心脏病患者非心脏手术围麻醉期中国专家临床管理共识(2020)

合并心脏病患者接受非心脏手术居围术期死因首位。随着我国人口老龄化及心脏病日趋年轻化,伴发心脏病接受心脏及非心脏手术的例数呈逐年增多趋势。合并心脏病患者接受非心脏手术术中及术后心血管不良事件的发生及患者预后与麻醉处理是否合理密切相关,且每一类心脏病围术期处理原则不尽相同,麻醉方式及药物对不同心脏病影响各异。对于合并心脏病患者接受非心脏手术的围麻醉期管理,目前尚无全面系统的全国性专家共识。中国心胸血管麻醉学会非心脏手术麻醉分会根据国内合并心脏病患者行非心脏手术例数较多的多家大型医院临床管理经验,在参考国内外相关指南及研究的基础上,通过分析、总结,形成《心脏病患者非心脏手术围麻醉期中国专家临床管理共识(2020)》。本共识不作为医学责任认定和判断的依据,不具强制性,仅供麻醉专业人员参考。     

非心脏手术围术期β受体阻滞剂的心脏保护作用

围术期心脏事件是非心脏手术围术期严重并发症和死亡的重要原因,有关该问题的研究已有数十年的历史[1]。尽管当今麻醉和手术技术迅猛发展,但在普通非心脏手术人群中,仍有约1%的患者发生围术期心脏事件[2]。临床上广泛应用的修订心脏风险指数及美国心脏病学会（American College of Cardiology,ACC）/美国心脏学会（American Heart Association,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的心脏风险,并作     

急性冠脉综合征患者经皮冠脉介入治疗术后心脏不良事件的发生情况与影响因素分析

目的:分析急性冠脉综合征患者接受经皮冠脉介入治疗(PCI)后发生心脏不良事件的基本情况以及患者发生心脏不良事件的相关影响因素。方法:2015年3月至2017年3月选择我院收治的急性冠脉综合征接受PCI术治疗的286例患者作为研究对象,对患者展开6—12个月的跟踪随访,使用心脏不良事件影响因素调查表分析这286例患者发生心脏不良事件的具体情况以及影响这种问题发生的相关因素。结果:跟踪随访结果显示6—12个月内有61例患者发生心脏不良事件,发生率为21.33%;患者心脏不良事件的独立性危险预测因素包括:不良生活习惯、独居、白细胞计数、甘油三脂。结论:急性冠脉综合征PCI术患者术后发生心脏不良事件的概率较高,需要详细掌握相关独立性危险预测因素,尽可能预防不良心脏事件,确保患者的健康安全。     

老年冠心病患者非心脏手术围术期心血管事件危险因素筛选与分析

目的:筛选并分析老年冠心病患者非心脏手术围术期心血管事件的危险因素.方法:行择期手术的老年冠心病非心脏手术患者223例,记录术中、术后心血管事件(恶性心律失常、心肌缺血、不稳定性心绞痛、心肌梗死、高血压),根据有无发生心血管事件分为不良事件组和无不良事件组,并进行单因素分析及多因素非条件Logistic回归分析.结果:不良事件组中术前有ST段压低≥0.05 mV、不稳定型心绞痛、高血压、年龄>70岁、吸烟、糖尿病、射血分数≤50%、心功能Ⅲ级、心肌梗死、心律失常、血红蛋白<120 g/L、纤维蛋白原增高的患者心血管事件发生率均高于无不良事件组,以上危险因素均与不良事件发生呈正相关性(P<0.05).结论:术前心律失常、糖尿病、心肌梗死、不稳定型心绞痛、纤维蛋白原增高、射血分数≤50%、血红蛋白<120 g/L及ST段压低≥0.05 mV是老年冠心病患者非心脏手术围术期心血管事件的主要危险因素.     

