1、心脏病人非心脏手术指南2014 ACC/AHA Guideline术中麻醉管理部分麻醉药物和麻醉技术麻醉药物和麻醉技术l Class IIa 1.Use of either a volatile anesthetic agent or total intravenous anesthesia is reasonable for patients undergoing noncardiac surgery,and the choice is determined by factors other than the prevention of myocardial ischemia and MI(
2、Level of Evidence:A)Landoni G,Fochi O,Bignami E,et al.Cardiac protection by volatile anesthetics in non-cardiac surgery?A metaanalysis of randomized controlled studies on clinically relevant endpoints.HSR Proc Intensive Care Cardiovasc Anesth.2009;1:34-43.Lurati Buse GAL,Schumacher P,Seeberger E,et
3、al.Randomized comparison of sevoflurane versus propofol to reduce perioperative myocardial ischemia in patients undergoing noncardiac surgery.Circulation.2012;126:2696-704.文献汇报文献汇报l文献1l 2768 to TIVA and 3451 receiving desflurane or sevoflurane in their anesthesia planl Volatile anesthetic dosage var
4、ied across studies,ranging 0.33-2 MAC in the 609 patients receiving desflurane and 0.25-2 MAC in the 2842 patients receiving sevofluranel Hospital stay was identical between groups(WMD 0.01 days-0.06,0.07,p for effect=0.88,p for heterogeneity=0.48,I2=0%with 1201 included patientsl No author reported
5、 any postoperative myocardial infarction or death among the study population,nor any significant cardiac adverse eventl Postoperative renal or respiratory failure and release of cardiac biomarkers were not reported心律失常l文献2l 在心脏手术中22 included trials included 1,922 randomly assigned patients(904 to TI
6、VA and 1018 receiving desflurane or sevoflurane in their anesthesia plan)Volatile anesthetic dosage varied across the studies,but was always 0.15 MAC and ranged from 0.15-2 MAC in the 475 patients receiving desflurane and 0.25-4 MAC in the 543 patients receiving sevoflurane MINERVA ANESTESIOL 2009;7
7、5:269-73 volatile anesthetics reduced the risk of MI(24/979 2.4%in the volatile anesthetics group vs.45/874 5.1%in controls,OR=0.510.32-0.84,P for effect=0.008),all-cause mortality was also reduced(4/977 0.4%vs.14/872 1.6%,OR=0.31 0.12-0.80,P for effect-0.02 a significant decrease in cTnI peak relea
8、se(WMD-2.35 ng/dl-3.09,-1.60,P for effect 0.00001,P for heterogeneity 0.00001,I2=94.1%with 1,463 included patients)and the need for inotropic support(170/679 25.0%vs.203/562 36.1%,OR=0.47 0.29,0.76,P for effect 0.002,P for heterogeneity=0.008,I2=53.1%with 1,241 included patients).a shorter ICU stay(
9、WMD=-7.10 hours-11.47;-2.73,P for effect0.001,P for heterogeneity 0.00001,I2=76.6%with 1,433 included patients),time to hospital discharge(WMD=-2.26 days-3.83;-0.68,P for effect=0.005,with 1,593 included patients)time on mechanical ventilation(WMD=-0.49 hours-0.97;-0.02,P for effect=0.04,p for heter
10、ogeneity 0.03,I2=44.1%with 1,846 included patients).Finally,only two studies reported one year follow-up data concerning major cardiac events(defined as cardiac death,non-fatal MI,unstable angina,intercurrent coronary angioplasty,CABG,arrhythmias requiring hospitalization and new episodes of congest
11、ive heart failureClass IIa 2.Neuraxial anesthesia for postoperative pain relief can be effective in patients undergoing abdominal aortic surgery to decrease the incidence of perioperative MI(Level of Evidence:B)Nishimori M,Low JHS,Zheng H,et al.Epidural pain relief versus systemic opioid-based pain
12、relief for abdominal aortic surgery.Cochrane Database Syst Rev.2012;7:CD005059.l 文献汇报 15 trials that involved 1297 patients(633 patients received epidural analgesia and 664 received systemic opioid analgesia)The postoperative duration of tracheal intubation and mechanical ventilation was significant
13、ly shorter,by about 48%,in the epidural analgesia group.The overall event rates of myocardial infarction,acute respiratory failure(defined as an extended need for mechanical ventilation),gastrointestinal complications,and renal complications were significantly lower in the epidural analgesia group.l
14、Class IIb1.Perioperative epidural analgesia may be considered to decrease the incidence of preoperative cardiac events in patients with a hip fracture(Level of Evidence:B)l文献Anesthesiology 2003;98:15663术中管理术中管理l Class IIa1.The emergency use of perioperative transesophageal echocardiogram is reasonab
15、le in patients with hemodynamic instability undergoing noncardiac surgery to determine the cause of hemodynamic instability when it persists despite attempted corrective therapy,if expertise is readily available.(Level of Evidence:C)l Class IIb 1.Maintenance of normothermia may be reasonable to redu
16、ce perioperative cardiac events in patients undergoing noncardiac surgery(150,151).(Level of Evidence:B)2.Use of hemodynamic assist devices may be considered when urgent or emergency noncardiac surgery is required in the setting of acute severe cardiac dysfunction(i.e.,acute MI,cardiogenic shock)tha
17、t cannot be corrected before surgery.(Level of Evidence:C)3.The use of pulmonary artery catheterization may be considered when underlying medical conditions that significantly affect hemodynamics(i.e.,HF,severe valvular disease,combined shock states)cannot be corrected before surgery.(Level of Evide
18、nce:C)lFrank SM,Fleisher LA,Breslow MJ,et al.Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events.A randomized clinical trial.JAMA.1997;277:1127-34C grouphypothermicPT35.4+/-0.136.7+/-0.10.01Postoperative ventricular tachycardia2.4%7.9%;P=.04morbid cardiac events1
19、.4%6.3%;P=.02Perioperative hypothermia(33 degrees C)does not increase theoccurrence of cardiovascular events in patients undergoing cerebral aneurysm surgery:findings from the Intraoperative Hypothermia for Aneurysm Surgery Trial.Anesthesiology.2010;113:327-42l Class III:No Benefit 1.Routine use of
20、pulmonary artery catheterization in patients,even those with elevated risk,is not recommended(Level of Evidence:A)2.Prophylactic intravenous nitroglycerin is not effective in reducing myocardial ischemia in patients undergoing noncardiac surgery(Level of Evidence:B)3.The routine use of intraoperativ
21、e transesophageal echocardiogram during noncardiac surgery to screen for cardiac abnormalities or to monitor for myocardial ischemia is not recommended in patients without risk factors or procedural risks for significant hemodynamic,pulmonary,or neurologic compromise.(Level of Evidence:C)lPAC文献lIv nitroglycerin文献1high-risk non-cardiac patients Holter electrocardiogram(ECG)l Iv nitroglycerin文献2 CABG surgery control group(n=23)Iv nitroglycerin(n=22)ischemiaSeven(30%)seven(32%)control group(n=20)Iv nitroglycerin(n=20)Pischemia35%35%MI10%5%0.23
