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。     

老年心血管高危患者非心脏手术后肌钙蛋白T的变化

目的 探讨监测肌钙蛋白T(cTnT)水平的变化对老年心血管高危患者围术期安全性的意义.方法 接受腹部手术全身麻醉的老年心血管高危患者52例,按术后cTnT监测结果分为2组:cTnT阴性组24例(46.2%),cTnT阳性组(≥0.01 ug/L)28例(53.8%),回顾性分析围术期患者心脏事件发生情况.结果 49...     

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。     

老年冠心病非心脏手术患者围手术期心肌梗死的特点及危险因素

目的研究老年冠心病非心脏手术患者围手术期心肌梗死发生的特点、规律及危险因素。方法选择412例连续的老年冠心病非心脏手术患者的病例资料,用统一的表格对术前、术中和术后的相关数据进行记录,并通过χ^2检验的方法得出围手术期心肌梗死发生的危险因素。结果在412例患者中共有10例发生围手术期急性心肌梗死,发生率为2.4%,均在术后发生。其中60%为非Q波心肌梗死,70%发生在术后7d内,仅30%表现为心绞痛。术前不稳定性心绞痛、心功能不全、ST段压低≥0.05mV及术后心肌缺血与围手术期心肌梗死的发生有关。结论老年冠心病非心脏手术患者围手术期心肌梗死大部分发生在术后1周内,多为无症状性和非Q波性心肌梗死。术前心功能不全、不稳定性心绞痛、ST段压低≥0.05mV及术后心肌缺血可能与围手术期心肌梗死的发生有关。     

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.     

麻醉管理在老年糖尿病手术患者中的应用

目的:探讨麻醉管理在老年糖尿病手术患者中的应用.方法:本次纳入2018年2月～2020年11月进行麻醉手术的老年糖尿病患者74例为对象,依据干预方法的不同,随机分为2组(各37例).对照组采用常规围手术期干预;观察组采用麻醉管理,分别于术前、手术开始时、手术开始15min、手术结束时、术后24h测定患者的血糖控制情况,...     

高血压患者非心脏手术围手术期心血管并发症的研究

目的:探讨高血压患者非心脏手术围手术期心血管并发症及心血管药物干预的影响。方法:回顾分析101例高血压患者非心脏大、中手术(观察组)的临床资料,与血压正常者64例(对照组)作比较。结果:观察组的心血管并发症明显高于对照组(P<0.05);硬膜外麻醉并发症明显高于对照组(P<0.05);腹部手术并发症明显高于对照组(P<0.05)。结论:高血压病明显增加非心脏手术围手术期心血管并发症。     

老年糖尿病患者腹部手术的围手术期处理

目的 探讨老年糖尿病患者腹部手术的围手术期处理方法.方法 对我院进行腹部手术的62例老年糖尿病患者的临床资料进行回顾性分析.结果 急诊手术39例,择期及限期手术23例,本组患者围手术期血糖控制在6.1～11.1mmol/L,无手术死亡,无严重并发症,所有病例全部顺利渡过围手术期,均痊愈出院.结论 加强围手术期处理,合理运用胰岛素,严格控制血糖,选择合理的手术方式及麻醉方式,合理使用抗生素,有效的营养支持,是获得理想的外科治疗效果的有效措施,对减少并发症、提高疗效具有重要意义.     

临时心脏起搏器在全麻手术中的应用

目的:评价严重心律失常患者安装临时心脏起搏器后实施手术的临床应用价值和安全性。方法:56例合并有明显心动过缓、Ⅱ~°以上房室或窦房传导阻滞及双束支阻滞、病窦综合症(SSS)等严重心律失常患者,安装临时心脏起搏器后在全身麻醉下行外科手术,对全部患者的疗效及安全性进行分析。结果:56例患者均在VVI起搏模式维持下成功实施外科手术。围手术期未发生心脏及放置起搏器有关的井发症。术后经过顺利。结论:严重心律失常患者安装临时心脏起搏器后在全身麻醉下可安全实施外科手术。     

胸腔镜下体外循环心脏手术的麻醉管理

目的 总结胸腔镜下体外循环心脏手术的麻醉管理经验。方法回顾性分析2011年1月至12月在广东省人民医院行胸腔镜下体外循环心脏手术患者的麻醉及围术期处理的相关资料。结果2011年我院共行胸腔镜辅助小切口或全胸腔镜下体外循环心脏手术85例,其中男30例,女55例,年龄（42．5±15．2）岁。手术类型包括：房间隔缺损修补术20例,同期三尖瓣成形术15例;左心房黏液瘤摘除术7例;二尖瓣成形术8例：二尖瓣置换术50例,同期三尖瓣成形术19例、心房颤动射频消融术5例、房间隔缺损修补术2例及左心房血栓清除术1例。麻醉均采用静吸复合全身麻醉,左侧双腔气管插管单肺通气,经皮上腔静脉插管、股动静脉插管建立外周体外循环,体外循环时间（151．8±63．6）min,心肌血运阻断时间（92．1±43．7）min。全组患者术后并发症8例（9．4％）,死亡1例。结论良好的单肺隔离通气、充分的静脉引流以及完善的术中监测有利于手术的顺利进行,维持血流动力学平稳和避免缺血、缺氧可以减少围术期并发症,是胸腔镜下体外循环心脏手术麻醉管理的重点。     

