老年非心脏手术围手术期心血管并发症危险因素分析

目的　探讨非心脏手术围手术期心血管并发症的影响因素。方法　将 1988年至 1997年住院的 6 0岁至 99岁大中型非心脏手术患者 16 5 8例分为心血管并发症组和无心血管并发症组 ,对比分析两组年龄、性别、手术类型、内科主要疾病史等对围手术期心血管并发症的影响 ,并探讨其发生的时间分布。结果　 2 72例心血管并发症中 80 %以上发生在术中及术后 72h以内。心血管并发症组平均年龄 (6 9± 6 )岁 ,无心血管并发症组 (6 7± 6 )岁(P <0 .0 1)。与无心血管并发症相比 ,心血管并发症组年龄≥ 70岁、男性、急诊手术、肺叶切除术、前列腺摘除术多。心血管并发症组心血管疾病及其他内科疾病史及体征 ,特别是患有两种以上心血管疾病及其他内科疾病者较无心血管并发症组显著增多 (38.6 %比 18.6 %和 5 7.4 %比 32 .0 % ,P <0 .0 0 1)。结论　年龄、性别、手术类型、心血管和其他内科病史及体征 ,尤其是患有两种以上心血管及其他内科病是老年非心脏手术围手术期心血管并发症发生的主要危险因素。术中、术后 72h内是心血管并发症的高发期 ,应严密监测 ,积极防治。     

70岁以上老年人体外循环心脏手术术后并发症分析

目的探讨70岁以上老年人体外循环心脏手术后严重并发症的高危因素。方法回顾性分析我院204例70岁以上老年患者接受体外循环心脏手术的一般情况、并存疾病、围术期情况及转归等临床资料。结果术后30d内早期死亡13例，病死率6．4％；术后出现严重并发症40例，发生率19．6％，明显高于同期非老年体外循环心脏手术患者的4．7％（P〈0．01）；回归分析显示，年龄≥70岁、主动脉阻断时间和体外循环转流时间是影响术后早期疗效的高危因素；急诊手术、并存高血压、糖尿病、慢性阻塞性肺疾病和脑血管疾病、冠状动脉狭窄程度和范围是影响手术预后的危险因素。结论70岁以上老年人体外循环心脏手术严重并发症发生率高，预后较差。术前积极治疗并存的慢性疾病，术中尽量减少主动脉阻断时间和体外循环转流时间或许可以提高老年人体外循环心脏手术的疗效。     

老年人非心脏手术后急性左心衰竭

目的旨在探讨老年人非心脏手术的内科保障水平，减少术后心血管危重并发症的发生。方法复习老年人大中型非心脏手术１０８８例临床资料，分析其中９例术后急性左心衰竭的可能诱发因素，探讨发病机理及防治方法。结果９例的平均年龄为７３．８岁，术前诊断冠心病７例，可疑冠心病１例；２例曾有心功不全。因术中输血、输液过快诱发３例，术后持续心动过速、血压增高，因疼痛、精神紧张诱发３例，高热、嗜铬细胞瘤发作及快速心房颤动诱发各１例。心力衰竭发生时，６例出现心肌缺血的心电图表现。结论老年心脏病患者非心脏手术时，术中应控制输液量及输液速度；术后积极控制血压，充分止痛，及时发现心力衰竭早期征象，早期处理，防止血液动力学进一步恶化。     

老年心血管手术患者术后认知功能障碍

由于老年病人病理生理的改变,各重要脏器的功能都有不同水平的下降,对各种手术尤其是心血管大手术的应激能力也有明显下降。同时由于老年病人常合并高血压、糖尿病、慢性阻塞性肺疾病(COPD)等,术后并发症的发生率也非常高。术后认知功能障碍(postoperative cognitive dysfunction,POCD)作为老年病人心血管手术后常见的神经系统并发症,是目前比较关注的问题之一。本文对老年病人心血管手术POCD的发病机制、临床表现、危险因素以及防治作一综述。     

老年髋部骨折围手术期合并疾病和并发症的分析和处理

目的 探讨老年髋部骨折的特点，分析其围手术期并发症、合并疾病及治疗措施，以提高手术效果，提高患者生存质量。方法 对217例75岁以上老年人髋部骨折围手术期治疗方法及结果进行回顾性总结。结果 本组病例术前有63．1％病人有内科合并疾病，患者均顺利度过手术期，术后发生并发症共30例，发生率为13．7％。手术治疗优良率82．7％。结论 高龄髋部骨折患者术前合并疾病多，根据病人情况，采取积极恰当的围手术期处理、不同的麻醉手术方法和康复治疗，可降低围手术期并发症的发生率和病死率，取得优良的治疗效果。     

