20例妊娠合并艾森曼格综合征剖宫产麻醉管理经验

目的:总结妊娠合并艾森曼格综合征孕妇剖宫产术中麻醉管理经验。方法:妊娠合并艾森曼格综合征患者20例。患者平均年龄(25.7±4.6)岁,平均孕周(25.0±8.8)w,术前肺动脉收缩压(systolic pulmonary artery pressure,SPAP)(105.8±26.6)mmHg(1 mmHg=0.133 kPa),氧分压(PO2)(43.0±16.1)mmHg。20例患者入院后均进行了剖宫产术。所有患者术中均行有创血流动力学监测。连续硬膜外麻醉遵循缓慢、分次给药、逐渐扩散平面的原则。全身麻醉在切皮前诱导,尽量缩短麻醉开始与胎儿娩出之间的时间间隔。术中严格控制液体入量及催产素用量,采用辅助措施减少回心血量骤然增加,酌情使用血管活性药物维持体循环阻力、降低肺血管阻力。所有患者术后均转入重症监护室(surgery intensive care unit,SICU)继续治疗。结果:15例患者行连续硬膜外麻醉,5例行全身麻醉。术中血流动力学波动主要在全身麻醉诱导阶段、连续硬膜外麻醉起效阶段及胎儿娩出前后较明显,表现为体循环血压下降、肺动脉压增加、血氧饱和度下降,其余时间多数患者较平稳。4例患者于术后2～13 d因肺动脉高压危象、多器官功能衰竭、肺部感染等死亡,术后1个月病死率为20%,其余均恢复出院。结论:剖宫产围术期是妊娠合并艾森曼格综合征患者发生心力衰竭、肺动脉高压危象甚至死亡的高危时期。持续进行有创血流动力学监测可以较好地了解患者循环状况,指导血管活性药物的应用及术中容量治疗。在辅助措施协助下硬膜外麻醉是较合适的选择。提高风险认识,做好术中麻醉管理,是降低病死率的关键环节。     

妊娠合并肺动脉高压患者行剖宫产麻醉管理17例分析

目的:探讨妊娠合并肺动脉高压(PAH)患者剖宫产术麻醉管理方法。方法:回顾性分析安贞医院2009年2月至2011年7月,妊娠合并PAH 17例患者的临床资料。结果:本组妊娠合并PAH17例患者,仅1例患者采用全身麻醉,其余16例采用了硬膜外麻醉,均采用小剂量、分次及缓慢的给药方法维持血流动力学平稳。连续硬膜外麻醉对合并PAH患者剖宫产生命体征影响较小,且新生儿Apgar评分较高。结论:妊娠合并PAH患者围术期血流动力学极易发生剧烈变化,如果麻醉处理不当会影响母婴安全,连续硬膜外麻醉是妊娠合并PAH患者行剖宫产术较理想的麻醉方法。     

妊娠合并先天性心脏病患者剖宫产麻醉管理45例分析

目的:总结合并先天性心脏病(先心病)患者剖宫产的麻醉管理经验。方法:回顾性分析45例妊娠合并先心病患者剖宫产的临床资料。结果:本组44例患者采用了硬膜外阻滞麻醉,其中包括15例合并中、重度肺动脉高压(PH)或艾森曼格综合征的患者,均采用小剂量、分次及缓慢的硬膜外给药方法,维持循环平稳。仅1例重症患者采用全麻。术中完善监护措施,积极防治心力衰竭,所有产妇均平安度过围术期。结论:硬膜外阻滞麻醉适应于大多数合并先心病患者剖宫产手术,术前进行多科会诊,围术期积极防治心衰,密切监测、维持循环稳定是确保围产期母婴安全的关键。     

老年非心脏手术患者围手术期心脏不良事件的影响因素

目的:研究老年非心脏手术患者围手术期心脏不良事件的影响因素。方法:分析112例老年非心脏手术患者围术期的临床资料,分析与发生围手术期心脏不良事件相关的因素,比较有心脏不良事件组与无心脏不良事件组之间的差异。结果:术后42例(37.5%)发生心脏不良事件。与无不良事件组相比,发生心脏不良事件的患者多合并冠心病、行冠状动脉支架及旁路移植手术、合并心脏瓣膜病、存在心律失常、术前射血分数EF50%、手术规模大、麻醉时间长、术前高敏C反应蛋白(hs-CRP)及B型利钠肽(BNP)增高(P0.05)。结论:老年非心脏手术患者围手术期危险因素包括合并冠心病、行冠状动脉支架及旁路移植手术、合并心脏瓣膜病、存在心律失常、术前EF值50%以及手术规模大、麻醉时间长、术前hs-CRP和BNP增高,其中术前hs-CRP和BNP水平可以作为预测指标,对高危老年患者进行充分评估、从而减少围手术期心脏不良事件的发生。     

