心脏病人非心脏手术培训ppt课件

心心脏病人非心病人非心脏手手术心脏病人非心脏手术1麻醉药物和麻醉技术麻醉药物和麻醉技术lClass IIa1.Use of either a volatile anesthetic agent or total intravenous anesthesia is reasonable for patients undergoing noncardiac surgery,and the choice is determined by factors other than the prevention of myocardial ischemia and MI(Level of Evidence:A)LandoniG,FochiO,BignamiE,etal.Cardiacprotectionbyvolatileanestheticsinnon-cardiacsurgery?Ametaanalysisofrandomizedcontrolledstudiesonclinicallyrelevantendpoints.HSRProcIntensiveCareCardiovascAnesth.2009;1:34-43.LuratiBuseGAL,SchumacherP,SeebergerE,etal.Randomizedcomparisonofsevofluraneversuspropofoltoreduceperioperativemyocardialischemiainpatientsundergoingnoncardiacsurgery.Circulation.2012;126:2696-704.2心脏病人非心脏手术麻醉药物和麻醉技术ClassIIa2心脏病人非心脏手术2文献汇报文献汇报l文献13心脏病人非心脏手术文献汇报文献13心脏病人非心脏手术3l2768toTIVAand3451receivingdesfluraneorsevofluraneintheiranesthesiaplanlVolatileanestheticdosagevariedacrossstudies,ranging0.33-2MACinthe609patientsreceivingdesfluraneand0.25-2MACinthe2842patientsreceivingsevofluranelHospitalstaywasidenticalbetweengroups(WMD0.01days-0.06,0.07,pforeffect=0.88,pforheterogeneity=0.48,I2=0%with1201includedpatientslNoauthorreportedanypostoperativemyocardialinfarctionordeathamongthestudypopulation,noranysignificantcardiacadverseeventlPostoperativerenalorrespiratoryfailureandreleaseofcardiacbiomarkerswerenotreported4心脏病人非心脏手术2768toTIVAand3451receivin4心律失常5心脏病人非心脏手术心律失常5心脏病人非心脏手术5l文献26心脏病人非心脏手术文献26心脏病人非心脏手术67心脏病人非心脏手术7心脏病人非心脏手术7心脏病人非心脏手术培训ppt课件8l在心脏手术中22includedtrialsincluded1,922randomlyassignedpatients(904toTIVAand1018receivingdesfluraneorsevofluraneintheiranesthesiaplan)Volatileanestheticdosagevariedacrossthestudies,butwasalways0.15MACandrangedfrom0.15-2MACinthe475patientsreceivingdesfluraneand0.25-4MACinthe543patientsreceivingsevofluraneMINERVAANESTESIOL2009;75:269-739心脏病人非心脏手术在心脏手术中9心脏病人非心脏手术9volatileanestheticsreducedtheriskofMI(24/9792.4%inthevolatileanestheticsgroupvs.45/8745.1%incontrols,OR=0.510.32-0.84,Pforeffect=0.008),all-causemortalitywasalsoreduced(4/9770.4%vs.14/8721.6%,OR=0.310.12-0.80,Pforeffect-0.02asignificantdecreaseincTnIpeakrelease(WMD-2.35ng/dl-3.09,-1.60,Pforeffect0.00001,Pforheterogeneity0.00001,I2=94.1%with1,463includedpatients)andtheneedforinotropicsupport(170/67925.0%vs.203/56236.1%,OR=0.470.29,0.76,Pforeffect0.002,Pforheterogeneity=0.008,I2=53.1%with1,241includedpatients).ashorterICUstay(WMD=-7.10hours-11.47;-2.73,Pforeffect0.001,Pforheterogeneity0.00001,I2=76.6%with1,433includedpatients),timetohospitaldischarge(WMD=-2.26days-3.83;-0.68,Pforeffect=0.005,with1,593includedpatients)timeonmechanicalventilation(WMD=-0.49hours-0.97;-0.02,Pforeffect=0.04,pforheterogeneity0.03,I2=44.1%with1,846includedpatients).Finally,onlytwostudiesreportedoneyearfollow-updataconcerningmajorcardiacevents(definedascardiacdeath,non-fatalMI,unstableangina,intercurrentcoronaryangioplasty,CABG,arrhythmiasrequiringhospitalizationandnewepisodesofcongestiveheartfailure10心脏病人非心脏手术volatileanestheticsreducedt10Class IIa 2.Neuraxial anesthesia for postoperative pain relief can be effective in patients undergoing abdominal aortic surgery to decrease the incidence of perioperative MI(Level of