老年患者麻醉管理與腦保護(hù)課件

老年患者麻醉管理與腦保護(hù)基于病例的學(xué)習(xí)病例報(bào)告患者，男，68歲，64kg，170cm，ASA

II級(jí)主訴：體檢發(fā)現(xiàn)右肺占位2個(gè)月入院診斷：右肺下葉腺癌（T1bN0M0）高血壓II級(jí)，極高危2型糖尿病高脂血癥腦梗死（右側(cè)丘腦）擬施手術(shù)：胸腔鏡下肺葉切除術(shù)既往史高血壓25年，最高140/100mmHg，氨氯地平5mgbid，平時(shí)130/90mmHg糖尿病史2年，二甲雙胍0.5gtid，空腹血糖8mmol/L，餐后2h血糖8mmol/L高脂血癥15年，阿托伐他汀10mgQN丘腦梗死1月余，遺留左面部麻木，氯吡格雷75mgQd，術(shù)前7天改依諾肝素0.4mlQd入院查體HR84bpm，BP125/86mmHg，RR18次/分，SpO296%雙肺呼吸音清；心律齊，無雜音及奔馬律；心臟濁音界正常左側(cè)三叉神經(jīng)分布區(qū)針刺覺減退，四肢肌力、肌張力正常，病理征（-）實(shí)驗(yàn)室檢查血常規(guī)：HB

166g/L，PLT

173×109/L糖化血紅蛋白：6.4%(6.1-7.9%)血?dú)夥治觯簆H

7.42,PaCO236.0mmHg,PaO2

83.7mmHg凝血全項(xiàng)：PT13.5s,APTT29.5s,Fib2.50g/L心電圖:

無異常輔助檢查超聲心動(dòng)：左室壁肥厚，左室舒張功能減低，升主動(dòng)脈輕度擴(kuò)張，EF63%肺功能檢查：FEV12.35，F(xiàn)EV1/FVC73%，RV/TLC39%，DLCO10.2，通氣儲(chǔ)備84%輔助檢查頭顱MRI:右側(cè)丘腦、雙側(cè)腦室旁及雙側(cè)放射冠可見散在斑點(diǎn)、斑片狀異常信號(hào)，提示腦內(nèi)多發(fā)腔隙性腦梗死，腦白質(zhì)變性頸動(dòng)脈超聲：雙側(cè)頸動(dòng)脈內(nèi)-中膜不均增厚TCD：未見異常術(shù)前高血壓既往腦卒中抗血小板治療他汀類治療Contents麻醉方法選擇麻醉深度維持術(shù)中血壓維持血糖水平管理血壓與腦卒中死亡率的關(guān)系Lancet.2002;360:1903–13收縮壓舒張壓血壓與缺血性心臟病死亡率的關(guān)系Lancet.2002;360:1903–13.收縮壓舒張壓血壓與其他血管相關(guān)死亡率關(guān)系Lancet.2002;360:1903–13.收縮壓舒張壓血壓每增加20/10mmHg，心血管死亡風(fēng)險(xiǎn)加倍Lancet.2002;360:1903-1913;JAMA.2003;289:2560-2572收縮壓下降2mmHg，心腦血管事件風(fēng)險(xiǎn)降低10%Lancet.2002;360:1903-1913美國(guó)成年人血壓隨年齡、種族的變化NEnglJMed.2007;357:789–96冠心病不良預(yù)后風(fēng)險(xiǎn)與年齡、血壓關(guān)系A(chǔ)geSBPDBP<601107560-701157570-8013575>8014070Bloodpressureandoutcomesinveryoldhypertensivecoronaryarterydiseasepatients:anINVESTsubstudy.AmJMed.2010;123:719–26.年齡與最佳血壓高血壓(合并疾病)的治療NEnglJMed2009;361:878-87末次ACEI/ARB服藥時(shí)間與術(shù)中低血壓風(fēng)險(xiǎn)AnesthAnalg2005;100:636–44JournaloftheAmericanSocietyofHypertension8(9)(2014)644–6517RCTswith571adults,anytypesurgeryunderGABenefitsandharmsofperioperativeACEIs/ARBsCochraneDatabaseofSystematicReviews2016,Issue1.Art.No.:CD009210.CochraneDatabaseofSystematicReviews2016,Issue1.Art.No.:CD009210.CochraneDatabaseofSystematicReviews2016,Issue1.Art.No.:CD009210.CochraneDatabaseofSystematicReviews2016,Issue1.Art.No.:CD009210.NoevidencetosupportthatperioperativeACEIsorARBscanpreventmortality,morbidity,andcomplicationsCochraneDatabaseofSystematicReviews2016,Issue1.Art.No.:CD009210.高血壓病人的圍術(shù)期治療術(shù)前規(guī)范抗高血壓治療術(shù)日晨給予抗高血壓藥物(ACEI/ARB除外？)術(shù)后盡早恢復(fù)抗高血壓治療術(shù)前高血壓既往腦卒中抗血小板治療他汀類治療Contents麻醉方法選擇麻醉深度維持術(shù)中血壓維持血糖水平管理iao微小腦卒中也會(huì)損害腦血流自身調(diào)節(jié)腦血流自身調(diào)節(jié)損害不限于卒中側(cè)，而是整個(gè)腦腦血流自身調(diào)節(jié)的變化：腦卒中的前5天進(jìn)行性惡化隨后的1-3個(gè)月內(nèi)逐漸恢復(fù)腦血流自身調(diào)節(jié)損害時(shí)，輕度低血壓即致腦缺血，但血壓過高同樣有害Stroke.2010;41:2697-2704TimeelapsedafterischemicstrokeandriskofadversecardiovasculareventsandmortalityfollowingelectivenoncardiacsurgeryComparedwithpatientswithoutstroke,apriorstrokewithin3monthsMoremajorCVevents(OR14.23,95%CI11.61–17.45)Higher30-daymortality(OR3.07,95%CI2.30–4.09)JAMA2014;312:269–77近期腦卒中病人的手術(shù)時(shí)間選擇擇期手術(shù)：

