AnesthesiaandtheCardiacPatient麻醉和心臟病患者課件

1、Pharmacologic Considerations in the Cardiac PatientWayne E. Ellis, Ph.D., CRNA第1頁，共58頁。第2頁，共58頁。8/4/2022Treatment of Ischemia(primary)ASA 325 mg immediatelyThrombolytics (Retevase) flow rate than TPA2 doses 30 min intervalslyse clots through the activation of plasminogen第3頁，共58頁。8/4/2022Primary Trea

2、tmentAntiplatelet agents(abciximab, eptifibatide, tirofiban, integullin)GPIIb-IIIa antagonistsinhibit platelet function by blocking the GPIIb-IIIa receptor, the final pathway of platelet aggregationthereby decreasing thrombi development and prevents arterial vessel occlusion 第4頁，共58頁。8/4/2022Percuta

3、neous Coronary InterventionAdvantages include: higher recanulazation ratesimproved blood flow through the infarct-related vesselimproved LV functionlower in-hospital mortality rates 第5頁，共58頁。Anesthetic TechniqueGoals of Anesthesialoss of consciousnessamnesiaanalgesiasuppression of reflexes (endocrin

4、e and autonomic)muscle relaxation第6頁，共58頁。Preoperative PreparationAnginaMedications to control itBlood pressure controlledDiastolic 95 torrCongestive heart failure treatedDiureticsAfterload reductionBed rest if indicatedControl diabetes第7頁，共58頁。Preoperative MedicationsSedationPrevent tachycardiaHype

5、rtensionPrepared for hypoxiaSupplemental oxygenCalcium channel blockers not protective of perioperative ischemiaAntihypertensives continue on day of surgeryStop Diuretics第8頁，共58頁。8/4/2022Low Molecular Weight HeparinEnoxaparin, DalteparinAnticoagulant activity by binding to antithrombin III, which fu

6、rther binds and inactivates the coagulation factors IIa (thrombin) and XaAdvantages include dosed per body wt.Given q12 sub q. Less trombocytopenia and bleeding第9頁，共58頁。8/4/2022OpioidsAdvantage relates to the relative lack of myocardial depression Exception Sufenta, Carfentanil, and high dose fentan

7、ylThey maintain stable hemodynamics and reduce heart rateA primary opioid technique may be of value in the patient with severe myocardial dysfunction第10頁，共58頁。OpioidsAdvantagesExcellent analgesiaHemodynamic stabilityBlunt reflexesCan use 100% oxygen第11頁，共58頁。OpioidsDisadvantagesMay not block hemodyn

8、amic and hormonal responses in patients with good LV functionDo not ensure amnesiaChest wall rigidityRespiratory depression第12頁，共58頁。8/4/2022Vasoconstrictorsare useful in the prevention and treatment of ischemia r/t the ability to increase systemic BPPhenylephrine improves coronary perfusion pressur

9、e, at the expense of increasing afterload and Mv02第13頁，共58頁。8/4/2022VasoconstrictorsAt the same time, phenylephrine causes venoconstriction, increasing venous return and left ventricular preload.The increase in CPP more than offsets the increase in wall tension第14頁，共58頁。Inhalation AgentsAdvantagesMy

10、ocardial oxygen balance altered favorably by reductions in contractility and afterloadEasily titratableCan be administered via CPB machineRapidly eliminated第15頁，共58頁。8/4/2022Inhalational AgentsDisadvantages include myocardial depressionsystemic hypotension with possible tachycardialack of postoperat

11、ive analgesia第16頁，共58頁。Inhalation AgentsDisadvantagesSignificant hemodynamic variabilityMay cause tachycardia or alter sinus node functionPossibility of “coronary steal syndrome”第17頁，共58頁。Inhalation AgentsPotential for coronary stealAlters coronary autoregulationAlters regional blood flowLittle infl

12、uence on outcome第18頁，共58頁。Coronary StealArteriolar dilation of normal vessels diverts blood away from stenotic areasCommonly associated with adenosine, dipyridamole, and SNPForane causes steal and new ST-T segment depressionMay not be important since Forane reduces SVR, depresses the myocardium yet

