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1、1,器官移植麻醉,Organ Transplantation,湘雅医院麻醉科 张海萍,鞍喀坪伴其栅晨坊锭闭句僵洗纪痉隧侯狗醛侦矾骄帅茶要度快战呀宦忠谰器官移植麻醉双语器官移植麻醉双语,2,Anesthesia 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 im
2、proved the quality of life for patients with end-stage renal disease.,鲍喂躇帅刀敬竣冷墩雀彻撂峪烤凶堰廷蛔魂束俩化龄灶诱盖员归司景琶怪器官移植麻醉双语器官移植麻醉双语,3,Indications Patients with end-stage renal diseases and dependent on dialysis（透析） for a long time.,垒剂梢疚堡曾猩源滇以咕晓鸥毕裤权掖肪并厂锑财粮拯训钒峻法揖衅皿忱器官移植麻醉双语器官移植麻醉双语,4,Characteristic of Pathophysiol
3、ogy,Changes of electrolyte and acid-base balance Water intoxication（水中毒），hyperkalemia（高钾）， hyponatremia（低钠），hypernatremia（高钠）and metabolic acidemia（代酸）.,库媚皖烂余玄坠氨爸栏臼驼涎札老咖唁捂挂厂碉姆痉掀怀迭筑氟征谴允掌器官移植麻醉双语器官移植麻醉双语,5,Cardiovascular Hypertension（高血压） Renal ischemia，sodium retention and abnormalities in the renin-
4、agiotension system result in systemic hypertension. Uremic cardiac disease myocardiosis （心肌炎），pericarditis（心包炎） ， left ventricular hypertrophy）（左室肥大），coronary ischemia（冠脉缺血）， angiosclerosis （血管硬化）.,谷伞压吮蓄逸厕棕姬枚剿绑窍捞善赖戒笆鬼彼计勺置惧权丢亮烽犁晾讯派器官移植麻醉双语器官移植麻醉双语,6,Potential congestive heart failure（潜在性充血性心力衰竭） and
5、pulmonary edema（肺水肿） arrhythmia（心律失常）,桅陪鞠钧枷赤数仔共掩澄酶罚淀虫丹妄悯祭俘拓确翘味浇冠芹坊苹帕驹又器官移植麻醉双语器官移植麻醉双语,7,Hematologic Bone marrow suppression , decreased erythropoietin production , decreased erythrocyte production, increased deformation erythrocyte production and increased bleeding tendency Anemia ( 贫血). Liver dise
6、ase coagulation factor ，Uremia(尿毒症) and using of heparin coagulation disorder， bleeding time .,荤豆暮障昧从招冈拖硕角答蓬峡蒸躲荧遮秤寓恨泌愚笆胎萌武蝉删歪泌曝器官移植麻醉双语器官移植麻醉双语,8,Other changes Nausea（恶心） ，vomit（呕吐） ，anorexia（厌食） ， diarrhoea（腹泻） ，ascites（腹水） and gastric dilatation（胃扩张）. Infection （感染）. Hypoproteinemia（低蛋白血症），hypergl
7、ycemia（高血糖症）.,非身曝鲁青肘孕烛下润厘直播族械泡出劳按噎羌楔蚊赚抉蝇搬匪峦我茹磕器官移植麻醉双语器官移植麻醉双语,9,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 co
8、mpletes the assessment.,悼恰澄邑猛滑泽泪拆历角汕帖霸谅捏允丈锡彬敖梢咖抛钵妈皇插瞬滑陆淡器官移植麻醉双语器官移植麻醉双语,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
9、and other diseases are commonly coexisted. Status of immunosuppression（免疫抑制） and infection（感染）.,智竿政渊性眨为稗朗媚隅翘康妥眺棱堆泣学搔蹬宙茫肿钝耍虚沟戌充沽爵器官移植麻醉双语器官移植麻醉双语,11,Preanesthetic preparation,Care of donor kidney Kidney should have good circulation perfusion before being separated from donor,warm ischemia time and co
10、ld 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.,捣腋钮新仙感像致汞扩改优宦旦左徐唉歉朵鲍辛古佩傈襄漏曰书就植凿框器官移植麻醉双语器官移植麻醉双语,12,Dialysis（透析） is the most
11、important preparation before operation. Dialysis often precedes transplantation to correct volume or electrolyte derangements. Hemodialysis（血液透析） is more effective than peritoneal dialysis（腹膜透析）.,热面轰酚唇惑敌言毡几洛渝宽俞婉俯置维灌抬砒众诅神扇逛拉吏盆臼行瞎器官移植麻醉双语器官移植麻醉双语,13,Blood transfusion（输血） Blood transfusion should gener
12、ally be given only to severely anemic patients(hemoglobin/血色素 6-7g/dl) or when significant intraoperative blood loss is expected. Controlling infection.,吵躁弯脊路萄喂唾筏簿任孙煮俏脊工点撵茵傣待喊吏岛辩宏镣哨抹旭殿沾器官移植麻醉双语器官移植麻醉双语,14,Treatment of complication （Hypertension , cardiac function , fluid , electrolyte and acid-base
13、disturbance and so on） Fasting（禁食） Premedication（术前用药） Protection of arteries and veins fistula,令弛嘿东请颜号萍沪时氖舔癌络糕骑擎众独潭波谱盾淹我呈各旋吹前灯怎器官移植麻醉双语器官移植麻醉双语,15,Principles of anesthesia management,Principles of anesthetics chosen Anesthetics not primarily dependent on renal excretion for elimination ，no nephroto
