心脏病人非心脏手术术前评估与术中管理-课件

心脏病人非心脏手术术前评估与术中管理 心脏病人非心脏手术术前评估与术中管理 ppt课件1心脏病人非心脏手术术前评估与术中管理 心脏病人非心脏手术术前Impact Factor 9.275心脏病人非心脏手术术前评估与术中管理 ppt课件2Impact Factor 9.275心脏病人非心脏手The Preambleu Guidelines and recommendations should help physicians and other healthcare providers to make decisions in their daily practice.However,the physician in charge of his/her care must make the ultimate judgement regarding the care of an individual patient 心脏病人非心脏手术术前评估与术中管理 ppt课件3The Preamble Guidelines and re心脏病人非心脏手术术前评估与术中管理 ppt课件4心脏病人非心脏手术术前评估与术中管理 ppt课件4IntroductionThe present guidelines focus on the cardiological management of patients undergoing non-cardiac surgery,i.e.patients where heart disease is a potential source of complications during surgery major non-cardiac surgery is associated with an incidence of cardiac death of between 0.5 and 1.5%,and of major cardiac complications of between 2.0 and 3.5%心脏病人非心脏手术术前评估与术中管理 ppt课件5IntroductionThe present guidelImpact of the ageing populationIt is estimated that elderly people require surgery four times more often than the rest of the population 心脏病人非心脏手术术前评估与术中管理 ppt课件6Impact of the ageing populatioPre-operative evaluationSurgical risk for cardiac events:the urgency,magnitude,type,and duration of the procedure,as well as the change in body core temperature,blood loss,and fluid shifts 心脏病人非心脏手术术前评估与术中管理 ppt课件7Pre-operative evaluationSurgic心脏病人非心脏手术术前评估与术中管理 ppt课件8心脏病人非心脏手术术前评估与术中管理 ppt课件8心脏病人非心脏手术术前评估与术中管理 ppt课件9心脏病人非心脏手术术前评估与术中管理 ppt课件9Functional capacity Functional capacity is measured in metabolic equivalents(METs)Exercise testing provides an objective assessment of functional capacity Without testing,functional capacity can be estimated by the ability to perform the activities of daily living 心脏病人非心脏手术术前评估与术中管理 ppt课件10Functional capacity Functional 4 METs indicates poor functional capacity and is associatedwith an increased incidence of post-operative cardiac events 心脏病人非心脏手术术前评估与术中管理 ppt课件11 4 METs indicates poor functiRisk indicesGoldman(1977),Detsky(1986),Lee(1999)The Lee index,to be the best currently available cardiac risk prediction index in non-cardiac surgery 心脏病人非心脏手术术前评估与术中管理 ppt课件12Risk indicesGoldman(1977),DeSix independent clinical determinants(The Lee index)a history of IHD a history of cerebrovascular diseaseheart failure insulin-dependent diabetes mellitus impaired renal functionHigh-risk type of surgery 心脏病人非心脏手术术前评估与术中管理 ppt课件13Six independent clinical deterThe Lee indexAll factors contribute equally to the index(with 1 point each)the incidence of major cardiac complications is estimated at 0.4,0.9,7,and 11%in patients with an index of 0,1,2,and 3 points,respectively 心脏病人非心脏手术术前评估与术中管理 ppt课件14The Lee indexAll factors contr心脏病人非心脏手术术前评估与术中管理 ppt课件15心脏病人非心脏手术术前评估与术中管理 ppt课件15BiomarkersCardiac troponins T and I(cTnT and cTnI)are the preferredmarkers for the diagnosis of MI because they demonstrate sensitivity