心肌酶谱与肌钙蛋白Ⅰ对老年冠心病非心脏手术围术期不良事件的预测价值

目的探讨围术期监测心肌酶谱与肌钙蛋白Ⅰ对老年冠心病患者实施非心脏手术预测围术期不良事件的价值。方法 223例择期行非心脏手术老年冠心病患者,根据围术期是否发生不良事件分为发生不良事件组(A组)与未发生不良事件组(B组),比较2组术前及术后3 d内心肌酶谱及肌钙蛋白I水平。结果 2组术前心肌酶谱各项指标与肌钙蛋白I水平均在正常值范围;术后3 d内2组肌酸激酶水平较术前升高(P<0.05),但2组间比较差异无统计学意义(P>0.05);术后肌钙蛋白Ⅰ水平逐渐升高,A组超出正常值范围,B组仍在正常值范围;与术前比较,差异均有统计学意义(P<0.05),且A组高于B组(P<0.05)。结论老年冠心病非心脏手术患者围术期检测心肌酶谱对预测不良事件价值有限;术后3 d内检测肌钙蛋白I对早期发现围术期不良事件有一定预测价值。     

冠心病患者围术期心肌缺血的防治措施

心肌缺血不仅干扰心脏泵功能．而且可诱发严重心律失常、心源性休克、心肌梗死等心脏事件．是围术期冠心病患者病死率增高的重要原因。现就我院2003年11月至2004年2月冠心病患者行非心脏手术期间心肌缺血的防治情况总结如下。     

围术期心肌缺血的监测与防治

近20年来,合并心血管疾病的手术患者越来越多,如何对这些患者进行系统的术前评估,合理地选择麻醉方案,加强围术期监测和治疗,避免不良心脏事件的发生,是麻醉医师和SICU医师研究的重要课题。目前的研究表明,围术期     

老年髋部骨折患者围术期新发心脏不良事件危险因素的研究进展

心脏不良事件是老年髋部骨折患者围术期常见且严重的并发症,其发生会延长住院天数,加重经济负担,影响治疗效果和预后生活质量,甚至增加患者死亡风险。现从年龄、术前合并症、美国麻醉医师协会分级(ASA分级)、贫血与输血等方面对老年髋部骨折患者围术期新发心脏不良事件的危险因素进行综述,以期为临床护理人员预防老年髋部骨折围术期新发心脏不良事件的发生提供参考。     

围术期室性心律失常及其相关因素

心脏危险事件(CRE)是麻醉、手术患者围术期死亡的最主要原因之一，其中室性心律失常(VA)又是发生最频繁的CRE之一。因此，如何积极预防和治疗围术期严重VA是确保患者安全度过围术期的重要措施和难题。本文就围术期VA及其相关因素的临床研究现状作一简述。     

非心脏手术围术期心肌缺血和心肌梗死

在过去几十年里,非心脏手术不论在治疗疾病还是在改善患者的生活质量方面均取得了巨大进步,因此全球每年接受非心脏手术患者的数量迅速增长。然而,接受非心脏手术患者的预后却与围术期心血管疾病发病率、死亡率有着重要的相关性。围术期心脏事件的严重程度全球每年约有10亿成年人接受非心脏手术,其中一半患者年龄大于50岁。     

Characteristics and outcome among patients suffering from out of hospital cardiac arrest of non-cardiac aetiology

