美托洛尔预防胸部肿瘤合并冠心病非心脏手术心脏并发症的临床研究

目的：评价围手术期应用美托洛尔控制心率对冠心病非心脏手术患者心脏并发症的影响。方法：经冠脉造影检查确诊 为冠心病并行开胸非心脏手术的患者65例,围手术期使用美托洛尔控制心率,根据心率的控制情况分为控制心率达标组（A 组）（55-80次/min, n =48）,控制心率未达标组（B组）（80-130次/min, n =17）,分别于术前24 h内及术后72 h内行Holter持续监测,记录各个时间段平均心率、早搏次数、异位心律失常及心肌缺血发生情况,以及术后72 h内心脏并发症,对两组数据 进行对比分析。结果：A组和B组术后相比,前者各项指标明显优于后者（P〈0.05）;A组术后无心梗,B组术后1例发生急 性心梗死亡,2例术后发生急性心梗,后经抢救治愈。结论：围手术期使用美托洛尔有效控制心率可以减少冠心病非心脏手术 患者心律失常的发生,预防心肌缺血。     

术前使用美托洛尔对非心脏手术患者心脏功能的影响

目的研究术前使用美托洛尔对非心脏手术患者心功能的影响。方法择期非心脏手术老年患者60例,随机分为试验组（美托洛尔）和对照组。试验组患者手术前3天开始口服美托洛尔（50mg/d）,手术期间不停药。记录围术期血流动力学指标、心肌缺血、及术后窦性心动过速的例数,并统计心率与收缩压的乘积（RPP）〉12000的例数（nRPP）。结果与对照组相比：美托洛尔组围手术期间血流动力学稳定,心肌缺血在术后差异有显著性,nRPP在术中差异有显著性,而期间心动过速的例数差异没有显著性。结论术前使用美托洛尔能够稳定非心脏手术患者的血流动力学,减少心肌耗氧量,从而减少心肌缺血的发生。     

术前使用美托洛尔对非心脏手术患者心脏功能的影响

目的 研究术前使用美托洛尔对非心脏手术患者心功能的影响.方法 择期非心脏手术老年患者60例,随机分为试验组(美托洛尔)和对照组.试验组患者手术前3天开始口服美托洛尔(50mg/d),手术期间不停药.记录围术期血流动力学指标、心肌缺血、及术后窦性心动过速的例数,并统计心率与收缩压的乘积(RPP)＞12000的例数(nRPP).结果 与对照组相比:美托洛尔组围手术期间血流动力学稳定,心肌缺血在术后差异有显著性,nRPP在术中差异有显著性,而期间心动过速的例数差异没有显著性.结论 术前使用美托洛尔能够稳定非心脏手术患者的血流动力学,减少心肌耗氧量,从而减少心肌缺血的发生.     

美托洛尔对高心脏风险患者接受非心脏手术的围手术期心血管事件的影响

目的 探讨酒石酸美托洛尔对高心脏风险患者接受非心脏手术的围手术期心血管事件的影响.方法 选择在我院择期行中高危非心脏手术患者,年龄大于50岁,且伴有1个或1个以上临床危险因素患者105例,随机分为2组,A组为剂量调整酒石酸美托洛尔组（n=50）,服用酒石酸美托洛尔从术前1周至术后30天,B组为空白对照组（n=55）,记录两组围术期的心血管事件、非致死性心肌梗死发生率及心性死亡率.结果 两组心血管事件发生率（10％ vs 40％,P=0.001）、非致死性心肌梗死发生率（0％ vs 14.5％,P=0.006）及心性死亡率（2％vs14.5％,P=0.033）差异均有统计学意义.结论 高心脏风险患者在进行中高危非心脏手术围术期接受酒石酸美托洛尔治疗可以降低心血管事件、非致死性心肌梗死发生率及心性死亡率.     

