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1、老年患者麻醉管理与脑保护老年患者麻醉管理与脑保护基于病例的学习基于病例的学习病例报告患者，男，68岁，64kg，170cm，ASA II级主诉：体检发现右肺占位2个月入院诊断：右肺下叶腺癌（T1bN0M0）高血压II级，极高危2型糖尿病高脂血症脑梗死（右侧丘脑）拟施手术：胸腔镜下肺叶切除术既往史高血压25年，最高140/100mmHg，氨氯地平 5mg bid，平时130/90mmHg糖尿病史2年，二甲双胍 0.5g tid，空腹血糖8mmol/L，餐后2h血糖8mmol/L高脂血症15年，阿托伐他汀 10mg QN丘脑梗死1月余，遗留左面部麻木，氯吡格雷 75mg Qd，术前7天改依诺肝素
2、0.4ml Qd入院查体HR 84bpm，BP 125/86mmHg，RR 18次/分，SpO2 96%双肺呼吸音清；心律齐，无杂音及奔马律；心脏浊音界正常左侧三叉神经分布区针刺觉减退，四肢肌力、肌张力正常，病理征（-）实验室检查血常规：HB 166g/L，PLT 173 109/L糖化血红蛋白：6.4%(6.1-7.9%)血气分析：pH 7.42,PaCO2 36.0mmHg,PaO2 83.7mmHg凝血全项：PT 13.5s,APTT 29.5 s,Fib 2.50g/L心电图:无异常辅助检查超声心动：左室壁肥厚，左室舒张功能减低，升主动脉轻度扩张，EF 63%肺功能检查：FEV1 2.
3、35，FEV1/FVC 73%，RV/TLC 39%，DLCO 10.2，通气储备 84%辅助检查头颅MRI:右侧丘脑、双侧脑室旁及双侧放射冠可见散在斑点、斑片状异常信号，提示脑内多发腔隙性脑梗死，脑白质变性颈动脉超声：双侧颈动脉内-中膜不均增厚TCD：未见异常术前高血压既往脑卒中抗血小板治疗他汀类治疗Contents 麻醉方法选择麻醉深度维持术中血压维持血糖水平管理血压与脑卒中死亡率的关系Lancet.2002;360:190313收缩压舒张压血压与缺血性心脏病死亡率的关系Lancet.2002;360:190313.收缩压舒张压血压与其他血管相关死亡率关系Lancet.2002;360:1
4、90313.收缩压舒张压血压每增加20/10mmHg，心血管死亡风险加倍Lancet.2002;360:1903-1913;JAMA.2003;289:2560-2572收缩压下降2 mmHg，心脑血管事件风险降低10%Lancet.2002;360:1903-1913美国成年人血压 随年龄、种族的变化N Engl J Med.2007;357:789 96冠心病不良预后风险与年龄、血压关系AgeSBPDBP8014070Blood pressure and outcomes in very old hypertensive coronary artery disease patients:a
5、n INVEST substudy.Am J Med.2010;123:719 26.年龄与最佳血压高血压(合并疾病)的治疗N Engl J Med 2009;361:878-87末次ACEI/ARB服药时间与术中低血压风险Anesth Analg 2005;100:636 44Journal of the American Society of Hypertension 8(9)(2014)6446517 RCTs with 571 adults,any type surgery under GABenefits and harms of perioperative ACEIs/ARBsCo
6、chrane Database of Systematic Reviews 2016,Issue 1.Art.No.:CD009210.Cochrane Database of Systematic Reviews 2016,Issue 1.Art.No.:CD009210.Cochrane Database of Systematic Reviews 2016,Issue 1.Art.No.:CD009210.Cochrane Database of Systematic Reviews 2016,Issue 1.Art.No.:CD009210.No evidence to support
7、 that perioperative ACEIs or ARBs can prevent mortality,morbidity,and complicationsCochrane Database of Systematic Reviews 2016,Issue 1.Art.No.:CD009210.高血压病人的围术期治疗术前规范抗高血压治疗术日晨给予抗高血压药物(ACEI/ARB除外？)术后尽早恢复抗高血压治疗术前高血压既往脑卒中抗血小板治疗他汀类治疗Contents 麻醉方法选择麻醉深度维持术中血压维持血糖水平管理iao微小脑卒中也会损害脑血流自身调节脑血流自身调节损害不限于卒中侧，而
8、是整个脑脑血流自身调节的变化：脑卒中的前5天进行性恶化随后的1-3个月内逐渐恢复脑血流自身调节损害时，轻度低血压即致脑缺血，但血压过高同样有害Stroke.2010;41:2697-2704Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery Compared with patients without stroke,a prior stroke within 3 months More ma
9、jor CV events(OR 14.23,95%CI 11.6117.45)Higher 30-day mortality(OR 3.07,95%CI 2.304.09)JAMA 2014;312:26977近期脑卒中病人的手术时间选择择期手术：推迟至3个月后改善危险因素急诊手术：认真监测、维持血压脑缺血监测(TCD、EEG、诱发电位)术前高血压既往脑卒中抗血小板治疗他汀类治疗Contents 麻醉方法选择麻醉深度维持术中血压维持血糖水平管理停用抗血小板药物增加围术期MACE风险A retrospective,observational study666 patients with cor