Evidence:B)NishimoriM,LowJHS,ZhengH,etal.Epiduralpainreliefversussystemicopioid-basedpainreliefforabdominalaorticsurgery.CochraneDatabaseSystRev.2012;7:CD005059.11心脏病人非心脏手术ClassIIa2.Neuraxialanesthe11l文献汇报15trialsthatinvolved1297patients(633patientsreceivedepiduralanalgesiaand664receivedsystemicopioidanalgesia)Thepostoperativedurationoftrachealintubationandmechanicalventilationwassignificantlyshorter,byabout48%,intheepiduralanalgesiagroup.Theoveralleventratesofmyocardialinfarction,acuterespiratoryfailure(definedasanextendedneedformechanicalventilation),gastrointestinalcomplications,andrenalcomplicationsweresignificantlylowerintheepiduralanalgesiagroup.12心脏病人非心脏手术文献汇报12心脏病人非心脏手术12lClass IIb1.Perioperative epidural analgesia may be considered to decrease the incidence of preoperative cardiac events in patients with a hip fracture(Level of Evidence:B)13心脏病人非心脏手术ClassIIb13心脏病人非心脏手术13l文献Anesthesiology2003;98:1566314心脏病人非心脏手术文献Anesthesiology2003;98:15614术中管理术中管理lClass IIa1.The emergency use of perioperative transesophageal echocardiogram is reasonable in patients with hemodynamic instability undergoing noncardiac surgery to determine the cause of hemodynamic instability when it persists despite attempted corrective therapy,if expertise is readily available.(Level of Evidence:C)15心脏病人非心脏手术术中管理ClassIIa15心脏病人非心脏手术15lClass IIb1.Maintenance of normothermia may be reasonable to reduce perioperative cardiac events in patients undergoing noncardiac surgery(150,151).(Level of Evidence:B)2.Use of hemodynamic assist devices may be considered when urgent or emergency noncardiac surgery is required in the setting of acute severe cardiac dysfunction(i.e.,acute MI,cardiogenic shock)that cannot be corrected before surgery.(Level of Evidence:C)3.The use of pulmonary artery catheterization may be considered when underlying medical conditions that significantly affect hemodynamics(i.e.,HF,severe valvular disease,combined shock states)cannot be corrected before surgery.(Level of Evidence:C)16心脏病人非心脏手术ClassIIb16心脏病人非心脏手术16lFrankSM,FleisherLA,BreslowMJ,etal.Perioperativemaintenanceofnormothermiareducestheincidenceofmorbidcardiacevents.Arandomizedclinicaltrial.JAMA.1997;277:1127-34CgrouphypothermicPT35.4+/-0.136.7+/-0.10.01Postoperativeventriculartachycardia2.4%7.9%;P=.04morbidcardiacevents1.4%6.3%;P=.0217心脏病人非心脏手术FrankSM,FleisherLA,Breslow17Perioperativehypothermia(33degreesC)doesnotincreasetheoccurrenceofcardiovasculareventsinpatientsundergoingcerebralaneurysmsurgery:findingsfromtheIntraoperativeHypothermiaforAneurysmSurgeryTrial.Anesthesiology.2010;113:327-4218心脏病人非心脏手术Perioperativehypothermia(3318lClass III:No Benefit1.Routine use of pulmonary artery catheterization in patients,even those with elevated risk,is not recommended(Level of Evidence:A)2.Prophylactic intravenous nitroglycerin is not effective in reducing myocardial ischemia in patients undergoing noncardiac surgery(Level of Evidence:B)3.The routine use of intraoperative transesophageal echocardiogram during noncardiac surgery to screen for cardiac abnormalities or to monitor for myocardial ischemia is not recommended in patients without risk factors or procedural risks for significant hemodynamic,pulmonary,or neurologic compromise.(Level of Evidence:C)19心脏病人非心脏手术ClassIII:NoBenefit19心脏病人非心脏19lPAC文献20心脏病人非心脏手术PAC文献20心脏病人非心脏手术20lIvnitroglycerin文献1high-risknon-cardiacpatientsHolterelectrocardiogram(ECG)lIvnitroglycerin文献2CABGsurgerycontrolgroup(n=23)Ivnitroglycerin(n=22)ischemiaSeven(30%)seven(32%)controlgroup(n=20)Ivnitroglycerin(n=20)Pischemia35%35%MI10%5%0.2321心脏病人非心脏手术Ivnitroglycerin文献1controlgro2122心脏病人非心脏手术谢谢！22心脏病人非心脏手术22