腎功能不全病人麻醉PPT課件

腎功能不全病人手術(shù)的麻醉1例,哈勵遜國際和平醫(yī)院麻醉科 齊文輝,1,病 歷 回 顧,患者李某某，女，58歲。主因腹痛半月入院。,擬行：膽囊切除術(shù)+T管引流術(shù)。,既往病史：既往“慢性腎衰竭”病史10余年，定期行透析治療，最高可達(dá) “170/100mmHg”，膽囊結(jié)石病史5年。,入院體檢： 聽診雙肺呼吸音粗，無干濕羅音 ，腹部平坦，腹軟，上腹壓痛明顯，“墨菲征”陽性。,T36.7，P82次/分，R20次/分，BP170/95mmHg，Wt 70Kg,2,術(shù) 前 檢 查,心電圖：大致正常心電圖。胸片：心肺膈無異常。,血常規(guī)：Hgb：108g/L生化：Cre：631 Urea：11.01。出凝血：PT ：11秒 APTT：41.6秒,CT：1、膽囊炎，膽囊結(jié)石；膽總管擴(kuò)張 2、雙腎囊腫，腎皮質(zhì)變薄，腎皮質(zhì)不全？,臨床診斷：膽囊炎并膽囊結(jié)石 慢性腎衰竭 高血壓病,3,手 術(shù) 經(jīng) 過,麻醉誘導(dǎo)：Sev 5% 順式阿曲庫銨 15mg 芬太尼 0.2mg,麻醉維持： Sev 4% 瑞芬太尼 300400ug/h 間斷肌松 iv,麻醉蘇醒：停Sev 15min有自主呼吸， 停20min拔管,4,術(shù)前準(zhǔn)備,麻醉方案,思 考,5,腎功能不全,急性腎功能不全各種原因引起腎功能急驟、進(jìn)行性減退出現(xiàn)的臨床綜合征 慢性腎功能不全指所有原發(fā)病或繼發(fā)性慢性腎臟疾病所致進(jìn)行性腎功能損害所出現(xiàn)的一系列癥狀或代謝紊亂組成的臨床綜合征,6,腎功能減退分期,腎貯備力下降期（腎功能不全代償期）Ccr 50%氮質(zhì)血癥期（腎功能不全失代償期）Ccr 25-50%sCr 442 mol/L,7,病因?qū)W,Diabetic nephropathy most common cause , 40%Hypertensive nephrosclerosis bidirectional relationship between BP and renal diseaseGlomerular disease nephrotic nephritic Interstitial diseases of the kidney Vascular diseases of the kidney Inherited kidney diseases,8,Systemic Manifestations of Renal Disease,9,麻醉前評估 系統(tǒng)回顧,Systemic disease processes affecting multiple organ systems基本代謝受影響麻醉藥物的異常作用，多器官功能不全，替代治療以及移植相關(guān)的特殊問題等等 A challenge to anesthesiologists,10,系統(tǒng)回顧 水和酸堿平衡紊亂,無尿患者只有不感失水 (500ml/day)鈉攝入過量 edema, hypertension水?dāng)z入過量 hyponatremia多尿患者尿濃縮功能障礙急性失水 hypovolemia代謝性酸中毒代償性呼吸性堿中毒Shock, diarrhea, or hypercatabolism (sepsis, trauma, steroid therapy) Profound metabolic acidosis,11,系統(tǒng)回顧 電解質(zhì)紊亂,細(xì)胞外鉀Maintained in narrow range (3.5 to 5.0 mmol/L)高鉀血癥（or低鉀血癥）臨床和ECG 表現(xiàn)更取決于鉀流量高分解代謝, 酸中毒 保鉀利尿劑 輸注RBC 急速致命的高鉀血癥高鎂血癥肌無力, 對肌松藥敏感低鎂血癥Associated with hypokalemia, ventricular irritability,12,系統(tǒng)回顧 電解質(zhì)紊亂,高磷血癥骨鈣沉積增加 ，低鈣血癥腎合成 vitD 減少低鈣血癥繼發(fā)性甲旁亢 ，骨質(zhì)吸收腎性骨營養(yǎng)不良綜合征低磷血癥過度透析， 氫氧化鋁治療, or TPN磷耗竭綜合征對肌松藥敏感性增加, 機(jī)械通氣撤機(jī)困難, CNS 功能障礙,13,系統(tǒng)回顧 心血管系統(tǒng),高血壓左室高電壓(向心性 or 非對稱性)高脂血癥加速動脈粥樣硬化貧血 和 AV 分流血流動力學(xué)：高排低阻循環(huán)儲備受損心肌缺血尿毒癥性心包炎，心包填塞心功能不全,14,系統(tǒng)回顧 呼吸系統(tǒng),早期肺活量減低，限制性通氣障礙和氧彌散能力下降氣促，代償代謝性酸中毒尿毒癥性肺胸片：以肺門為中心向兩側(cè)放射的對稱型蝴蝶狀陰影病理：肺水腫肺毛細(xì)血管通透性增加 