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Enflurane 只在肾毒性、肝毒性或者酶诱导剂的情况下产生肾损害 Compound A a metabolite produced by the interaction of sevoflurane with outdated sodalime when fresh gas flows are 2 L/min * Perioperative Management * 复旦大学附属中山医院 麻醉规划与管理 —— 术中 Summary of perioperative considerations Anaesthetic options –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