推遲至3個(gè)月后改善危險(xiǎn)因素急診手術(shù)：認(rèn)真監(jiān)測(cè)、維持血壓腦缺血監(jiān)測(cè)(TCD、EEG、誘發(fā)電位)術(shù)前高血壓既往腦卒中抗血小板治療他汀類治療Contents麻醉方法選擇麻醉深度維持術(shù)中血壓維持血糖水平管理停用抗血小板藥物增加圍術(shù)期MACE風(fēng)險(xiǎn)Aretrospective,observationalstudy666patientswithcoronarystent(s)MACE=CVdeath,MI,orstrokeThrombHaemost2015;113:272–282ThrombHaemost2015;113:272–282MACECVdeathMIStrokePredictorsof30-dayMACEThrombHaemost2015;113:272–282持續(xù)抗血小板治療增加圍術(shù)期出血風(fēng)險(xiǎn)RCT,a2-by-2factorialtrialdesign10,010patientspreparingfornoncardiacsurgeryandatriskforvascularcomplicationsAspirin(initiation:200mgbefore,100mg/d*30d;continuation:100mg/d*7d,continue)PlaceboDeathormajorvascularcomplicationsat30daysNEnglJMed2014;370:1494-503PrimaryCompositeOutcomeNEnglJMed2014;370:1494-503RiskofLife-ThreateningorMajorBleedingNEnglJMed2014;370:1494-503圍術(shù)期小心使用抗血小板藥物出血風(fēng)險(xiǎn)?。豪^續(xù)使用出血風(fēng)險(xiǎn)大、CV風(fēng)險(xiǎn)?。和Ｖ故褂贸鲅L(fēng)險(xiǎn)大、CV風(fēng)險(xiǎn)大：停止使用，LMWH術(shù)前高血壓既往腦卒中抗血小板治療他汀類治療Contents麻醉方法選擇麻醉深度維持術(shù)中血壓維持血糖水平管理5RCTswith178participantsPerioperativeshort-termstatintherapyandoutcomesCochraneDatabaseofSystematicReviews2013,Issue7.Art.No.:CD009971EvidencewasinsufficienttoconcludethatstatinuseresultedineitherareductionoranincreaseinanyoftheoutcomesexaminedCochraneDatabaseofSystematicReviews2013,Issue7.Art.No.:CD00997117RCTswith2138participants,on-/off-pumpmyocardialrevascularisationEffectivenessofpreoperativestatintherapyCochraneDatabaseofSystematicReviews2015,Issue8.Art.No.:CD008493.PreoperativestatintherapyReducespostopAF,shortensLOSinICUandhospitalNoinfluenceonperiopmortality,stroke,MIorRFCochraneDatabaseofSystematicReviews2015,Issue8.Art.No.:CD008493.如果病人在服用他汀類治療，繼續(xù)術(shù)前高血壓既往腦卒中抗血小板治療他汀類治療Contents麻醉方法選擇麻醉深度維持術(shù)中血壓維持血糖水平管理Anoverviewof9CochranesystematicreviewsNeuraxialblock+/-GAGAaloneCochraneDatabaseofSystematicReviews2014,Issue1.Art.No.:CD010108Postoperativemortality

(0-30days)RAvs.GACochraneDatabaseofSystematicReviews2014,Issue1.Art.No.:CD010108Postoperativemortality

(0-30days)RA+GAvs.GACochraneDatabaseofSystematicReviews2014,Issue1.Art.No.:CD010108Postoperativepneumonia(0-30days)RA+GAvs.GARAvs.GACochraneDatabaseofSystematicReviews2014,Issue1.Art.No.:CD010108P=0.07PostoperativeMI

