器官移植麻醉雙語

1、1湘雅醫(yī)院麻醉科湘雅醫(yī)院麻醉科 張海萍張海萍2anesthesia for kidney transplantation kidneys 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.3u

2、indications patients with end-stage re n a l d i s e a s e s a n d dependent on dialysis（透（透析）析） for a long time.4u characteristic of pathophysiology changes of electrolyte and acid-base balance water intoxication（水中毒），（水中毒），hyperkalemia（ 高 鉀 ） ，（ 高 鉀 ） ， h y p o n a t re m i a（ 低 鈉 ） ，（ 低 鈉 ） ，hype

3、rnatremia（高鈉）（高鈉）and metabolic acidemia（代酸）（代酸）. 5 cardiovascular hypertension（高血壓（高血壓） renal ischemia，sodium retention and abnormalities in the renin-agiotension system result in systemic hypertension. uremic cardiac disease myocardiosis （心（心肌炎），肌炎），pericarditis（心包炎）（心包炎） ， left ventricular hypertr

4、ophy）（左室肥大），）（左室肥大），c o ro n a r y i s c h e m i a （ 冠 脈 缺 血 ） ，（ 冠 脈 缺 血 ） ， angiosclerosis （血管硬化）（血管硬化）.6potential congestive heart failure（潛在性充血性心力衰竭）（潛在性充血性心力衰竭） and pulmonary edema（肺水（肺水腫）腫） arrhythmia（心律失常）（心律失常）7 hematologic bone marrow suppression , decreased erythropoietin production , decr

5、eased erythrocyte production, increased deformation erythrocyte production and increased bleeding tendency anemia ( 貧血貧血). liver disease coagulation factor ，uremia(尿毒癥尿毒癥) and using of heparin coagulation disorder， bleeding time . 8 other changes nausea（惡心）（惡心） ，vomit（嘔吐）（嘔吐） ，anorexia（厭食）（厭食） ， dia

6、rrhoea（腹（腹瀉）瀉） ，ascites（腹水）（腹水） and gastric dilatation（胃擴張）（胃擴張）. infection （感染）（感染）. hypoproteinemia（低蛋白血癥）（低蛋白血癥），hyperglycemia（高血糖癥）（高血糖癥）.9u evaluation and preparation before anesthesia preanesthetic evaluation this assessment includes a patient history,a physical examination and any indicated l

7、ab tests , classifying the patient according to the asa physical status scale completes the assessment. 10 general condition patients are often combined with hypoproteinemia , anemia, coagulation disorder and fluid , electrolyte and acid-base disturbance and so on. concurrent diseases cardiovascular

8、, pulmonary, cerebral, hepatic and other diseases are commonly coexisted. status of immunosuppression（免疫抑制）（免疫抑制） and infection（感染）（感染）.11preanesthetic preparation care of donor kidney kidney should have good circulation perfusion before being separated from donor,warm ischemia time and cold ischemi

9、a 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. 12 dialysis（透析）（透析） is the most important preparation before operation. dialysis often

10、precedes transplantation to correct volume or electrolyte derangements. hemodialysis（血液透析）（血液透析） is more effective than peritoneal dialysis（腹膜（腹膜透析）透析）.13 blood transfusion（輸血）（輸血） blood transfusion should generally be given only to severely anemic patients(hemoglobin/血色素血色素 6-7g/dl) or when signifi

11、cant 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（術前用藥）（術前用藥）protection of arteries and veins fistula15uprinciples of anesthesia manage

12、ment principles of anesthetics chosen anesthetics not primarily dependent on renal excretion for elimination ，no nephrotoxicity（腎毒性）（腎毒性） and having short duration of action should be used. 16 venous anesthetics propofol（異丙酚）（異丙酚）, fentanyl（芬太尼）（芬太尼）, midazolum（咪達唑侖）（咪達唑侖） ,etomidate（依托（依托咪酯）咪酯） and

13、 small doses of sodium pentothal（硫噴妥鈉）（硫噴妥鈉） are often used. inhalational anesthetics isoflurane（異氟烷）（異氟烷）,enflurane（安氟（安氟烷）烷）,nitrous oxide（笑氣）（笑氣）, desflurane(地氟地氟烷烷)and sevoflurane（七氟烷）（七氟烷） are often used，methoxyflurane（甲氧氟烷）（甲氧氟烷） is forbidden because of its nephrotoxicity .17 muscle relaxants

14、atracurium（阿曲庫（阿曲庫銨 ）銨 ）,rocuroni um（ 羅 庫 溴 銨 ）（ 羅 庫 溴 銨 ） a n d vecuronium（維庫溴銨）（維庫溴銨） are often used，dont use succinylcholine（琥珀膽堿）（琥珀膽堿）. local asnesthetics lidocaine, bupivacaine, rupivacaine and dicaine are often used，notice toxicity reactions induced by excessive of local anesthetics, dont use

15、 epinephrine（腎上腺素）（腎上腺素）. 18 postoperative analgesics dolantin , tramal , fortanoryn , pcea. choice of anesthesia principles no pain ,muscle relaxed, sedation perfectly ,vital signs stable , no complications.1920 continuous epidural anesthesia for kidney transplantation is often used in china now. c

16、hoice of puncture sites, t11-12 or t12l1 ，l2-3 or l3-4 .21 advantage 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.22 d

17、isadvantage mental stress, epidural hemorrhage（出血）（出血） and hematoma（血腫）（血腫） (direct pressure and ischemia to spinal cord ) , circulation and respiration depression(if the block level is inadequate controlled). 23 general anesthesia combined intravenous and inhalational anesthesia is often used. comb

18、ined spinal and epidural anesthesia24 intraoperative 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 manage

19、ment prevention and cure of hypotension prevention and cure of hypertension monitoring serum kalium urinary output drugs 26 venous road 1 5%glucose 250ml/iv by drip dxm 75 mg / iv by drip( 3060) 5%glucose 250ml / iv by drip lasilix（速尿）（速尿） 80mg iv when starting to anastomose renal artery 20% mannitol（甘露醇）（甘露醇） 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