828例高龄非心脏手术患者麻醉方式、围术期预后分析

目的 探讨高龄非心脏手术患者的麻醉方式及其围术期预后。方法 回顾性分析上海市松江区中心医院2020年1月1日—2021年12月31日80岁以上行非心脏手术的828例高龄患者的临床资料。患者年龄80～99(84.4±4.2)岁,美国麻醉医师协会(ASA)分级Ⅰ级+Ⅱ级469例,Ⅲ级317例,Ⅳ级36例,Ⅴ级为5例。所有患者根据所接受麻醉方法的不同分为全身麻醉组和区域阻滞麻醉组两组。观察并记录两组患者术前一般情况、手术类型、术前合并症、术前ASA分级;围术期并发症和围术期死亡情况。结果 与区域阻滞麻醉组比较,全身麻醉组患者手术类型更复杂(P<0.001),患者术前全身状态更差(P<0.001)。按照手术部位分层分析后,两组患者术后并发症的发生率比较无统计学差异(χ²=2.435,P=0.296;OR=1.186,95%CI:0.653～2.151);两组患者术后病死率比较无统计学差异(χ²=1.320,P=0.251;OR=0.314,95%CI:0.051～1.925)。结论 对于高龄非心脏手术患者,全身麻醉、区域阻滞麻醉的合理选择...     

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     

全身麻醉复合硬膜外麻醉对老年腹部手术患者术后肺部感染及肺功能的影响

目的探讨全身麻醉复合硬膜外麻醉对老年腹部手术患者术后肺部感染及肺功能的影响。方法选取拟行全身麻醉复合硬膜外麻醉下腹部手术的患者200例,根据年龄分组,≥60岁者82例为老年组,年龄<60岁者118例为非老年组,均在全身麻醉复合硬膜外麻醉下行手术治疗,观察麻醉及手术相关指标、术后住院期间肺部感染,术前、术后3 d时第1秒用力呼气量(FEV1)、每分钟最大通气量(MVV)、残气量(RV)、肺总量(TLC)、每分静息通气量(VE)变化。结果两组患者麻醉时间、术后苏醒时间、拔管时间、手术时间、术中出血量比较差异无统计学意义(P>0.05);老年组术后肺部感染率为21.95%,明显高于非老年组6.78%(P<0.05);术后3 d时老年组(MVV-VE)/FEV1、MVV/FEV1、RV/TLC均较术前下降(P<0.05),术后3 d时非老年组以上指标与术前比较无明显变化(P>0.05),术后3 d时老年组以上指标明显低于非老年组(P<0.05)。结论全身麻醉复合硬膜外麻醉对老年腹部患者术后肺功能影响较非老年人明显,术后肺部感染的发生率高于非老年人群。     

风湿性心脏病患者剖宫产的麻醉处理

目的:总结妊娠合并风湿性心脏病产妇剖宫产的麻醉管理。方法:回顾性分析58例妊娠合并风湿性心脏病产妇剖宫产的临床资料。结果:52例患者术前接受强心、利尿、扩血管治疗,多数选择硬膜外麻醉,小量、分次注射局部麻醉药维持循环平稳。术中积极防治心力衰竭(心衰),产妇平安度过围术期。结论:硬膜外麻醉适应于大多数风湿性心脏病产妇剖宫产手术。围术期积极防治心衰,密切监测、维持循环稳定是确保围产期母婴安全的关键。     

