肝病患者麻醉

1、Preoperative Evaluation of the Liver Disease术前肝脏疾病的评估GuoyanhuaClinical Assessment临床评估? Clinical manifestations： loss of appetite, easy fatigability, malaise, altered sleep patterns, or subtle changes in personality.?临床表现：食欲不振，容易疲劳，倦怠，睡眠模式改变，轻度性格改变。Clinical Assessment临床评估?obvious signs： peripheral ed

2、ema, overt ascites, or encephalopathy develops?体征：外周水肿、重度腹水、脑病Biochemical Tests生化监测?1、 Hepatocellular Injury肝细胞损害?1 Aminotransferases氨基转移酶类?serum levels increase：?aspartate aminotransferase (AST)?谷草转氨酶?alanine aminotransferase (ALT)?谷丙转氨酶Biochemical Tests 生化监测?1、 Hepatocellular Injury? ALT is relati

3、vely specific to the liver, whereas considerable AST are present in extrahepatic tissues, including the heart, skeletal muscle ， et.al.?ALT 是肝脏相对特异性的酶，而相当大量的AST 存于肝外组织，包括心脏、骨骼肌等。Biochemical Tests生化监测?1、 Hepatocellular Injury?2Lactate Dehydrogenase 乳酸脱氢酶?lactate dehydrogenase (LDH) may reflectacute o

4、r chronic liver injury?LDH 可反响急性或是慢性肝损害Biochemical Tests生化监测?1、 Hepatocellular Injury?3 Glutathione S-Transferase 谷胱甘肽S -转移酶?relatively sensitive and specific test for detecting drug-induced hepatocellular damage?GST 是一个比拟敏感、特异性检测药物诱导肝细胞的损害的指标。Biochemical Tests生化监测?2、 Hepatic Synthetic Capacity肝合成能力

5、?1 Serum Albumin血清白蛋白?Serum albumincan provideuseful informationabout hepatocellularfunctionin certain clinical settings.在某些临床情况中，血清白蛋白可用于提示肝细胞功能。Biochemical Tests生化监测?2、 Hepatic Synthetic Capacity肝合成能力?2 Prothrombin Time凝血酶原时间?the PT, or internationalnormalized ratio (INR), can beuseful for detecti

6、ng rapidly declining liver function.?PT 或 INR可用于检测急性肝功能减退。Biochemical Tests生化监测?3、 Cholestatic Disorders胆汁淤积?1 Alkaline Phosphatase 碱性磷酸酶?AP is a useful screening test fordiseases of the liveror biliarytree, includingacute hepatitis, malignancies, and cholestatic disorders.?AP 可用于筛查肝脏、胆道系统，包括急性肝炎、恶性

7、肿瘤、胆汁淤积Biochemical Tests生化监测?Cholestatic Disorders胆汁淤积?2 Serum Bilirubin血清胆红素?Serum bilirubin is the most useful test for assessing the excretory function of the liver.?血清胆红素是评估肝脏排泄功能最有价值的指标Biochemical Tests生化监测?4、 Others其他?1 serum -globulin level血清球蛋白?2 Serum tumor markers 血清肿瘤标记物:?alpha-fetoprotei

8、n (AFP)?3 viral, microbial, and autoimmune diseases病毒，微生物，免疫疾病?4 serum 1-AT level 1 - 抗胰蛋白酶Preoperative Preparationof the Patient With Liver Disease肝病患者的术前准备chenyePreoperative Preparation?一.Coagulopathy? 二 . Ascites?三.Encephalopathy? 四 . Malnutrition?一.凝血障碍? 二 . 腹 水?三.脑病?四 .营养不良一. Coagulopathy(1)凝血障

9、碍?all the coagulation factors are produced in the liver (except Factor VIII).?portal hypertension= hyper splenism= peripheral thrombocytopenia.?所有的凝血因子均在肝脏内合成(除了第八因子 ).?门脉高压=脾亢=外周血小板减少?Coagulopathy (2)凝血障碍?Tx: vitaminK .FFP .platelets.cryoprecipitationare recommended to reduce PT and to achieve a go

