冠脉支架患者非心脏手术的围手术期处理

背景 近三十年来,心脏冠脉支架患者日益增多,此类患者在接受非心脏手术时其围手术期将面临特殊挑战.目的 现将重点讨论支架血栓的病理生理以及冠脉支架患者非心脏手术围手术期的处理策略.内容 冠脉支架患者为预防支架内血栓的发生,通常接受由阿司匹林和氯吡格雷为主要药物的双联抗血小板治疗,其疗程为裸金属支架bare metal s...     

2014年欧美心脏病患者非心脏手术围术期评估管理指南解读

合并心脏疾病的患者行普胸外科手术时风险较高,围术期麻醉评估和管理是一大难点,2014年欧、美心脏病学权威机构美国心脏协会(AHA)/美国心脏病学会(ACC)和欧洲心脏病学会(ESC)/欧洲麻醉学学会(ESA)分别发布了心脏病患者非心脏手术围术期评估管理指南,为接受非心脏手术成人患者的围手术期心血管评估和治疗提供指导。该文主要根据上海市胸科医院的临床处理经验对欧美指南加以解读,以期在两个方面为临床医生提供借鉴:一是评估合并心脏疾病的患者哪些因素可能会增加胸科手术围术期发病率和病死率;二是如何设计合理的围术期治疗策略来降低心脏病患者胸科手术时的围术期风险。     

冠心病患者实施非心脏手术相关危险因素筛选的研究进展

冠心病患者实施非心脏手术的相关危险因素很多,因为疾病本身、麻醉和手术导致围手术期与心脏相关的不良事件日益增多,且多与麻醉及手术直接相关.现就冠心病患者实施非心脏的相关危险因素(涉及麻醉与手术)作一综述.     

经皮冠状动脉支架介入治疗患者行非心脏手术抗血小板治疗的困惑与思考

冠状动脉粥样硬化性心脏病患者日益增多,其中有相当比例的患者接受了经皮冠状动脉介入治疗及术后双联抗血小板治疗。这些患者如果短期内需要接受非心脏手术将面临失血增加的危害,但是如果停止抗血小板治疗,围手术期支架内血栓形成的风险和心肌梗死的发生率将增加。文章针对上述问题就冠状动脉支架植入患者术后抗凝治疗的主要药物、有效性及安全性、治疗时限、并发症、围手术期抗血小板药物的停用及桥接策略等方面进行了详细阐述,以期对此类患者的围手术期安全提供帮助。     

非心脏手术围术期心脏事件危险评估与保护性干预

围术期心脏事件是非心脏手术围手术期严重并发症和死亡的重要原因。在临床广泛应用的修订心脏风险指数及ACC／AHA制定的非心脏手术围术期评估指南．可协助临床医生评价非心脏手术心脏风险并做出围术期诊治决策。β受体阻滞剂和他汀类药物可减少高危患者非心脏手术围术期心脏事件及死亡的发生,术前血管重建治疗对于严重冠心病患者是必要和有益的。     

围手术期血压与非心脏手术后心肌损伤的研究进展

非心脏手术后心肌损伤(myocardial injury after non-cardiac surgery,MINS)作为一种心血管系统的严重并发症,是非心脏手术患者术后可归因死亡的重要原因。近来的研究发现MINS与围手术期血压显著相关,合理的围手术期血压管理策略可能减少MINS的发生。文章重点介绍了MINS的研究新进展与围手术期血压的特点,阐述了围手术期血压调控对减少MINS的潜在益处,为围手术期血压管理和MINS的预防提供新的依据。围手术期个体化血压管理策略可能成为预防MINS的新方向。     

心血管病人非心脏手术的麻醉管理

随着老龄化社会的到来 ,心血管疾病的发病率逐年增加 ,此类患者接受非心脏手术麻醉的机会也日益增多。本文讨论心血管病人行非心脏手术时提高围术期安全的几个问题。术前正确评估是决定围术期处理的决定因素此类患者的术前评估是个难点 ,手术风险不仅与原有心血管疾病的严重程度相关 ,也与需手术治疗的疾病相关 ,还与手术创伤、手术医师的技巧、麻醉医师的处理水平等相关。一般而言 ,心脏疾病检查和治疗的适应证与非手术期相同 ,但是在时间上则与非心脏外科情况的紧迫性相关。对于威胁生命必需急症手术的患者而言 ,原则上无绝对手术禁忌。内…     

冠脉支架病人的围术期处理

经皮冠状动脉介入治疗是冠心病的有效治疗手段.近来的研究表明术前冠脉介入治疗对于非心脏手术病人(特别是植入了冠脉支架的病人)的预后可能有不良影响,主要的风险在于严重的出血以及支架内血栓形成.术前对病人的详尽评价以及围术期最佳化处理可以改善这类病人预后.     