and tissue specificity superior to other available biomarkers 心脏病人非心脏手术术前评估与术中管理 ppt课件16BiomarkersCardiac troponins T Plasma BNP and NT-proBNPimportant prognostic indicators in patients with heart failure additional prognostic value for long-term mortality and for cardiac events 心脏病人非心脏手术术前评估与术中管理 ppt课件17Plasma BNP and NT-proBNPimportNon-invasive testingthree cardiac risk markers:LV dysfunction myocardial ischaemia heart valve abnormalities 心脏病人非心脏手术术前评估与术中管理 ppt课件18Non-invasive testing心脏病人非心脏手术术心脏病人非心脏手术术前评估与术中管理 ppt课件19心脏病人非心脏手术术前评估与术中管理 ppt课件19Echocardiography A meta-analysis of the available data demonstrated that an LV ejection fraction of 100 mmHg 心脏病人非心脏手术术前评估与术中管理 ppt课件25b-blockersThe dose of b-blocke心脏病人非心脏手术术前评估与术中管理 ppt课件26心脏病人非心脏手术术前评估与术中管理 ppt课件26心脏病人非心脏手术术前评估与术中管理 ppt课件27心脏病人非心脏手术术前评估与术中管理 ppt课件27Nitrates:Nitroglycerin 心脏病人非心脏手术术前评估与术中管理 ppt课件28Nitrates:Nitroglycerin 心脏病人非心心脏病人非心脏手术术前评估与术中管理 ppt课件29心脏病人非心脏手术术前评估与术中管理 ppt课件29心脏病人非心脏手术术前评估与术中管理 ppt课件30心脏病人非心脏手术术前评估与术中管理 ppt课件30Diuretics心脏病人非心脏手术术前评估与术中管理 ppt课件31Diuretics心脏病人非心脏手术术前评估与术中管理 pAspirin心脏病人非心脏手术术前评估与术中管理 ppt课件32Aspirin心脏病人非心脏手术术前评估与术中管理 pptAnticoagulant therapy 心脏病人非心脏手术术前评估与术中管理 ppt课件33Anticoagulant therapy 心脏病人非心脏手心脏病人非心脏手术术前评估与术中管理 ppt课件34心脏病人非心脏手术术前评估与术中管理 ppt课件34心脏病人非心脏手术术前评估与术中管理 ppt课件35心脏病人非心脏手术术前评估与术中管理 ppt课件35心脏病人非心脏手术术前评估与术中管理 ppt课件36心脏病人非心脏手术术前评估与术中管理 ppt课件36Revascularization心脏病人非心脏手术术前评估与术中管理 ppt课件37Revascularization心脏病人非心脏手术术前评估心脏病人非心脏手术术前评估与术中管理 ppt课件38心脏病人非心脏手术术前评估与术中管理 ppt课件38Specific diseases Arterial hypertensionValvular heart diseaseAortic stenosisMitral stenosisAR and MRprosthetic valve(s)心脏病人非心脏手术术前评估与术中管理 ppt课件39Specific diseases Arterial hypArterial hypertensionantihypertensive medications should be continued during the perioperative period.In patients with grade 3 hypertension(systolic blood pressure 180 mmHg and/or diastolic blood pressure 110 mmHg),the potential benefits of delaying surgery to optimize the pharmacological therapy should be weighed against the risk of delaying the surgical procedure 心脏病人非心脏手术术前评估与术中管理 ppt课件40Arterial hypertensionantihyperValvular heart diseasehigher risk Echocardiography should be performed 心脏病人非心脏手术术前评估与术中管理 ppt课件41Valvular heart diseasehigher rAortic stenosisSevere AS:aortic valve area 1 cm2 1.5 cm2)and in asymptomatic patients with significant MS(valve area 1.5 cm2)and systolic pulmonary artery pressure 50 mmHg control of heart rate Strict control of fluid overload anticoagulation AF心脏病人非心脏手术术前评估与术中管理 ppt课件43Mitral stenosisrelatively lowrAR and MR Non-significant AR and MR(low risk)asymptomatic patients with severe AR and MR and preserved LV function(low risk)Symptomatic patients and LV EF30%(High risk,only if necessary,optimization of pharmacological therapy)心脏病人非心脏手术术前评估与术中管理 ppt课件44AR and MR Non-significant AR aprosthetic valve(s)no evidence of valve or ventricular dysfunction(without additional risk)endocarditis