肾功能不全病人手术与麻醉.ppt

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Enflurane 只在肾毒性、肝毒性或者酶诱导剂的情况下产生肾损害 Compound A a metabolite produced by the interaction of sevoflurane with outdated sodalime when fresh gas flows are 2 L/min Perioperative Management 复旦大学附属中山医院 麻醉规划与管理 —— 术中 Summary of perioperative considerations Anaesthetic options – GA,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