围术期抗血小板治疗的相关问题

目前对冠状动脉硬化尤其是植入冠状动脉支架的病人采用抗血小板药物治疗,抑制血小板的黏附、聚集和释放,对心脏意外事件的预防取得较好效果[1,2].但外科、麻醉科医师对植入冠状动脉支架病人拟行非心脏手术前是否停用抗血小板药物及相关病人面临的围术期栓塞/出血问题仍存有争议,现就有关问题进行报道.     

非体外循环冠状动脉旁路移植术联合中度以上创伤非心脏手术的围手术期安全性研究及可行性评价

目的探讨非体外循环冠状动脉旁路移植术(OPCAB)联合中度以上创伤非心脏手术的围手术期安全性及可行性。方法回顾性分析2013年9月至2019年1月在北京大学第一医院心脏外科行同期OPCAB联合非心脏手术54例患者的临床资料,男性46例,女性8例,年龄(65.8±8.8)岁(范围:41~85岁)。联合非心脏手术包括血管手术1例、胸外科手术26例、普通外科手术12例、泌尿外科手术15例,手术侵袭度评分均为中度以上创伤级别。每例患者选取相同心脏手术团队临近时间完成的、手术方式类似的另2例单纯OPCAB患者作为对照。采用t检验、Mann-Whitney U检验、χ2检验或Fisher确切概率法比较两组围手术期临床指标。结果两组患者术前各项基本指标基本匹配,欧洲心脏手术风险评估系统(EuroSCOREⅡ)评分无差异[1.185(0.758)%比1.215(0.905)%,Z=-0.036,P=0.972]。两组均无围手术期死亡患者。尽管同期联合手术组手术时间延长[(324.9±97.1)min比(166.7±36.7)min,t=11.564,P<0.01],且术中出血量增加[(462.2±269.6)ml比(304.5±177.8)ml,t=3.866,P<0.01],但两组主要术后并发症包括围手术期心肌梗死、新发心房颤动、围手术期卒中、急性肾功能不全、切口感染及出血再手术比例无差异(P值均>0.05),围手术期总输血量、机械通气时间及ICU停留时间也无差异(P值均>0.05)。结论对于符合指征的OPCAB患者,同期施行中度以上创伤的非心脏手术安全可行,与单纯OPCAB手术患者相比不增加围手术期并发症发生风险。     

Herzklappenerkrankungen

The probability of treating patients with valvular heart disease during non-cardiac surgery increases with the age of the patient. The prevalence of valvular heart disease is approximately 2.5% and increases further in the patient group aged over 75 years old. Patients with valvular heart disease undergoing non-cardiac surgery have an increased perioperative cardiovascular risk depending on the severity of the disease. Knowledge of the hemodynamic alterations and compensation mechanisms which accompany diseases of the valve apparatus is essential for a suitable treatment of patients with such pre-existing diseases. The most common valvular heart diseases lead to volume (mitral valve insufficiency) or pressure load (aortic stenosis) of the left ventricle and in the case of mitral stenosis to a pressure load on the left atrium. Depending on the underlying disease and the type of surgery planned a corresponding choice of anesthesia procedure and medication must be made. In the present review article the pathophysiology of the relevant valvular heart diseases and the implications for perioperative anesthesia management will be presented. An individually tailored extended perioperative monitoring allows hemodynamic alterations to be rapidly recognized and adequately treated.     

Can statins reduce perioperative morbidity and mortality in patients undergoing non-cardiac vascular surgery?

AIMS: To determine whether statins can reduce perioperative morbidity and mortality in patients undergoing non-cardiac vascular surgery. METHODS: A search using Pubmed was performed to identify reports in English. The search terms were: "statins", "perioperative morbidity", "perioperative mortality" and "vascular surgery". We excluded studies dealing with the effect of statins in cardiac surgery. Retrieved articles were manually searched. RESULTS: Current evidence shows that statins decrease perioperative morbidity and mortality in patients undergoing non-cardiac vascular surgery. Any benefit probably occurs soon (within a month) after initiating treatment. CONCLUSIONS: Appropriately designed trials need to confirm the beneficial effect of perioperative statin therapy in various patient categories. The optimal duration and dose of perioperative statin therapy should be defined.     

