主動(dòng)脈夾層手術(shù)的麻醉課件講義

主動(dòng)脈夾層手術(shù)的麻醉主動(dòng)脈夾層手術(shù)的麻醉1主動(dòng)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LOGO主動(dòng)脈夾層手2Contents1.主動(dòng)脈夾層病理生理特點(diǎn)2.麻醉前訪視與評(píng)估3.麻醉誘導(dǎo)與維持4.麻醉管理重點(diǎn)Contents3主動(dòng)脈夾層定義主動(dòng)脈內(nèi)膜和中層彈力膜發(fā)生撕裂,血液進(jìn)入主動(dòng)脈中層形成壁間假腔,并與主動(dòng)脈真腔相交通,稱為主動(dòng)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)先天性心臟病主動(dòng)脈夾層定義4分型StanfordA型StanfordB型累及升主動(dòng)脈僅累及降主動(dòng)和弓部主動(dòng)脈脈起始以遠(yuǎn)的,約占60%部位,約占7525%-40%分型5A型夾層升主動(dòng)脈全弓置換+升主動(dòng)脈Bental人工血管象鼻支架置換置換術(shù)置入術(shù)sun氏術(shù)A型夾層6主動(dòng)脈夾層病理生理特點(diǎn)高血壓波動(dòng)幅度多中心臨床與動(dòng)物實(shí)驗(yàn)發(fā)現(xiàn):1.80%以上的主動(dòng)脈夾層患者患有高血壓,部分患者主動(dòng)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(dòng)的幅度而不是血壓值高度與主動(dòng)脈夾層分裂相關(guān)研究表明:血壓波動(dòng)的幅度破壞了主動(dòng)脈血管的自我調(diào)節(jié)性和代償能力主動(dòng)脈夾層病理生理特點(diǎn)7主動(dòng)脈夾層病理生理特點(diǎn)主動(dòng)脈通道功能嚴(yán)重受損:真腔血流受阻+裂開(kāi)的夾層形成雙腔主動(dòng)脈。主動(dòng)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(dòng)脈夾層病理生理特點(diǎn)8主動(dòng)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(dòng)脈夾層破裂腦、腎等循環(huán)衰竭多器官缺血主動(dòng)脈夾層病理生理特點(diǎn)9Circulation2010se281221312839.d101181RCULATIONAHA109.92942.:20108013.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,enrolledinRADtom1996to200,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-riskgroupCirculation2010se281221312839.10jac,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-curverelationshipwithin-hospitalmortalityinpatientswithAAD.Althoughthisssociabonwasrelatedtoincreasedratesofcomorbidconditionsattheedgesofthecurve,SaPsadmrmHgwasanindependet'elateoTin-nospltalmortalitjac,201日.01.06411主動(dòng)脈夾層手術(shù)的麻醉課件講義12主動(dòng)脈夾層手術(shù)的麻醉課件講義13主動(dòng)脈夾層手術(shù)的麻醉課件講義14主動(dòng)脈夾層手術(shù)的麻醉課件講義15主動(dòng)脈夾層手術(shù)的麻醉課件講義16主動(dòng)脈夾層手術(shù)的麻醉課件講義17主動(dòng)脈夾層手術(shù)的麻醉課件講義18主動(dòng)脈夾層手術(shù)的麻醉課件講義19主動(dòng)脈夾層手術(shù)的麻醉課件講義20主動(dòng)脈夾層手術(shù)的麻醉課件講義21主動(dòng)脈夾層手術(shù)的麻醉課件講義22主動(dòng)脈夾層手術(shù)的麻醉課件講義23主動(dòng)脈夾層手術(shù)的麻醉課件講義24主動(dòng)脈夾層手術(shù)的麻醉課件講義25主動(dòng)脈夾層手術(shù)的麻醉課件講義26主動(dòng)脈夾層手術(shù)的麻醉課件講義27主動(dòng)脈夾層手術(shù)的麻醉課件講義28主動(dòng)脈夾層手術(shù)的麻醉課件講義29主動(dòng)脈夾層手術(shù)的麻醉課件講義30主動(dòng)脈夾層手術(shù)的麻醉課件講義31主動(dòng)脈夾層手術(shù)的麻醉課件講義32主動(dòng)脈夾層手術(shù)的麻醉課件講義33主動(dòng)脈夾層手術(shù)的麻醉課件講義34主動(dòng)脈夾層手術(shù)的麻醉課件講義35主動(dòng)脈夾層手術(shù)的麻醉課件講義36謝謝你的閱讀知識(shí)就是財(cái)富豐富你的人生71、既然我已經(jīng)踏上這條道路，那么，任何東西都不應(yīng)妨礙我沿著這條路走下去?！档?/p>

72、家庭成為快樂(lè)的種子在外也不致成為障礙物但在旅行之際卻是夜間的伴侶?！魅_

73、堅(jiān)持意志偉大的事業(yè)需要始終不渝的精神?！鼱柼?/p>

74、路漫漫其修道遠(yuǎn)，吾將上下而求索?！?/p>

75、內(nèi)外相應(yīng)，言行相稱?！n非謝謝你的閱讀知識(shí)就是財(cái)富71、既然我已經(jīng)踏上這條道路，那么，37主動(dòng)脈夾層手術(shù)的麻醉主動(dòng)脈夾層手術(shù)的麻醉38主動(dòng)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LOGO主動(dòng)脈夾層手39Contents1.主動(dòng)脈夾層病理生理特點(diǎn)2.麻醉前訪視與評(píng)估3.麻醉誘導(dǎo)與維持4.麻醉管理重點(diǎn)Contents40主動(dòng)脈夾層定義主動(dòng)脈內(nèi)膜和中層彈力膜發(fā)生撕裂,血液進(jìn)入主動(dòng)脈中層形成壁間假腔,并與主動(dòng)脈真腔相交通,稱為主動(dòng)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)先天性心臟病主動(dòng)脈夾層定義41分型StanfordA型StanfordB型累及升主動(dòng)脈僅累及降主動(dòng)和弓部主動(dòng)脈脈起始以遠(yuǎn)的,約占60%部位,約占7525%-40%分型42A型夾層升主動(dòng)脈全弓置換+升主動(dòng)脈Bental人工血管象鼻支架置換置換術(shù)置入術(shù)sun氏術(shù)A型夾層43主動(dòng)脈夾層病理生理特點(diǎn)高血壓波動(dòng)幅度多中心臨床與動(dòng)物實(shí)驗(yàn)發(fā)現(xiàn):1.80%以上的主動(dòng)脈夾層患者患有高血壓,部分患者主動(dòng)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(dòng)的幅度而不是血壓值高度與主動(dòng)脈夾層分裂相關(guān)研究表明:血壓波動(dòng)的幅度破壞了主動(dòng)脈血管的自我調(diào)節(jié)性和代償能力主動(dòng)脈夾層病理生理特點(diǎn)44主動(dòng)脈夾層病理生理特點(diǎn)主動(dòng)脈通道功能嚴(yán)重受損:真腔血流受阻+裂開(kāi)的夾層形成雙腔主動(dòng)脈。主動(dòng)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(dòng)脈夾層病理生理特點(diǎn)45主動(dòng)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(dòng)脈夾層破裂腦、腎等循環(huán)衰竭多器官缺血主動(dòng)脈夾層病理生理特點(diǎn)46Circulation2010se281221312839.d101181RCULATIONAHA109.92942.:20108013.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,enrolledinRADtom1996to200,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-riskgroupCirculation2010se281221312839.47jac,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).Notab