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肝移植手术的麻醉与围术期管理东方肝胆外科医院俞卫锋课件

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移植 手术 麻醉 围术期 管理 东方 肝胆 外科 医院 俞卫锋 课件
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Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肝移植手术的麻醉 与围术期管理 东方肝胆外科医院 俞 卫 锋 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 一 肝移植的历史 Welch 1955年在狗的下腹部植入一个新的肝脏 从此开始了肝脏移植的动物实验研究 1963年 Starzl施行了第一例人类肝移植 在1978年 1985年 我国共施行了57例肝移植 存活时间最长者为264天 1995年以来 各 地广泛开展了肝移植手术 术后存活率正接近 国际水平 我院的情况 一 概述 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 1 原位肝移植 切除受体病肝 将供肝植入受体 原肝部位 2 异位肝移植 保留受体原肝 将供肝植入受体 体腔的其他部位 如脾床 盆腔或脊柱旁等 3 标准式肝移植 供肝大小和受体腹腔大小相匹 配 按原血管解剖将整个供肝植入受体的原肝 部位 4 减体积性肝移植 在受体腹腔较小而供肝体积 相对较大 受体体腔不能容纳的情况下 切除 供肝的一部分后再原位植入 二 肝移植的种类 肝移植分为同种异体肝移植和异种肝移植 同种异体肝移植的术式可分为如下几种 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 5 活体部分肝移植 从活体上切取肝左外叶作为 供肝植入受体的原肝部位 6 劈离式肝移植 将供肝分成两半 分别移植给 两个受体 7 原位辅助性肝移植 保留受体的部分肝脏 将 减体积后的供肝植入病肝切除部分的位置 8 背驮式技术 切除病肝时保留受体的肝后下腔 静脉 将供肝的肝上下腔静脉与受体的三支肝 静脉或肝中 肝左静脉所形成的共同开口相吻 合 或供受体肝后下腔静脉行侧侧吻合 重建 肝脏的血液流出道 同时结扎供肝的肝后下腔 静脉 此技术不论是全肝移植或减体积性肝移 植均可应用 在活体 部分肝移植时必须采用 背驮式技术 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 经典肝移植 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 背驮式肝移植 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 门静脉吻合 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肝动脉吻合 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 胆道重建 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 二 肝移植病人受体的术前评估和治疗 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 一 心血管功能的改变 肝硬化门脉高压病人的心血管功能总的 特点为高动力状态即高心输出量 低外 周血管阻力 而灌注压 心率 动脉压 则正常 肝硬化病人的心血管功能变化 见下表 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肝硬化病人的心血管功能 血管阻力降低 外周血管扩张扩张 动动静脉分流增加 循环环容量增加 心排量增加 维维持动动脉血压压 灌注压压 心率 晚期则则下降 可能引起心肌病 动动静脉氧含量差降低及静脉氧含量升高 对对儿茶酚胺的敏感性降低 内脏脏脏脏 器 除肝脏脏 肺 骨骼肌和皮肤血流增加 门门脉供肝血流减少 维维持或降低肝动动脉血流 维维持或降低肾肾血流 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 心血管功能改变的原因 血浆胰高糖素 铁蛋白 血管活性肠肽浓度的 升高 对应激所致的血管收缩及心动过速的能力降低 由于压力感受器介导的反应能力降低有关 心血管系统对交感及儿茶酚胺的敏感性降低 腹水膈肌上抬胸内压升高 跨心壁压力梯度下 降 洒精能降低心肌的收缩力 同时伴随着体内儿 茶酚胺浓度的升高 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肝硬化心血管功能 肾循环 肾血管阻力增加导致肾血流尤其肾皮质的 血流下降 肾血管阻力之所以增加是肝 肾输入血管阻力增加超过肾输出血管阻 力增加所造成的 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肝硬化心血管功能 肝循环 门脉高压 倒流学说 认为肝硬化时肝组织的纤维 化导致门脉血管阻力增加而引起门脉高 压 进流学说 认为某些因子 如胰高血糖 素及其它一些扩血管的物质 导致肠道 及脾脏的血管扩张和动静脉分流 引起 与内脏血流及心排量增加所并行的高动 力状态是门脉高压的基础 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 门腔分流的血流动力学的变化 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 二 呼吸功能及肺循环的改变 肝硬化门脉高压病人红细胞2 3 二磷 酸甘油酸 2 3 DPG 含量升高 导 致血红蛋白与氧的亲和力下降 氧离曲 线右移 肝硬化患者常有腹水 闭合气 量增加 从而导致功能残气量增加 这 些变化导致低位肺区通气及通气血流比 例失调 最终引起低氧血症 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肝硬化患者低氧血症 氧离曲线线右移 通气血流比例失调调 损伤损伤 肺贫贫氧性肺血管收缩缩反应应 腹水引起通气不足 细细胞外液体增加导导致肺弥散能力下降 肺内右向左分流增加 肺内蜘蛛痣 门门肺静脉交通 激素物质质 扩扩血管物质质 胰高血糖素 铁铁 蛋白等 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 三 血液及凝血功能改变 肝硬化患者红细胞压积由于血容量增加 或由于胃肠道出血而下降 白细胞减少及血小板降低通常与脾亢及 乙醇诱导的骨髓抑制有关 大多数肝硬化患者多少都有一些凝血功 能的改变 