10、al of platelet counts of 50 X 10 3/L.?A prolonged bleeding time can be corrected with diamino-8-D-arginine vasopressin (DDAVP)?处理：输 vitaminK .FFP . 血小板 .冷沉淀可以缩短PT 时间，并使血小板到达50 X 10 3/L 的目标。?出血时间延长时可以用1-二氨基 -8-二-精氨酸 -加压素来纠正。二 . Ascites 腹 水?To Cirrhosis with ascites:mortality rate 37-83%Cirrhosis with

11、out ascites: mortality rate 11-53% (Conn, 1991).?Ascites = reduced lung expansion, abdominal-wall herniation, and wound dehiscence.?Tx: diuretics and/or large-volume paracentesis with albumin if necessary before surgery.肝硬化合并腹水：死亡率在37-83%；未合并腹水的在11-53%(Conn, 1991).腹水 = 减少肺膨胀运动，产生腹壁疝，切口裂开。处理：利尿剂，穿刺放腹

12、水，必要时在术前输白蛋白。三. Encephalopathy 脑病?encephalopathy88%mortality,higher than the emergency surgery 50。Factors toencephalopathy:Infection,metabolicalkalosis,constipation,use ofdiuretics,CNS depressants, hypoxia, azotemia, or GI bleeding.?肝病合并脑病的死亡率为88% ，高于急诊手术50。?诱发脑病的因素：感染、代谢性碱中毒，便秘、使用利尿剂和中枢抑制剂、低氧血症、氮质血

13、症以及胃肠道出血等。?Tx : (1)Correction of electrolyte abnormalitiestreatment of infection and GI bleedingrestriction of sedativeslactulose处理： (1纠正电解质紊乱治疗感染和胃肠道出血尽量防止镇静药的使用乳果糖的使用四 . Malnutrition营养不良?Inpatientswithend-stage liverdisease, enteralnutritionshould be started, preferablyinthe preoperative period (W

14、eimann, 1998).?Prevent aggravate hepatic encephalopathy =high-carbohydrate and/or high-lipid supplements with a decreased amino acid content (Wiklund, 2004).?肝病晚期的患者，在术前就应该开始进行肠内营养治疗了(Weimann, 1998).?为预防肝性脑病，应提高饮食中碳水化合物和脂类的含量以减少氨基酸的含量(Wiklund, 2004).Pathophysiology of liver disfunctionFunction?The l

15、iveris the largest organ in the body and plays a criticalrole in the homeostasis of many physiologic systems?nutrient and drug metabolism?synthesis of plasma proteins and critical hemostatic factors?detoxification and elimination of many endogenous and exogenous substances.?Acute or chronic liverdys

16、functioncan impairthe response to anesthesia and surgery in several critical ways?Certainanesthetics and hemodynamicdisturbances can induceserious alternationsinhepatic function.Protein Metabolism?Liversynthesizes and degrades an enormous varietyof proteins and peptides(肽链 ) and has an essential rol

17、e in the production and breakdown of amino acids.Protein Metabolism?Albuminplayskey role inmaintainingplasma oncoticpressure(血浆渗透压). Plasma oncotic pressure regulates the intravascular albumin concentration.?Albuminalso has importance as a plasma transport protein: it binds to many differentsubstanc

18、es (e.g., drugs, hormones, unconjugated bilirubin( 非结合胆红素), free fattyacids), influencingtheir biologic actions and elimination.Protein Metabolism?Hepatocytes convert amino acids to ammonia and intermediary metabolites and transform ammonia and other nitrogenous compounds to urea.?Thus, in patients

19、with severe liver disease (and normal renal function), the blood urea nitrogen (BUN) level typically remains low, whereas nitrogenous wastes increase in blood and other tissues and may contribute to hepatic encephalopathy( 肝性脑病 ).Carbohydrate Metabolism? A 12- to 24-hour fast exhausts liverglycogen

