1、心脏病人非心脏手术心脏病人非心脏手术麻醉药物和麻醉技术麻醉药物和麻醉技术lClass IIa1.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(Level of Evidence:A)Lando
2、ni 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 al.Randomized comparison
3、of sevoflurane versus propofol to reduce perioperative myocardial ischemia in patients undergoing noncardiac surgery.Circulation.2012;126:2696-704.2心脏病人非心脏手术文献汇报文献汇报l文献13心脏病人非心脏手术l2768 to TIVA and 3451 receiving desflurane or sevoflurane in their anesthesia planlVolatile anesthetic dosage varied acr
4、oss studies,ranging 0.33-2 MAC in the 609 patients receiving desflurane and 0.25-2 MAC in the 2842 patients receiving sevofluranelHospital 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 any pos
5、toperative myocardial infarction or death among the study population,nor any significant cardiac adverse eventlPostoperative renal or respiratory failure and release of cardiac biomarkers were not reported4心脏病人非心脏手术心律失常5心脏病人非心脏手术l文献26心脏病人非心脏手术7心脏病人非心脏手术l在心脏手术中22 included trials included 1,922 random
6、ly assigned patients(904 to TIVA 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 sevoflu
7、rane MINERVA ANESTESIOL 2009;75:269-739心脏病人非心脏手术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-0.02a s
8、ignificant decrease in cTnI peak release(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
9、included patients).a shorter ICU stay(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.
10、97;-0.02,P for effect=0.04,p for heterogeneity 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 hospi
11、talization and new episodes of congestive heart failure10心脏病人非心脏手术Class 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.Epidur
12、al pain relief versus systemic opioid-based pain relief for abdominal aortic surgery.Cochrane Database Syst Rev.2012;7:CD005059.11心脏病人非心脏手术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 trac
13、heal intubation and mechanical ventilation was significantly 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
14、were significantly lower in the epidural analgesia group.12心脏病人非心脏手术lClass 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)13心脏病人非心脏手术l文献Anesthesiology 2003;98:1566314心脏病人非心脏手术术中管理术中管
15、理lClass IIa1.The emergency use of perioperative transesophageal echocardiogram is reasonable 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 availabl
16、e.(Level of Evidence:C)15心脏病人非心脏手术lClass IIb1.Maintenance of normothermia may be reasonable to reduce 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
17、 is required in the setting of acute severe cardiac dysfunction(i.e.,acute MI,cardiogenic shock)that 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.,
18、HF,severe valvular disease,combined shock states)cannot be corrected before surgery.(Level of Evidence:C)16心脏病人非心脏手术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 group
19、hypothermicPT35.4+/-0.136.7+/-0.10.01Postoperative ventricular tachycardia2.4%7.9%;P=.04morbid cardiac events1.4%6.3%;P=.0217心脏病人非心脏手术Perioperative hypothermia(33 degrees C)does not increase theoccurrence of cardiovascular events in patients undergoing cerebral aneurysm surgery:findings from the Int
20、raoperative Hypothermia for Aneurysm Surgery Trial.Anesthesiology.2010;113:327-4218心脏病人非心脏手术lClass III:No Benefit1.Routine use of pulmonary artery catheterization in patients,even those with elevated risk,is not recommended(Level of Evidence:A)2.Prophylactic intravenous nitroglycerin is not effectiv
21、e in reducing myocardial ischemia in patients undergoing noncardiac surgery(Level of Evidence:B)3.The routine use of intraoperative transesophageal echocardiogram during noncardiac surgery to screen for cardiac abnormalities or to monitor for myocardial ischemia is not recommended in patients withou
22、t risk factors or procedural risks for significant hemodynamic,pulmonary,or neurologic compromise.(Level of Evidence:C)19心脏病人非心脏手术lPAC文献20心脏病人非心脏手术lIv nitroglycerin文献1high-risk non-cardiacpatients 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%0.2321心脏病人非心脏手术22心脏病人非心脏手术