10、onary stent(s)MACE=CV death,MI,or strokeThromb Haemost 2015;113:272282Thromb Haemost 2015;113:272282MACECV deathMIStroke Predictors of 30-day MACEThromb Haemost 2015;113:272282持续抗血小板治疗增加围术期出血风险RCT,a 2-by-2 factorial trial design10,010 patients preparing for noncardiac surgery and at risk for vascula
11、r complicationsAspirin(initiation:200 mg before,100 mg/d*30 d;continuation:100 mg/d*7 d,continue)PlaceboDeath or major vascular complications at 30 daysN Engl J Med 2014;370:1494-503Primary Composite OutcomeN Engl J Med 2014;370:1494-503Risk of Life-Threatening or Major BleedingN Engl J Med 2014;370
12、:1494-503围术期小心使用抗血小板药物出血风险小：继续使用出血风险大、CV风险小：停止使用出血风险大、CV风险大：停止使用，LMWH术前高血压既往脑卒中抗血小板治疗他汀类治疗Contents 麻醉方法选择麻醉深度维持术中血压维持血糖水平管理5 RCTs with 178 participantsPerioperative short-term statin therapy and outcomesCochrane Database of Systematic Reviews 2013,Issue 7.Art.No.:CD009971Evidence was insufficient to
13、 conclude that statin use resulted in either a reduction or an increase in any of the outcomes examinedCochrane Database of Systematic Reviews 2013,Issue 7.Art.No.:CD00997117 RCTs with 2138 participants,on-/off-pump myocardial revascularisationEffectiveness of preoperative statin therapyCochrane Dat
14、abase of Systematic Reviews 2015,Issue 8.Art.No.:CD008493.Preoperative statin therapy Reduces postop AF,shortens LOS in ICU and hospital No influence on periop mortality,stroke,MI or RFCochrane Database of Systematic Reviews 2015,Issue 8.Art.No.:CD008493.如果病人在服用他汀类治疗，继续术前高血压既往脑卒中抗血小板治疗他汀类治疗Contents
15、麻醉方法选择麻醉深度维持术中血压维持血糖水平管理An overview of 9 Cochrane systematic reviewsNeuraxial block+/-GAGA aloneCochrane Database of Systematic Reviews 2014,Issue 1.Art.No.:CD010108Postoperative mortality(0-30 days)RA vs.GACochrane Database of Systematic Reviews 2014,Issue 1.Art.No.:CD010108Postoperative mortality(
16、0-30 days)RA+GA vs.GACochrane Database of Systematic Reviews 2014,Issue 1.Art.No.:CD010108Postoperative pneumonia(0-30 days)RA+GA vs.GARA vs.GACochrane Database of Systematic Reviews 2014,Issue 1.Art.No.:CD010108P=0.07Postoperative MI(0-30 days)RA vs.GARA+GA vs.GACochrane Database of Systematic Revi
17、ews 2014,Issue 1.Art.No.:CD010108P=0.11高危病人尽可能选择区域阻滞麻醉术前高血压既往脑卒中抗血小板治疗他汀类治疗Contents 麻醉方法选择麻醉深度维持术中血压维持血糖水平管理Meta-analysis39 RCTs,16,082 participantsNon-pharmacological or pharmacological interventions for preventing deliriumCochrane Database of Systematic Reviews 2016,Issue 3.Art.No.:CD005563.BIS-gu