老年人急性心肌梗死的急诊介入治疗

老年人急性心肌梗死 (ＡＭＩ)的发病率逐渐增高 ,成为老年人死亡的最常见疾病。近 10年来再灌注治疗 (包括溶栓急诊介入或外科血运重建术 )在老年ＡＭＩ人群中的应用逐渐增多。我们着重论述近年来急诊介入技术治疗老年ＡＭＩ的进展。1　溶栓治疗对老年ＡＭＩ的局限性1.1　老年ＡＭＩ病人溶栓禁忌证者较非老年人群多　如各种出血倾向和出血性疾病、严重肝肾疾病、不易控制的高血压病等溶栓禁忌证在老年人中明显高于中青年人 ,故实际上能接受溶栓治疗的老年ＡＭＩ病人明显少于中青年ＡＭＩ病人。1.2　老年人溶栓后出血并发症发生率明显高于非…     

老年妇科手术患者的临床特点及围术期处理

目的总结老年妇科手术患者的临床特点及围术期处理措施。方法选取2015年1~12月在该院进行妇科手术的56例老年患者作为老年组(年龄≥60岁),同时选取同一时期采取妇科手术治疗的62例非老年患者作为非老年组(年龄<60岁),并分析两组手术前后临床特点,同时总结老年妇科手术患者围术期处理措施。结果两组恶性肿瘤疾病和术后合并疾病发病率比较差异有统计学意义(P<0.05),两组并发症发生率比较差异无统计学意义(P>0.05)。结论老年患者以妇科恶性肿瘤疾病为主,且多数术后合并各种并发症,因此掌握老年妇科手术治疗的临床特点,围术期做好术前准备和术后护理干预,有助于提高患者对麻醉和手术的耐受力,减少术后并发症的发生以及死亡率。     

老年急性胰腺炎的临床特点及预后分析

目的研究老年急性胰腺炎的临床特点及预后。方法回顾性分析51例老年与53例同期非老年病人（非老年组）的临床资料。结果老年组病人合并糖尿病及高血压者明显高于非老年组，多器官功能衰竭明显多于非老年组。老年组中血CRP水平〉100mg／L，占47．1％，非老年组中血CRP水平〉100mg／L，占20．6％（P〈0．01）。结论老年人急性胰腺炎具有临床表现不典型、病情重、并发症多的特点，积极内科综合治疗，能改善病人预后。     

老年胃癌手术患者并存心肺疾病71例临床分析

目的　探讨手术治疗老年胃癌患者并存内科心肺疾病的临床特点。方法　2001 -02 ~2004 -08对广东省高州市中医院老年胃癌病人合并内科心肺疾病又需要手术治疗者,努力做好围手术期处理。结果　106例老年胃癌患者中有71例(66. 98% )并存高血压、心脏病、肺部疾患,这些手术前有科心肺疾病者术后发生并发症21例,发生率为29 .58%,而35例手术前无内科心肺疾病患者术后发生并发症3例,发生率8. 57%,经统计学处理χ2 =3 98,P<0. 05,差异有显著性。结论　对老年胃癌手术病人并存内科心肺疾病患者应加强围手术期的处理,可减少手术的风险性,减少并发症的发生。     

老年病人上腹部手术麻醉的安全性

老年人施行手术麻醉时，年龄本身就是一个危险因素，老年病人麻醉术过程中及术后并发症的发病率或病死率远比年轻人高，主要原因是各系统器官功能减退和并发症比一般多。有资料报道，外科手术的并发症第一位是胸内手术，其次上腹部手术和颅脑手术。所以，麻醉成败的关键在于按老年人的病理生学特点处理围手术期的有关问题。     