AIM: To describe the epidemiology for out of hospital cardiac arrest of a non-cardiac aetiology. PATIENTS: All patients suffering from out of hospital cardiac arrest in whom resuscitation efforts were attempted in the community of G?teborg between 1981 and 2000. METHODS: Between October 1, 1980 and October 1, 2000, all consecutive cases of cardiac arrest in which the emergency medical service (EMS) system responded and attempted resuscitation were reported and followed up to discharge from hospital. RESULTS: In all, 5415 patients participated in the evaluation. Among them 1360 arrests (25%) were judged to be of a non-cardiac aetiology. Among these 24% were caused by a surgical cause or accident, 20% by obstructive pulmonary disease, 13% by drug abuse and the remaining 43% by 'another cause'. Of the patients with out of hospital cardiac arrest of a non-cardiac aetiology 4.0% survived to discharge from hospital as compared with 10.1% of the patients with a cardiac aetiology (P<0.0001). In the various subgroups survival was highest in those with drug abuse (6.8%) and lowest in those with 'another cause' (4.2%). Cerebral performance categories (CPC) score at hospital discharge tended to be worse among survivors from an arrest of non-cardiac than cardiac aetiology. Patients with a cardiac arrest of a non-cardiac aetiology differed from the remaining patients by being younger, including more women, less frequently having a witnessed arrest and less frequently being found in ventricular fibrillation/tachycardia. When simultaneously considering age, sex, witnessed status, presence of bystander cardiopulmonary resuscitation (CPR) and initial arrhythmia, the aetiology (non-cardiac vs. cardiac aetiology) was not an independent predictor of survival. CONCLUSION: Among patients with out of hospital cardiac arrest in whom resuscitation was attempted 25% were judged to be of a non-cardiac aetiology. These patients had a lower survival than patients with a cardiac arrest of cardiac aetiology. However, this was mainly explained by a lower occurrence of ventricular fibrillation and witnessed cardiac arrest.     

围手术期病人心跳骤停的危险因素分析及对策

目的探讨围手术期病人心跳骤停的原因,并提出相应的护理对策,为改善围手术期病人的护理措施提供科学依据。方法采用病历回顾的方法,对围手术期病人心跳骤停的危险因素进行单因素和多因素Logistic回归分析。结果61051例手术病人发生围手术期心跳骤停19例,发生率为3．1／万。病人高龄、ASA分级差、术中缺氧、失血性休克、低血钾、代谢性酸中毒、迷走神经反射是围手术期病人发生心跳骤停的危险因素。结论术前改善择期手术病人特别是高龄病人的身体机能;手术室护士在术中严密观察病人的病情变化,及时纠正电解质平衡紊乱,对减少围手术期病人心跳骤停发生率具有积极的意义。     

Long-term prognosis following resuscitation from out-of-hospital cardiac arrest: role of aetiology and presenting arrest rhythm

ObjectiveLittle is known about long-term prognosis following resuscitation from out-of-hospital cardiac arrest, especially as it relates to the presenting rhythm or arrest aetiology. We investigated long-term survival among those discharged alive following resuscitation according to presenting rhythm and arrest aetiology.MethodsWe conducted a cohort investigation of all non-traumatic adult out-of-hospital cardiac arrest patients resuscitated and discharged alive from hospital between January 1, 2001 and December 31, 2009 in a large metropolitan emergency medical service system. Information about demographics, circumstances, presenting arrest rhythm and aetiology was collected using the dispatch, EMS, and hospital records. Long-term vital status was ascertained using state death records and the Social Security Death Index through 31st December 2010. We used Kaplan Meier to evaluate survival.ResultsDuring the study period, a total of 1001/5958 (17%) persons were resuscitated and discharged alive, of whom 313/1001 (31%) presented with a non-shockable rhythm and 210/1001 (21%) had a non-cardiac aetiology. Overall median survival was 9.8 years with 64% surviving >5 years. Five-year survival was 43% for non-shockable rhythms compared to 73% for shockable rhythms, and 45% for non-cardiac aetiology compared to 69% for cardiac aetiology (p < 0.001 respectively).ConclusionCardiac arrest due to non-shockable rhythm or non-cardiac aetiology comprises a substantial proportion of those who survive to hospital discharge. Although long-term survival in these groups is less than their shockable or cardiac aetiology counterparts, nearly half are alive 5 years following discharge. The findings support efforts to improve resuscitation care for those with non-shockable rhythms or non-cardiac cause.     