PCWP增加尿毒癥性胸膜炎,15,系統(tǒng)回顧 血液系統(tǒng),貧血正細(xì)胞正色素性貧血腎生成EPO減少骨髓抑制RBC壽命縮短胃腸道慢性失血,尿毒癥性凝血病血小板功能異常出血時間延長血小板凝集功能受損血栓形成傾向動靜脈內(nèi)瘺易阻塞,16,系統(tǒng)回顧 代謝和免疫系統(tǒng),高血糖，高甘油三酯血癥外周胰島素抵抗，脂蛋白脂酶活性降低蛋白質(zhì) 營養(yǎng)不良 (kwashiorkor, hypoalbuminemic malnutrition)蛋白飲食限制，長期蛋白尿CAPD蛋白丟失 (經(jīng)腹膜10-40 g/dl)低蛋白血癥，低膠體滲透壓周圍組織水腫，肺水腫淋巴細(xì)胞趨化性和免疫球蛋白反應(yīng)性受損易感染尿毒癥分解代謝效應(yīng)傷口不愈，瘺，褥瘡,17,系統(tǒng)回顧 消化系統(tǒng),表現(xiàn)最早、最突出厭食，呃逆，惡心，嘔吐自主神經(jīng)系統(tǒng)病變胃排空延遲麻醉誘導(dǎo)易反流誤吸消化道潰瘍up to 25% in CRF patientsHepatitis B and Chigh incidence in patients on chronic hemodialysis常 anicteric or in a carrier state,18,系統(tǒng)回顧 神經(jīng)系統(tǒng),中樞神經(jīng)系統(tǒng)早期為功能抑制淡漠，疲勞，記憶力減退加重記憶力，判斷力，定向力，計算力障礙欣快感，抑郁癥，妄想，幻覺，撲翼樣震顫嗜睡，昏迷,周圍神經(jīng)病變下肢不安綜合征下肢疼痛，灼痛，痛覺過敏，運動后消失肢體無力，步態(tài)不穩(wěn)，深肌腱反射減退運動障礙自主神經(jīng)功能障礙體位性低血壓，發(fā)汗障礙，神經(jīng)源性膀胱，早泄病理改變神經(jīng)纖維脫髓鞘變,19,麻醉前評估,The cause of CRF, complicated systemic disease, the other manifestations of the diseaseDaily urine output, type of dialysis, recent treatment,20,麻醉前評估 心血管系統(tǒng),Anaesthesia for renal transplant: Recent developments and recommendations. Current Anaesthesia & Critical Care (2008) 19, 247253按心臟病人非心臟手術(shù)麻醉術(shù)前流程評估長期藥物治療史,21,麻醉前評估 心血管系統(tǒng),22,麻醉前評估 心血管系統(tǒng),23,術(shù)前準(zhǔn)備 透析,血液透析controls the manifestations of ARF (fluid overload, acidosis, hyperkalemia, acute uremia)不能完全糾正血小板病變或逆轉(zhuǎn)腎性骨營養(yǎng)不良和神經(jīng)病變Preoperative dialysis 1224 h before surgeryEffects of recent dialysis液體不足和重分布到血管外致血管內(nèi)容量不足電解質(zhì)紊亂，尤其是低鉀血癥血透治療時全身肝素化后的殘留抗凝作用,復(fù)旦大學(xué)附屬中山醫(yī)院,24,術(shù)前準(zhǔn)備 透析,腹膜透析provides hemodynamic stability but not effective in hypermetabolic statesAbdominal distension compromise perioperative pulmonary function腹部手術(shù)改為血透直至腹部傷口愈合,25,術(shù)前準(zhǔn)備 血液系統(tǒng),術(shù)前輸血Not indicated for patients with a stable Hct 26%適應(yīng)癥急性出血，心肺疾病患者行重大手術(shù)Transfusion during dialysis only (risk of hypervolemia and hyperkalemia)Causes immunosuppression, increase the infection riskHuman recombinant erythropoietin腎病導(dǎo)致的慢性貧血非常有效The response to rHuEPO takes 26 weeks50 - 75 IU/kg subcutaneously three times weekly不良反應(yīng)高血壓, 增加動靜脈內(nèi)瘺血栓形成風(fēng)險,26,術(shù)前準(zhǔn)備,Sedative