最新器官移植麻醉双语精品课件.ppt

器官移植麻醉双语器官移植麻醉双语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.9u Evaluation and preparation before anesthesia Preanesthetic evaluation This assessment includes a patient history,a physical examination and any indicated lab 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, 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 ischemia 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 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（输血）（输血） Blood transfusion should generally be given only to severely anemic patients(hemoglobin/血色素血色素 6-7g/dl) or when significant 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（术前用药）（术前用药）Protection of arteries and veins fistula15uPrinciples of anesthesia management Principles of anesthetics chosen Anesthetics not primarily dependent on renal excretion for elimination ，no nephrotoxicity（肾毒性）（肾毒性） and having short duration of action should be used. 16 Venous anesthetics Propofol（异丙酚）（异丙酚）, Fentanyl（芬太尼）（芬太尼）, Midazolum（咪达唑仑）（咪达唑仑） ,Etomidate（依托（依托咪酯）咪酯） and small doses of Sodium pentothal（硫喷妥钠）（硫喷妥钠） are often used. Inhalational anesthetics Isoflurane（异氟烷）（异氟烷）,Enflurane（安氟（安氟烷）烷）,Nitrous oxide（笑气）（笑气）, 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 Atracurium（阿曲库（阿曲库铵 ）铵 ）,Rocuroni um（ 罗 库 溴 铵 ）（ 罗 库 溴 铵 ） a n d Vecuronium（维库溴铵）（维库溴铵） are often used，dont use succinylcholine（琥珀胆碱）（琥珀胆碱）. Local asnesthetics Lidocaine, Bupivacaine, Rupivacaine and Dicaine are often used，notice toxicity reactions induced by excessive of local anesthetics, dont use epinephrine（肾上腺素）（肾上腺素）. 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. Choice 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 Disadvantage Mental stress, Epidural hemorrhage（出血）（出血） and hematoma（血肿）（血肿） (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. Combined 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 management 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（多尿）（多尿）28 Venous road 2 Blood transfusion should be given and Dopamine 23g/kg.min iv by drip when it is necessary to enhance 1020mmHg of pressure before rebuilding circulation. Maintenance of intravenous fluids is decided by anesthetist.29 Postoperative management Sterilize Avoid anoxia ，prevent and cure respiratory airway complications Recover the function of transplanted kidney as soon as possible Postoperative pain management30 Transfuse albumin1020g each day， correct acid-base and electrolyte disorder. Resist infection. Diagnose , prevent and cure rejection response immunosuppressant drug( Cyclosprine , Azathioprine and Prednisone). 31Thank you!32 结束语结束语