最常见的是血浆VII V X 和II 凝血酶原 因子减少 I因子 纤 维蛋白原 也通常减少 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 四 蛋白质代谢的改变 当肝功能障碍时 蛋白质代谢障碍的突 出表现为 低蛋白血症 甲种胎儿 球蛋白 AFP 重现 血浆氨基酸含量升 高 尿素合成减少 这类病人常发生低蛋白血症 血中与血 浆蛋白结合的药物浓度相对减少 游离 药物浓度增多 从而增强药物的作用 所以术中应适当减少药物的用量 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 五 碳水合物代谢的改变 肝脏是维持血糖浓度的重要器官 肝功 能障碍病人易发生低血糖 糖耐量降低 血中乳酸和丙酮酸增多 肝功能障碍时 利用乳酸再合成糖原的 能力降低 以致血中乳酸浓度亦增高 因此在肝病手术过程中 应尽可能监测 血 尿糖的水平 并根据监测结果决定 术中糖的用量很有必要 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 六 脂类代谢的改变 肝脏对脂类的代谢和调节血脂浓度有重 要作用 肝功能障碍时 由于卵磷脂胆固醇酰基 转移酶合成减少 血浆胆固醇酯化作用 减弱 血浆胆固醇总量不一定有变化 但血浆胆固醇酯浓度下降 临床上可根 据血清胆固醇酯的含量推测肝功能损害 的程度 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 七 激素代谢的改变 许多激素在发挥其调节作用之后 主要 是在肝脏内被分解转化 从而降低或失 去其活性 此种过程称为激素的灭活 灭活过程对于激素作用的时间长短及强 度具有调节控制作用 肝细胞功能障碍 时 由于激素灭活能力减弱 必然会对 机会产生一系列的影响 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 激素灭活障碍对机体的影响 图 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 八 电解质代谢的改变 肝功能与电解质代谢具有密切关系 肝 功能障碍时常发生 低钾血症 常由以下原因引起 肝细 胞对醛固酮灭活减弱 腹水形成致有 效循环血量减少 反射性醛固酮分泌增 加 术前利尿剂应用 输注葡萄糖 使钾离子转移到细胞内 所以术前应针 对低血钾的原因给予纠正 对防止术中 肝昏迷的发生很重要 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 八 电解质代谢的改变 低钠血症 水潴留是形成稀释性低钠血症的主 要原因 水潴留往往与肝病时有效循环血量减 少引起抗利尿激素分泌过多或与抗利尿激素灭 活减少有关 低钠血症是机体濒于死亡的表现 常预示病人预后险恶 低磷血症和低钙血症 肝功能不全时降钙素灭 活减少是钙磷代谢紊乱的主要原因 当磷缺乏 过甚时 糖酵解所需的磷也逐渐不足 必然使 大脑细胞不能很好地利用葡萄糖 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 九 肝脏解毒功能的改变 肝病主要通过三方面影响肝脏的药物代谢 通过血流灌注的改变而间接地使药物或毒物代 谢发生异常 例如通过侧支分流 使门脉血中 药物逃避肝细胞的代谢 肝病损害了肝脏代谢药物的能力 如肝脏混合 功能氧化酶的活力的改变 血清白蛋白合成减少 药物同血浆蛋白结合率 降低 从而使药物在体内的分布 代谢或排泄 也发生改变 而易发生药物中毒 肝病病人对肌松药常有异常反应 主要为对肌 松药的拮抗性增强和肌松作用延长 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 十 受体的术前治疗 内镜下硬化剂注射或曲张静脉套扎术是一种有 效和安全的治疗方法 受体阻滞剂 血管加压素 生长抑素等可用 于急 慢性出血的治疗 药物治疗和硬化剂治疗均失败时 可以采用双 气囊三腔管压迫止血 必要时可采用手术止血 常用的手术有两种 即门体分流术和断流术 1 胃底 食道曲张静脉破裂出血 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 门脉高压 低蛋白血症和钠潴留是腹水 产生的主要原因 控制盐和水 给予利尿治疗 注意水和 电解质平衡 顽固性腹水可以腹腔穿刺放水 同时补 充大量的白蛋白以维持循环容量 2 腹水 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 4 其他原因的胃肠道出血 5 细菌性胆管炎 6 肝性脑病 7 肝肾综合征 肝硬化病人如果出现发热 肝功能突然损害 腹痛或肝脑综合征的先兆 则应行腹腔穿刺 腹水白细胞计数 250 mm3 即可明确诊断 确诊后应立即开始抗生素治疗 3 自发性细菌性腹膜炎 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 三 肝移植病人的麻醉实施 一 选择合理的麻醉方式 静吸互补全身麻醉再复合硬膜外阻滞麻 醉最为理想 一则全身麻醉药的用药量减少 二则麻 醉更趋稳定安全 三则硬膜外留管可以 进行术后镇痛治疗 麻醉效果要求的总原则 适度麻醉 足 够的肌肉松驰及足够深度的镇痛 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 二 麻醉药物选择 麻醉诱导 以迅速起效 对循环无明显 抑制的药物首选 若病人情况尚可 异 丙酚 1 1 5mg kg 1 芬太尼 3 5 g kg 1 及阿曲库胺 0 4 mg kg 1 是较 常应用的药物 肌肉松驰药 多采用阿曲库胺 因其在 血液中经Hoffmann消除 而不经过肝脏 的降解 连续输注0 25 0 5mg kg 1 h 1可 维持良好的肌松 Evaluation only Evaluation only Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Created with Aspose Slides for NET 3 5 Client Profile 5 2 0 0 Copyright 2004 2011 Aspose Pty Ltd Copyright 2004 2011 Aspose Pty Ltd Five weeks of practice ended in this way and my feelings can only be summed up in eight words although
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本文标题:肝移植手术的麻醉与围术期管理东方肝胆外科医院俞卫锋课件
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