心臟病人非心臟手術術前評估與術中管理課件

心臟病人非心臟手術術前評估與術中管理楊柳青6、露凝無游氛，天高風景澈。7、翩翩新來燕，雙雙入我廬，先巢故尚在，相將還舊居。8、吁嗟身后名，于我若浮煙。9、陶淵明（約365年—427年），字元亮，（又一說名潛，字淵明）號五柳先生，私謚“靖節(jié)”，東晉末期南朝宋初期詩人、文學家、辭賦家、散文家。漢族，東晉潯陽柴桑人（今江西九江）。曾做過幾年小官，后辭官回家，從此隱居，田園生活是陶淵明詩的主要題材，相關作品有《飲酒》、《歸園田居》、《桃花源記》、《五柳先生傳》、《歸去來兮辭》等。10、倚南窗以寄傲，審容膝之易安。心臟病人非心臟手術術前評估與術中管理楊柳青心臟病人非心臟手術術前評估與術中管理楊柳青6、露凝無游氛，天高風景澈。7、翩翩新來燕，雙雙入我廬，先巢故尚在，相將還舊居。8、吁嗟身后名，于我若浮煙。9、陶淵明（約365年—427年），字元亮，（又一說名潛，字淵明）號五柳先生，私謚“靖節(jié)”，東晉末期南朝宋初期詩人、文學家、辭賦家、散文家。漢族，東晉潯陽柴桑人（今江西九江）。曾做過幾年小官，后辭官回家，從此隱居，田園生活是陶淵明詩的主要題材，相關作品有《飲酒》、《歸園田居》、《桃花源記》、《五柳先生傳》、《歸去來兮辭》等。10、倚南窗以寄傲，審容膝之易安。心臟病人非心臟手術術前評估與術中管理江蘇省蘇北人民醫(yī)院麻醉科楊柳青2009ESC/ESA指南本文檔由醫(yī)學百事通高端醫(yī)生網專家制作在線咨詢醫(yī)生網址:12320bstImpactFactor9.275IntroductionThepresentguidelinesfocusonthecardiologicalmanagementofpatientsundergoingnon-cardiacsurgery,i.e.patientswhereheartdiseaseisapotentialsourceofcomplicationsduringsurgerymajornon-cardiacsurgeryisassociatedwithanincidenceofcardiacdeathofbetween0.5and1.5%,andofmajorcardiaccomplicationsofbetween2.0and3.5%ImpactoftheageingpopulationItisestimatedthatelderlypeoplerequiresurgeryfourtimesmoreoftenthantherestofthepopulation

Pre-operativeevaluationSurgicalriskforcardiacevents:theurgency,magnitude,type,anddurationoftheprocedure,aswellasthechangeinbodycoretemperature,bloodloss,andfluidshiftsFunctionalcapacity

Functionalcapacityismeasuredinmetabolicequivalents(METs)ExercisetestingprovidesanobjectiveassessmentoffunctionalcapacityWithouttesting,functionalcapacitycanbeestimatedbytheabilitytoperformtheactivitiesofdailyliving

<4METsindicatespoorfunctionalcapacityandisassociatedwithanincreasedincidenceofpost-operativecardiaceventsRiskindicesGoldman(1977),Detsky(1986),Lee(1999)TheLeeindex,tobethebestcurrentlyavailablecardiacriskpredictionindexinnon-cardiacsurgerySixindependentclinicaldeterminants(TheLeeindex)ahistoryofIHDahistoryofcerebrovasculardiseaseheartfailureinsulin-dependentdiabetesmellitusimpairedrenalfunctionHigh-risktypeofsurgery

TheLeeindexAllfactorscontributeequallytotheindex(with1pointeach)theincidenceofmajorcardiaccomplicationsisestimatedat0.4,0.9,7,and11%inpatientswithanindexof0,1,2,and≥3points,respectivelyBiomarkersCardiactroponinsTandI(cTnTandcTnI)arethepreferredmarkersforthediagnosisofMIbecausetheydemonstratesensitivityandtissuespecificitysuperiortootheravailablebiomarkersPlasmaBNPandNT-proBNPimportantprognosticindicatorsinpatientswithheartfailureadditionalprognosticvalueforlong-termmortalityandforcardiaceventsNon-invasivetestingthreecardiacriskmarkers:

LVdysfunctionmyocardialischaemiaheartvalveabnormalities

EchocardiographyAmeta-analysisoftheavailabledatademonstratedthatanLVejectionfractionof<35%hadasensitivityof50%andaspecificityof91%forpredictionofperioperativenon-fatalMIorcardiacdeathawell-establishedinvasivediagnosticprocedure

rarelyindicatedtoassesstheriskofnoncardiacsurgery

AngiographyRiskreductionstrategies

Pharmacological

Besidesspecificriskreductionstrategiesadaptedtopatientcharacteristicsandthetypeofsurgery,preoperativeevaluationisanopportunitytocheckandoptimizethecontrolofallcardiovascularriskfactorsb-blockersThedoseofb-blockersshouldbetitrated,whichrequiresthattreatmentbeinitiatedoptimallybetween30daysandatleast1weekbeforesurgery.treatmentstartwithadailydoseof2.5mgofbisoprololor50mgofmetoprololsuccinatewhichshouldthenbeadjustedbeforesurgerytoachievearestingheartrateofbetween60and70bpmwithSBP>100mmHgNitrates:NitroglycerinDiureticsAspirinAnticoagulanttherapyRevascularizationSpecificdiseasesArterialhypertensionValvularheartdiseaseAorticstenosisMitralstenosisARandMRprostheticvalve(s)Arterialhypertensionantihypertensivemedicationsshouldbecontinuedduringtheperioperativeperiod.Inpatientswithgrade3hypertension(systolicbloodpressure≧180mmHgand/ordiastolicbloodpressure≧110mmHg),thepotentialbenefitsofdelayingsurgerytooptimizethepharmacologicaltherapyshouldbeweighedagainsttheriskofdelayingthesurgicalprocedureValvularheartdiseasehigherriskEchocardiographyshouldbeperformedAorticstenosisSevereAS:aorticvalvearea<1cm2

<0.6cm2/m2bodysurfacearea)Mitralstenosisrelativelylowrisk:non-significantmitralstenosis(MS)(valvearea>1.5cm2)andinasymptomaticpatientswithsignificantMS(valvearea<1.5cm2)andsystolicpulmonaryarterypressure<50mmHgcontrolofheartrateStrictcontroloffluidoverloadanticoagulationAFARandMRNon-significantARandMR(lowrisk)asymptomaticpatientswithsevereARandMRandpreservedLVfunction(lowrisk)SymptomaticpatientsandLVEF<30%(Highrisk,onlyifnecessary,optimizationofpharmacologicaltherapy)prostheticvalve(s)noevidenceofvalveorventriculardysfunction(withoutadditionalrisk)endocarditisprophylaxisanticoagulationregimenmodificationBradyarrhythmiasTemporarycardiacpacingisrarelyrequired,eveninthepresenceofpre-operativeasymptomaticbifascicularblockorCLBBBTheindicationsfortemporarypacemakersaregenerallythesameasthoseforpermanentpacemakersPacemaker/implantablecardioverterdefibrillatorunipolarelectrocauteryrepresentsasignificantriskbeavoidedby

positioningthegroundplateKeepingtheelectrocauterydeviceawayfromthepacemaker,givingonlybriefburstsandusingthelowestpossibleamplitudeTheimplantablecardioverterdefibrillatorshouldbeturnedoffduringsurgeryandswitchedonintherecoveryphasebeforedischargetothewardPerioperativemonitoring

V5(75%),V4(61%),V5+V4(90%),V5+V4+II(96%)ContinuousautomatedSTtrendingmonitors(sensitivityandspecificityof74and73%)ECGTransesophagealechocardiographyRightheartcatherizationbothalargeobservationalstudyandarandomizedmulticentreclinicaltrialdidnotshowabenefitassociatedwiththeuseofrightheartcatheterizationnodifferenceinmortalityandhospitalduration/ahigherincidenceofpulmonaryembolismDisturbedglucosemetabolismpromotesatherosclerosis,endothelialdysfunction,andactivationofplateletsandproinflammatorycytokinesIntraoperativeanaestheticmanagementproperorganperfusionpressureSpinalandepiduralanaesthesia(T4)Onemeta-analysisre