Predicting adverse postoperative outcomes in patients aged 80 years or older

OBJECTIVE: The identification of reversible factors that are associated with postoperative morbidity in geriatric surgical patients is critical to improving perioperative outcomes in such patients. Our study aimed to compare the relative importance of intraoperative versus preoperative factors in predicting adverse postoperative outcomes in geriatric patients. DESIGN: Retrospective cohort study of consecutive patients undergoing noncardiac surgery in 1995. SETTING: Two University of California, San Francisco, teaching hospitals--Moffitt/Long and Mount Zion medical centers. PARTICIPANTS: All men and women 80 years of age or older undergoing noncardiac surgery. MEASUREMENTS: Medical records of all patients were reviewed to measure predefined pre- and intraoperative risk factors and postoperative outcomes. Predictors of postoperative outcomes were identified by multivariate logistic regression analyses. RESULTS: Three hundred sixty-seven patients were studied. The most prevalent preoperative risk factors were a history of hypertension and coronary artery, pulmonary, and neurologic diseases. Postoperative in-hospital mortality rate was 4.6%, and 25% of patients developed adverse postoperative outcomes, of which neurological and cardiovascular complications were the leading causes of morbidity (15% and 12%, respectively). By multivariate logistic regression, a history of neurological disease (odds ratio [OR] 4.0, 95% confidence interval [CI] 2.3 - 6.9, P = .0001), congestive heart failure (OR 2.7, 95% CI 1.4 - 5.3, P = .004), and a history of arrhythmia (OR 2.3, 95% CI 1.2 - 4.3, P = .01) increased the odds of adverse postoperative events. The only intraoperative event shown to be predictive of postoperative complications was the use of vasoactive agents (OR 8.0, 95% CI 1.6 - 40.5, P = .009). CONCLUSIONS: In this group of geriatric surgical patients, the overall postoperative in-hospital mortality rate was 4.6%, and 25% of the patients developed adverse postoperative outcomes involving either the neurological, cardiovascular, or pulmonary systems. Intraoperative events appeared to be less important than preoperative comorbidities in predicting adverse postoperative outcomes.     

高龄心脏病患者非心脏手术麻醉管理经验

目的:总结合并心血管疾病的高龄患者行非心脏手术麻醉管理的经验,提高麻醉管理质量。方法:回顾性分析189例年龄70～101岁,平均(77.5±6.3)岁,合并心血管疾病患者行非心脏手术的麻醉管理资料。总结麻醉方法、药物应用、监测和围术期不良事件的预防及处理措施。结果:71例行下肢和下腹部手术患者选择硬膜外麻醉,首次剂量1%利多卡因6～8mL;其余为全身麻醉;全身麻醉在诱导时容易发生血压波动,急诊手术患者更明显。全组患者术前穿刺动、静脉监测,72%患者术中应用硝酸甘油治疗,34例患者术中应用多巴胺,63例心律失常者应用胺碘酮或艾司洛尔。麻醉期无死亡病例,1例患者术后2d死于急性心肌梗死。结论:重视术前准备和术中监测;硬膜外麻醉选择低浓度、小容量多次给药方法;全麻诱导药应用缓慢给药、延长诱导时间方法;维持术中循环稳定,积极改善冠状动脉供血,心功能较差者适当应用强心利尿药。     

Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients

OBJECTIVES: To determine the prevalence and predictors of adverse postoperative outcomes in older surgical patients undergoing noncardiac surgery. DESIGN: Prospective cohort study of consecutive patients undergoing noncardiac surgery in 1997. SETTING: A medical school-affiliated teaching community hospital. PARTICIPANTS: Patients age 70 and older undergoing noncardiac surgery. Patients presenting for surgery requiring only local anesthesia or monitored anesthesia care were excluded. MEASUREMENTS: Potential pre- and intra-operative risk factors were measured and evaluated for their association with the occurrence of predefined in-hospital postoperative adverse outcomes. Univariate predictors of postoperative outcomes were first measured using the chi-square or Fisher's exact tests followed by multivariate logistic regression. Odds ratios (OR) with 95% confidence interval (CI), and two-sided P-values were reported. RESULTS: Five hundred forty-four consecutive patients were studied. Overall, 21% of patients developed one or more postoperative adverse outcomes and 3.7% died during the in-hospital postoperative period. Of all the adverse outcomes, cardiovascular complications (10.3%) were the leading cause of morbidity, followed by neurological (7.7%) and pulmonary complications (5.5%). By multivariate logistic regression analysis, American Society of Anesthesiologists (ASA) classification (OR = 2.7, CI = 1.6-4.4), emergency surgery (OR = 2.0, CI = 1.1-3.4), and intraoperative tachycardia (OR = 3.8, CI = 1.9-7.6) were the most important predictors of postoperative adverse outcomes. Of all the preoperative physical symptoms and signs, decreased functional status (OR = 3.0, CI = 1.4-6.4) and clinical signs of congestive heart failure (OR = 2.1, CI = 1.1-5.1) were the two most important predictors of postoperative adverse neurological and cardiac outcomes, respectively. The median hospital stay was 4 days. The patients who developed postoperative adverse outcomes had significantly longer median hospital stays (9 days) than those without complications (3 days), (P < .0001). CONCLUSION: Our study demonstrates that the postoperative mortality rate in geriatric surgical patients undergoing noncardiac surgery is low. Despite the prevalence of preoperative chronic medical conditions, most patients do well postoperatively. The ASA classification (a reflection of the severity of preoperative comorbidities), emergency surgery, and intraoperative tachycardia increase the odds of developing any postoperative adverse events. Future studies aimed at modifying some of the potentially reversible risk factors, such as preoperative heart function and intraoperative heart rate are warranted.     

