主動脈夾層手術(shù)的麻醉課件整理

主動脈夾層手術(shù)的麻醉皖南醫(yī)學(xué)院弋磯山醫(yī)院麻醉科王立鵬LOGOContents1.主動脈夾層病理生理特點(diǎn)2.麻醉前訪視與評估3.麻醉誘導(dǎo)與維持4.麻醉管理重點(diǎn)主動脈夾層定義主動脈內(nèi)膜和中層彈力膜發(fā)生撕裂,血液進(jìn)入主動脈中層形成壁間假腔,并與主動脈真腔相交通,稱為主動脈夾層。致病因素:高血壓病史(約80%患者)性別(男性居多)結(jié)締組織病(馬凡氏綜合征)先天性心臟病分型StanfordA型StanfordB型累及升主動脈僅累及降主動和弓部主動脈脈起始以遠(yuǎn)的,約占60%部位,約占7525%-40%A型夾層升主動脈全弓置換+升主動脈Bental人工血管象鼻支架置換置換術(shù)置入術(shù)sun氏術(shù)主動脈夾層病理生理特點(diǎn)高血壓波動幅度多中心臨床與動物實(shí)驗(yàn)發(fā)現(xiàn):1.80%以上的主動脈夾層患者患有高血壓,部分患者主動脈囊性中層壞死2.高血壓并非是囊性壞死的原因,但可促進(jìn)其進(jìn)展。3.血壓波動的幅度而不是血壓值高度與主動脈夾層分裂相關(guān)研究表明:血壓波動的幅度破壞了主動脈血管的自我調(diào)節(jié)性和代償能力主動脈夾層病理生理特點(diǎn)主動脈通道功能嚴(yán)重受損:真腔血流受阻+裂開的夾層形成雙腔主動脈。主動脈通道功能喪失:冠狀A(yù)、頭臂干/左頸總A、腎A等血管斷流→心、腦、腎重要臟器缺血主動脈夾層病理生理特點(diǎn)心臟壓塞、心律失常等心臟并發(fā)癥主動脈夾層破裂腦、腎等循環(huán)衰竭多器官缺血Circulation2019se281221312839.d101181RCULATIONAHA109.92942.:20198013.ImportanceofrefractorypainandhypertensioninacutetypeBaorticdissection:insightsfromtheInternationalRegistryofAcuteAorticDissection(IRADIPrimarchs,Ee,,既如,SP出chansonS!RamnoldivGrassi,9ossoneE距m啪A,TsaiTT,FroehlichJB,Coopery,MontgomeryD,MeinhardG,MyrmelT,UnchurchGR,SundtTIn,IsselbacherEMInternationalRegistryofAcuteAortic4AuthorintormationAbstractBACKGROUND:InpatientswithacutetypeBarticdissection,presenceDfrecurrentorretractorypainand/orrefractoryhypertensionmedicaltherapyissometimesusedasanindicationfarimvasletreatmentTheInternationalRegistyofAcuteAorticdissectionIRAD)wasusedtoinvestgatetheimpactofrefractorypainandrorrefractoryrypertensionontheoutcomesofacutetypeBaortCdissectionMETHODSANDRESULTS:Threehundredsity-fivepatientsaffectedbyuncomplicatedacutetypeBaorticdissection,enrolledinRADtom2019to200,werecategorizedaccordingtonskprotleinto2groupsPatientsworthrecurrentandorrefractorypainorretractoryypertension(groupln=69andpatentswithoutclinicalcomplicatonsatpresentation(grouplln=296)werecompared."High-riskIatientsmthclassiccomplicationswereExcludedfromthisanalysis.Theoverallin-hospitalmortalityMras6.5%and'nasincreasedingroupIcomparedwithgroupll(17.49versus4.0%P=0.000S).Thein-hospitalmortalityaftermedicalmanagementwrassignifcantlyicreasedingroupIcomparedwithgroupl[356%versus16%P=.0003)Mortalityratesaftersurgical[20versus28%P=0.74)ement(S.7%versus9.1%5P=0.50)didnotdiffersignificantybetweengrauplandgroupI,respectively.Aulbvariablelogisticregressionmodelconfirmedthatrecurrentandorrefractorypainorrefractoryhypertensionwasapredictorofinkhospitalmortality[oddsratio,3.31:95%confidenceinterval,1.04to10.45,P=0.041]CONCLUSIONS:Recurrentpainandrparticularlywhenmanagedmedically.Theseobservationssuggestthataorticintervention,suchasviaanendovascularapproachmaybeindicatedinthisintermediate-riskgroupjac,201日.01.064PresentingSystolicBloodPressureandoutcomesinPatientsWithAcuteAorticDissection.BossoneE1GorlaR,LaBountyThd3Suzuki,GilonD5,straussc5BallottaA'PatelHJB,EvangelistaA9.EhrlichMp10.Hutchison511,Kllne-Rogers三aktAuthorintormationAbstractBACKGROUND:Presentingsystolicbloodpressure(SBP)isapowerfulpredictorofmortalityinmamycardiovascularsettings,includingOBJECTIVES:ThisstuctyevaluatedtheassociationofpresentingSEPwithin-hosptaloutcomes.specificallyalk-causemortality.inMETHODS:Thestudyincluded6,23Bconsecutivepatients(4,167wothbypeAand2.071wnthtypeBAAD)enrolledintheInternationalRegIstyofAcuteaortiton.Patientswerestabledin4groupsaccordingtopresentingsBP:SBP>150,5BP101to150,SBPse0mmHdRESULIS:TherelationshipbeteenpresentingSBPandin-hospitalmortalitydisplayedaJ-curveassociation,unthsignifcantyhigtmortalityratesinpatientswi'thvelBP[26.3%forsBP>180mmHgintypeAAAD,13.3%5forsBP>200mmHgintypeBAAD0.005andp=0.018,respective)aswellasinthosesuitSBP$100mmHg(29.9%ointypeA,22.4intypeB,p=0.035andp=0.015,respectivelyl.Thisrelationshipwasmainlyfromincreasedratesofin-hospitalcamplications(acuterenalfailurE,coma,andmesentericischemiaanfarctioninpatientswthsBP>15DmmHg:stroke,coma,cardiactamponade,myocardialischemia/nfarctionandacuterenalfailureinpatientswithSBPs80mmHg).NotablypresentingSEPsBUmmHgmasindependentlyassociatedwithin-ospitalmortalityinbothtpeA[p=0.001)andtypeBAAD(p=0.003)CONCLUSIONS:PresentingSEPshowedaclearJ-