预防性输注β1-受体拮抗剂对行非心脏手术的高危患者保护作用的研究

目的 研究观察预防性静脉输注选择性β1-受体阻滞剂(艾司洛尔)在麻醉期间对高危因素患者血液动力学与不良心脏事件等的影响.方法 40例择期行单侧初次全髋置换术伴有心脏高危因素患者,随机分为2组(艾司洛尔组与对照组,每组20例),所有患者均不用术前药.艾司洛尔组在麻醉诱导前开始通过输液泵给予艾司洛尔80～100 μg/(kg·min),维持心率＜80次/min.对照组输入生理盐水.两组患者均接受常规全身麻醉,术后48h收集Holter记录的磁带进行分析.结果 与对照组相比,艾司洛尔组心率与平均动脉压变化较为平缓.围术期心肌缺血的人次数艾司洛尔组为1/20,明显低于对照组(5/15)(P＜0.05).其中,除对照组心肌缺血1例外,其他均发生在术后,并且均为一过性的,不伴随其他自觉症状.两组患者均未见明显的不良反应.结论 在心脏高危因素患者中,麻醉期间预防性应用选择性β1-受体阻滞剂可维持稳定的血液动力学变化,有效地降低心肌缺血事件的发生.     

成人体外循环下心脏手术后围术期并发症的相关因素分析

目的探讨成人患者体外循环下心脏手术围术期并发症发生的相关因素。方法收集120例成人患者行体外循环下心脏手术的临床资料,采用单因素分析、多因素Logistic回归分析与围术期并发症发生的相关影响因素。结果 （1）患者手术死亡率为1.7%（2/120）,并发症发生率为31.7%（38/120）;（2）发生与未发生并发症两组患者在术前吸烟、伴发高血糖、体外循环时间≥2 h、主动脉阻断时间≥90 min、输血量≥2 000 ml共5项指标比较差异均有统计学意义（P〈0.05）;（3）多因素Logistic回归分析显示,术前吸烟、伴发高血糖、体外循环时间≥2 h、输血量≥2 000 ml是围术期发生并发症的危险因素（OR〉1,P〈0.05）。结论患者术前吸烟、伴发高血糖、术中体外循环时间≥2 h以及输血量≥2 000 ml是成人行体外循环下心脏手术围术期并发症发生的危险因素。     

强化调脂对行非心脏手术的冠状动脉粥样硬化性心脏病患者的心肌保护作用及机制初探

目的:探讨强化阿托伐他汀治疗对稳定型冠状动脉粥样硬化性心脏病(冠心病)患者行非心脏的择期外科手术围手术期的心肌保护作用及可能机制.方法:将拟行非心脏外科手术的60名稳定型冠心病患者随机分为强化组(n=30)和常规组(n=30),强化组在术前12 h给予阿托伐他汀80 mg顿服,术前2h给予阿托伐他汀40 mg顿服,术前每晚服用阿托伐他汀40 mg;常规组术前每晚服用阿托伐他汀20 mg;而后进行非心脏的外科手术,术后强化组每晚服用阿托伐他汀40 mg,常规组每晚服用阿托伐他汀20 mg.比较两组围手术期主要不良心脏事件(包括心脏性猝死、急性心肌梗死、非计划性血运重建)的发生情况,术前、术后48 h血脂水平(总胆固醇和低密度脂蛋白胆固醇)及炎症指标水平(高敏C反应蛋白和白细胞介素-6)的变化情况.结果:常规组出现1例急性前壁ST段抬高型心肌梗死(行急诊前降支介入再灌注治疗)和7例无症状型心肌梗死,强化组出现1例无症状型心肌梗死,强化组围手术期心肌梗死发生率较常规组明显降低(P＜0.05);两组术前和术后血脂水平变化差异无统计学意义(P＞0.05);与常规组相比,强化组的炎症指标水平显著降低(P＜0.05).结论:强化组可显著降低稳定型冠心病患者非心脏的择期外科手术围手术期主要不良心脏事件,特别是无症状型心肌梗死的发生率,抑制炎症反应可能是其保护作用的机制之一,但尚需大样本多中心随机对照临床试验进一步证实.     