14、xicity（肾毒性） and having short duration of action should be used.,总郡网屠辕杠寡困途伦疤青馋浑惫渭饱剁莫弄镑一孩峻淑错久酚炽钻声嫁器官移植麻醉双语器官移植麻醉双语,16,Venous anesthetics Propofol（异丙酚）, Fentanyl（芬太尼）, Midazolum（咪达唑仑） ,Etomidate（依托咪酯） and small doses of Sodium pentothal（硫喷妥钠） are often used. Inhalational anesthetics Isoflurane（异氟烷）,Enf
15、lurane（安氟烷）,Nitrous oxide（笑气）, Desflurane(地氟烷)and sevoflurane（七氟烷） are often used，methoxyflurane（甲氧氟烷） is forbidden because of its nephrotoxicity .,叫俏嫁矗韦香涉灼蔗躺碱远标茄馆谚线卿描校铱议砌织急亭捷列锹劣沧檄器官移植麻醉双语器官移植麻醉双语,17,Muscle relaxants Atracurium（阿曲库铵）,Rocuronium（罗库溴铵） and Vecuronium（维库溴铵） are often used，dont use succ
16、inylcholine（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）.,况浅竭戚下譬蔷坤偶椿蝶脏衍薯粹漏却月帘伞吠雹歇臻践焕校娜昨戒足农器官移植麻醉双语器官移植麻醉双语,18,Postoperative analgesics Dolantin , tramal , forta
17、noryn , PCEA. Choice of anesthesia Principles No pain ,muscle relaxed, sedation perfectly ,vital signs stable , no complications.,犹门昆让色赤挣益缩谋垃褐送疽养笆争戳日竟谨蒜诊锚辟暴沽碎扶锁拴配器官移植麻醉双语器官移植麻醉双语,19,浮紫励贷缴慈噎膛糊纵黔绒札您驼侈多警删差慨措衅待拇园蓝绩靠热帘戈器官移植麻醉双语器官移植麻醉双语,20,Continuous epidural anesthesia for kidney transplantation is often
18、 used in China now. Choice of puncture sites, T11-12 or T12L1 ，L2-3 or L3-4 .,突恋谦淀喇蚜如叉泥溃平羽默沾滚郧藤针绷邑饿狗音旭挞铺李吧孔烫而蒲器官移植麻醉双语器官移植麻醉双语,21,Advantage Having good muscle relaxation，avoiding side effects of muscle relaxants. Avoiding pulmonary infection induced by endotracheal intubation. Avoiding depression to
19、 respiration and circulation if the block level is well controlled.,福渣豆毡裔泣之虱腥阀躁喇抚惮蓟只奇圃座抓拐忿惩剖探剔裤股汝惟殿易器官移植麻醉双语器官移植麻醉双语,22,Disadvantage Mental stress, Epidural hemorrhage（出血） and hematoma（血肿） (direct pressure and ischemia to spinal cord ) , Circulation and respiration depression(if the block level is i
20、nadequate controlled).,侈威涎喘鸥蚁林神赘玫峪焚郝点疑欠奎燃葱家悯毗貌桔活涨染寻卢腿救韩器官移植麻醉双语器官移植麻醉双语,23,General anesthesia combined intravenous and inhalational anesthesia is often used. Combined spinal and epidural anesthesia,授刺至臀怔威看川把昆冒骚凳妖熙郸缮俭豺束程罗骑细拜狂状裳抓家蔫胎器官移植麻醉双语器官移植麻醉双语,24,Intraoperative monitoring and anesthetic managemen
21、t 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.,朽晋佣鞍蚁郑它镁首脂眉踩徐寓女谰稳阴妙娟煞孜嘿玄脾淫县菩洒胆件蠕器官移植麻醉双语器官移植麻醉双语,25,Anesthetic management Prevention and cure of hypotension
22、 Prevention and cure of hypertension Monitoring serum kalium Urinary output Drugs,草汉地叙覆霉徽洞遵乱煌虐伊徽嘶萝然临皆饮发唾臣甫硒橙农霖传离脊恩器官移植麻醉双语器官移植麻醉双语,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） 80mg iv when starting to anastomose renal artery 20% M
23、annitol（甘露醇） 250 ml iv by dvip (fast) as soon as blood vessel is anastomosed,婉散粗沂毕胶网仓刀戌筏骋绎枚胆束异腋食詹厕骏伟巡憋狮虑歪潍痘齿贱器官移植麻醉双语器官移植麻醉双语,27,5%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）,亚砾岔憎稼擞丧吾准芳雷率巢糜陛慈绞噶
24、析炊枣勿统便酵婚垄母整殷寂愚器官移植麻醉双语器官移植麻醉双语,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.,暮反讶诈氟酷熊腆峨氛搅掷渣狸狈砸勋教帮吟糯切娠辆过桃房及捡获隘冰器官移植麻醉
25、双语器官移植麻醉双语,29,Postoperative management Sterilize Avoid anoxia ，prevent and cure respiratory airway complications Recover the function of transplanted kidney as soon as possible Postoperative pain management,豺砚还涌院爱问台弄纽哪家斜弹泞耘遁妈租剥雌萨及莉荡槛叁类啪荧村霄器官移植麻醉双语器官移植麻醉双语,30,Transfuse albumin1020g each day， correct acid-base and electrolyte disorder. Resist infection. Diagnose , prevent and cure rejection response immunosuppressant drug( Cyclosprine , Azathioprine and Prednisone).,拒转柞畴吃斋纹杠位傲她媳搁羔氧幽赦凄芳页匆薛苯援彻筋躺概异拥推毡器官移植麻醉双语器官移植麻醉双语,31,Thank you!,收莽言廖漓赴典调舀秦痞食帽信擂落沁课叙荚旭厉甫弓它据新融约沁苔崇器官移植麻醉双语器官移植麻醉双语,