1、心功能不全病人的麻醉管理心功能不全病人的麻醉管理钟泰迪钟泰迪浙江大学医学院附属邵逸夫医院浙江大学医学院附属邵逸夫医院Company Logo 患者何患者何XX，男，男，66岁，因岁，因“反复胸闷气急反复胸闷气急4年余，加重年余，加重1周周”于于2012-4-1入院。入院。4年前出现胸闷气急，活动时气急加重，心超（年前出现胸闷气急，活动时气急加重，心超（2008.12.8）：先）：先天性心脏病，动脉导管未闭。于天性心脏病，动脉导管未闭。于2008.12.10行行“PDA封堵术封堵术”；1年前患者以上症状再次出现，年前患者以上症状再次出现，1月余前患者再感胸闷气急；月余前患者再感胸闷气急；入院后予
2、以多巴胺强心，利尿，扩血管等治疗后病情有所好转，入院后予以多巴胺强心，利尿，扩血管等治疗后病情有所好转，心功能有所改善后出院。心功能有所改善后出院。病史简介病史简介Company Logo半月前，患者劳累后再次出现胸闷气急，伴面部浮肿，恶心，无双下肢水肿，无半月前，患者劳累后再次出现胸闷气急，伴面部浮肿，恶心，无双下肢水肿，无明显胸痛头晕。明显胸痛头晕。5天前，患者自觉胸闷气急较前加重，遂至我院就诊；天前，患者自觉胸闷气急较前加重，遂至我院就诊；心超示：心超示：“先天性心脏病动脉导管未闭介入封堵术后，全心增大（左心为主），先天性心脏病动脉导管未闭介入封堵术后，全心增大（左心为主），左室收缩功能
3、弥漫性减低左室收缩功能弥漫性减低，左室舒张末压增高，二尖瓣退行性变伴重度二尖瓣反，左室舒张末压增高，二尖瓣退行性变伴重度二尖瓣反流，中度三尖瓣反流轻轻度肺动脉高压，主动脉瓣退行性变伴轻度反流，肺动脉流，中度三尖瓣反流轻轻度肺动脉高压，主动脉瓣退行性变伴轻度反流，肺动脉增宽，轻度肺动脉瓣反流，心律不齐，增宽，轻度肺动脉瓣反流，心律不齐，EF：30%”。CT示：示：1、左下肺病灶，肿瘤不能除外，心影增大。、左下肺病灶，肿瘤不能除外，心影增大。活检组织病理：（左肺穿刺）鳞状细胞癌。活检组织病理：（左肺穿刺）鳞状细胞癌。冠脉造影示：左主干尾部冠脉造影示：左主干尾部30%狭窄，前降支无明显狭窄。回旋支未
4、见明显狭窄；狭窄，前降支无明显狭窄。回旋支未见明显狭窄；右冠状动脉：右冠中段右冠状动脉：右冠中段60%狭窄，未予支架植入。狭窄，未予支架植入。Company Logo 诊断：冠状动脉粥样硬化性心脏病诊断：冠状动脉粥样硬化性心脏病 不稳定性心绞痛不稳定性心绞痛 扩张型心肌病扩张型心肌病 二尖瓣重度关闭不全二尖瓣重度关闭不全 心房颤动伴快速心室率心房颤动伴快速心室率 心功能心功能IV级级 动脉导管未闭伞片封堵术后动脉导管未闭伞片封堵术后 左肺占位左肺占位 高血压病高血压病 肝功能不全肝功能不全心内科予扩血管、改善心功能、护肝等对症处后，胸闷气急较前好转；心内科予扩血管、改善心功能、护肝等对症处后，
5、胸闷气急较前好转；Company Logo 患者于患者于2012-4-6转入胸外科拟手术治疗；转入胸外科拟手术治疗；我科会诊：术中单肺通气及左下肺切除均加重患者心脏负担我科会诊：术中单肺通气及左下肺切除均加重患者心脏负担，易急性心衰，手术风险极大，望手术医生及家属慎重抉择，易急性心衰，手术风险极大，望手术医生及家属慎重抉择。经外科与家属沟通后，患者家属强烈要求手术治疗经外科与家属沟通后，患者家属强烈要求手术治疗。Company Logo术前术前CX-Company Logo术前术前CBCCompany Logo术前肝功能术前肝功能Company Logo术前治疗及相关指标术前治疗及相关指标Co
6、mpany Logo 2012-04-12 全麻下行全麻下行“左肺下叶切除左肺下叶切除+淋巴结清扫淋巴结清扫”；0830 麻醉诱导、双腔气管插管顺利，予保温，标准监麻醉诱导、双腔气管插管顺利，予保温，标准监测测+A-Line，CVP，漂浮导管，熵指数及血气监测；，漂浮导管，熵指数及血气监测；0930 手术开始，术中泵注多巴胺调节血压，过程顺利手术开始，术中泵注多巴胺调节血压，过程顺利；Company LogoABG Company Logo 1110 手术结束时，患者突发室速并迅速转为手术结束时，患者突发室速并迅速转为室颤，立即改平卧位行室颤，立即改平卧位行CPR，先后予肾上腺素，先后予肾上腺
7、素，利多卡因，胺碘酮，碳酸氢钠等药物并更换，利多卡因，胺碘酮，碳酸氢钠等药物并更换气管导管，间断三次气管导管，间断三次200j除颤；除颤；Company LogoVBG Company LogoVBG Company LogoPurpose 1135 恢复自主心律，肾上腺素及多巴胺持续泵注转ICU继续治疗。ABG Company LCompany LogoICU ABG Company LogoICU CX-Company LogoICU ABG患者于当晚2200拔除气管导管，神清，呼吸循系系统稳定。Company LogoICU 肌钙蛋白肌钙蛋白（12-13号）号）Company LogoI
8、CU 肌钙蛋白肌钙蛋白（13-14号）号）Company Logo病房病房CX-Company Logo病房肌钙蛋白病房肌钙蛋白 Company Logo患者于患者于2012-04-14 1300转入普转入普通病房。通病房。Anesth Analg.2006 Sep;103(3):557-75.Perioperative management of chronic heart failure.Groban L,Butterworth J.SourceDepartment of Anesthesiology,Wake Forest University School of Medicine,Wi
