心臟病人非心臟手術(shù)術(shù)前評估與術(shù)中管理

江蘇省蘇北人民醫(yī)院麻醉科楊柳青

2009ESC/ESA指南ImpactFactor9.275Guidelinesandrecommendationsshouldhelpphysiciansandotherhealthcareproviderstomakedecisionsintheirdailypractice.However,thephysicianinchargeofhis/hercaremustmaketheultimatejudgementregardingthecareofanindividualpatientIntroductionThepresentguidelinesfocusonthecardiologicalmanagementofpatientsundergoingnon-cardiacsurgery,i.e.patientswhereheartdiseaseisapotentialsourceofcomplicationsduringsurgerymajornon-cardiacsurgeryisassociatedwithanincidenceofcardiacdeathofbetween0.5and1.5%,andofmajorcardiaccomplicationsofbetween2.0and3.5%ItisestimatedthatelderlypeoplerequiresurgeryfourtimesmoreoftenthantherestofthepopulationPre-operativeevaluationNo.3Surgicalriskforcardiacevents:theurgency,magnitude,type,anddurationoftheprocedure,aswellasthechangeinbodycoretemperature,bloodloss,andfluidshiftsNo.2No.1Functionalcapacity

Functionalcapacityismeasuredinmetabolicequivalents(METs)ExercisetestingprovidesanobjectiveassessmentoffunctionalcapacityWithouttesting,functionalcapacitycanbeestimatedbytheabilitytoperformtheactivitiesofdailyliving123<4METsindicatespoorfunctionalcapacityandisassociatedwithanincreasedincidenceofpost-operativecardiaceventsRiskindicesGoldman(1977),Detsky(1986),Lee(1999)TheLeeindex,tobethebestcurrentlyavailablecardiacriskpredictionindexinnon-cardiacsurgery12Sixindependentclinicaldeterminants(TheLeeindex)High-risktypeofsurgeryahistoryofIHDahistoryofcerebrovasculardiseaseheartfailureinsulin-dependentdiabetesmellitusimpairedrenalfunction030405060102TheLeeindexAllfactorscontributeequallytotheindex(with1pointeach)01theincidenceofmajorcardiaccomplicationsisestimatedat0.4,0.9,7,and11%inpatientswithanindexof0,1,2,and≥3points,respectively02BiomarkersCardiactroponinsTandI(cTnTandcTnI)arethepreferred1markersforthediagnosisofMIbecausetheydemonstratesensitivityandtissuespecificitysuperiortootheravailablebiomarkers2PlasmaBNPandNT-proBNPimportantprognosticindicatorsinpatientswithheartfailureadditionalprognosticvalueforlong-termmortalityandforcardiaceventsNon-invasivetesting01threecardiacriskmarkers:03myocardialischaemia02LVdysfunction04heartvalveabnormalitiesAmeta-analysisoftheavailabledatademonstratedthatanLVejectionfractionof<35%hadasensitivityof50%andaspecificityof91%forpredictionofperioperativenon-fatalMIorcardiacdeathawell-establishedinvasivediagnosticprocedure01rarelyindicatedtoassesstheriskofnoncardiacsurgery02AngiographyBesidesspecificriskreductionstrategiesadaptedtopatientcharacteristicsandthetypeofsurgery,preoperativeevaluationisanopportunitytocheckandoptimizethecontrolofallcardiovascularriskfactorsb-blockersThedoseofb-blockersshouldbetitrated,whichrequiresthattreatmentbeinitiatedoptimallybetween30daysandatleast1weekbeforesurgery.treatmentstartwithadailydoseof2.5mgofbisoprololor50mgofmetoprololsuccinatewhichshouldthenbeadjustedbeforesurgerytoachievearestingheartrateofbetween60and70bpmwithSBP>100mmHgSpecificdiseasesArterialhypertensionValvularheartdiseaseAorticstenosisMitralstenosisARandMRprostheticvalve(s)Arterialhypertension0102antihypertensivemedicationsshouldbecontinuedduringtheperioperativeperiod.Inpatientswithgrade3hypertension(systolicbloodpressure≧180mmHgand/ordiastolicbloodpressure≧110mmHg),thepotentialbenefitsofdelayingsurgerytooptimizethepharmacologicaltherapyshouldbeweighedagainsttheriskofdelayingthesurgicalprocedurehigherriskEchocardiographyshouldbeperformedAorticstenosisSevereAS:aorticvalvearea<1cm201<0.6cm2/m2bodysurfacearea)02Mitralstenosisrelativelylowrisk:non-significantmitralstenosis(MS)(valvearea>1.5cm2)andinasymptomaticpatientswithsignificantMS(valvearea<1.5cm2)andsystolicpulmonaryarterypressure<50mmHg1controlofheartrate2Strictcontroloffluidoverload3anticoagulation4AF5ARandMRNon-significantARandMR(lowrisk)asymptomaticpatientswithsevereARandMRandpreservedLVfunction(lowrisk)SymptomaticpatientsandLVEF<30%(Highrisk,onlyifnecessary,optimizationofpharmacologicaltherapy)prostheticvalve(s)noevidenceofvalveorventriculardysfunction(withoutadditionalrisk)endocarditisprophylaxisanticoagulationregimenmodification010302BradyarrhythmiasTemporarycardiacpacingisrarelyrequired,eveninthepresenceofpre-operativeasymptomaticbifascicularblockorCLBBBTheindicationsfortemporarypacemakersaregenerallythesameasthoseforpermanentpacemakersPacemaker/implantablecardioverterdefibrillatorunipolarelectrocauteryrepresentsasignificantriskbeavoidedbypositioningthegroundplateKeepingtheelectrocauterydeviceawayfromthepacemaker,givingonlybriefburstsandusingthelowestpossibleamplitudeTheimplantablecardioverterdefibrillatorshouldbeturnedoffduringsurgeryandswitchedonintherecoveryphasebeforedischargetothewardPerioperativemonitoring

V5(75%),V4(61%),V5+V4(90%),V5+V4+II(96%)ContinuousautomatedSTtrendingmonitors(sensitivityandspecificityof74and73%)ECGRightheartcatherizationbothalargeobservationalstudyandarandomizedmulticentreclinicaltrialdidnotshowabenefitassociatedwiththeuseofrightheartcatheterization01nodifferenceinmortalityandhospitalduration/ahigherincidenceofpulmonaryembolism02promotesatherosclerosis,endothelialdysfunction,andactivationofplateletsandproinflammatorycytokinesproper