An analysis of time factors in out-of-hospital cardiac arrest in Osaka Prefecture

OBJECTIVE: To ascertain important factors in the improvement of out-of-hospital cardiac arrest survival rates through analysis of data for Osaka Prefecture with the focus on time factors. DESIGN: Prospective cohort study according to the Utstein style. SETTING: Osaka Prefecture (population 8,830,000) served by a single emergency medical services system. PATIENTS: Consecutive prehospital cardiac arrests occurring between May 1998 and April 1999. MAIN OUTCOME MEASURES: One-year survival from cardiac arrest, and time factors. RESULT: Of the 5047 cases of confirmed cardiac arrests, resuscitation was attempted in 4871 subjects. Of the 982 cases of cardiac origin and witnessed by bystanders, 31 (3.2%) were still alive, and of the 576 cases of non-cardiac origin and witnessed by bystanders, ten (1.7%) were still alive at the 1 year follow-up. The median time from receipt of the emergency call until ambulance arrival was 5 min and that from receipt of the call until the start of cardiopulmonary resuscitation (CPR) was 7 min. For the 214 patients for whom defibrillation was attempted, the median time from receipt of the call until the first shock was 15 min. The median time from receipt of the call until departure of the ambulance from the scene was 16 min and that until arrival of the ambulance at a hospital was 22 min. CONCLUSIONS: This study using the standardized format according to the Utstein style clearly elucidates the specific delay of the start of defibrillation by paramedics and also indicates the inappropriate rule for this procedure in Japan.     

Refractory Anaphylactic Shock Requiring Emergent Venoarterial Extracorporeal Membrane Oxygenation in the Emergency Department: A Case Report

Venoarterial extracorporeal membrane oxygenation is a viable salvage intervention for patients who experience cardiopulmonary arrest or profound shock from any cause. Acute anaphylactic shock is a rare cause of cardiac arrest. We present a case of a 35-year-old male who experienced cardiac arrest owing to anaphylactic shock while receiving general anesthesia for a routine outpatient surgical procedure. Traditional advanced cardiac life support therapies were provided by paramedics en route to the emergency department of a suburban, community-based hospital. Maximal medical management including endotracheal intubation, intravenous steroids, intravenous crystalloid fluid administration, intravenous vasoactive medications, and high-quality cardiopulmonary resuscitation was provided. Although return of spontaneous circulation was achieved, profound cardiogenic shock persisted. Venoarterial extracorporeal membrane oxygenation was initiated by the emergency department provider and nursing team. The patient survived, was neurologically intact, had full recovery, and was discharged home several days later. We have extensive experience with venoarterial extracorporeal membrane oxygenation, and this case exemplifies the value of an established emergency department extracorporeal membrane oxygenation program in managing all causes of cardiac arrest or refractory shock.     

Anaesthetic assessment and management of cardiac patients for non-cardiac surgery. Part 2: Management

In an earlier article in this journal (June 1999) we discussed the risk that the presence of cardiac disease poses to patients undergoing non-cardiac surgery. We outlined factors in the patient's medical history, examination findings and the value of various tests in arriving at an overall assessment of risk for any given patient. In this article we concentrate on the management of these patients as they undergo surgery itself. We shall consider what measures may usefully be employed in order to minimise the risk of an adverse cardiac event occurring in the perioperative period.     

Factors at resuscitation and outcome among patients suffering from out of hospital cardiac arrest in relation to age

AIM: To describe various factors at resuscitation and outcome among patients suffering from out-of-hospital cardiac arrest in relation to age. PATIENTS: All patients included in the Swedish Cardiac Arrest Registry during the period 1990-1999. The registry covers about 60% of all ambulance organisations in Sweden. METHODS: All patients reached by the ambulance crew and in whom resuscitative efforts were attempted. Crew witnessed cases were excluded. Only patients aged over 18 years were included. Patients were divided into three age groups: less than 65 years (n=7810), 65-75 years (n=7261) and over 75 years (n=8390). RESULTS: The proportion of cases with a cardiac aetiology increased with increasing age (P<0.0001). The proportion of witnessed cases increased with increasing age among those with a non-cardiac aetiology (P<0.0001) and decreased with increasing age among cases with a cardiac aetiology (P=0.02). The proportion of patients exposed to bystander CPR decreased with increasing age (P<0.0001). The proportion of patients found in ventricular fibrillation (VF) decreased with increasing age among patients with a cardiac aetiology (P<0.0001) but was not related to age in those with a non-cardiac aetiology. The proportion of patients being alive after 1 month in the three age groups (youngest first) were: 4.5, 3.2 and 2.5% (P<0.0001). The corresponding figures for patients with a cardiac aetiology found in VF were: 10.7, 7.6 and 6.6% (P<0.0001). After multiple regression analysis controlling for other factors increasing age was still associated with decreased survival to 1 month (odds ratio 0.85; 95% confidence limits 0.80-0.91). CONCLUSION: Among patients suffering from out-of-hospital cardiac arrest various factors at resuscitation, including initial rhythm, aetiology and bystander CPR, are strongly related to age. The chance of survival diminishes with increasing age. When correcting for the dissimilarities in terms of factors at resuscitation, age is still significantly associated with survival, being lower among the elderly.     