老年心血管疾病患者腹腔镜手术的麻醉管理

目的 探讨老年心血管疾病患者腹腔镜手术的麻醉及围术期管理方式,提高此类手术的安全性.方法 收集该院76例患有心血管疾病且行腹腔镜手术的老年患者的麻醉资料,回顾麻醉方法、药物应用、围术期不良事件的发生情况以及处理方式.结果 76例老年患者术中出现血压超过基础值25％者16例,血压偏低7例,心率减慢4例,房颤或室上性心动过速5例,室性早搏3例,经积极处理后均顺利完成手术.诱导麻醉后(T2),老年患者心率(HR)、平均动脉压(MAP)比诱导前(T1)降低(P＜0.05);气腹后(T3)HR、MAP迅速升高,甚至高于诱导前(T1)(P＜0.05),麻醉诱导后(T2)与气腹后(T3)血浆肾上腺素(E)及去甲肾上腺素(NE)水平持续上升,与麻醉诱导前(T1)相比,差异有统计学意义(P＜0.05).结论 重视术前手术风险评估,加强术中监测,维持术中循环系统稳定是提高老年心血管患者腹腔镜手术成功率的关键.     

全麻复合硬膜外阻滞对冠心病手术患者影响观察

目的　比较全身麻醉复合上胸段硬膜外阻滞麻醉(TEA)与单纯全身麻醉对冠心病开胸非心脏手术患者的影响。方法　80例冠心病患者随机分为全麻复合TEA组(GE组,n =4 0 )与单纯全麻组(G组,n =4 0 )。观察两组病人麻醉前、硬膜外注药后5min、15min、30min、全麻诱导后5min、气管插管后即刻、术中强烈刺激时及拔除气管导管时的心电图、血压、心率、中心静脉压;观察术中失血量、输血输液总量及术后72小时内患者心绞痛或心肌梗死的发生情况。结果　G组患者气管插管后即刻、术中强烈刺激时及拔除气管导管时的MAP及HR均明显高于麻醉前和GE组(P <0 . 0 5 ) ,术中需用硝酸甘油、艾司洛尔等血管活性药的患者比率明显高于GE组(P <0 0 5 ) ,而术中原有ST -T变化的改善率又明量低于GE组(P <0 .0 5 )。结论　全身麻醉复合硬膜外阻滞麻醉较单纯全身麻醉能使冠心病开胸非心脏手术患者的血流动力学更平稳,从而使该类手术患者的麻醉更安全。     

Leberchirurgische Eingriffe aus an?sthesiologischer Sicht

Liver surgery is complex and is a major abdominal procedure. The preoperative assessment is essential and allows optimization of renal function and coagulation. Because 50% of major perioperative complications are due to cardiovascular events, patients undergoing liver surgery should be evaluated according to the recommendations of the American Heart Association. The anesthesiologist should actively search for clinical signs of liver cirrhosis since many manifestations thereof directly affect anesthetic practice. The pharmacology of many medications, including anesthetics, is difficult to predict in patients with cirrhosis. Hence, all medications should be carefully titrated to their clinical effects. For anesthetic maintenance, modern halogenated ethers should be preferred. Optimization of liver perfusion during the critical intraoperative phase is one of the anesthesiologist’s most important tasks. Whenever possible, thoracic epidural anesthesia/analgesia should be used for optimal postoperative pain therapy. This allows early mobilization of the patient and also helps prevent pulmonary complications and thrombosis.     

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.     

Heart rate variability and cardiac troponin I are incremental and independent predictors of one-year all-cause mortality after major noncardiac surgery in patients at risk of coronary artery disease

OBJECTIVES: The aim of this study was to determine whether perioperative measurements of heart rate variability (HRV) and cardiac troponin I (cTnI) add additional prognostic information to established risk scores for first-year mortality in patients at risk of coronary artery disease (CAD) undergoing major noncardiac surgery. BACKGROUND: In cardiac-risk patients undergoing major noncardiac surgery, the short- and long-term prognoses are mainly influenced by perioperative cardiac complications. Heart rate variability and cTnI are important prognostic markers in patients with congestive heart failure and myocardial infarction. METHODS: In a prospective study, 173 patients with CAD or at high risk of CAD undergoing major noncardiac surgery were followed up for one year. The main outcome measure was all-cause mortality. In addition to clinical parameters and established risk scores, HRV and cTnI were assessed perioperatively. RESULTS: Twenty-eight (16%) patients died within one year. Multivariate logistic regression analysis revealed three findings that were independently associated with death within the first year after surgery: the revised cardiac risk index (odds ratio 6.2 [95% confidence interval 1.6 to 25], depressed HRV before induction of anesthesia (16.2 [2.8 to 94]), and elevation of cTnI on postoperative day 1 or 2 (9.8 [3.0 to 32]). CONCLUSIONS: Depressed HRV before induction of anesthesia and elevated cTnI postoperatively are independent and powerful predictors of one-year mortality for patients at risk of CAD undergoing major noncardiac surgery and add incremental prognostic information to established risk scores that only consider preoperative information.     