Anesthesia for patients with congenital heart disease undergoing non-cardiac surgery

An increasing number of children who have undergone corrective surgery for congenital heart disease (CHD) reach adulthood every year. These survivors defy commonly used classification schemes for adults undergoing non-cardiac surgery. Due to lack of data, the risk-benefit assessment for undergoing non-cardiac interventions must be individualized. An interdisciplinary team approach is the corner stone for the safe delivery of anesthesia to this patient population. This review is meant to equip the anesthesiologist with the necessary tools for the safe perioperative sailing of his patient suffering from CHD.     

Cardiac risk reduction in non-cardiac surgery: the role of anaesthesia and monitoring techniques

Cardiac complications are the major cause of perioperative morbidity and mortality of patients undergoing non-cardiac surgery. This is related to the frequent presence of underlying coronary artery disease. In the last few decades, attention has focused on preoperative cardiac risk assessment that may help to identify patients at increased cardiac risk for whom cardioprotective medication and, when indicated, coronary revascularization may improve perioperative outcome. On the other hand, less attention was given to the role of anaesthesia and monitoring techniques in the cardiac risk management of high-risk patients undergoing non-cardiac surgery. The aim of this review was to summarize the current evidence from published studies on the effect of the type of anaesthesia and monitoring techniques on perioperative cardiac outcome in non-cardiac surgery.     

Monitored anesthesia care with dexmedetomidine of a patient with severe pulmonary arterial hypertension for inguinal hernioplasty

The presence of severe pulmonary arterial hypertension (PAH) is a significant risk factor of major perioperative cardiovascular complications in patients undergoing even non-cardiac surgery under anesthetic management. The most important aspect of perioperative care of PAH patients is to avoid pulmonary hypertensive crisis, which can be induced by alveolar hypoxia, hypoxemia, hypercarbia, metabolic acidosis, airway manipulations, and activation of the sympathetic nervous system by noxious stimuli. We report a case of successful monitored anesthesia care supplemented by dexmedetomidine for inguinal hernioplasty of a patient with severe PAH secondary to congenital heart disease.     

Perioperative cardiovascular evaluation and management for non-cardiac surgery in patients with valvular heart disease

A significant perioperative cardiac morbidity and mortality should be anticipated during non-cardiac surgery when patients have cardiac risks. Especially the non-cardiac surgical risk is very high in the patient with aortic stenosis. Non-cardiac surgery should be postponed to cardiac interventions, such as balloon valvuloplasty or prosthetic valve replacement, in patients with severe heart failure. Non-cardiac surgery can be performed with a relatively low risk even if the patients have a symptomatic regurgitatant valvular heart diseases, however, the cardiac risk is always very high in the patients with left ventricular ejection fraction lowerer than 40%. Surgical invasion, anesthetic agents, analgegic agents, and fluid transfusion during the non-cardiac surgery will give a significant effects on the circulatory condition, therefore, non-cardiac surgery should be performed with an adequate cardiac monitoring and careful perioperarive managements according to the pathophysiology of each valvular heart disaease. Afterload control is very important in the patients with regurgitant valvular heart diseases, contrary preload control is very important in the patients with stenotic valvular heart diseases. Anesthetic agents and methods are not the determinant factor of the clinical outcome, but the associated cardiac diseases and the surgical procedure are important determinant factor of the clinical outcome of the non-cardiac surgery.     

Possible indications of beta-blockers in the perioperative period other than prevention of cardiac ischemia

According to the guidelines of the American College of Cardiology/American Heart Association 2006 for perioperative cardiovascular evaluation for non-cardiac surgery, beta-blocker therapy should be considered for high-risk individuals undergoing vascular surgery or high- and intermediate-risk patients undergoing non-cardiac surgery. This guideline might induce physicians to increasingly use beta-blockers in the hope of preventing perioperative cardiac complications. However, beta-blockers have potential beneficial effects outside the prevention of cardiac events. In addition to reducing anesthetic and analgesic requirements during the perioperative period, beta-blockers have neuroprotective effects in patients with brain trauma and possible effectiveness in the management of intraoperative awareness-induced post-traumatic stress disorder. Moreover, intrathecal administration of beta-blockers may have antinociceptive effects. Physicians need to bear in mind the benefits of beta-blockers for purposes other than preventing cardiac events when applied in the perioperative period, and they should be familiar with the pharmacodynamics and risk–benefit ratio with their use. This review focuses on possible extracardiac indications of beta-blockers.     