13、maintains CO第19頁，共58頁。8/4/2022WE Ellis20Antianginal medicationsBeta-blockersCalcium Channel BlockersNitratesNitropaste morning of surgery第20頁，共58頁。8/4/2022NitratesNitroglycerin = venodialator, reduces venous return, decreases wall tension(Mv02) also a coronary arterial dialator.Drug of choice for co

14、ronary vasospasmAlthough primarily is a systemic venodialator, at high doses causes arterial dilatation and systemic hypotension第21頁，共58頁。Cardioactive drugsNitroglycerinLower LVEDPVasodilatorPoor ventricular function第22頁，共58頁。8/4/2022Beta BlockersBeta blockers reduce myocardial workload(Mv02), and o

15、xygen consumption(V02) by reducing HR,BP, and contractility, and they increase the threshold for ventricular fibrillation.Indications for beta blockers include: sinus tachycardia, supraventricular dysrhythmias and hyperdynamic states第23頁，共58頁。Beta BlockersNegative inotropic effectsWithdrawal followi

16、ng stoppage of beta blockerUnstable anginaMyocardial infarction第24頁，共58頁。8/4/2022Beta BlockersPropranolol (non-selective) t1/2 = 4-6 hoursMetoprolol (B1 selective) t 1/2 = 4-6 hoursLabatelol (1:7 ratio) t 1/2 = 2-4hoursEsmolol (Beta1 selective) t1/2 = 9.5 minutes第25頁，共58頁。EsmololControl heart rate a

17、nd blood pressureInductionEmergence第26頁，共58頁。LabetalolMixed alpha and betaControl hypertensionHeart rate management第27頁，共58頁。8/4/2022Ca Channel BlockersEvidence for beneficial effects post mi is less compellingNifedipine treatment is associated with a trend towards increased mortality and reinfarcti

18、onVerapamil does not reduce mortality or reinfarctionVerapamil - useful for slowing the ventricular response in atrial fibrillation/flutter第28頁，共58頁。8/4/2022Ca Channel BlockersCardizem- in pts with non-Q wave infarction seems to reduce the reinfarction rate during the 1st 6 months after the infarcti

19、on, but incidence of late infarction was similar to a placebo.Cardizem increases cardiac events in pts with LVEF3.37 mmol/1第37頁，共58頁。ClonidineLess hypertensionDecreased anesthesia requirements第38頁，共58頁。Anesthetic ManagementRegional vs. generalAnesthetic management skills more important than techniqu

20、eSafest technique is the one the practitioner does best第39頁，共58頁。Regional AnesthesiaMonitor patient more accuratelyControl sympathetic responsesFluidsEsmolol第40頁，共58頁。General anesthesiaAvoids sympathectomyRisks with intubationSympathetic stimulationHypoxiaIncreased catecholaminesLoss of subjective m

21、onitorChest painIschemia第41頁，共58頁。General Anesthesia requiredNarcoticsEffective control of catecholaminesRespiratory depressionProlonged ventilation第42頁，共58頁。LidocaineBlunt effects of intubation1.5 mg/kg 4-6 minutes prior to intubation第43頁，共58頁。Nitrous OxideRarely used due to:increased PVRdepression

22、 of myocardial contractilitymild increase in SVRair expansion第44頁，共58頁。Induction DrugsBarbituratesBenzodiazepinesKetamineEtomidate第45頁，共58頁。Avoid KetamineHypertensionTachycardiaUse in trauma第46頁，共58頁。EtomidatePainful to injectMore CV stability第47頁，共58頁。BarbiturateDirect depressantExtended duration o

23、f activitySmaller doses1-2 mg/kgAdd benzodiazepines and narcotic第48頁，共58頁。BenzodiazepinesQuell anxietyHemodynamic stabilityExtended duration of actionPotential for hypoxiaLidocaineEsmolol第49頁，共58頁。Muscle RelaxantsUsed to:facilitate intubationprevent shiveringattenuate skeletal muscle contraction during defibrillation第50頁，共58頁。Muscle RelaxantsAvoid pancuroniumTachycardiaST segment changes consistent with ischemiaDoxacurium Duration similar to pancuroniumNo cardiovascular effects第51頁，共58頁。Avoid Histamine releas