Anesthesia management of patients with hypertrophic obstructive cardiomyopathy

Hypertrophic obstructive cardiomyopathy presents a challenge to the anesthesiologist. Because the condition is relatively prevalent, it is important for anesthesiologist to be aware of the pathophysiology. In this review, we draw upon case reports and studies of the anesthesia management of patients with hypertrophic obstructive cardiomyopathy to enhance medical decision making. The scope of this article ranges from the preoperative period, when the severity of the obstruction needs to be assessed; the intraoperative period, with monitoring, as well as general management guidelines; and finally, the postoperative period, when it is important to minimize the sympathetic response. Furthermore, we address the management of the obstetric patient, with particular focus on neuraxial anesthesia, and extrapolate how this type of anesthesia may be applied to the management of patients undergoing nonlaboring, noncardiac surgery.     

Local anesthetic volume in ultrasound-guided interscalene block and opioid consumption during shoulder arthroscopic surgery: A retrospective comparative study

Interscalene block (ISB) is commonly performed for regional anesthesia in shoulder surgery. Ultrasound-guided ISB enables visualization of the local anesthetic spread and a reduction in local anesthetic volume. However, little is known about the appropriate local anesthetic dose for surgical anesthesia without sedation or general anesthesia. The purpose of our study was to evaluate the appropriate local anesthetic volume by comparing intraoperative analgesics and hemodynamic changes in ISB in arthroscopic shoulder surgery.Overall, 1007 patients were divided into groups 1, 2, and 3 according to the following volume of local anesthetics: 10–19, 20–29, and 30–40 mL, respectively. The use of intraoperative analgesics and sedatives, and the reduction in intraoperative maximum blood pressure and heart rate were compared through retrospective analysis.Fentanyl was used in 55.6% of patients in group 1, which was significantly higher than in those groups 2 and 3 (22.3% and 30.7%, respectively); furthermore, it was also higher than those in groups 2 and 3 in dose-specific comparisons (P < .05). The percent of the maximum reduction in intraoperative systolic blood pressure and heart rate in group 3 was significantly higher than those in groups 1 and 2. Ephedrine administration was lower in group 2 than that in other groups (P < .05). The incidence of hypotensive bradycardic events was lowest (9.1%) at the local anesthetic volume of 24 mL as revealed by the quadratic regression analysis (R² = 0.313, P = .003).Decreasing the local anesthetic volume to less than 20 mL for ultrasound-guided ISB as the sole anesthesia increases the opioid consumption during shoulder arthroscopic surgery. Local anesthetics >30 mL or increased opioid consumption with <20 mL of local anesthetics could increase the risk of cardiovascular instability intraoperatively. Our findings indicate that 24 mL of local anesthetic could be used to lower the incidence of hypotensive bradycardic events.     

Types of anesthesia and cardiovascular outcomes in patients with congestive heart failure undergoing vascular surgery

BACKGROUND. Whether regional anesthesia is preferable to general anesthesia for patients with congestive heart failure (CHF) undergoing noncardiac surgery remains controversial. The purpose of this study was to determine whether anesthetic technique affects postoperative cardiac outcome in patients with CHF; we hypothesized that cardiac outcomes would be superior with regional anesthesia compared with general anesthesia. DESIGN. 106 patients with prior or persistent CHF, undergoing femoral to distal artery bypass surgery, were randomized to general anesthesia (29 patients) or regional anesthesia (epidural, 42 patients, or spinal anesthesia, 35 patients). The primary end point was death or adverse cardiac events (myocardial infarction, unstable angina, or CHF). RESULTS. There was no statistically significant difference between groups in incidence of combined cardiac events, death, myocardial infarction, death or myocardial infarction combined, unstable angina, or CHF. CONCLUSION. Although larger studies are required to establish equivalence of the anesthetic strategies, this large single center study preliminarily indicates that regional anesthesia may not be superior to general anesthesia in patients with heart failure undergoing femoral to distal artery bypass surgery. (c)1999 by CHF, Inc.     