9、nston-Salem,NC 27157-1009,USA.lgrobanwfubmc.edu问题问题 1.术前准备是否足够？2.麻醉选择和监测是否合理?3.心脏骤停的可能原因？4.围手术期心肺复苏的要点？复习文献 Anesth Analg.2006 Sep;103(3):557-75.Perioperative management of chronic heart failure.Groban L,Butterworth J.Source Department of Anesthesiology,Wake Forest University School of Medicine,Winst
10、on-Salem,NC 27157-1009,USA.lgrobanwfubmc.edu Current guidelines begin pharmacotherapy of HF with primary prevention of left ventricular dysfunction.ACE inhibitors,and possibly-adrenergic blockers,should be initiated in diabetic,hypertensive,and hypercholesterolemia patients(AHA/ACC,Stage A HF)who ar
11、e at increased risk for CV events,despite normal contractile function,to reduce the onset of new HF.卡维地洛片属片剂，是抗高血压药。1和非选择性 受体阻滞作用 本品用于治疗有症状的充血性心力衰竭，可降低死亡率和心血管疾患的住院率，改善病人的一般情况，并减慢疾病的进展。亦可做为标准治疗的附加药物，也可用于不耐受血管紧张素转换酶抑制剂或没有使用洋地黄、肼苯哒嗪、硝酸盐类药物治疗的病人。也适用于原发性高血压的治疗，可单独使用或与其它抗高血压药特别是噻嗪类利尿剂联合使用 雷米普利片雷米普利为一前体药物，
12、经胃肠道吸收后在肝脏水解成有活性的血管紧张素转化酶（ACE）抑制剂雷米普利拉而发挥作用。服用雷米普利可导致血浆肾素活性的升高，和血管紧张素II及醛固酮血浆浓度的下降。因为血管紧张素II的减少，ACE抑制剂可导致外周血管扩张和血管阻力下降，从而产生有益的血流动力学效应【适应症】高血压。充血性心力衰竭。急性心梗发作后的前几天之内出现的充血性心力衰竭症状者。In the symptomatic HF patient(Stage C),diuretics are titrated to relieve symptoms of pulmonary congestion and peripheral ed
13、ema and to restore a normal state of intravascular volume.呋塞米也称速尿，临床上用于治疗心脏性水肿、肾性水肿、肝硬化腹水、机能障碍或血管障碍所引起的周围性水肿，并可促使上部尿道结石的排出。其利尿作用迅速、强大，多用于其它利尿药无效的严重病例。由于水、电解质丢失明显等原因，故不宜常规使用。静脉给药（2080mg）可治疗肺水肿和脑水肿。药物中毒时可用以加速毒物的排泄 螺内酯片 螺内酯片结构与醛固酮相似，为醛固酮的竞争性抑制剂。作用于远曲小管和集合管，阻断Na-K和Na-H交换，结果Na、C1和 水排泄增多，K、Mg2和H排泄减少，对Ca2和
14、P3的作用不定。由于本 药仅作用于远曲小管和集合管，对肾小管其他各段无作用，故利尿作用较弱 Although digoxin has no effect on patient survival,it may be considered in Stage C if the patient remains symptomatic despite adequate doses of ACE inhibitors and diuretics.地高辛 一种主要来自毛地黄的毒性强心糖苷 用于治疗充血性心力衰竭，对于高血压、瓣膜病、先天性心脏病所引起的充血性心力衰竭疗效良好。What is an anest
15、hesiologist to do when faced with a patient with Stage D or decompensated Stage C HF who requires emergency surgery?When feasible(this will be rare because these patients often cannot lie flat on the operating table),regional nerve block techniques,rather than general anesthesia or neuroaxial block
