器官移植麻醉双语专家讲座

器官移植麻醉OrganTransplantation湘雅医院麻醉科张海萍1第1页AnesthesiaforKidneyTransplantation

Kidneysarethemostcommonmajororgantransplanted，thesuccessofkidneytransplantation，whichislargelyduetoadvancesinimmunosuppressivetherapy，hasgreatlyimprovedthequalityoflifeforpatientswithend-stagerenaldisease.2第2页Indications

Patientswithend-stagerenaldiseasesanddependentondialysis（透析）foralongtime.3第3页

Characteristicof

Pathophysiology

Changesofelectrolyteandacid-basebalance

Waterintoxication（水中毒），hyperkalemia（高钾），hyponatremia（低钠），hypernatremia（高钠）andmetabolicacidemia（代酸）.

4第4页

Cardiovascular

Hypertension（高血压）

Renal

ischemia，sodiumretentionandabnormalitiesintherenin-agiotensionsystemresultinsystemichypertension.Uremiccardiacdisease

myocardiosis（心肌炎），pericarditis（心包炎），leftventricularhypertrophy）（左室肥大），coronaryischemia（冠脉缺血），angiosclerosis（血管硬化）.5第5页Potentialcongestiveheartfailure（潜在性充血性心力衰竭）andpulmonaryedema（肺水肿）

arrhythmia（心律失常）6第6页

Hematologic

Bonemarrowsuppression,decreasederythropoietinproduction,decreasederythrocyteproduction,increaseddeformationerythrocyteproductionandincreasedbleedingtendencyAnemia(

贫血).

Liverdiseasecoagulationfactor，Uremia(尿毒症)andusingofheparincoagulationdisorder，bleedingtime.

7第7页

Otherchanges

Nausea（恶心），vomit（呕吐），anorexia（厌食），diarrhoea（腹泻），ascites（腹水）andgastricdilatation（胃扩张）.Infection（感染）.

Hypoproteinemia（低蛋白血症），hyperglycemia（高血糖症）.8第8页Evaluationandpreparationbeforeanesthesia

Preanestheticevaluation

Thisassessmentincludesapatienthistory,aphysicalexaminationandanyindicatedlabtests,classifyingthepatientaccordingtotheASAphysicalstatusscalecompletestheassessment.

9第9页

Generalcondition

Patientsareoftencombinedwithhypoproteinemia,anemia,coagulationdisorderandfluid,electrolyteandacid-basedisturbanceandsoon.

ConcurrentdiseasesCardiovascular,pulmonary,cerebral,hepaticandotherdiseasesarecommonlycoexisted.

Statusofimmunosuppression（免疫克制）andinfection（感染）.10第10页Preanestheticpreparation

CareofdonorkidneyKidneyshouldhavegoodcirculationperfusionbeforebeingseparatedfromdonor,warmischemiatimeandcoldischemiatimeshouldbeminimized,separatedkidneyshouldbefrozenforpreservationinreason,transplantedkidneyshouldhavegoodperfusionafterrebuildingcirculationandrenalfunctionshouldberecoveredintime.11第11页

Dialysis（透析）isthemostimportantpreparationbeforeoperation.

Dialysisoftenprecedestransplan－tationtocorrectvolumeorelectrolytederangements.

Hemodialysis（血液透析）

ismoreeffectivethan

peritonealdialysis（腹膜透析）.12第12页

Bloodtransfusion（输血）

Bloodtransfusionshouldgenerallybegivenonlytoseverelyanemicpatients(hemoglobin/血色素<6-7g/dl)orwhensignificantintraoperativebloodlossisexpected.

Controllinginfection.

13第13页Treatmentofcomplication（Hypertension,cardiacfunction,fluid,electrolyteandacid-basedisturbanceandsoon）Fasting（禁食）Premedication（术前用药）Protectionofarteriesandveinsfistula14第14页Principlesofanesthesiamanagement

Principlesofanestheticschosen

Anestheticsnotprimarilydependentonrenalexcretionforelimination，nonephrotoxicity（肾毒性）andhavingshortdurationofactionshouldbeused.

15第15页

Venousanesthetics

Propofol（异丙酚）,

Fentanyl（芬太尼）,Midazolum（咪达唑仑）,Etomidate（依托咪酯）andsmalldosesofSodiumpentothal（硫喷妥钠）areoftenused.

Inhalationalanesthetics

Isoflurane（异氟烷）,Enflurane（安氟烷）,Nitrousoxide（笑气）,Desflurane(地氟烷)andsevoflurane（七氟烷）areoftenused，methoxyflurane（甲氧氟烷）isforbiddenbecauseofitsnephrotoxicity.16第16页

Musclerelaxants

Atracurium（阿曲库铵）,Rocuronium（罗库溴铵）

andVecuronium（维库溴铵）

areoftenused，don’tusesuccinylcholine（琥珀胆碱）.

Localasnesthetics

Lidocaine,Bupivacaine,RupivacaineandDicaineareoftenused，noticetoxicityreactionsinducedbyexcessiveoflocalanesthetics,don’tuseepinephrine（肾上腺素）.

17第17页

Postoperativeanalgesics

Dolantin,tramal,fortanoryn,PCEA.

Choiceofanesthesia

PrinciplesNopain,musclerelaxed,sedationperfectly,vitalsignsstable,nocomplications.18第18页19第19页

Continuousepiduralanesthesia

forkidneytransplantationisoftenusedinChinanow.Choiceofpuncturesites,T11-12orT12L1，L2-3orL3-4.20第20页

Advantage

Havinggoodmusclerelaxation，avoidingsideeffectsofmusclerelaxants.Avoidingpulmonaryinfectioninducedbyendotrachealintubation.Avoidingdepressiontorespirationandcirculationiftheblockleveliswellcontrolled.21第21页

DisadvantageMentalstress,Epiduralhemorrhage（出血）andhematoma（血肿）(directpressureandischemiatospinalcord),Circulationandrespirationdepression(iftheblocklevelisinadequatecontrolled).

22第22页

Generalanesthesiacombinedintravenousandinhalationalanesthesiaisoftenused.

Combinedspinalandepiduralanesthesia23第23页

Intraoperativemonitoringandanestheticmanagement

MonitoringIncludesECG,Bloodpressure,SPO2,Temperature,Electrolyte,Bloodgasanalysisandurinaryoutput，monitoringdirectintra-arterialbloodpressureandCVPifitisnecessary.

24第24页

Anestheticmanagement

PreventionandcureofhypotensionPreventionandcureofhypertensionMonitoringserumkaliumUrinaryoutputDrugs25第25页

Venousroad15%Glucose250ml/ivbydrip

DXM75

mg/ivbydrip(30～60′)

5%Glucose250ml/ivbydrip

Lasilix（速尿）80mgivwhenstartingtoanastomoserenalartery

20%Mannitol（甘露醇）250mlivbydvip(fast)assoonasbloodvesselisanastomosed26第26页

5%Glucose250ml/ivbydvip

DXM75mg/ivbydrip(30～60′)5%Glucose250ml/ivbydvip0.9%NS250ml/ivbydvip10%kclivwhenpatienthasdiuresis（多尿）27第27页

Venousroad2

Bl