高龄危重患者手术麻醉方法和管理

目的探讨合并多个脏器功能异常、年龄逾90岁患者手术麻醉方法和管理的特点。方法总结近3年年龄超过90岁手术患者16例次，其中开腹手术6例次，人工髋关节置换术10例次，术前依据病史有针对性检查各重要脏器的功能，并作相应的积极准备，依手术种类和病情特点选择麻醉方法，应用Hemosonic TM100食道超声多普勒监测血流动力学、A-Line自动回归指数（AAL）监测麻醉深度以及4个成串刺激（TOF）指导追加肌肉松弛剂。结果全组患者术前均伴有2～4个脏器功能异常，且以循环、呼吸和内分泌系统改变较为常见；控制血压、营养心肌、抗心律失常、降血糖和抗感染是术前准备常用且有效的方法；开腹手术以全麻为主，追加维库溴铵间隔时间（87±16）min；人工髋关节置换术全部选择硬膜外阻滞，首次剂量1％利多卡因（7．6±0．9）ml，追加间隔时间（63±17）min。用6％羟乙基淀粉按10ml／kg静输后15min，患者每搏输出量、心输出量、心脏指数和主动脉内血流量（ABF）均分别较扩容前平均增加17％、11％、14％和15％，外周血管阻力和心率分别下降16％和9．6％。术中维持AAI 50～60，术毕出现咳嗽（吞咽）和清醒应答时AAI分别为73±9．4和81±7．3，随访术后无知晓。结论重视术前准备和术中监测；硬膜外阻滞应选用低浓度、小容量局麻药，6％羟乙基淀粉适合用于人工髋关节置换术；分次、小剂量应用静脉麻醉药，间隔更长时间再加肌松剂和维持相对较高AAI，是开腹手术实施全麻应遵循的原则。     

Noncardiac surgery in the elderly patient with cardiovascular disease

The elderly patient with cardiovascular disease who undergoes noncardiac surgery presents a challenge to the medical-surgical team. A high prevalence of cardiac disease necessitates a preoperative in-depth search for the presence of cardiovascular risk factors and their reversal if possible. Aging is associated with an altered physiologic response to the stress of surgery as well as to anesthetic agents and perioperative medications, requiring that the elderly patient often be treated quite differently than the younger surgical patient. This article provides guidelines for the estimation of the risk of cardiac complication due to noncardiac surgery and discusses the identification and management of acute and chronic cardiovascular problems in the perioperative period.     

孕产妇行心血管手术的麻醉分析

目的：分析孕产妇行心血管手术的麻醉管理.方法：回顾性分析我院9例孕产妇行心血管手术的麻醉资料.平均年龄（28.3±4.7）岁,妊娠8w至产后2d,术中行二尖瓣手术2例,二尖瓣＋主动脉瓣置换＋冠状动脉旁路移植术1例,主动脉瓣手术1例,黏液瘤切除术3例,Bentall＋主动脉弓置换术2例.3例先行剖宫产的患者采用小剂量氯胺酮或雷米芬太尼麻醉诱导,待胎儿娩出后再使用芬太尼或舒芬太尼加深麻醉外,另6例均采用芬太尼或舒芬太尼麻醉诱导.心血管手术中采用芬太尼或舒芬太尼为主的静吸复合麻醉,其中芬太尼平均用量（50±0.5）μg/kg,舒芬太尼平均用量（5.3±2.0）μg/kg.1例孕妇心脏复跳后因心功能低下采用体外膜肺（ECMO）辅助后脱机.结果：孕产妇术后顺利康复6例,死亡3例,术后病死率为33.3％,死亡原因为低心排血综合征、肺部感染与肾功能衰竭,其中3例行血液透析治疗,1例行ECMO及主动脉内球囊反搏（IABP）辅助治疗.术后新生儿健康成活5例,家属放弃抢救胎儿2例,人工流产2例,胎儿丢失率为44.4％.结论：孕产妇实施心血管手术的危险性较高,加强围术期麻醉管理,选择恰当的手术时机与手术方式,采取多学科合作的综合处理,有利于母婴顺利度过围术期.