20、stores, makingthe production of bloodglucose dependent on hepatic gluconeogenesis(糖异生 ).?Patients with liver dysfunction result in hypoglycemia(低血糖 ) easily.Bile Metabolism?Bileacids are producedbyhepatocytes and facilitatethegastrointestinalabsorption ofmany lipophilic( 亲脂性 ) molecules, including v

21、itamin K.?In cholestatic disorders, the liver synthesizes, clotting factors. Parenteral(胃肠外 ) vitamin K therapy will rapidly correct the resultant coagulopathy(凝血病 ).Coagulation?The liver synthesizes all coagulant factors, except for factors III , IV (Ca),and VIII .?Many of factors (II, VII, IX, X,

22、protein C, protein S) is vitamin K-dependent. Coagulation?When prothrombin time (PT) is prolonged solely because of malnutrition, it should be readily corrected by oral or parenteral vitamin K.? With severe hepatocellular dysfunction (acute hepatitis, cirrhosis( 肝 硬 化 ), vitamin K therapy is ineffec

23、tive because the problem is insufficient synthesis of vitamin K-dependent factors, not a shortage of vitamin K.Metabolism of DrugsThe liver is the major organ for metabolizing and removing a wide variety of substances through oxidations with cytochrome P450( 细胞色素氧化酶) mostly.Metabolism of Drugs?The m

24、ajor pharmacokineticparameters ofhepatic drug clearance are liverbloodflow,protein binding, intrinsic clearance, and extraction ratio (ER摄取率 ).?Decreases in liverblood flowonly lowerthe hepatic clearances of drugs that have a high ER, whereas decreases in drug metabolizing capacity or increases in p

25、rotein binding only lower hepatic clearances of drugs that have a low ER.肝功能不全病人的麻醉Anesthesia for the Patient with Hepatic Inadequacy李丽萌2021 02 23术前准备preoperative preparation肝脏是人体内最大的实质性脏器，它在保持生理系统内环境稳定中起着重要的作用，其功能包括营养物质和药物代谢、血浆蛋白和凝血因子的合成、内源性和外源性物质的解毒和消除。因此肝功能不全病人术前必须有良好的准备。The liver is the largest

26、parenchymatous organ in the body and plays a critical role in the homeostasis of many physiologic systems, including nutrient and drug metabolism, synthesis of plasma proteins and critical hemostatic factors, and detoxification and elimination of many endogenous and exogenous substances. So satisfac

27、tory preoperative preparation is necessary in the patients with hepatic inadequacy.肝功能不全的病人进行手术治疗，通常有两种情况：一是患有与肝病无关的一些疾病；二是肝脏疾病本身需行手术治疗。There are two situations in those patients who exist hepatic inadequacy and will undergo operation. One is that the patient has hepatic inadequacy but not to underg

28、o hepatic surgery. The other is that the patient with hepatic disease should accept hepatic surgery.应积极进行以“保肝为主的术前准备，包括：加强营养、改善凝血功能、纠正血浆低蛋白和贫血、给予广谱抗生素治疗、备血等。麻醉前用药量宜小，对个别情况差或处于肝性脑病前期的病人，术前仅给阿托品或东莨菪碱即可。Preoperative preparation for protecting hepatic function should be carried out positively,including

29、strengthening nutrition,improvementof coagulation function,correction of low serum protein and anemia,treatmentofbroad-spectrumantibiotic,bloodpreparation,andso on.Drugdose of preanesthetic medicationshould be small. To the patient withsevere conditionorprophase of hepatocerebral disease, only atrop

30、ine or scopolamine can be given before anesthesia.麻醉选择anesthetic selection选用麻醉药和方法需要了解：所患肝脏疾病；肝脏在药物解毒中的作用；药物对肝脏的影响。When selecting anesthetics and methods, the following things should be understood: what kind of hepatic disease is? the role of liver in drug detoxification the influence of drug on liv

31、er药物的选用应选择对肝脏毒性和血流的影响较小的药物。术中管理， 如术中供氧、 补充血容量、纠正酸中毒、维持循环稳定等比麻醉药的选择更重要。The drug which has a minor hepatotoxicity and a smaller influence on liver blood flow can be chosen. Intraoperativeadministrations,whichincludeintraoperativeoxygen supply, supplement ofblood volume, correction of acidosis, mainten

32、ance of stabilization of circulation, are more important than the selection of anethetics上肢手术可选择臂丛阻滞；下肢及下腹部手术可选择腰硬联合麻醉；上腹部及胸部手术可选择全身麻醉或全麻复合硬膜外麻醉。Brachial plexus block can be selected in surgery of upper limb.Combinedspinaland epiduralanesthesia can be used inoperations on lowerlimband lower abdomen.

