器官移植麻醉雙語

1器官移植麻醉OrganTransplantation湘雅醫(yī)院麻醉科張海萍AnesthesiaforKidneyTransplantationKidneysarethemostcommonmajororgantransplanted，thesuccessofkidneytransplantation，whichislargelyduetoadvancesinimmunosuppressivetherapy，hasgreatlyimprovedthequalityoflifeforpatientswithend-stagerenaldisease.IndicationsPatientswithend-stagerenaldiseasesanddependentondialysis（透析）foralongtime.Characteristicof

PathophysiologyChangesofelectrolyteandacid-basebalanceWaterintoxication（水中毒），hyperkalemia（高鉀），hyponatremia（低鈉），hypernatremia（高鈉）andmetabolicacidemia（代酸）.CardiovascularHypertension（高血壓）Renalischemia，sodiumretentionandabnormalitiesintherenin-agiotensionsystemresultinsystemichypertension.Uremiccardiacdiseasemyocardiosis（心肌炎），pericarditis（心包炎），leftventricularhypertrophy）（左室肥大），coronaryischemia（冠脈缺血），angiosclerosis（血管硬化）.Potentialcongestiveheartfailure（潛在性充血性心力衰竭）andpulmonaryedema（肺水腫）arrhythmia（心律失常）12Hematologic1Bonemarrowsuppression,decreasederythropoietinproduction,decreasederythrocyteproduction,increaseddeformationerythrocyteproductionandincreasedbleedingtendencyAnemia(貧血).2Liverdiseasecoagulationfactor，Uremia(尿毒癥)andusingofheparincoagulationdisorder，bleedingtime.3OtherchangesNausea（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）.EvaluationandpreparationbeforeanesthesiaPreanestheticevaluationThisassessmentincludesapatienthistory,aphysicalexaminationandanyindicatedlabtests,classifyingthepatientaccordingtotheASAphysicalstatusscalecompletestheassessment.10

GeneralconditionPatientsareoftencombinedwithhypoproteinemia,anemia,coagulationdisorderandfluid,electrolyteandacid-basedisturbanceandsoon.ConcurrentdiseasesCardiovascular,pulmonary,cerebral,hepaticandotherdiseasesarecommonlycoexisted.Statusofimmunosuppression（免疫抑制）andinfection（感染）.PreanestheticpreparationCareofdonorkidneyKidneyshouldhavegoodcirculationperfusionbeforebeingseparatedfromdonor,warmischemiatimeandcoldischemiatimeshouldbeminimized,separatedkidneyshouldbefrozenforpreservationinreason,transplantedkidneyshouldhavegoodperfusionafterrebuildingcirculationandrenalfunctionshouldberecoveredintime.Dialysis（透析）isthemostimportantpreparationbeforeoperation.Dialysisoftenprecedestransplan－tationtocorrectvolumeorelectrolytederangements.Hemodialysis（血液透析）ismoreeffectivethanperitonealdialysis（腹膜透析）.Bloodtransfusion（輸血）Bloodtransfusionshouldgenerallybegivenonlytoseverelyanemicpatients(hemoglobin/血色素<6-7g/dl)orwhensignificantintraoperativebloodlossisexpected.Controllinginfection.Treatmentofcomplication（Hypertension,cardiacfunction,fluid,electrolyteandacid-basedisturbanceandsoon）Fasting（禁食）Premedication（術(shù)前用藥）ProtectionofarteriesandveinsfistulaPrinciplesofanesthesiamanagementPrinciplesofanestheticschosenAnestheticsnotprimarilydependentonrenalexcretionforelimination，nonephrotoxicity（腎毒性）andhavingshortdurationofactionshouldbeused.VenousanestheticsPropofol（異丙酚）,Fentanyl（芬太尼）,Midazolum（咪達(dá)唑侖）,Etomidate（依托咪酯）andsmalldosesofSodiumpentothal（硫噴妥鈉）areoftenused.InhalationalanestheticsIsoflurane（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.MusclerelaxantsAtracurium（阿曲庫銨）,Rocuronium（羅庫溴銨）andVecuronium（維庫溴銨）areoftenused，don’tusesuccinylcholine（琥珀膽堿）.LocalasnestheticsLidocaine,Bupivacaine,RupivacaineandDicaineareoftenused，noticetoxicityreactionsinducedbyexcessiveoflocalanesthetics,don’tuseepinephrine（腎上腺素）.PostoperativeanalgesicsDolantin,tramal,fortanoryn,PCEA.ChoiceofanesthesiaPrinciplesNopain,musclerelaxed,sedationperfectly,vitalsignsstable,nocomplications.19ContinuousepiduralanesthesiaforkidneytransplantationisoftenusedinChinanow.Choiceofpuncturesites,T11-12orT12L1，L2-3orL3-4.AdvantageHavinggoodmusclerelaxation，avoidingsideeffectsofmusclerelaxants.Avoidingpulmonaryinfectioninducedbyendotrachealintubation.Avoidingdepressiontorespirationandcirculationiftheblockleveliswellcontrolled.DisadvantageMentalstress,Epiduralhemorrhage（出血）andhematoma（血腫）(directpressureandischemiatospinalcord),Circulationandrespirationdepression(iftheblocklevelisinadequatecontrolled).Generalanesthesiacombinedintravenousandinhalationalanesthesiaisoftenused.Combinedspinalandepiduralanesthesia12IntraoperativemonitoringandanestheticmanagementMonitoringIncludesECG,Bloodpressure,SPO2,Temperature,Electrolyte,Bloodgasanalysisandurinaryoutput，monitoringdirectintra-arterialbloodpressureandCVPifitisnecessary.126543AnestheticmanagementPreventionandcureofhypotensionPreventionandcureofhypertensionMonitoringserumkaliumUrinaryoutputDrugs123456

Venousroad15%Glucose250ml/ivbydrip

DXM75

mg/ivbydrip(30～60′)

5%Glucose250ml/ivbydrip

Lasilix（速尿）80mgivwhenstartingtoanastomoserenalartery

20%Mannitol（甘露醇）

250mlivbydvip(fast)assoonasbloodvesselisanastomosed5%Glucose250ml/ivbydvipDXM75mg/ivbydrip(30～60′)5%Glucose250ml/ivbydvip9%NS250ml/ivbydvip10%kclivwhenpatienthasdiuresis（多尿）Venousroad2Bloodtransfusi