or opiod premedicationminimized or avoidedBP cuffs or arterial catheters should be avoided on the arm with an AV fistula or shuntActive warming devices (prevent hypothermia),27,Pharmacologic Effects of Renal Failure,28,腎功能不全對藥物的影響 靜脈藥物,Drugs with increased unbound fraction in hypoalbuminemia硫噴妥鈉，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，先鋒霉素，氨基糖苷類， 萬古霉素，環(huán)孢素A負(fù)荷量 ()，維持量 ,29,腎功能不全對藥物的影響 靜脈藥物,Drugs depend in part on renal elimination抗膽堿能藥物和膽堿能藥物泮庫溴銨, 哌庫溴銨, 杜什庫銨米力農(nóng)，氨力農(nóng)苯巴比妥，抑肽酶氨基己酸，氨甲環(huán)酸維持量 30-50%,30,腎功能不全對藥物的影響 靜脈藥物,Drugs with active metabolites that are eliminated by the kidneysExert a prolonged effect in CRFThe parent drugs should be avoided or maintenance doses must be 30-50%,31,腎功能不全對藥物的影響 吸入麻醉藥,Nephrotoxic effects長時間的甲氧氟烷麻醉可導(dǎo)致多尿性腎衰腎毒性與氟化物代謝產(chǎn)物相關(guān)與氟化物血漿峰值濃度及使用時間直接相關(guān)Enflurane只在腎毒性、肝毒性或者酶誘導(dǎo)劑的情況下產(chǎn)生腎損害Compound Aa metabolite produced by the interaction of sevoflurane with outdated sodalime when fresh gas flows are 2 L/min,32,Perioperative Management,33,麻醉規(guī)劃與管理 術(shù)中,Summary of perioperative considerationsAnaesthetic options GA, RA or LAAirway managementVascular accessFluid and electrolyte managementBlood transfusionImmune function and antibiotic prophylaxisSteroid supplementation,復(fù)旦大學(xué)附屬中山醫(yī)院,34,麻醉規(guī)劃與管理 術(shù)中,Regional anesthesiaNot contraindicated if coagulopathy is correctedIncrease risk of hypotension (autonomic neuropathy) and site infectionGeneral anesthesiaAt induction : aspiration precautions, preoxygenation,SuccinylcholineNot contraindicated if serum K 5.0 mEq/l, had dialysis within 24hs,35,麻醉規(guī)劃與管理 術(shù)中,nondepolarizing agentspancuronium and pipecuronium be avoidedmivacurium and cisatracuriumMetabolized independent of renal eliminationvecuronium and rocuronium okIncrease mechanical minute ventilationCompensate chronic metabolic acidosisIn anuric patientsMaintenance fluid kept in minimal, fluid losses must be fully replaced,36,麻醉規(guī)劃與管理 術(shù)后蘇醒,蘇醒延遲，持續(xù)神經(jīng)肌肉阻滯，嘔吐，誤吸 高血壓，呼吸抑制，肺水腫 In patient with chronic metabolic acidosisopioid-induced respiratory depressionCaus