酒石酸美托洛尔对接受非心脏手术的冠心病及高危因素患者围术期心血管事件的影响

目的 评价酒石酸美托洛尔对接受非心脏手术的冠心病及高危冈素患者围术期心脏事件的影响.方法 102例择期非心脏手术患者,有明确冠心病或高危因素,随机分为2组,A组为对照组(n=51),B组为酒石酸美托洛尔组(n=51),从术前2 h一直到术后30 d,口服或静注洒石酸美托洛尔,根据血压、心率来调整剂量;记录围术期心率变化、肌酸激酶同功酶(CK-MB)水平、围术期不稳定心绞痛、心肌梗死、死亡以及脑卒中例数.结果 酒石酸美托洛尔组术中、术后心率显著低于对照组(P<0.05).两组各有1例心肌梗死发生,对照组有1例死亡,2例脑梗死,对照组发生伴有ST段压低的不稳定心绞痛5(9.8%)例,酒石酸美托洛尔组1(2.0%)例,术后至少1件心血管事件对照组有15例,酒石酸美托洛尔组13例(P>0.05).结论 酒石酸美托洛尔可能降低冠心病及高危因素患者非心脏手术后严重心血管不良事件发生率.     

心脏瓣膜置换术围术期脑钠肽水平的变化及临床意义

目的探讨风湿性心脏病瓣膜置换术患者围术期脑钠肽（BNP）水平的变化及其规律。方法检测35例风心病瓣膜置换术患者围术期的血浆BNP水平,手术前、术后6、24、48及72h,术后1周测定。分析术前BNP水平与心功能分级（NYHA）及左室射血分数（LVEF）的关系,比较术后早期严重室性心律失常组与对照组围术期BNP水平的差异。结果患者BNP水平在术后24h内上升,24～48h达到高峰,术后1周明显下降,但仍高于术前水平（P〈0．05）。术前心功能Ⅱ级、Ⅲ级、Ⅳ级患者BNP水平比较差异均有显著性（P〈0.01）：瓣膜置换术患者术前心功能分级与BNP水平呈正相关（r=0．781,P〈0．01）,并随心功能损伤程度的加重而呈显著增加。术后早期发生严重室性心律失常患者,其血浆BNP水平与对照组比较术前、术后24h,术后1周差异均有统计学意义（P〈0．05）,室性心律失常组较高。结论对心脏瓣膜置换患者BNP水平的测定及动态观察,对术前病情评估、手术时机的选择、术后处理的指导及术后早期严重室性心律失常发生风险的评估均有一定的指导意义。     

老年消化道恶性肿瘤患者非心脏手术围手术期心脏事件发生分析

目的:探讨老年消化道肿瘤患者行非心脏手术治疗时围手术期心脏事件发生的特点.方法:分析32例老年消化道肿瘤患者非心脏手术的围手术期临床病例资料.结果:术后15例(46%)发生了心脏不良事件,其中心肌梗死3例,心功能不全10例,心律失常2例,死亡3例,9例发生在术后1～3 d.结论:老年消化道恶性肿瘤患者行非手术治疗,术后...     

RISK OF PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY UNDERGOING NONCARDIAC SURGERY

Objective To determine the risk of noncardiac surgery in patients with hypertrophic cardiomyopathy.Methods We reviewed the medical records of all patients who were diagnosed as hypertrophic cardiomyopathy at Peking Union Medical College Hospital from January 1998 to August 2006 and identified 24 patients who subsequently underwent noncardiac surgery.Results There were no intraoperative cardiac events.Postoperative cardiac events were identified in 3 patients including 1 death due to acute myocardial infarction and 2 episodes of transient hypotension.Conclusions The risk of anesthesia and noncardiac surgery is low in patients with hypertrophic cardiomyopathy.During the perioperative period,beta-blockers and/or calcium channel blockers should be given;vasodilator and inotropic agents should be avoided due to the side effects on hemodynamics.     

