesthetics Propofol（异异丙丙酚酚）,Fentanyl（芬芬太太尼尼）,Midazolum（咪咪达达唑唑仑仑）,Etomidate（依依托托咪咪 酯酯）and small doses of Sodium pentothal（硫喷妥钠）（硫喷妥钠）are often used.Inhalational anesthetics Isoflurane（异异氟氟烷烷）,Enflurane（安安氟氟烷烷）,Nitrous oxide（笑笑气气）,Desflurane(地地氟氟烷烷)and sevoflurane（七七 氟氟 烷烷）are often used，methoxyflurane（甲甲 氧氧 氟氟 烷烷）is forbidden because of its nephrotoxicity.17 Muscle relaxants Atracurium（阿阿曲曲库库铵铵）,Rocuronium（罗罗 库库 溴溴 铵铵）and Vecuronium（维维库库溴溴铵铵）are often used，dont use succinylcholine（琥珀胆碱）（琥珀胆碱）.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）.18Postoperative analgesics Dolantin,tramal,fortanoryn,PCEA.Choice of anesthesia Principles No pain,muscle relaxed,sedation perfectly,vital signs stable,no complications.1920Continuous epidural anesthesia for kidney transplantation is often used in China now.Choice of puncture sites,T11-12 or T12L1，L2-3 or L3-4 .21Advantage Having 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.22Disadvantage Mental stress,Epidural hemorrhage（出出血血）and hematoma（血血 肿肿）(direct pressure and ischemia to spinal cord ),Circulation and respiration depression(if the block level is inadequate controlled).23General anesthesia combined intravenous and inhalational anesthesia is often used.Combined spinal and epidural anesthesia24Intraoperative monitoring and anesthetic management 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.25 Anesthetic management Prevention and cure of hypotension Prevention and cure of hypertension Monitoring serum kalium Urinary output Drugs 26Venous road 1 5%Glucose 250ml/iv by drip DXM 75 mg/iv by drip(3060)5%Glucose 250ml/iv by drip Lasilix（速速尿尿）80mg iv when starting to anastomose renal artery 20%Mannitol（甘甘露露醇醇）250 ml iv by dvip(fast)as soon as blood vessel is anastomosed27 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）28Venous road 2 Blood transfusion should be given and Dopamine 2 3g/kg.min iv by drip when it is necessary to enhance 1020mmHg of pressure before rebuilding circulation.Maintenance of intravenous fluids is decided by anesthetist.29Postoperative management Sterilize Avoid anoxia，prevent and cure respiratory airway complications Recover the function of transplanted kidney as soon as possible Postoperative pain management30Transfuse albumin1020g each day，correct acid-base and electrolyte disorder.Resist infection.Diagnose,prevent and cure rejection response immunosuppressant drug(Cyclosprine,Azathioprine and Prednisone).31Thank you!