器官移植麻醉雙語專家講座

器官移植麻醉OrganTransplantation湘雅醫(yī)院麻醉科張海萍1第1頁AnesthesiaforKidneyTransplantation

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

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

Characteristicof

Pathophysiology

Changesofelectrolyteandacid-basebalance

Waterintoxication（水中毒），hyperkalemia（高鉀），hyponatremia（低鈉），hypernatremia（高鈉）andmetabolicacidemia（代酸）.

4第4頁

Cardiovascular

Hypertension（高血壓）

Renal

ischemia，sodiumretentionandabnormalitiesintherenin-agiotensionsystemresultinsystemichypertension.Uremiccardiacdisease

myocardiosis（心肌炎），pericarditis（心包炎），leftventricularhypertrophy）（左室肥大），coronaryischemia（冠脈缺血），angiosclerosis（血管硬化）.5第5頁P(yáng)otentialcongestiveheartfailure（潛在性充血性心力衰竭）andpulmonaryedema（肺水腫）

arrhythmia（心律失常）6第6頁

Hematologic

Bonemarrowsuppression,decreasederythropoietinproduction,decreasederythrocyteproduction,increaseddeformationerythrocyteproductionandincreasedbleedingtendencyAnemia(

貧血).

Liverdiseasecoagulationfactor，Uremia(尿毒癥)andusingofheparincoagulationdisorder，bleedingtime.

7第7頁

Otherchanges

Nausea（惡心），vomit（嘔吐），anorexia（厭食），diarrhoea（腹瀉），ascites（腹水）andgastricdilatation（胃擴(kuò)張）.Infection（感染）.

Hypoproteinemia（低蛋白血癥），hyperglycemia（高血糖癥）.8第8頁Evaluationandpreparationbeforeanesthesia

Preanestheticevaluation

Thisassessmentincludesapatienthistory,aphysicalexaminationandanyindicatedlabtests,classifyingthepatientaccordingtotheASAphysicalstatusscalecompletestheassessment.

9第9頁

Generalcondition

Patientsareoftencombinedwithhypoproteinemia,anemia,coagulationdisorderandfluid,electrolyteandacid-basedisturbanceandsoon.

ConcurrentdiseasesCardiovascular,pulmonary,cerebral,hepaticandotherdiseasesarecommonlycoexisted.

Statusofimmunosuppression（免疫克制）andinfection（感染）.10第10頁P(yáng)reanestheticpreparation

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

Dialysis（透析）isthemostimportantpreparationbeforeoperation.

Dialysisoftenprecedestransplan－tationtocorrectvolumeorelectrolytederangements.

Hemodialysis（血液透析）

ismoreeffectivethan

peritonealdialysis（腹膜透析）.12第12頁

Bloodtransfusion（輸血）

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

Controllinginfection.

13第13頁Treatmentofcomplication（Hypertension,cardiacfunction,fluid,electrolyteandacid-basedisturbanceandsoon）Fasting（禁食）Premedication（術(shù)前用藥）Protectionofarteriesandveinsfistula14第14頁P(yáng)rinciplesofanesthesiamanagement

Principlesofanestheticschosen

Anestheticsnotprimarilydependentonrenalexcretionforelimination，nonephrotoxicity（腎毒性）andhavingshortdurationofactionshouldbeused.

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Venousanesthetics

Propofol（異丙酚）,

Fentanyl（芬太尼）,Midazolum（咪達(dá)唑侖）,Etomidate（依托咪酯）andsmalldosesofSodiumpentothal（硫噴妥鈉）areoftenused.

Inhalationalanesthetics

Isoflurane（異氟烷）,Enflurane（安氟烷）,Nitrousoxide（笑氣）,Desflurane(地氟烷)andsevoflurane（七氟烷）areoftenused，methoxyflurane（甲氧氟烷）isforbiddenbecauseofitsnephrotoxicity.16第16頁

Musclerelaxants

Atracurium（阿曲庫銨）,Rocuronium（羅庫溴銨）

andVecuronium（維庫溴銨）

areoftenused，don’tusesuccinylcholine（琥珀膽堿）.

Localasnesthetics

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

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Postoperativeanalgesics

Dolantin,tramal,fortanoryn,PCEA.

Choiceofanesthesia

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

Continuousepiduralanesthesia

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

Advantage

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

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

22第22頁

Generalanesthesiacombinedintravenousandinhalationalanesthesiaisoftenused.

Combinedspinalandepiduralanesthesia23第23頁

Intraoperativemonitoringandanestheticmanagement

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

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Anestheticmanagement

PreventionandcureofhypotensionPreventionandcureofhypertensionMonitoringserumkaliumUrinaryoutputDrugs25第25頁

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頁

5%Glucose250ml/ivbydvip

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

Venousroad2

Bl