双源CT冠状动脉血管成像用于老年患者非心脏手术术前评估的价值

目的 评价双源CT冠状动脉血管成像(CTA)技术用于老年患者非心脏手术术前评估的价值。方法 回顾性分析本院2011年5月至2013年5月行冠状动脉CTA患者的临床资料,共有111例老年患者合并冠心病危险因素而既往未明确诊断冠心病,在非心脏手术术前评估时行CTA检查。冠状动脉CTA均采用双源CT前瞻性心电触发序列扫描。分析111例患者的CTA图像质量、狭窄程度、术前处理与围手术期并发症。结果 111例患者的1 779段冠状动脉可评价血管节段为1 676段(97.4%),患者的CTA有效放射剂量为(2.7±0.9) mSv。71例患者冠状动脉狭窄程度<50%,按期进行手术治疗,围手术期无心血管并发症发生;36例患者冠状动脉狭窄程度≥50%,其中狭窄程度≥70%的17例患者进行动脉造影检查：冠状动脉CTA诊断冠状动脉≥50%狭窄的敏感性为95%、特异性为96%;诊断冠状动脉≥70%狭窄的敏感性为97%、特异性为98%。这17例患者行冠状动脉支架或搭桥手术治疗。其余19例患者冠状动脉狭窄在50%~70%,积极内科保守治疗后行预定手术,术后2例患者出现心肌酶的一过性升高,无其他心血管并发症发生。结论 对于老年患者,术前行冠状动脉CTA检查能有效评估动脉狭窄程度,用于术前危险分层,指导进一步治疗,减少围手术期心血管并发症的发生。     

胸科非心脏手术后心律失常高危因素分析

对 2 38例胸科非心脏手术后并发心律失常进行分析 ,结果显示 :发生心律失常 38例 ,年龄≥ 6 5岁、血氧饱和度 <0 .96、术前有合并症、术后有并发症、酸碱电解质紊乱者发病率明显升高 (P <0 .0 5 )。认为胸科非心脏手术后并发心律失常与高龄、低氧血症、术前合并症、术后并发症、酸碱电解质紊乱密切相关。     

In-hospital and long-term mortality in male veterans following noncardiac surgery. The Study of Perioperative Ischemia Research Group.

OBJECTIVES--To determine the causes of and risk factors for mortality following noncardiac surgery. DESIGN--Prospective cohort study. SETTING--A university-affiliated Veterans Affairs medical center. PATIENTS--Consecutive series of 474 men between the ages of 38 and 89 years (mean age, 68 years) who were undergoing major noncardiac surgery involving general anesthesia. All subjects had known coronary artery disease or were at high risk for coronary artery disease. MEASUREMENTS AND RESULTS--During the initial hospitalization, 26 patients (5%) died, most commonly from sepsis (n = 6) or cardiac diseases (n = 6). Deaths occurred from postoperative days 2 to 69; half occurred more than 3 weeks after surgery. Multivariable analysis disclosed that a history of hypertension (odds ratio [OR] = 3.8; 95% confidence interval [CI], 1.1 to 13), a severely limited activity level (OR = 9.7; 95% CI, 2.5 to 37), and a creatinine clearance of less than 0.83 mL/s (OR = 6.8; 95% CI, 2.8 to 16) were all independently associated with an increased risk of postoperative mortality. The mortality rate in patients with two or more of these risk factors was 20%, nearly eight times higher (95% CI, 3.6 to 16) than those with one or no risk factors. An additional 82 patients died within the next 2 years; cancer, renal dysfunction, congestive heart failure, and obstructive pulmonary disease were independently associated with long-term mortality. CONCLUSIONS--Even in patients at high risk of cardiac complications following surgery, noncardiac causes of death are more common. Patients with a history of hypertension, severely limited activity, and reduced renal function appear to be at especially high risk of in-hospital mortality after noncardiac surgery.     

Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study

CONTEXT: Right heart catheterization (RHC) is commonly performed before high-risk noncardiac surgery, but the benefit of this strategy remains unproven. OBJECTIVE: To evaluate the relationship between use of perioperative RHC and postoperative cardiac complication rates in patients undergoing major noncardiac surgery. DESIGN: Prospective, observational cohort study. SETTING: Tertiary care teaching hospital in the United States. PATIENTS: Patients (n = 4059 aged >/=50 years) who underwent major elective noncardiac procedures with an expected length of stay of 2 or more days between July 18, 1989, and February 28, 1994. Two hundred twenty one patients had RHC and 3838 did not. MAIN OUTCOME MEASURE: Combined end point of major postoperative cardiac events, including myocardial infarction, unstable angina, cardiogenic pulmonary edema, ventricular fibrillation, documented ventricular tachycardia or primary cardiac arrest, and sustained complete heart block, classified by a reviewer blinded to preoperative data. RESULTS: Major cardiac events occurred in 171 patients (4.2%). Patients who underwent perioperative RHC had a 3-fold increase in incidence of major postoperative cardiac events (34 [15.4%] vs 137 [3.6%]; P<.001). In multivariate analyses, the adjusted odds ratios (ORs) for postoperative major cardiac and noncardiac events in patients undergoing RHC were 2.0 (95% confidence interval [CI], 1.3-3.2) and 2.1 (95% CI, 1.2-3.5), respectively. In a case-control analysis of a subset of 215 matched pairs of patients who did and did not undergo RHC, adjusted for propensity of RHC and type of procedure, patients who underwent perioperative RHC also had increased risk of postoperative congestive heart failure (OR, 2.9; 95% CI, 1.4-6.2) and major noncardiac events (OR, 2.2; 95% CI, 1.4-4.9). CONCLUSIONS: No evidence was found of reduction in complication rates associated with use of perioperative RHC in this population. Because of the morbidity and the high costs associated with RHC, the impact of this intervention in perioperative care should be evaluated in randomized trials.     

青壮年择期非心脏手术后谵妄的发生率及危险因素分析

目的探讨青壮年择期非心脏手术后谵妄的发生率及危险因素.方法采用整群抽样调查的方法,观察2010年3至6月期间18～50岁择期非心脏手术患者,术前即存在谵妄状态或诊断为痴呆、抑郁、认知功能障碍的患者除外,符合纳入标准共1 276例.术前1 d探视病人,手术结束当日,术后1、2、3 d密切随访患者,采用谵妄评定法（CAM）进行诊断评估.记录围术期的相关因素及谵妄的发生情况,建立数据库,根据是否发生谵妄分为谵妄组和对照组.结果有91例术后发生谵妄,发生率为7.13%.多因素Logistic逐步回归分析结果表明,全身麻醉、手术时间≥3 h、术后疼痛评分=4分、饮酒≥3次/w为谵妄的危险因素.结论全身麻醉、长时间手术、术后剧烈疼痛、长期饮酒是青壮年择期非心脏手术后谵妄的独立危险因素.     

Perioperative anesthetic risk of noncardiac surgery in hypertrophic obstructive cardiomyopathy

To determine their perioperative risk, we reviewed the records of 35 patients with hypertrophic cardiomyopathy diagnosed by cardiac ultrasound and/or catheterization who underwent general (52) or spinal (four) anesthesia--a total of 56 major surgical procedures. There were no operative or related perioperative deaths and no significant ventricular tachyarrhythmias. Intraoperative or postoperative complications included: myocardial infarction with heart failure in one patient who also had coronary artery disease and was one of three patients who had spinal anesthesia, arrhythmia requiring therapy in eight, and angina during supraventricular tachycardia in one. We conclude that the risk of general anesthesia and major noncardiac surgery is low in patients with hypertrophic obstructive cardiomyopathy. Spinal anesthesia, which decreases systemic vascular resistance and increases capacitance, may be relatively contraindicated. Concomitant coronary artery disease may increase the risk.     

老龄患者术后谵妄的发生率及危险因素分析

目的探讨老龄非心脏手术患者术后谵妄的发生率及危险因素.方法选择2010年3月～6月期间,年龄≥65岁择期非心脏手术患者共226例,术前访视病人,手术结束当日、术后1、2、3 d密切随访患者,用谵妄评定法（confusion assessment method,CAM）进行谵妄评估.按设计调查表祥细记录患者一般情况、合并症、麻醉方式、手术时间、术中失血量、术中输库存血量、术后疼痛评分及谵妄的发生情况,建立数据库、根据是否发生谵妄分为谵妄组和对照组.结果有42例术后发生谵妄,发生率为18.58%.多因素Logistic逐步回归分析结果表明,年龄、术前合并肺心病、全身麻醉、手术时间≥3 h、术后疼痛评分=4分为谵妄的危险因素.结论老龄、术前合并肺心病、全身麻醉、长时间手术、剧烈疼痛是老龄术后谵妄的独立危险因素.缩短手术时间、有效的术后镇痛可能会降低老龄患者术后谵妄的发生率.     

Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk

THIS IS THE FIRST OF 2 ARTICLES EVALUATING cardiac events in patients undergoing noncardiac surgery. In this article, we review the magnitude of the problem, the pathophysiology of these events, approaches to risk assessment and communication of risk. The number of patients undergoing noncardiac surgery worldwide is growing, and annually 500 000 to 900 000 of these patients experience perioperative cardiac death, nonfatal myocardial infarction (MI) or nonfatal cardiac arrest. Although the evidence is limited, a substantial proportion of fatal perioperative MIs may not share the same pathophysiology as nonoperative MIs. A clearer understanding of the pathophysiology is needed to direct future research evaluating prophylactic, acute and long-term interventions. Researchers have developed tools to facilitate the estimation of perioperative cardiac risk. Studies suggest that the Lee index is the most accurate generic perioperative cardiac risk index. The limitations of the studies evaluating the ability of noninvasive cardiac tests to predict perioperative cardiac risk reveals considerable uncertainty as to the role of these popular tests. Similarly, there is uncertainty as to the predictive accuracy of the American College of Cardiology / American Heart Association algorithm for cardiac risk assessment. Patients are likely to benefit from improved estimation and communication of cardiac risk because the majority of noncardiac surgeries are elective and accurate risk estimation is important to allow informed patient and physician decision-making.     

Monitoring for myocardial ischemia during noncardiac surgery. A technology assessment of transesophageal echocardiography and 12-lead electrocardiography. The Study of Perioperative Ischemia Research Group.

OBJECTIVE--Transesophageal echocardiography (TEE) and 12-lead electrocardiography (ECG) are sophisticated techniques that are increasingly being used to monitor for myocardial ischemia during noncardiac surgery. We examined whether the routine use of these techniques has incremental clinical value in identifying patients at high risk for perioperative ischemic outcomes when compared with preoperative clinical data and intraoperative monitoring using continuous two-lead bipolar ECG. DESIGN--Cohort study. SETTING--Veterans Affairs medical center. PATIENTS--A total of 332 men undergoing noncardiac surgery who had or were at high risk for coronary artery disease. INTERVENTIONS--TEE, 12-lead ECG, and two-lead ECG were performed continuously during noncardiac surgery (47% vascular, 53% nonvascular). Monitoring results were not available to anesthesiologists or surgeons, and data were blindly analyzed after surgery. MAIN OUTCOME MEASURE--Perioperative ischemic outcomes (cardiac death, nonfatal myocardial infarction, unstable angina). RESULTS--In a subset of 285 patients who were adequately studied by all three techniques, 111 patients (39%) were identified as having intraoperative myocardial ischemia (by one or more monitoring techniques). By univariate analysis, intraoperative ischemia was associated with all perioperative cardiac outcomes, including ischemic outcomes, congestive heart failure, and ventricular tachycardia (P less than or equal to .02 for each of the three monitoring techniques). However, when monitoring results for TEE and 12-lead ECG were added to a multivariate model that included preoperative clinical data and continuous two-lead ECG results, the incremental value of TEE was small (odds ratio, 2.6; 95% confidence interval [CI], 1.2 to 5.7; P = .02) and that of 12-lead ECG was not significant (odds ratio, 1.5; 95% CI, 0.6 to 3.8). Furthermore, when the multivariate analysis was repeated with only ischemic outcomes, neither TEE nor 12-lead ECG retained significant associations (odds ratio, 2.2; 95% CI, 0.5 to 9.4, and odds ratio, 1.1; 95% CI, 0.2 to 6.1, respectively). CONCLUSION--When compared with preoperative clinical data and intraoperative monitoring using two-lead ECG, routine monitoring for myocardial ischemia with TEE or 12-lead ECG during noncardiac surgery has little incremental clinical value in identifying patients at high risk for perioperative ischemic outcomes.