心臟病人非心臟手術(shù)課件

1、心臟病人非心臟手術(shù)指南2014 ACC/AHA Guideline術(shù)中麻醉管理部分麻醉藥物和麻醉技術(shù)Class IIa1. Use of either a volatile anesthetic agent or total intravenous anesthesia is reasonable for patients undergoing noncardiac surgery, and the choice is determined by factors other than the prevention of myocardial ischemia and MI (Level of

2、Evidence: A)Landoni G, Fochi O, Bignami E, et al. Cardiac protection by volatile anesthetics in non-cardiac surgery? A metaanalysis of randomized controlled studies on clinically relevant endpoints. HSR Proc Intensive Care Cardiovasc Anesth. 2009;1:34-43.Lurati Buse GAL, Schumacher P, Seeberger E, e

3、t al. Randomized comparison of sevoflurane versus propofol to reduce perioperative myocardial ischemia in patients undergoing noncardiac surgery. Circulation. 2012;126:2696-704.文獻(xiàn)匯報文獻(xiàn)12768 to TIVA and 3451 receiving desflurane or sevoflurane in their anesthesia planVolatile anesthetic dosage varied

4、across studies, ranging 0.33-2 MAC in the 609 patients receiving desflurane and 0.25-2 MAC in the 2842 patients receiving sevofluraneHospital stay was identical between groups(WMD 0.01 days -0.06, 0.07, p for effect=0.88, p for heterogeneity =0.48,I2=0% with 1201 included patients No author reported

5、 any postoperative myocardial infarction or death among the study population, nor any significant cardiac adverse eventPostoperative renal or respiratory failure and release of cardiac biomarkers were not reported心律失常文獻(xiàn)2在心臟手術(shù)中22 included trials included 1,922 randomly assigned patients (904 to TIVA

6、and 1018 receiving desflurane or sevoflurane in their anesthesia plan)Volatile anesthetic dosage varied across the studies,but was always 0.15 MAC and ranged from 0.15-2 MAC in the 475 patients receiving desflurane and 0.25-4 MAC in the 543 patients receiving sevofluraneMINERVA ANESTESIOL 2009;75:26

7、9-73volatile anesthetics reduced the risk of MI (24/979 2.4% in the volatile anesthetics group vs. 45/874 5.1% in controls, OR = 0.510.32-0.84, P for effect = 0.008), all-cause mortality was also reduced (4/977 0.4% vs. 14/872 1.6%,OR=0.31 0.12-0.80, P for effect - 0.02a significant decrease in cTnI

8、 peak release (WMD-2.35 ng/dl -3.09,-1.60, P for effect 0.00001, P for heterogeneity 0.00001, I2=94.1% with 1,463 included patients) and the need for inotropic support (170/679 25.0% vs. 203/562 36.1%, OR=0.47 0.29, 0.76, P for effect 0.002, P for heterogeneity= 0.008, I2=53.1% with 1,241 included p

9、atients). a shorter ICU stay (WMD=-7.10 hours -11.47; -2.73, P for effect0.001, P for heterogeneity 0.00001, I2=76.6% with 1,433 included patients), time to hospital discharge (WMD = -2.26 days -3.83; -0.68, P for effect = 0.005, with 1,593 included patients) time on mechanical ventilation (WMD = -0

10、.49 hours -0.97; -0.02, P for effect = 0.04, p for heterogeneity 0.03, I2 = 44.1% with 1,846 included patients). Finally, only two studies reported one year follow-up data concerning major cardiac events (defined as cardiac death, non-fatal MI, unstable angina, intercurrent coronary angioplasty,CABG

11、, arrhythmias requiring hospitalization and new episodes of congestive heart failureClass IIa 2. Neuraxial anesthesia for postoperative pain relief can be effective in patients undergoing abdominal aortic surgery to decrease the incidence of perioperative MI (Level of Evidence: B)Nishimori M, Low JH

12、S, Zheng H, et al. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev. 2012;7:CD005059.文獻(xiàn)匯報15 trials that involved 1297 patients (633 patients receivedepiduralanalgesia and 664 receivedsystemicopioid analgesia) The postoperative dur

13、ation of tracheal intubation and mechanical ventilation was significantly shorter, by about 48%, in theepiduralanalgesia group. The overall event rates of myocardial infarction, acute respiratory failure (defined as an extended need for mechanical ventilation), gastrointestinal complications, and re

14、nal complications were significantly lower in the epiduralanalgesia group. Class IIb1. Perioperative epidural analgesia may be considered to decrease the incidence of preoperative cardiac events in patients with a hip fracture (Level of Evidence: B)文獻(xiàn)Anesthesiology 2003; 98:15663術(shù)中管理Class IIa1. The

15、emergency use of perioperative transesophageal echocardiogram is reasonable in patients with hemodynamic instability undergoing noncardiac surgery to determine the cause of hemodynamic instability when it persists despite attempted corrective therapy, if expertise is readily available. (Level of Evi

16、dence: C)Class IIb1. Maintenance of normothermia may be reasonable to reduce perioperative cardiac events in patients undergoing noncardiac surgery (150, 151). (Level of Evidence: B)2. Use of hemodynamic assist devices may be considered when urgent or emergency noncardiac surgery is required in the

17、setting of acute severe cardiac dysfunction (i.e., acute MI, cardiogenic shock) that cannot be corrected before surgery. (Level of Evidence: C)3. The use of pulmonary artery catheterization may be considered when underlying medical conditions that significantly affect hemodynamics (i.e., HF, severe

18、valvular disease, combined shock states) cannot be corrected before surgery. (Level of Evidence: C)Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA. 1997;277:1127-34C grouphypothermic

19、PT35.4+/-0.136.7+/-0.10.01Postoperative ventricular tachycardia2.4%7.9%;P=.04morbid cardiac events1.4%6.3%;P=.02Perioperative hypothermia (33 degrees C) does not increase theoccurrence of cardiovascular events in patients undergoing cerebral aneurysm surgery: findings from the Intraoperative Hypothe

20、rmia for Aneurysm Surgery Trial. Anesthesiology. 2010;113:327-42Class III: No Benefit1. Routine use of pulmonary artery catheterization in patients, even those with elevated risk, is not recommended (Level of Evidence: A)2. Prophylactic intravenous nitroglycerin is not effective in reducing myocardial i