心臟病人非心臟手術(shù)術(shù)前評(píng)估與術(shù)中管理

1、心臟病人非心臟手術(shù)術(shù)前評(píng)估與術(shù)中管理,江蘇省蘇北人民醫(yī)院麻醉科 楊柳青,2009 ESC/ESA 指南,,,Impact Factor 9.275,The Preamble,Guidelines and recommendations should help physicians and other healthcare providers to make decisions in their daily practice. H

2、owever, the physician in charge of his/her care must make the ultimate judgement regarding the care of an individual patient,,Introduction,The present guidelines focus on the cardiological management of patients underg

3、oing 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 o

4、f major cardiac complications of between 2.0 and 3.5%,Impact of the ageing population,It is estimated that elderly people require surgery four times more often than the rest of the population,,,Pre-operative evaluation,S

5、urgical 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,,,,Functional capacity,Functional capacity

6、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 dail

7、y living,,< 4 METs indicates poor functional capacity and is associatedwith an increased incidence of post-operative cardiac events,Risk indices,Goldman (1977), Detsky (1986), Lee (1999)The Lee index, to be the best

8、 currently available cardiac risk prediction index in non-cardiac surgery,Six independent clinical determinants (The Lee index),a history of IHD a history of cerebrovascular diseaseheart failure insulin-dependent diab

9、etes mellitus impaired renal functionHigh-risk type of surgery,The Lee index,All 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

10、 11% in patients with an index of 0, 1, 2, and ≥ 3 points, respectively,,Biomarkers,Cardiac troponins T and I (cTnT and cTnI) are the preferredmarkers for the diagnosis of MI because they demonstrate sensitivity and tis

11、sue specificity superior to other available biomarkers,Plasma BNP and NT-proBNP,important prognostic indicators in patients with heart failure additional prognostic value for long-term mortality and for cardiac events,N

12、on-invasive testing,three cardiac risk markers: LV dysfunction myocardial ischaemia heart valve abnormalities,,,Echocardiography,A meta-analysis of the available data demonstrated that an LV ejection fraction o

13、f <35% had a sensitivity of 50% and a specificity of 91% for prediction of perioperative non-fatal MI or cardiac death,,,a well-established invasive diagnostic procedure rarely indicated to assess the risk of noncar

14、diac surgery,Angiography,,,,,,Risk reduction strategiesPharmacological,Besides specific risk reduction strategies adapted to patient characteristics and the type of surgery, preoperative evaluation is an opportunity to

15、check and optimize the control of all cardiovascular risk factors,b-blockers,The dose of b-blockers should be titrated,which requires that treatment be initiated optimally between 30 days and at least 1 week before surg

16、ery. treatment start with a daily dose of 2.5 mg of bisoprolol or 50 mg of metoprolol succinate which should then be adjustedbefore surgery to achieve a resting heart rate of between 60 and 70 bpm with SBP >100 mm

17、Hg,,,,,Nitrates :Nitroglycerin,,,,,Diuretics,Aspirin,Anticoagulant therapy,,,,,,,,,,Revascularization,,,Specific diseases,Arterial hypertensionValvular heart diseaseAortic stenosisMitral stenosisAR and MRprosthetic

18、valve(s),Arterial hypertension,antihypertensive medications should be continued during the perioperative period. In patients with grade 3 hypertension (systolic blood pressure ≧180 mmHg and/or diastolic blood pressure ≧

19、110 mmHg), the potential benefits of delaying surgery to optimize the pharmacological therapy should be weighed against the risk of delaying the surgical procedure,Valvular heart disease,higher risk Echocardiography sho

20、uld be performed,Aortic stenosis,Severe AS : aortic valve area <1 cm2 < 0.6 cm2/m2 body surface area),Mitral stenosis,relatively lowrisk : non-significant mitral stenosis (MS) (valve area >1.5 c

21、m2) 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,AR and MR,Non

22、-significant AR and MR (low risk) asymptomatic patients with severe AR and MR and preserved LV function (low risk)Symptomatic patients and LV EF<30% (High risk, only if necessary ,optimization of pharmacological t

23、herapy ),prosthetic valve(s),no evidence of valve or ventricular dysfunction (without additional risk )endocarditis prophylaxis anticoagulation regimen modification,Bradyarrhythmias,Temporary cardiac pacing is rarely

24、 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,Pacemaker/implantable cardiover

25、ter defibrillator,unipolar 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 lowe

26、st possible amplitude,,The implantable cardioverter defibrillator should be turned off during surgery and switched on in the recovery phase before discharge to the ward,Perioperative monitoring,V5(75%),V4(61%),V5+V4(90%)

27、, V5+V4+II(96%)Continuous automated ST trending monitors (sensitivity and specificity of 74 and 73% ),ECG,,Transesophageal echocardiography,Right heart catherization,both a large observational study and a randomized mul

28、ticentre 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,Disturbed glucose metab

29、olism,promotes atherosclerosis, endothelial dysfunction, and activation of platelets and proinflammatory cytokines,,,Intraoperative anaesthetic management,proper organ perfusion pressureSpinal and epidural anaesthesia (

30、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,Putti

31、ng the puzzle together,,,,患者和外科特殊因素決定治療策略，不需進(jìn)一步心臟檢查和治療，請(qǐng)求會(huì)診以加強(qiáng)術(shù)中管理，監(jiān)測(cè)心臟事件和擬定長(zhǎng)期藥物治療方案,多學(xué)科會(huì)診以決定最佳治療方案，如能推遲手術(shù)則可進(jìn)行CABG、球囊成形術(shù)、支架植入術(shù),明確危險(xiǎn)因素、進(jìn)行手術(shù)治療、提供正確的生活方式和適當(dāng)?shù)乃幬镏委煟愿纳菩g(shù)后長(zhǎng)期生存質(zhì)量,明確心功能狀態(tài)、進(jìn)行手術(shù)治療、適當(dāng)?shù)男g(shù)前藥物治療（他汀類，β受體阻滯劑）,適當(dāng)?shù)男g(shù)前藥物治療（他