Anesthetic management of patients with dilated cardiomyopathy undergoing non-cardiac surgery

BACKGROUND: A considerable amount of data are available regarding cardiac risk in patients with coronary artery disease, but not with patients with cardiomyopathy, undergoing non-cardiac surgery. METHODS: Reports of the anesthetic management of patients with dilated cardiomyopathy (DCM) undergoing non-cardiac surgery were identified using Medline and the Igaku-chuou-zassi (Japana Centra Revuo Medicina) database (1981-2001). The data were analyzed in terms of patient characteristics, methods of intraoperative care, and clinical outcome. RESULTS: Seventy-three patients were included. The mean value of the preoperative left ventricular ejection fraction (EF) was 31%. About 70% of patients revealed poor ventricular function (EF < 35%). EF did not correlate with the severity of congestive heart failure (CHF). Major complications occurred in 6 cases and minor ones in 23 cases. A history of CHF, advanced NYHA classification and lack of preoperative diagnosis of DCM were suggested as perioperative risk factors. CONCLUSIONS: Careful planning is inevitable in anesthesia for patients with DCM, although the rate of major perioperative complications is relatively low. Evaluation of cardiac reserve is more important than the resting value of ejection fraction. In order to clearly elucidate risk factors for adverse perioperative outcomes, further analysis will be necessary as more cases are documented.     

Benefits and harms of perioperative beta-blockade

Cardiac events in patients undergoing surgery may have serious consequences for both short- and long-term postoperative prognosis. Recently conducted trials have not demonstrated beneficial effects of perioperative beta-blockade, although originally small trials with methodological flaws did suggest this. We evaluate the evidence for using perioperative beta-blockade in both cardiac and non-cardiac surgery, and conclude that there is no statistically significant effect on mortality and insufficient evidence for a reduction of the incidence of mycocardial infarction in meta-analyses of all randomized trials. However, confidence intervals of the intervention effects in the meta-analyses are wide, leaving room for both benefits and harms. The largest observational study performed suggests that perioperative beta-blockade is associated with higher mortality in patients with low cardiac risk or diabetes, and with lower mortality in patients with high cardiac risk undergoing non-cardiac surgery. Larger randomized trials are needed to determine dosage, optimal duration, and safety of therapy, and to identify populations in whom-and how-perioperative beta-blockade may be beneficial.     

Perioperative transesophageal echocardiography for non-cardiac surgery

Purpose

The use of transesophageal echocardiography (TEE) has evolved to include patients undergoing high-risk non-cardiac procedures and patients with significant cardiac disease undergoing non-cardiac surgery. Implementation of basic TEE education in training programs has increased across a broad spectrum of procedures in the perioperative arena. This paper describes the use of perioperative TEE in non-cardiac surgery and provides an overview of the basic TEE examination.

Principal findings

Perioperative TEE is used to monitor hemodynamic parameters in non-cardiac procedures where there is a high risk of hemodynamic instability. Its use extends to include moderate-risk procedures for patients with significant cardiac diseases such as low ejection fraction, hypertrophic cardiomyopathy, severe valve lesions, or congenital heart disease. Vascular procedures involving the aorta, blunt trauma, and liver transplantation are all examples of procedures that may benefit from TEE. Transesophageal echocardiography examination allows assessment of volume status, ventricular function, diagnosis of gross valvular pathology and pericardial tamponade, as well as close monitoring of cardiac output, response to therapy, and the impact of ongoing surgical manipulation. In patients with unexplained and unexpected hemodynamic instability, “rescue TEE” can be used to help identify the underlying cause.

Conclusions

Perioperative TEE is emerging as a preferred tool to manage hemodynamics in high-risk procedures and in high-risk patients undergoing non-cardiac surgery. A rescue TEE examination protocol is a helpful approach for early identification of the etiology of hemodynamic instability.