慢性阻塞性肺疾病的合并症/并发症的发病率和病死率分析

目的探讨慢性阻塞性肺疾病(chronic obstructive pulmonary disease, COPD)的合并症/并发症的发病率和病死率。 方法选择我院呼吸与危重症医学中心2018年1月至2018年12月住院的COPD患者1 210例,按照其合并症/并发症的类型进行分组,以单纯COPD为对照组,其余为病例组,观察各合并症/并发症的发病率和病死率,同时分析各组病例在性别、年龄、病程、吸烟、每年急性加重次数间的差异,以及合并各类疾病的发病率和病死率。 结果COPD患者中合并症/并发症发病率为98.60%,病死率为1.34%。在COPD患者合并症/并发症发病率分析中,结果显示肺外合并症中以血管系统疾病为主,占36.37%,肺内合并症以肺癌为主,占36.37,并发症中以呼吸衰竭为主,占20.95%;在病死率分析中结果显示合并心血管系统疾病、神经系统疾病、血液系统、并发呼吸衰竭、肺性脑病病死率较高,其病死率分别为4.25%、4.28%、5.00%、3.60%、6.25%;而合并症/并发症组患者在病程、急性加重次数方面较对照组有不同程度的增加。在COPD合并各系统疾病亚分类发病率和病死率分析中,结果表明COPD合并高血压发病率最高,为25.81%,以COPD合并消化道出血病死率最高,达16.66%。 结论COPD合并症/并发症患者发病率较高,病死率显著增加,严重影响COPD患者的预后。COPD的诊治中对其合并症/并发症的需要十分重视。     

并发心血管病的80岁以上患者行非心脏手术围术期处理

目的 :探讨并发心血管疾病的 80岁以上高龄患者行非心脏手术围术期处理的特殊性。方法 :总结行这类手术患者 94例 ,术前行各项检查 ,评估心血管系统功能异常程度 ,并作相应的准备 ,选择合适的麻醉方法、药物、监测及调控措施 ,预防术中心肌氧供需失衡和心血管事件发生。结果 :术前心血管疾病以心肌供血不足的发生率 （83% ）居首位 ,其次是高血压或低血压 （6 1% ） ,列居第三位的是各种类型心律不齐 （46 % ）。接受扩冠脉血管治疗 2 2例 ,营养心肌治疗 6 2例 ,抗高血压治疗 4 1例 ,抗心律失常治疗 2 7例。上腹部手术 76 %选用全麻 ,下腹部、下肢手术均选用椎管内麻醉。术中心肌供血不足、高血压或低血压和心律不齐的发生率分别较术前下降 11% ,5 %和 6 %。结论 :高龄患者并发心血管疾病以心肌供血不足最常见 ,术前充分准备、麻醉选择适当、术中调控合理是安全渡过围术期的重要措施     

The risk of noncardiac surgery in patients with heart disease: a new way for an easy approach to a right preoperative assessment]

The aim of cardiovascular preoperative evaluation in noncardiac surgery is to assess the current cardiovascular status of patients, to find underlying unknown diseases, to advise about medical management for patients in the preoperative period and, eventually, to postpone noncardiac surgery until cardiac conditions are improved or stabilized. The basic clinical evaluation, obtained by history, physical and ECG examination, provides enough data to estimate the cardiovascular risk. Cardiovascular risk factors and specific surgery risk have a huge importance in this evaluation; the specific surgery risk can be classified into three categories: high, intermediate, and low. However, the evaluation of cardiac risk is not simple and the eventual legal consequences are important. For this reason we propose this hypothesis for an easy approach to a right preoperative assessment based on a succession of eight steps; this way would be a support for specialists and young physicians that are called to give a clinical report on surgery timing and on possible problems of patients with cardiovascular disease undergoing noncardiac surgery.     

