MindMap Gallery Anesthesia and liver and kidneys
The surgical site, surgical method, surgical scope, and surgical time will all affect: abdominal surgery, especially upper abdominal surgery, because the surgical scope is larger and the time is longer, it has a greater impact on liver blood flow, while surgery on the limbs and trunk has less impact.
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Anesthesia and liver and kidneys
Case analysis
Chief complaint
I have had anorexia and fatigue for more than a month, and my skin and sclera have been jaundiced for 10 days.
Physical examination
Chronic disease appearance, anemic appearance, pale and yellow conjunctiva, poor nutrition, no venous distention
B-ultrasound examination
Consider the possibility of stones. Ultrasonography of gallbladder polyps. Ultrasounds of pancreas and spleen showed no obvious abnormalities.
Kidney atrophy
There was no dilatation of the upper ureters on both sides.
current diagnosis
Causes of hilar bile duct stricture
bile duct stones
Uremia
hypertension
anemia
lung infection
Emphysema
Preoperative liver and kidney evaluation
liver evaluation
Liver routine and liver damage grading assessment
Impaired liver function but normal coagulation function
Renal evaluation
The patient had a history of chronic nephritis for more than 10 years and was diagnosed with renal failure. He underwent hemodialysis and peritoneal dialysis regularly.
Anesthesia method
General anesthesia combined with epidural anesthesia
Inhalation general anesthesia uses desflurane, which is nontoxic to the liver and kidneys.
neuraxial anesthesia
subarachnoid anesthesia
Mainly perform puncture anesthesia at waist 2-3/lumbar 3-4
Administered into the cerebrospinal fluid in the subarachnoid space
Dominated area of all segments below the block level
Influencing factors are related to dose, position, block plane, etc., which can all affect the anesthesia effect.
Epidural anesthesia
Any intervertebral puncture of the spine
Administer drug into epidural space
The block is limited to the corresponding segments (three or four segments above and below the administration site)
Regardless of body position
Narcotic drugs
analgesics
Opioids
Remifentanil is hydrolyzed by plasma esterase and is not metabolized by the liver and kidneys. It has a rapid onset of action, few adverse reactions, and no accumulation in the body after long-term use.
inhaled general anesthetic
Desflurane
It is non-toxic to the liver and kidneys and is almost completely eliminated from the body through the lungs.
Sevoflurane
Reduce portal vein blood flow, but increase hepatic artery blood flow, maintaining total hepatic blood flow and oxygen supply while maintaining systemic hemodynamics.
Muscle relaxants
This patient is prohibited from using depolarizing muscle relaxants (succinylcholine). In patients with impaired liver function, reduced synthesis of cholinesterase will prolong the efficacy of the drug. Non-depolarizing muscle relaxants such as pancuronium bromide and vecuronium bromide can be used. Ammonium etc.
Anesthesia and liver
hepatic blood flow
The liver receives dual blood supply from the hepatic artery and hepatic portal vein
Hepatic blood flow is directly proportional to hepatic perfusion pressure and inversely proportional to hepatic blood flow resistance
The liver has a rich blood supply, and liver surgery often requires blocking the liver portal.
Controlled low central venous pressure technology can be used to reduce intraoperative blood loss during liver resection
Adjust Trendelenburg position
bile reflex
When performing hepatobiliary surgery, excessive traction on the gallbladder and bile duct area should be avoided as much as possible during the operation. The area should have abundant vagus nerve innervation. Reflexive traction can cause slowing of the heart rate, drop in blood pressure, and even cardiac arrest.
Pre-administration of M-receptor blockers to prevent the occurrence of the bile-cardiac reflex
Acid-base balance disorder
Hypercapnia and acidosis increase hepatic blood flow, whereas hypocapnia and alkalosis decrease hepatic blood flow.
right heart failure
Due to the increase in vena cava pressure, hepatic venous pressure increases, liver congestion and swelling occur, and liver blood flow decreases accordingly.
surgical trauma
The surgical site, surgical method, surgical scope, and surgical time will all affect
Abdominal surgery, especially upper abdominal surgery, has a greater impact on liver blood flow because of its larger scope and longer operation time, while surgery on the limbs and trunk has less impact on it.
Anesthesia and kidneys
Prerenal factors
surgical stress trauma
Causes the body's stress response, catecholamines, antidiuretic hormone and angiotensin | Decreases renal blood flow (RBF) by inducing renal vasoconstriction
Surgery type
Major surgeries, especially abdominal surgeries, require long operation times, excessive visceral stretching, hypotension, and even shock. Major bleeding can lead to a sharp decrease in RBF and damage the kidneys.
renal factors
Perioperative renal oliguria is usually caused by long-term renal ischemia due to prerenal causes or misuse of nephrotoxic drugs, both of which can be caused by decreased glomerular GRF and tubular necrosis.
postrenal factors
Caused by obstruction, less common
Hypotension, hypothermia, ischemia, hypoxia, mechanical ventilation, artificial pneumoperitoneum
Make adequate preoperative preparations, choose anesthesia methods and drugs that have less physiological interference on the body, and adjust the patient's preoperative physiological state to the best
Maintain effective renal perfusion pressure
The adverse effects of artificial ventilation on cardiac output should be reduced, mechanical ventilation should be mild hyperventilation, and patients with acidosis and hyperkalemia should be prevented and treated.
Choose anesthesia methods and drugs that minimally interfere with renal function