33、General anesthesia or GA combined epidural anesthesia can be chosen in surgery of upper abdomen and thoracic region.全麻诱导可用咪唑安定、舒芬太尼、阿曲库铵或爱可松、丙泊酚复合，麻醉维持可用全凭静脉麻醉或静脉和吸入麻醉复合，但应防止使用对肝有损害的药物，如氟烷。The combined administration of midazolam, sufentanil, atracurium or rocuronium, propofol can be applied to indu

34、ction of anesthesia. The maintenance of anesthesia can use TIVA or intravenous and inhalant combination. But the drug with hepatic lesion should be avoided, like halothane.术中管理intraoperative management严防低血压和缺氧prevention of hypotension and hypoxia.术中保肝： 10%葡萄糖液500ml+ 维生素 C 5g+ 维生素 K 1 20mg 静滴。Protect

35、ionofhepatic function:10%glucose liquid500ml+vitaminC 5g+vitaminK 1 20mg intravenously guttae.术中输液：以胶体液为主，并根据术前检查补给白蛋白、血浆、冷沉淀或血细胞，维护有效血容量和平稳血压。Intraoperative infusion: The main fluid used to maintain effective blood volume and stable blood pressure is colloids. The else solutions like albumin, plasm

36、a, cryoprecipitate or blood cell can be applied according to preoperative examination.术中监测尿量，保护肾功能。Monitoring urine output and protecting renal function during surgery.积极预防和处理术中并发症，如失血性休克、 心律失常、 酸碱失衡、 术毕苏醒延迟和肝昏迷等。Positivepreventionand protectionofintraoperativecomplication,such as hemorrhagicshock,

37、arrhythmia, acid-base imbalance, delayed recovery and hepatic coma after surgery.加强监测。Strengthening monitoringconclusion麻醉原那么：anesthetic rules作好充分的术前准备，尽一切可能纠正机体的内环境紊乱；Satisfied preoperative preparation and correction of disorders of homeostasis are necessary术中减少一切不必要的用药，以减轻肝脏的解毒负担；Reduction of all

38、unnecessary medication during surgery in order to lessen the burden of hepatic detoxification.选用对肝脏血流代谢等影响最小的麻醉药；The anesthetics with smaller influence on liver blood flow can be selected.术中力求血流动力学平稳，减轻肝脏的缺血再灌注损伤；Hemodynamics stabilization during surgery should be maintained and hepatic ischemical r

39、eperfusion injury should be lessened.围手术期除加强生理监测外，更应注意动态监测生化及凝血功能；Dynamicmonitoringsofbiochemicaland coagulationfunctionare also importantas wellas monitoring of physiological functions during operation.保肝治疗应贯穿于术前、术中及术后始终。The measures of protecting hepatic function should be taken pre-, intra- and p

40、ost operatively.Liver cancer surgery s anesthesia肝癌手术的麻醉Divided into primary and secondary:? 1. Primary liver cancer, liver function in general is still good? 2. Secondary to cirrhosis, often incorporate a number of organ dysfunction? 分为原发性和继发性：? 1.原发性肝癌，一般肝功能尚好? 2.继发于肝硬化的，合并有多脏器功能障碍Secondary liver cancer继发性肝癌? Livercancer secondarytocirrhosis,manyhavehypersplenism,ascites,jaundice,blood coagulationabnormalityorevenhepaticcoma,anesthesiawouldneedtoconsidertheabove-mentioned pathophysiological changes? 如继发于肝硬化肝癌，多合并有脾功能亢进，腹水，黄疸，凝血