肾功能不全病人手术的麻醉

单击此处编辑母版标题样式,编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,复旦大学附属中山医院,大家好,肾功能不全,急性肾功能不全,各种原因引起肾功能急骤、,进行性减退出现的临床综合征,慢性肾功能不全,指所有原发病或继发性慢性肾脏疾病所致进行性肾功能损害所出现的一系列症状或代谢紊乱组成的临床综合征,复旦大学附属中山医院,肾功能评估,serum creatinine,insensitive,readily available clinical data,复旦大学附属中山医院,慢性肾脏疾病 CKD,2002 National Kidney FoundationKidney Disease Outcomes Quality Initiative (NKFK/DOQI),复旦大学附属中山医院,肾功能减退分期,肾贮备力下降期（肾功能不全代偿期）,Ccr 50%,氮质血症期（肾功能不全失代偿期）,Ccr 25-50%,sCr 221mol/L,肾功能衰竭期 尿毒症早期,Ccr 10-25%,sCr 221- 442 mol/L,终末期肾病 尿毒症晚期,Ccr 442 mol/L,复旦大学附属中山医院,流行病学,NHANES III,stage 2 CKD,3% of the adult population in the USA,stage 3 CKD,4.7%,ESRD receiving chronic dialysis in USA,35% /y, 45.6% of chronic dialysis patients, 65 y,复旦大学附属中山医院,病因学,Diabetic nephropathy,most common cause , 40%,Hypertensive nephrosclerosis,bidirectional relationship between BP and renal disease,Glomerular disease,nephrotic,nephritic,Interstitial diseases of the kidney,Vascular diseases of the kidney,Inherited kidney diseases,复旦大学附属中山医院,Systemic Manifestations of Renal Disease,麻醉前评估 系统回顾,Systemic disease processes,affecting multiple organ systems,基本代谢受影响,麻醉药物的异常作用，多器官功能不全，替代治疗以及移植相关的特殊问题等等,A challenge to,anesthesiologists,复旦大学附属中山医院,系统回顾 ,水和酸碱平衡紊乱,无尿患者,只有不感失水,(500ml/day),钠摄入过量,edema, hypertension,水摄入过量,hyponatremia,多尿患者,尿浓缩功能障碍,急性失水,hypovolemia,代谢性酸中毒,代偿性呼吸性碱中毒,Shock, diarrhea, or,hypercatabolism (sepsis, trauma, steroid therapy), Profound metabolic acidosis,复旦大学附属中山医院,系统回顾 电解质紊乱,细胞外钾,Maintained in narrow range (3.5 to 5.0 mmol/L),高钾血症（,or,低钾血症）临床和,ECG,表现更取决于钾流量,高分解代谢, 酸中毒,保钾利尿剂,输注,RBC,急速致命的高钾血症,高镁血症,肌无力, 对肌松药敏感,低镁血症,Associated with hypokalemia, ventricular irritability,复旦大学附属中山医院,系统回顾 电解质紊乱,高磷血症,骨钙沉积增加,，低钙血症,肾合成,vitD 减少,低钙血症,继发性甲旁亢,，骨质吸收,肾性骨营养不良综合征,低磷血症,过度透析，,氢氧化铝治疗, or TPN,磷耗竭综合征,对肌松药敏感性增加, 机械通气撤机困难, CNS 功能障碍,复旦大学附属中山医院,系统回顾 心血管系统,高血压,左室高电压,(向心性,or 非对称性),高脂血症,加速动脉粥样硬化,贫血,和,AV 分流,血流动力学：高排低阻,循环储备受损,心肌缺血,尿毒症性心包炎，心包填塞,心功能不全,复旦大学附属中山医院,系统回顾 呼吸系统,早期肺活量减低，限制性通气障碍和氧弥散能力下降,气促，代偿代谢性酸中毒,尿毒症性肺,胸片：以肺门为中心向两侧放射的对称型蝴蝶状阴影,病理：肺水肿,肺毛细血管通透性增加,PCWP增加,尿毒症性胸膜炎,复旦大学附属中山医院,系统回顾 血液系统,贫血,正细胞正色素性贫血,肾生成EPO减少,骨髓抑制,RBC寿命缩短,胃肠道慢性失血,尿毒症性凝血病,血小板功能异常,出血时间延长,血小板凝集功能受损,血栓形成倾向,动静脉内瘘易阻塞,复旦大学附属中山医院,系统回顾 代谢和免疫系统,高血糖，高甘油三酯血症,外周胰岛素抵抗，脂蛋白脂酶活性降低,蛋白质 营养不良,(kwashiorkor, hypoalbuminemic malnutrition),蛋白饮食限制，长期蛋白尿,CAPD蛋白丢失 (经腹膜10-40 g/dl),低蛋白血症，低胶体渗透压,周围组织水肿，肺水肿,淋巴细胞趋化性和免疫球蛋白反应性受损,易感染,尿毒症分解代谢效应,伤口不愈，瘘，褥疮,复旦大学附属中山医院,系统回顾 消化系统,表现最早、最突出,厌食，呃逆，恶心，呕吐,自主神经系统病变,胃排空延迟,麻醉诱导易反流误吸,消化道溃疡,up to 25% in CRF patients,Hepatitis B and C,high incidence in patients on chronic hemodialysis,常 anicteric or in a carrier state,复旦大学附属中山医院,系统回顾 神经系统,中枢神经系统,早期为功能抑制,淡漠，疲劳，记忆力减退,加重,记忆力，判断力，定向力，计算力障碍,欣快感，抑郁症，妄想，幻觉，扑翼样震颤,嗜睡，昏迷,周围神经病变,下肢不安综合征,下肢疼痛，灼痛，痛觉过敏，运动后消失,肢体无力，步态不稳，深肌腱反射减退,运动障碍,自主神经功能障碍,体位性低血压，发汗障碍，神经源性膀胱，早泄,病理改变,神经纤维脱髓鞘变,复旦大学附属中山医院,麻醉前评估,The cause of CRF, complicated systemic disease, the other manifestations of the disease,Daily urine output, type of dialysis, recent treatment,复旦大学附属中山医院,麻醉前评估 心血管系统,Anaesthesia for renal transplant: Recent developments and recommendations. Current Anaesthesia & Critical Care (2008) 19, 247253,按心脏病人非心脏手术麻醉术前流程评估,长期药物治疗史,复旦大学附属中山医院,麻醉前评估 心血管系统,复旦大学附属中山医院,麻醉前评估 心血管系统,复旦大学附属中山医院,术前准备 透析,血液透析,controls the manifestations of ARF (fluid overload, acidosis, hyperkalemia, acute uremia),不能完全纠正血小板病变或逆转肾性骨营养不良和神经病变,Preoperative dialysis 1224 h before surgery,Effects of recent dialysis,液体不足和重分布到血管外致血管内容量不足,电解质紊乱，尤其是低钾血症,血透治疗时全身肝素化后的残留抗凝作用,复旦大学附属中山医院,术前准备 透析,腹膜透析,provides hemodynamic stability but not effective in hypermetabolic states,Abdominal distension compromise perioperative pulmonary function,腹部手术,改为血透直至腹部伤口愈合,复旦大学附属中山医院,术前准备 血液系统,术前输血,Not indicated for patients with a stable Hct 26%,适应症,急性出血，心肺疾病患者行重大手术,Transfusion during dialysis only (risk of hypervolemia and hyperkalemia),Causes immunosuppression, increase the infection risk,Human recombinant erythropoietin,肾病导致的慢性贫血非常有效,The response to rHuEPO takes 26 weeks,50 - 75 IU/kg subcutaneously three times weekly,不良反应,高血压, 增加动静脉内瘘血栓形成风险,复旦大学附属中山医院,术前准备,Sedative or opiod premedication,minimized or avoided,BP cuffs or arterial catheters should be avoided on the arm with an AV fistula or shunt,Active warming devices (prevent hypothermia),复旦大学附属中山医院,Pharmacologic Effects of Renal Failure,肾功能不全对药物的影响 静脉药物,Drugs with increased unbound fraction in hypoalbuminemia,硫喷妥钠，美索比妥，地西泮,20 - 50%,Drugs that depend predominantly on renal elimination,加拉明，箭毒，地高辛，青霉素，先锋霉素，氨基糖苷类，,万古霉素，环孢素,A,负荷量,(),，维持量, ,复旦大学附属中山医院,肾功能不全对药物的影响 静脉药物,Drugs depend in part on renal elimination,抗胆碱能药物和胆碱能药物,泮库溴铵, 哌库溴铵, 