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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Impact Factor 9.275The Preambleu Guidelines and recommendations should help physicians and other healthcare providers to make decisions in their daily practice.However,the physician in charge of his/her care must m
2、ake 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 during surgery major non-cardiac surgery
3、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 population Pre-operative evaluationSurgical
4、 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 provides an objective assessment of function
5、al 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 indicesGoldman(1977),Detsky(1986),Lee(1999)The Lee in
6、dex,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 renal functionHigh-risk type of surgery The
7、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 cTnI)are the preferredmarkers for the diagnos
8、is 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 cardiac events Non-invasive testingthree card
9、iac 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 RevascularizationSpecific diseases Arterial hyperte
10、nsionValvular 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 and/or diastolic blood pressure 110 mmHg),
11、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 valve area 1 cm2 1.5 cm2)and in asymptomatic
12、 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 and preserved LV function(low risk)Symptom
13、atic 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 BradyarrhythmiasTemporary cardiac pacing is rarely r
14、equired,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 represents a significant risk be avoided by
15、 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 recovery phase before discharge to the ward Per
16、ioperative 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 multicentre clinical trial did not show a ben
17、efit 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 and proinflammatory cytokines Intraoperative
18、 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 blockade compared with general anaesthesia Put
19、ting 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