Preoperative plasma N-terminal pro-brain natriuretic peptide concentration and perioperative cardiovascular risk in elderly patients.

BACKGROUND: The prediction of perioperative cardiovascular complications is important in the medical management of patients undergoing noncardiac surgery. Several indices have been developed, but a simpler, more practical and accurate method is needed. The purpose of this study was to determine whether the N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration before operation can be used to predict perioperative cardiovascular complications in elderly patients undergoing noncardiac surgery. METHODS AND RESULTS: The study group comprised 279 patients older than 60 years who were scheduled for elective surgery. The plasma NT-proBNP concentration, clinical cardiac indices and left ventricular ejection fraction were measured prior to operation. The postoperative cardiac outcomes were followed and predictors for postoperative cardiac risk were identified. Cardiovascular complications occurred in 25 patients (9.0%). Age, the incidence of prior ischemic heart disease or congestive heart failure, and the plasma NT-proBNP concentration were significantly higher in patients with perioperative cardiovascular complications than in those without. Using receiver operating characteristic analysis to predict perioperative cardiovascular events, a cut-off value of 201 pg/ml was identified as the optimal predictor of perioperative complications, showing a sensitivity of 80.0% and specificity of 81.1%. Multivariate analysis revealed that NT-proBNP >201 pg/ml (odds ratio (OR) 7.6, 95% confidence interval (CI) 2.2-26.6, p=0.003) and revised cardiac index > or =2 (OR 6.3, 95% CI 1.7-23.8, p=0.007) were independent predictors for perioperative cardiovascular complications. CONCLUSIONS: Elevated NT-proBNP levels are independently associated with an increase in the risk of perioperative cardiovascular complications in elderly patients undergoing noncardiac and nonvascular operations.     

Systemic complications of acromegaly: epidemiology, pathogenesis, and management

This review focuses on the systemic complications of acromegaly. Mortality in this disease is increased mostly because of cardiovascular and respiratory diseases, although currently neoplastic complications have been questioned as a relevant cause of increased risk of death. Biventricular hypertrophy, occurring independently of hypertension and metabolic complications, is the most frequent cardiac complication. Diastolic and systolic dysfunction develops along with disease duration; and other cardiac disorders, such as arrhythmias, valve disease, hypertension, atherosclerosis, and endothelial dysfunction, are also common in acromegaly. Control of acromegaly by surgery or pharmacotherapy, especially somatostatin analogs, improves cardiovascular morbidity. Respiratory disorders, sleep apnea, and ventilatory dysfunction are also important contributors in increasing mortality and are advantageously benefitted by controlling GH and IGF-I hypersecretion. An increased risk of colonic polyps, which more frequently recur in patients not controlled after treatment, has been reported by several independent investigations, although malignancies in other organs have also been described, but less convincingly than at the gastrointestinal level. Finally, the most important cause of morbidity and functional disability of the disease is arthropathy, which can be reversed at an initial stage, but not if the disease is left untreated for several years.     

Case presentations of potential applications of computed tomographic angiography in the geriatric population

Recent technical advances have enabled the use of computed tomography (CT) to visualize the beating heart, including the coronary arteries. This ability to perform noninvasive coronary angiography and to precisely evaluate other cardiovascular structures using CT may be especially valuable in the geriatric population. CT angiography can be used not only to investigate chest pain syndromes in the elderly but also for preoperative evaluation before cardiac and noncardiac surgery to detect intracardiac thrombi and tumors and to evaluate valves, the myocardium, and other cardiovascular structures, including the aorta. The authors present examples of the application of CT angiography in various older adult patients with cardiovascular disease to highlight potential applications.     

高龄合并呼吸及循环系统疾病后腹腔镜手术的围手术期处理

目的探讨高龄合并呼吸及循环系统疾病患者后腹腔镜手术的围手术期处理。方法对65岁以上合并呼吸及循环系统疾病的46例患者行后腹腔镜手术围手术期资料进行研究。结果 46例均安全度过围手术期,无一例死亡,术后出现肺部及心血管并发症12例,经积极治疗后痊愈出院。结论高龄合并呼吸及循环系统疾病的患者做好充分的术前准备,加强术前、术中及术后围手术期监测及处理,施行后腹腔镜手术是安全的。