18、ided anaesthesia vs BIS-blinded anaesthesiaCochrane Database of Systematic Reviews 2016,Issue 3.Art.No.:CD005563.Light propofol sedation vs deep propofol sedationCochrane Database of Systematic Reviews 2016,Issue 3.Art.No.:CD005563.Retrospective cohort study4087例恶性肿瘤手术病人麻醉期间BIS45累积时间手术时恶性肿瘤分期术后2年死亡率
19、Anesth Analg 2009;108:508 12BIS45时间与术后远期死亡风险TBIS 45持续时间与2年死亡率明显相关Anesth Analg 2009;108:508 12A pilot RCT125 patients ASA III-IV,aged 60 years,surgery 2 hours,and receiving general anesthesia“Low”group:BIS/SE target 35“High”group:BIS/SE target 50 Anesth Analg 2014;118:9816Anesth Analg 2014;118:9816Po
20、stoperative OutcomesAnesth Analg 2014;118:9816深麻醉累积时间与术后病人预后的关系有待研究麻醉医生倾向于维持过深麻醉常规麻醉深度监测，避免全身麻醉过深术前高血压既往脑卒中抗血小板治疗他汀类治疗Contents 麻醉方法选择麻醉深度维持术中血压维持血糖水平管理Lancet 2008;371:183947RCT8351 patients with,or at risk of,atherosclerotic disease who were undergoing non-cardiac surgeryExtended-release metoprolol(
21、n=4174)Placebo(n=4177)Started 24 h before surgery and continued for 30 daysMyocardial infarction Death Stroke Cardiovascular deathNon-fatal MINon-fatal CA Lancet 2008;371:183947低血压导致围术期脑卒中风险增加Lancet 2008;371:183947巢式病例对照研究48,241例病人，非心脏、非神外手术42例围术期脑卒中(0.09%)252例对照病人(年龄、手术种类)Anesthesiology 2012;116:65
22、864术中低血压时间与围术期脑卒中Anesthesiology 2012;116:65864 Statistically significant in multiple testing 术中低血压幅度与围术期脑卒中Anesthesiology 2012;116:65864Intraop hypotension and PODAn observational cohort study734 patients,on-pump cardiac surgery99 patients(13%)developed PODBritish Journal of Anaesthesia,2015,42733OR
23、s for the association between AUC of intraoperative hypotension and occurrence of PODBritish Journal of Anaesthesia,2015,427330.05Intraop hypotension and PODSystematic review11 studies,1427 patients,GI surgeryRisk factors for PoDBJS 2016;103:e21e28Intraop hypotension associated with POD术中血压(SBP/MBP)
24、不低于基础血压20%术中最佳血压？术前高血压既往脑卒中抗血小板治疗他汀类治疗Contents 麻醉方法选择麻醉深度维持术中血压维持血糖水平管理Detrimental effects of elevated glucose in strokeStroke.2004;35:363-364.血糖升高伴随脑卒中病人预后恶化Anesthesiology 2012;116:2445129 patients with acute ischemic stroke treated with endovascular therapyPredictors of good neurologic outcomeIntr
25、aop tight glucose controlRCT198 adult patients undergoing cardiac surgeryTight intraop glucose control(80-110 mg/dl)Standard therapy(150 mg/dl)Anesthesiology 2015;122:1214-23Anesthesiology 2015;122:1214-23Patients with tight glucose control were more likely to develop delirium (26/93 tight control vs.15/105 routine;P=0.03)Anesthesiology 2015;122:1214-23RCT6104 adult patients,ICU treatment 3 days 3054 intensive control(4.5-6.0 mmol/L)3050 conventional control(10.0 mmol/L)N Engl J Med 2009;360:1283-97.N Engl J Med 2009;360:1283-97.术中血糖水平维持8-10mmol/L时给予胰岛素感谢关注感谢关注!