(0-30days)RAvs.GARA+GAvs.GACochraneDatabaseofSystematicReviews2014,Issue1.Art.No.:CD010108P=0.11高危病人盡可能選擇區(qū)域阻滯麻醉術(shù)前高血壓既往腦卒中抗血小板治療他汀類治療Contents麻醉方法選擇麻醉深度維持術(shù)中血壓維持血糖水平管理Meta-analysis39RCTs,16,082participantsNon-pharmacologicalorpharmacologicalinterventionsforpreventingdeliriumCochraneDatabaseofSystematicReviews2016,Issue3.Art.No.:CD005563.BIS-guidedanaesthesiavsBIS-blindedanaesthesiaCochraneDatabaseofSystematicReviews2016,Issue3.Art.No.:CD005563.LightpropofolsedationvsdeeppropofolsedationCochraneDatabaseofSystematicReviews2016,Issue3.Art.No.:CD005563.Retrospectivecohortstudy4087例惡性腫瘤手術(shù)病人麻醉期間BIS<45累積時(shí)間手術(shù)時(shí)惡性腫瘤分期術(shù)后2年死亡率AnesthAnalg2009;108:508–12BIS<45時(shí)間與術(shù)后遠(yuǎn)期死亡風(fēng)險(xiǎn)TBIS<45持續(xù)時(shí)間與2年死亡率明顯相關(guān)AnesthAnalg2009;108:508–12ApilotRCT125patientsASAIII-IV,aged≥60years,surgery≥2hours,andreceivinggeneralanesthesia“Low”group:BIS/SEtarget35“High”group:BIS/SEtarget50AnesthAnalg2014;118:981–6AnesthAnalg2014;118:981–6PostoperativeOutcomesAnesthAnalg2014;118:981–6深麻醉累積時(shí)間與術(shù)后病人預(yù)后的關(guān)系有待研究麻醉醫(yī)生傾向于維持過深麻醉常規(guī)麻醉深度監(jiān)測(cè)，避免全身麻醉過深術(shù)前高血壓既往腦卒中抗血小板治療他汀類治療Contents麻醉方法選擇麻醉深度維持術(shù)中血壓維持血糖水平管理Lancet2008;371:1839–47RCT8351patientswith,oratriskof,atheroscleroticdiseasewhowereundergoingnon-cardiacsurgeryExtended-releasemetoprolol(n=4174)Placebo(n=4177)Started2–4hbeforesurgeryandcontinuedfor30daysMyocardialinfarctionDeathStrokeCardiovasculardeathNon-fatalMINon-fatalCALancet2008;371:1839–47低血壓導(dǎo)致圍術(shù)期腦卒中風(fēng)險(xiǎn)增加Lancet2008;371:1839–47巢式病例對(duì)照研究48,241例病人，非心臟、非神外手術(shù)42例圍術(shù)期腦卒中(0.09%)252例對(duì)照病人(年齡、手術(shù)種類)Anesthesiology2012;116:658–64術(shù)中低血壓時(shí)間與圍術(shù)期腦卒中Anesthesiology2012;116:658–64?Statisticallysignificantinmultipletesting術(shù)中低血壓幅度與圍術(shù)期腦卒中Anesthesiology2012;116:658–64IntraophypotensionandPODAnobservationalcohortstudy734patients,on-pumpcardiacsurgery99patients(13%)developedPODBritishJournalofAnaesthesia,2015,427–33ORsfortheassociationbetweenAUCofintraoperativehypotensionandoccurrenceofPODBritishJournalofAnaesthesia,2015,427–330.05IntraophypotensionandPODSystematicreview11studies,1427patients,GIsurgeryRiskfactorsforPoDBJS2016;103:e21–e28IntraophypotensionassociatedwithPOD術(shù)中血壓(SBP/MBP)不低于基礎(chǔ)血壓20%術(shù)中最佳血壓？術(shù)前高血壓既往腦卒中抗血小板治療他汀類治療Contents麻醉方法選擇麻醉深度維持術(shù)中血壓維持血糖水平管理DetrimentaleffectsofelevatedglucoseinstrokeStroke.2004;35:363-364.血糖升高伴隨腦卒中病人預(yù)后惡化Anesthesiology2012;116:244–5129patientswithacuteischemicstroketreatedwithendovasculartherapyPredictorsofgoodneurologicoutcomeIntraoptightglucosecontrolRCT198adultpatientsundergoingcardiacsurgeryTightintraopglucosecontrol(80-110mg/dl)Standardtherapy(<150mg/dl)Anesthesiology2015;122:1214-23Anesthesiology2015;122:1214-23Patientswithtightglucosecontrolweremorelikelytodevelopdelirium

(26/93tightcontrolvs.15/105routine;P=0.03)Anesthesiology2015;122:1214-23RCT6104adultpatients,ICUtreatment≥3days3054intensivecontrol(4.5-6.0mmol/L)3050conventionalcontrol(≤10.0mmol/L)NEnglJMed2009;360:1283-97.NEnglJMed2009;360:1283-97.術(shù)中血糖水平維持<8-10