【高血壓英文課件】-心血管疾病的麻醉

CardiovascularComplicationsrelatedtoAnesthesiaWanawimolSaengchoteM.D.DepartmentofAnesthesiology,RamathibodiHospital,MahidolUAnestheticGoals

SAFETYAnesthesiaIncidentMonitoringStudyJanuarytoJune2007.200,000cases,2537incidentsAstandardizedincidentreportformwasdevelopedinordertofillinwhat,where,when,how,andwhyithappenedTHAIAIMSJMedAssocThai2008;91(7):1011-9DO2=COx10xCaO2TissueO2delivery=cardiacoutputxarterialO2

contentCO=SVxHRSV∞preload,contractility,afterloadCO=EFxLVEDVxSVRxHRBasicCVSphysiologyPatient’scomorbid:controllability?Anestheticmanagement:drugs,techniques,process,anesthesiapersonnelSurgicalprocedureFactorscontributingtoCVScomplicationsA.HYPOTENSIONPreoperativeIntraoperative&PO.HypovolemiaPreopNPOTrauma-fracturesPeritonitisN/v,diarrheaBowelprepDiureticsBloodlossMajorfluidshiftTissueedemaEffusionDiuresis(concealedbloodloss)TachycardiaPeripheralvasoconstrictionLowsystolicbloodpressureNarrowpulsepressureCold,clammyskinandextremitiesLowurineoutput(anemianotapparentinacutelosswithoutadequatevolumereplacement)Withbetablockereffect,notachycardiadetectedSymptoms&SignsofHypovolemiaClinicalClassesofSeverityof

HypovolemicShock

ClassIClassIIClassIIIClassIVPulserate<100/min>100/min>120/min>140/minBPnormalnormaldroppeddroppedPulsepr.normaldecreaseddecreaseddecreasedRR14-20/min20-30/min>30/min>35/minUrine>30ml/hr20-30ml/hr5-15ml/hrminimalCapill.refilnormaldelayeddelayeddelayedMentalst.Sl.anxiousanxiousconfusedlethargicBl.loss(ml.,%)<750<15%750-1,50015-30%1,500-2,00030-40%>2,000>40%Fluidcrystalloid+colloid+colloid,bl.+colloid,bl.Alerttoenvironment,noticesurgeon’s(andteam)expressionGoodcommunicationAdequatevolumeloadingisallthetimenecessary(crystalloid–colloid)BloodandbloodcomponentasrequiredCriticalperfusionpressureshouldbemaintained(MAP>65mmHg)ConcernaboutdistributionofregionalbloodflowIntraoperativemanagement

AccessoryforfastIVinfusionColloidsavailability1.Drugeffect:nearlyallanestheticagentsdepressmyocardialcontractilityPotentinhalationagentsNitrousoxideincompromisedheartIntravenous:thiopental,propofol,ketamineOpioid:pethidine (arrhythmogeniceffecttobediscussedlater)B.ImpairedmyocardialcontractilityCoronaryarterydiseaseMyocardialischemia/infarctCardiogenicshockValvularheartdiseaseCongestiveheartfailuremostcommonrheumaticheartdisease:mitral,aortic,tricuspidvalveB.IMC:PumpingfailureAcuteischemicepisodelargeorsignificantmyocardialloss?seriousventriculararrhythmia,pulmonarycongestion,hypotension.....Hemodynamicsupport:inotropes,antiarrhythmic,mechanicaldeviceCardiacmarkers:troponinI,AST,LDH,CK-MBcTnT<0.1ng/L,cTnI<2.0ng/L,CK-MB0-25u/L(>2xnormal)IschemicheartdiseaseObstructiontoheart,cardiacchambersorgreatvesselsreducedstrokevolumeCauses:1.Cardiactamponadefrominjury,postcardiacsurgery,cardiaccatheterization*2.Tensionpneumothorax*3.Pulmonaryembolism*4.Surgicalmanipulationinchest,esophageal,cardiacsurgery5.SupinehypotensivesyndromeB.ObstructivelesionsAcuteonsetofpulmonaryembolism1.druginteractions:concurrentdruguse+anestheticeffect ACEI,CCB,opioids,IVanesthetic,inhalationagent2.regionalanesthesia:spinal,epiduralan.withsympatheticblockadeeffect3.variousdrugeffect:antibiotics,protamine,4.bonecement5.sepsis,adrenalinsufficiency,bloodtransfusionC.Decreasedafterload20%ofpopulationwithhypertensivediseasesCausesofintraoperativeHTNResponsetolaryngoscopyandintubationLightanesthesiaHypercarbiaHypoxemiaDrugeffectHypervolemiaSpecificsurgicalprocedureD.HYPERTENSIONCausesofHTNpostopandatemergence1.Stimulifromendotracheal&extubation2.Pain3.Hypoventilation,airwayobstruction4.Hypothermia,shivering5.Acidosis6.Fullbladder7.AntihypertensivewithdrawalHYPERTENSIONRiskFactorsHypertensionDiabetesmellitusUnderlyingheartdisease:CAD,VHDLiverdisease,renaldiseaseHeadinjurySepsisCarbonmonoxidepoisoning(elderly,malnutrition,hypoalbuminemia)HYPERVOLEMIA,pulmonaryedemaA62yr-oldfemalesuspectedCBDstone,scheduledforERCP,planforpostproceduraladmission.Anesthetictime1hr15mins.,uneventfulan.andsurgicalprocedureAfterextubation,?Abn.breathingpattern,occ.finecrepitationsBLL.LaterSPO2dropIVfluid800mL,minimalbloodlossDiureticgiven,PACU>2hrs.AtwardSBPdrop,intubate–ventilate,ondopaInterestingCase1.PhysiologicaldisturbancesduringanesthesiaAnestheticsmodifybodymechanism+vagaldominant,acidosis,hypoxia/hypercarbia,electrolytedisorder,hypovolemia2.PathologicaldisturbancesCAD:heartblock,PVC,Thyrotoxicosis,MH,pheochromocytoma3.Pharmacologicalcauses:ketamine,NMB4.Anesthesiapro