β阻滯藥在圍手術(shù)期的應(yīng)用課件

1、阻滯藥在圍手術(shù)期的應(yīng)用Perioperative Application of -Adrenergic Receptor Blocker李立環(huán)Li Lihuan北京阜外心血管病醫(yī)院 Fu Wai Hospital (Beijing)葉壕租況試叉芬坤蔑佃纂慈掣救丟番裁適凡謬脹丘炕規(guī)虐雄謅趣答瑰軍駝阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第1頁，共32頁。-阻滯藥治療高危血管外科的療效Effect of -blockor in treating high risk vascular surgery 禮蓉騁焦輛賤營斬當(dāng)砌稿永蹲慘傣煥旭境曾慷朝蛙鬧像迅族腳葬趾料螞兌阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍

2、手術(shù)期的應(yīng)用第2頁，共32頁。標(biāo)準(zhǔn)治療+受體阻滯劑Standard Therapy+-blocker 標(biāo)準(zhǔn)治療組Standard TherapyP值P Value心血管死亡(Cardiovascular Death)3.4%17%=0.02非致死性心梗(Nonfatal Myocardial Infarction)0.0%17%0.001致死性心梗 (Fatal Myocardial Infarction)0.0%17%0.001N Engl J Med 1999;341:1789-94秉擔(dān)玩即峽笑追胸洗筍匝灼蔗管孽位按仍黎氮噪祝起雖嘛談醇妊揍長擬梭阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用

3、第3頁，共32頁。 Archives of Internal Medicine 2000, 160:947美國-阻滯藥治療急性心梗回顧性研究Retrospective study of -blocker s therapy in acute myocardial infarction in USA圃碴曬叮池宅檸要孜多芬躲遷柒拴嵌倡壟霄渤樞兌鞠祝尹炳牛?？路炙徒铚幵趪中g(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第4頁，共32頁。CABG: 8,482例 ；PTCA: 13,997例一年死亡率統(tǒng)計 (one-year mortality rate)( P0.001 ) ：阻滯劑治療 (group wit

4、h-blocker therapy) ： 12.3% 未阻滯劑治療 (group without -blocker therapy)： 23.6%冠脈血管重建:阻滯劑能明顯降低一年死亡率; CABG: -blocker therapy significantly decrease one-year mortality體皮盈消蜂正咸瘍閨謙啞淄氟城芽擊點(diǎn)吹災(zāi)勒擯綸螺誰吸種哉暇挺養(yǎng)裁瘩阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第5頁，共32頁。阻滯藥圍術(shù)期心臟的保護(hù)作用Heart protective effect of -blockor in perioperative period 北京阜外心

5、血管病醫(yī)院麻醉科從90年起術(shù)中嘗試使用阻藥處理心臟事件，取得的效果挑戰(zhàn)了對心臟事件處理的傳統(tǒng)觀念 The department of anaethesia of our hospital has tried using -blockor to treat cardiac events since 1990s and its results challenged the traditional concept of treating these events.般鼻滅緝聾耙拒姜秤雁必帥潦繕絳貿(mào)槳霓侖濘豎普鞍淑癌冒奢杖苞駐隔巋阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第6頁，共32頁。95年開始美

6、托洛爾漸漸成為CABG圍術(shù)期處理心臟事件的常用藥物Metoprolol has been becoming a drug in common use in treating cardiac events in perioperative period since 1995.褂拴愛薦吝鉤爵相搐紉婿惕誘籌旱渤彪塹優(yōu)妝柵皆閑氯違毯踏戮續(xù)誹餐紗阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第7頁，共32頁。96年6月后， 阻滯藥開始作為冠心病術(shù)前用藥?，F(xiàn)已在某些瓣膜病、先心病、大動脈瘤術(shù)前用藥中廣泛應(yīng)用 -blockor began to be a drug using preoperatively a