杜什库铵,米力农，氨力农,苯巴比妥，抑肽酶,氨基己酸，氨甲环酸,维持量,30-50%,复旦大学附属中山医院,肾功能不全对药物的影响 静脉药物,Drugs with active metabolites that are eliminated by the kidneys,Exert a prolonged effect in CRF,The parent drugs should be avoided or maintenance doses must be,30-50%,复旦大学附属中山医院,肾功能不全对药物的影响 吸入麻醉药,Nephrotoxic effects,长时间的甲氧氟烷麻醉可导致多尿性肾衰,肾毒性与氟化物代谢产物相关,与氟化物血浆峰值浓度及使用时间直接相关,Enflurane,只在肾毒性、肝毒性或者酶诱导剂的情况下产生肾损害,Compound A,a metabolite produced by the interaction of sevoflurane with outdated sodalime when fresh gas flows are 2 L/min,复旦大学附属中山医院,Perioperative Management,麻醉规划与管理 术中,Summary of perioperative considerations,Anaesthetic options GA, RA or LA,Airway management,Vascular access,Fluid and electrolyte management,Blood transfusion,Immune function and antibiotic prophylaxis,Steroid supplementation,复旦大学附属中山医院,麻醉规划与管理 术中,Regional anesthesia,Not contraindicated if coagulopathy is corrected,Increase risk of hypotension (autonomic neuropathy) and site infection,General anesthesia,At induction : aspiration precautions, preoxygenation,Succinylcholine,Not contraindicated if serum K 5.0 mEq/l, had dialysis within 24hs,复旦大学附属中山医院,麻醉规划与管理 术中,nondepolarizing agents,pancuronium and pipecuronium be avoided,mivacurium and cisatracurium,Metabolized independent of renal elimination,vecuronium and rocuronium ok,Increase mechanical minute ventilation,Compensate chronic metabolic acidosis,In anuric patients,Maintenance fluid kept in minimal, fluid losses must be fully replaced,复旦大学附属中山医院,麻醉规划与管理 术后苏醒,苏醒延迟，持续神经肌肉阻滞，呕吐，误吸,高血压，,呼吸抑制，肺水肿,In patient with chronic metabolic acidosis,opioid-induced respiratory depression,Cause a decrease in pH and acute hyperkalemia,A short period of postoperative mechanical ventilation,Controlled emergence, avoids reversal agents, fascilitates evaluation of neurologic and ventilatory function before extubation,复旦大学附属中山医院,麻醉规划与管理 术后镇痛,选择合适的术后镇痛方式,Patient factors,Patient preference,Physical and mental capabilities (e.g. PCA),Co-morbidities (e.g. bleeding diathesis and epidural analgesia),Surgical factors,Surgical procedure and anatomical site,药物选择,NSAIDS be avoided,morphine, meperidine particular concern,复旦大学附属中山医院,麻醉规划与管理,复旦大学附属中山医院,小结,CKF已经成为患者中的常见病，尤其是老年患者,CKF患者围术期有相当大的风险使 CKF 恶化，即使术前没有显著的危险因素,CKF患者对药物影响明显，需慎重选择和密切监测使用如肌松药和镇痛药等,围术期注意保护动静脉内瘘,复旦大学附属中山医院,Thank You !,复旦大学附属中山医院,