prophylaxis anticoagulation regimen modification 心脏病人非心脏手术术前评估与术中管理 ppt课件45prosthetic valve(s)no evidencBradyarrhythmiasTemporary cardiac pacing is rarely required,even in the presence of pre-operative asymptomatic bifascicular block or CLBBB The indications for temporary pacemakers are generally the same as those for permanent pacemakers 心脏病人非心脏手术术前评估与术中管理 ppt课件46BradyarrhythmiasTemporary cardPacemaker/implantable cardioverter defibrillatorunipolar electrocautery represents a significant risk be avoided by positioning the ground plate Keeping the electrocautery device away from the pacemaker,giving only briefbursts and using the lowest possible amplitude心脏病人非心脏手术术前评估与术中管理 ppt课件47Pacemaker/implantable cardioveThe implantable cardioverter defibrillator should be turned off during surgery and switched on in the recovery phase before discharge to the ward 心脏病人非心脏手术术前评估与术中管理 ppt课件48The implantable cardioverter dPerioperative monitoringV5(75%),V4(61%),V5+V4(90%),V5+V4+II(96%)Continuous automated ST trending monitors(sensitivity and specificity of 74 and 73%)ECG心脏病人非心脏手术术前评估与术中管理 ppt课件49Perioperative monitoringV5(75心脏病人非心脏手术术前评估与术中管理 ppt课件50心脏病人非心脏手术术前评估与术中管理 ppt课件50Transesophageal echocardiography心脏病人非心脏手术术前评估与术中管理 ppt课件51Transesophageal echocardiograpRight heart catherizationboth a large observational study and a randomized multicentre clinical trial did not show a benefit associated with the use of right heart catheterization no difference in mortality and hospital duration /a higher incidence of pulmonary embolism心脏病人非心脏手术术前评估与术中管理 ppt课件52Right heart catherizationboth Disturbed glucose metabolism promotes atherosclerosis,endothelial dysfunction,and activation of platelets and proinflammatory cytokines 心脏病人非心脏手术术前评估与术中管理 ppt课件53Disturbed glucose metabolism p心脏病人非心脏手术术前评估与术中管理 ppt课件54心脏病人非心脏手术术前评估与术中管理 ppt课件54Intraoperative anaesthetic managementproper organ perfusion pressureSpinal and epidural anaesthesia(T4)One meta-analysis reported significantly improved survival and reduced incidence of post-operative thromboembolic,cardiac and pulmonary complications with neuraxial blockade compared with general anaesthesia 心脏病人非心脏手术术前评估与术中管理 ppt课件55Intraoperative anaesthetic manPutting the puzzle together心脏病人非心脏手术术前评估与术中管理 ppt课件56Putting the puzzle together心脏病心脏病人非心脏手术术前评估与术中管理 ppt课件57心脏病人非心脏手术术前评估与术中管理 ppt课件57心脏病人非心脏手术术前评估与术中管理 ppt课件58心脏病人非心脏手术术前评估与术中管理 ppt课件58心脏病人非心脏手术术前评估与术中管理 ppt课件59心脏病人非心脏手术术前评估与术中管理 ppt课件59患者和外科特殊因素决定治疗策略，不需进一步心脏检查和治疗，请求会诊以加强术中管理，监测心脏事件和拟定长期药物治疗方案多学科会诊以决定最佳治疗方案，如能推迟手术则可进行CABG、球囊成形术、支架植入术明确危险因素、进行手术治疗、提供正确的生活方式和适当的药物治疗，以改善术后长期生存质量明确心功能状态、进行手术治疗、适当的术前药物治疗（他汀类，受体阻滞剂）适当的术前药物治疗（他汀类，受体阻滞剂）、左室收缩功能障碍者（ACE-inhibitors）、进进行手术治疗行手术治疗、围术期ECG监测心脏病人非心脏手术术前评估与术中管理 ppt课件60患者和外科特殊因素决定治疗策略，不需进一步心脏检查和治疗，请适当的术前药物治疗（他汀类，受体阻滞剂）、左室收缩功能障碍者（ACE-inhibitors）non-invasive stress test Revascularization bridging therapy心脏病人非心脏手术术前评估与术中管理 ppt课件61适当的术前药物治疗（他汀类，受体阻滞剂）、左室收缩功能障碍