老年患者麻醉管理与脑保护课件.pptx

1、老年患者麻醉老年患者麻醉管理与脑保护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

2、Qd，术前7天改依诺肝素 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

3、，升主动脉轻度扩张，EF 63% 肺功能检查：FEV1 2.35，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;360:1

4、90313.收缩压舒张压血压与其他血管相关死亡率关系Lancet. 2002;360:190313.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

5、 hypertensive coronary artery disease patients: an 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) 644651 7 RCTs with 571 adults, any type surgery u

6、nder GA Benefits and harms of perioperative ACEIs/ARBsCochrane 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 Sys

7、tematic Reviews 2016, Issue 1. Art. No.: CD009210. No evidence to support 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

8、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

9、 noncardiac surgery Compared with patients without stroke, a prior stroke within 3 months More major 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

10、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 study 666 patients with coronary stent(s) MACE = CV death, MI, or strokeThromb Haemost 2015; 113: 272282Thromb Haemost 2015; 113: 272282MACECV deathMIStroke Predictors of 30-day MACEThromb Haemost 2015; 11

11、3: 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 design 10,010 patients preparing for noncardiac surgery and at risk for vascular complications Aspirin (initiation: 200 mg before, 100 mg/d * 30 d; continuation: 100 mg/d * 7 d, continue) Placebo Death or major vascular complications at 30 day

12、sN 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;370:1494-503 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

13、participants Perioperative short-term statin therapy and outcomesCochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD009971 Evidence was insufficient to conclude that statin use resulted in either a reduction or an increase in any of the outcomes examinedCochrane Database of Systemati

14、c Reviews 2013, Issue 7. Art. No.: CD009971 17 RCTs with 2138 participants, on-/off-pump myocardial revascularisation Effectiveness of preoperative statin therapyCochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD008493. Preoperative statin therapy Reduces postop AF, shortens LOS in

15、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 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 reviews Neuraxial block +/- GA GA aloneCochr

16、ane 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 (0-30 days)RA + GA vs. GACochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: C

17、D010108Postoperative 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 Reviews 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

18、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-analysis 39 RCTs, 16,082 participants Non-pharmacological or pharmacological interventions for preventing deliriumCochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD005563.BIS-guided anaesthesia vs BIS-blinded anaesthesiaCochra

19、ne 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 study 4087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Anesth Analg 2009;108:508 12BIS45时间与

20、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 12 A pilot RCT 125 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;118:9816Postoperative OutcomesAnest

21、h 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: 183947 RCT 8351 patients with, or at risk of, atherosclerotic disease who were undergoing non-cardiac surgery Extended-release metoprolol (n=4174)

22、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; 1

23、16:65864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 POD An observational cohort study 734 patients, on-pump cardiac surgery 99 patients (13%) developed PODBritish Journal of Anaesthesia

24、, 2015, 42733ORs for the association between AUC of intraoperative hypotension and occurrence of PODBritish Journal of Anaesthesia, 2015, 427330.05Intraop hypotension and POD Systematic review 11 studies, 1427 patients, GI surgery Risk factors for PoDBJS 2016; 103: e21e28Intraop hypotension associat

25、ed with POD 术中血压(SBP/MBP)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;116:2445 129 patients with acute ischemic stroke treated with endovascular therapyPredic

26、tors of good neurologic outcomeIntraop tight glucose control RCT 198 adult patients undergoing cardiac surgery Tight intraop glucose control (80-110 mg/dl) Standard therapy (150 mg/dl)Anesthesiology 2015; 122:1214-23Anesthesiology 2015; 122:1214-23 Patients with tight glucose control were more likel

27、y to develop delirium (26/93 tight control vs. 15/105 routine; P = 0.03)Anesthesiology 2015; 122:1214-23 RCT 6104 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!