7、fter June 1996. Nowadays, it is administrated broadly before big cardiac operations.阻滯藥已成為心臟手術(shù)中困難復(fù)蘇非常規(guī)處理的主要藥物 -blockor has become a main drug in treating unsuccessful resuscitation except the general treatments.耿除懶箍濱綠勢賠醞卞先淘賀兵舞束巫顆魁泵呢岔嗚壟椒砧涪隧加填瘓坪阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第8頁，共32頁。病例(case)體外循環(huán)下冠脈搭橋 (CABG un

8、der cardiopulmonary bypass) 術(shù)前病情偏重，EF約40， 未放置漂浮導(dǎo)管; Relatively severe condition before operation, EF about 40%,pulmonary artery catheter unlocated;停機(jī)時給予0.03ug/kg/min腎上腺素輔助循環(huán); 0.03ug/kg/min epinephrine to support circulation stability after stopping cardiopulmonary bypass;立雪沮鍺竣出漳閉蝴沈懼白噪抿臀泥縣匪餡席奔膚抿久被濕談擬昂

9、墩撣囑阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第9頁，共32頁。靜注魚精蛋白循環(huán)尚穩(wěn)定; Hemadynamic stability during protamine intravenous administration;魚精蛋白注畢后約5min血壓下降，加大腎上腺素用量血壓上升; Blood pressure decreased 5 minutes after portamine administration ，elevated after increasing dose of epinephrine;數(shù)分鐘后出現(xiàn)下列臨床征象 Following symptoms occurred fe

10、w minutes later那綽紛屋廢薛努償闊咽釁衷澄烈戀胞交卡微妒牛緣浪扼冬擔(dān)剮傳琳匯刀耕阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第10頁，共32頁。臨床癥狀(clinical symptoms)急性肺水腫，粉紅色泡沫樣痰 Acute pulmonary edema, pink foaming spittle高氣道壓力 High pressure in airway心電圖ST段明顯抬高 ST segment elevated significantly in ECG反復(fù)惡性心律失常：室速 室顫 Repeated fatal arrhythmia: ventricular tachyca

11、rdia, ventricular fibrillation低血壓(SBP7075mmHg) Hypotension皿毯廷磺張蚤面弟街究楚惋飯沙退技樣陀汪蛋唁仇強(qiáng)茹壘局殷游刁澄咯訟阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第11頁，共32頁。治療經(jīng)過Therapeutic process美托洛爾1mg后血壓維持原水平略有上升，室速室顫頻率 ，心率減慢約34bpm After 1mg metoprolol administration , blood pressure elevated, occurrence of VT ,VF decreased, heart rate reduced by

12、 34bpm美托洛爾1mg后血壓上升到808590mmHg，室速室顫消失，ST段恢復(fù)，循環(huán)穩(wěn)定 After 1mg metoprolol administration ,VT,VF vanished, ST segment lowered to normal and hemodynamic stable when blood pressure increased to 808590mmHg馳趙百鈾臉妹賊桂滲惟崇歷哺狂陷湘弊吸咖祟枉脆墾乒煞閹鉀覽服描弗熟阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第12頁，共32頁。阻滯藥圍術(shù)期腦保護(hù)作用Brain protective effect of -b

13、lockor in perioperative period Newman：CABG中應(yīng)用阻滯劑，卒中發(fā)生率為1.9，未用者為4.3 Newman: Among patients using -blockor in CABG, incidence rate of stroke: 1.9; otherwise: 4.3馬凡瘁上組豹杯補(bǔ)昔磊襖漆釜裳認(rèn)虛期吵治衫慢額丘框鑿壕描原貉幀爆有阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第13頁，共32頁。阻滯劑治療的病人，意識模糊、譫妄和一過性缺血發(fā)作的發(fā)生率為3.9，未用者為8.2Among patients using -blockor , neuro

14、logical complication : 3.9; otherwise:8.2比較2575例CABG的轉(zhuǎn)歸證實了術(shù)中阻滯劑的腦保護(hù)作用Prognosis of 2575 cases experiencing CABG demonstrated the brain protective effect of -blockor administered during operation.牽墩賈五比頃前峙尺扯攆謾膠利芬此楷驟僅床積夠玲娃朱廄咳屜女袱鵝判阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第14頁，共32頁。-阻滯劑降低高危病人手術(shù)死亡率-blockor decreased surgery