16、techniques,may avoid intraoperative crystalloid infusions.There is no evidence basis by which to select either an induction or a maintenance anesthetic drug in these patients We have successfully used most IV induction drugs in these patients(including thiopental,propofol,ketamine,etomidate,midazola
17、m,and diazepam)and have seen no obvious reason to recommend any one of them over the others.Similarly,our usual practice is to maintain anesthesia with inhaled anesthetics.We find intraoperative fluid and medical management considerably more challenging than anesthetic choice in these patients.Accor
18、dingly,when HF patients must undergo major surgery,we suggest invasive arterial BP monitoring and transesophageal echocardiography(TEE)to help guide intraoperative decision-making.TEE is especially useful in diagnosing whether hypotensive episodes are the result of inadequate circulating blood volum
19、e,worsening ventricular function,or arterial vasodilation.Pulmonary artery catheters have long been used in these patients for this purpose;if TEE is not available,pulmonary artery catheters may be a useful Large volumes of blood,colloid,or crystalloid should be used to treat hypotension in HF patie
20、nts only when there is a reasonable suspicion that true hypovolemia is present.This advice may be even more important for patients receiving spinal or epidural anesthesia(in the latter case there seems to be an even greater tendency to use IV fluid/colloid/blood rather than vasoactive drugs to treat
21、 hypotension).Finally,transfusion for perioperative anemia in a hemodynamically stable patient with a history of HF(e.g.,stage C)must be approached with greater caution than usual.It is easy to produce intravascular volume overload in these patients When we consider our aging patient population in w
22、hich prolonged survival with hypertension and/or coronary artery disease is expected and the better HF treatment strategies now available to them,we conclude that anesthesiologists will encounter an increasing number of patients with either a predisposition to HF(stages A and B)or a history of HF(stages C and D).Thus,knowledge of the evolving pharmacologic strategies for the management of chronic HF is essential both for patient care and for our continued credibility as perioperative