尿毒症血液透析患者自体动静脉内瘘成熟的影响因素

目的分析尿毒症血液透析患者自体动静脉内瘘成熟的影响因素。方法选取2016年7月—2020年7月在医院接受血液透析的134例尿毒症患者,查阅病历资料,收集相关信息,采取Logistic回归分析法,确定自体动静脉内瘘成熟的影响因素。结果 134例尿毒症血液透析患者中有114例内瘘成熟,20例内瘘未成熟,未成熟率为14.93%,二分类Logistic回归分析显示,低血压、年龄≥60岁、糖尿病、低白蛋白血症以及围术期未使用钙通道阻滞剂是尿毒症血液透析患者自体动静脉内瘘成熟的独立影响因素(P<0.05)。结论影响尿毒症血液透析患者自体动静脉内瘘成熟的原因与血压高低、糖尿病、年龄、低白蛋白血症以及围术期未使用钙通道阻滞剂有关。     

Respiratory controversies in the critical care setting. Should all patients be treated with hypothermia following cardiac arrest?

Cardiac arrest is a common and lethal medical problem; each year more than half a million people in the United States and Canada suffer cardiac arrest treated by emergency medical personnel or in-hospital providers. Of those who survive to hospital admission or suffer in-hospital arrest, 40-60% die prior to discharge. Neurologic injury is the major source of morbidity and mortality after recovery of spontaneous circulation. Therapeutic options to prevent neurologic injury are limited, but recent randomized trials showed that moderate therapeutic hypothermia improves neurologic outcome in selected patients following cardiac arrest. Clear consensus statements recommend that unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled if the initial rhythm was ventricular fibrillation, and that therapeutic hypothermia should be considered for other patients (other rhythms or in-hospital arrest). However, the position that all patients should be cooled following cardiac arrest is probably too broad, given the lack of studies on patients with non-ventricular-fibrillation rhythms, in-hospital arrest, or non-cardiac causes of arrest. Further research is needed to determine the broadest application of moderate therapeutic hypothermia.     

脑卒中后发生便秘的原因、影响因素及护理对策

目的分析脑卒中患者发生便秘的现状、原因及其相关因素,探讨预防和解决便秘的对策。方法回顾性分析山东聊城市第三人民医院神经内科2008年6月至2008年12月间住院治疗的150例脑卒中患者的资料,以患者发病之日作为观察起点,观察患者发病4周内的大便次数,分析脑卒中患者便秘发生的相关因素。结果 150例住院患者发病前有便秘史者19例(12.70%);在住院治疗的4周时间内发生便秘者100例,其中新发生便秘85例,便秘总发生率66.67%;卒中前后,便秘的发生率差异有统计意义(P=0.000)。女性、高龄、出血性脑卒中、病变部位在基底神经节区、神经功能缺损严重者便秘发生率较高。行多因素Logistic逐步回归方程分析,性别、年龄、卒中类型为便秘的独立影响因素。结论脑卒中患者便秘的发生率较高,原因复杂多样。护理人员应根据患者的具体情况具体分析,采取个体化、适应患者病情变化的有效预防措施和治疗便秘的方法,使其保持大便通畅,预防并发症发生,促进疾病康复。