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1、心脏病人非心脏手术心脏病人非心脏手术术前评估与术中管理术前评估与术中管理 江苏省苏北人民医院麻醉科江苏省苏北人民医院麻醉科 杨柳青杨柳青 2009 ESC/ESA 指南指南本文档由医学百事通高端医生网专家制作本文档由医学百事通高端医生网专家制作在线咨询医生Impact Factor 9.275The Preambleu Guidelines and recommendations should help physicians and other healthcare providers to make decisions in their daily practice.However,the
2、physician in charge of his/her care must make the ultimate judgement regarding the care of an individual patient IntroductionThe present guidelines focus on the cardiological management of patients undergoing non-cardiac surgery,i.e.patients where heart disease is a potential source of complications
3、 during surgery major non-cardiac surgery is associated with an incidence of cardiac death of between 0.5 and 1.5%,and of major cardiac complications of between 2.0 and 3.5%Impact of the ageing populationIt is estimated that elderly people require surgery four times more often than the rest of the p
4、opulation Pre-operative evaluationSurgical risk for cardiac events:the urgency,magnitude,type,and duration of the procedure,as well as the change in body core temperature,blood loss,and fluid shifts Functional capacity Functional capacity is measured in metabolic equivalents(METs)Exercise testing pr
5、ovides an objective assessment of functional capacity Without testing,functional capacity can be estimated by the ability to perform the activities of daily living 4 METs indicates poor functional capacity and is associatedwith an increased incidence of post-operative cardiac events Risk indicesGold
6、man(1977),Detsky(1986),Lee(1999)The Lee index,to be the best currently available cardiac risk prediction index in non-cardiac surgery Six independent clinical determinants(The Lee index)a history of IHD a history of cerebrovascular diseaseheart failure insulin-dependent diabetes mellitus impaired re
7、nal functionHigh-risk type of surgery The Lee indexAll factors contribute equally to the index(with 1 point each)the incidence of major cardiac complications is estimated at 0.4,0.9,7,and 11%in patients with an index of 0,1,2,and 3 points,respectively BiomarkersCardiac troponins T and I(cTnT and cTn
8、I)are the preferredmarkers for the diagnosis of MI because they demonstrate sensitivity and tissue specificity superior to other available biomarkers Plasma BNP and NT-proBNPimportant prognostic indicators in patients with heart failure additional prognostic value for long-term mortality and for car
9、diac events Non-invasive testingthree cardiac risk markers:LV dysfunction myocardial ischaemia heart valve abnormalities Echocardiography A meta-analysis of the available data demonstrated that an LV ejection fraction of 100 mmHg Nitrates:Nitroglycerin DiureticsAspirinAnticoagulant therapy Revascula
10、rizationSpecific diseases Arterial hypertensionValvular heart diseaseAortic stenosisMitral stenosisAR and MRprosthetic valve(s)Arterial hypertensionantihypertensive medications should be continued during the perioperative period.In patients with grade 3 hypertension(systolic blood pressure 180 mmHg
11、and/or diastolic blood pressure 110 mmHg),the potential benefits of delaying surgery to optimize the pharmacological therapy should be weighed against the risk of delaying the surgical procedure Valvular heart diseasehigher risk Echocardiography should be performed Aortic stenosisSevere AS:aortic va
12、lve area 1 cm2 1.5 cm2)and in asymptomatic patients with significant MS(valve area 1.5 cm2)and systolic pulmonary artery pressure 50 mmHg control of heart rate Strict control of fluid overload anticoagulation AFAR and MR Non-significant AR and MR(low risk)asymptomatic patients with severe AR and MR
13、and preserved LV function(low risk)Symptomatic patients and LV EF30%(High risk,only if necessary,optimization of pharmacological therapy)prosthetic valve(s)no evidence of valve or ventricular dysfunction(without additional risk)endocarditis prophylaxis anticoagulation regimen modification Bradyarrhy
14、thmiasTemporary cardiac pacing is rarely required,even in the presence of pre-operative asymptomatic bifascicular block or CLBBB The indications for temporary pacemakers are generally the same as those for permanent pacemakers Pacemaker/implantable cardioverter defibrillatorunipolar electrocautery r
15、epresents a significant risk be avoided by positioning the ground plate Keeping the electrocautery device away from the pacemaker,giving only briefbursts and using the lowest possible amplitudeThe implantable cardioverter defibrillator should be turned off during surgery and switched on in the recov
16、ery phase before discharge to the ward Perioperative monitoringV5(75%),V4(61%),V5+V4(90%),V5+V4+II(96%)Continuous automated ST trending monitors(sensitivity and specificity of 74 and 73%)ECGTransesophageal echocardiographyRight heart catherizationboth a large observational study and a randomized mul
17、ticentre clinical trial did not show a benefit associated with the use of right heart catheterization no difference in mortality and hospital duration /a higher incidence of pulmonary embolismDisturbed glucose metabolism promotes atherosclerosis,endothelial dysfunction,and activation of platelets an
18、d proinflammatory cytokines Intraoperative anaesthetic managementproper organ perfusion pressureSpinal and epidural anaesthesia(T4)One meta-analysis reported significantly improved survival and reduced incidence of post-operative thromboembolic,cardiac and pulmonary complications with neuraxial bloc
19、kade compared with general anaesthesia Putting the puzzle together患者和外科特殊因素决定治疗策略，不需进一步心脏检查和治疗，请求会诊以加强术中管理，监测心脏事件和拟定长期药物治疗方案多学科会诊以决定最佳治疗方案，如能推迟手术则可进行CABG、球囊成形术、支架植入术明确危险因素、进行手术治疗、提供正确的生活方式和适当的药物治疗，以改善术后长期生存质量明确心功能状态、进行手术治疗、适当的术前药物治疗（他汀类，受体阻滞剂）适当的术前药物治疗（他汀类，受体阻滞剂）、左室收缩功能障碍者（ACE-inhibitors）、进进行手术治疗行手术治疗、围术期ECG监测适当的术前药物治疗（他汀类，受体阻滞剂）、左室收缩功能障碍者（ACE-inhibitors）non-invasive stress test Revascularization bridging therapy