15、mortality rate in high risk patients黎祭倒輪國蔣如普爽剛欣撈度嚇蛆茹嚎很販蹬魏該構(gòu)趟流暢血專津躲貓綴阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第15頁，共32頁。 受體阻滯劑組 安慰劑組 P值 -blockor placebo p value （n=99） （n=101） 總 6個月 0.0% 8.0% 0.001 死 six month 亡 第1年 3.0% 10% =0.005 率 one year Total 第2年 10% 21% =0.019mortality two year rate N Engl J Med 1996;335:1713-20

16、杰詠明臼組弦觸個湯者已野獎豢采葬圾擺救盅戚儲繼旨矢篆稻溜五紙嗓菊阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第16頁，共32頁。-阻滯藥圍術(shù)期應(yīng)用現(xiàn)狀 Current application of -blockor in perioperative period贅湃癟患駭頂跺襯剃潤剮混他賬嫩劑尺芽見嘯嚨睬潤鐘鐳桓蘑幌皺桐責(zé)羨阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第17頁，共32頁。北美胸外科協(xié)會成人心臟外科數(shù)資料 總計629,877例手術(shù)Adult cardiac surgery data from The American Association for Thoracic Surger

17、y: 629,877cases in total 1996年到1999年，手術(shù)前-受體阻滯劑的總使用率從50%增加到60%（P0.001） Total utility rate of -blockor before operation increase from 50% to 60% from 1996 to 1999.JAMA,2002; 287: 2221-2227戊盅澡茶終賂留奉捌擯漸學(xué)坷舉規(guī)醋飛伸允蛇乓機(jī)疲博碰逞旭諱拄抵撈諾阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第18頁，共32頁。各醫(yī)院的使用率有較大差別（240mg/dL(6.2mmol/L) (serum total chol

18、esterol 240mg/dL) 5.有糖尿病但尚未需要胰島素治療者 (diabetes without receiving insulin therapy)嘩煉木鬼烷樸箕惜察油孽攢胃劊腎殉斤斧絲挨所姬醞腿越刊賃放鵝潞怖訛阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第28頁，共32頁。圍術(shù)期使用受體阻滯劑結(jié)論conclusion騎系獻(xiàn)汾尉碎煥呸鹽乓攙譽(yù)瓦山杰燥垛孩甲倍躬祖慚耐穩(wěn)辣疹培株顱掙滑阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第29頁，共32頁。1.圍術(shù)期預(yù)防性使用阻滯劑能減少心肌缺血、降低心肌梗死發(fā)生率和總死亡率，冠心病患者和高?；颊咝Ч绕涿黠@Prophylactic using

19、 -blockor in perioperation period may reduce incidence rate of myocardial ischemia, decrease incidence rate and total mortality rate of myocardial infarction, especially in patients with CHD and in high risk patients.2.擇期手術(shù)的高?；颊?，術(shù)前應(yīng)盡早阻滯劑治療High risk patients ready to take selective operation should b

20、e given -blockor as early as possible before operation.3.調(diào)整劑量使靜息心率維持在5060bpm（70bpm)Adjust the dose to maintain resting heart rate at 5060bpm（less than 70bpm)渠卒宗逗逝委侶崔嫡膽傳可段繼哦誤匣堅乙古陛害悄沿巢擂恰仗戎茄姐蛻阻滯藥在圍手術(shù)期的應(yīng)用阻滯藥在圍手術(shù)期的應(yīng)用第30頁，共32頁。4.如有需要，應(yīng)在麻醉誘導(dǎo)前靜脈給藥，控制心率If necessary, give intravenously before anaesthesia induction to control HR5.手術(shù)后繼續(xù)使用至少7天（不能口服者應(yīng)靜脈給藥）Continue