The risk of cardiac complications following noncardiac surgery in patients with drug eluting stents implanted at least six months before surgery

Aims : Given the anecdotal reports and case series suggesting that drug-eluting coronary stents [DES] may be still vulnerable to coronary thrombosis after six months, we sought to assess this risk in patients undergoing non-cardiac surgery six months after stenting. Methods and Results : Linking the Rabin Medical Centre interventional cardiology database with its non-cardiac surgical database, we identified 78 patients who underwent DES placement and subsequently [after six months] had noncardiac surgery [15-vascular, 37- abdominal and genitourinary and 26-others, excluding ophthalmic surgery]. Outcome measures included 30-day rate of postoperative myocardial infarction (MI), DES-related thrombosis, and cardiac mortality. Major adverse cardiac events [death and non-fatal MI] occurred in 6 (7.7%) patients including 2 cardiac deaths (2.6%), 4 (5.1%) non-fatal myocardial infarctions (MIs). Two patients (2.6%) sustained stent thrombosis [one patient had ‘definite’ and one ‘probable’ stent thrombosis]. All MIs [including stent thrombosis] occurred in the vascular and abdominal surgery group. Two of the MIs events occurred while the patients were on dual antiplatelet agents. In conclusions : Perioperative cardiac events during non cardiac surgery after six months of DES deployment still occur. These cardiac complications [not entirely prevented by continued dual antiplatelet agents] remain a matter of diagnostic and therapeutic challenge and concern. © 2009 Wiley-Liss, Inc.     

Combined open-heart valve surgery and elective abdominal operations

From January 1970 to December 1984, at the "A. De Gasperis" Division of cardiac surgery in 73 patients an open-heart valvular operation and an elective abdominal surgical procedure were simultaneously performed. Abdominal surgery was indicated for: cholelithiasis (41 cases), hernia (22 cases), uterine fibroleiomyomas (7 cases), pregnancy (1 case), marginal ulcer after gastric resection (1 case), association of cholelithiasis and hernia (1 case). The etiology of valvular disease was: previous rheumatic fever (69 cases) and acute bacterial endocarditis (1 case); there were 3 cases of periprosthetic leak. All patients were classified in NYHA class III or IV. In all patients the abdominal procedure was carried out first. No significant differences were noted between this group of patients and patients with isolated open-heart operations regarding: postoperative bleeding, stay in Postoperative Intensive Care Unit, overall postoperative hospital stay. There were 5 hospital deaths, all related to cardiac causes. There were no infectious complications, nor early or late abdominal wound complications. The rationale for the combined approach to abdominal and cardiac diseases includes: risk of non cardiac surgery in patients with critical heart disease, risk of non cardiac surgery in patients with previous cardiac valve operations and anticoagulant therapy and risk of abdominal complications after cardiopulmonary bypass surgery. Simultaneous abdominal and cardiac surgery is suggested on clinical, psychological and social grounds.     

Value of autopsy in cardiac surgery

IntroductionWith improvements in preoperative diagnostics and postoperative care the value of autopsy has been questioned. The aim of our study was to prospectively assess the current value of autopsy in patients after cardiac surgery.MethodsBetween January 2007 and December 2013 there were 7800 patients operated on for heart disease. Two hundred and thirteen of them died postoperatively, resulting in an overall in-hospital mortality of 2.7%. Autopsy was performed on 158 patients (74%). Data regarding the cause of death from clinical and autopsy findings were analysed and compared.ResultsArtificial ventilation, inotropic support before operation, NYHA class IV, and renal failure were the most common preoperative risk factors and surgery for postinfarction ventricular septal defect, emergency operation, operation for acute dissection, triple valve surgery and the necessity for circulatory arrest were the most significant operative risk factors. The most frequent cause of death was cardiac failure or a sepsis and/or multiorgan failure. Missed major diagnosis (class I and II) was found in 21 patients (13.3%) and missed minor diagnosis was found in 17 patients (10.4%). Of the seven patients with class I error, six died due to unidentified abdominal complications.ConclusionAutopsy remains the most specific indicator of errors in diagnostics and surgery in patients with cardiac disease. It is a valuable tool for quality assessment and may contribute to the improvement of patient healthcare. Clinicians should pay special attention to abdominal symptomatology in patients after cardiac surgery because this was the main cause of diagnostic errors.     

体外膜肺氧合对心脏术后心肺复苏患者的应用

目的:探讨体外膜肺氧合技术(ECMO)在成年心脏手术后心肺复苏(CPR)困难患者的应用经验。方法:回顾分析2010年1月至2012年9月期间,7例心脏手术后因CPR困难应用ECMO救治的成年患者的临床资料,男性4例,女性3例,年龄42～65岁,平均(54±7)岁,其中冠状动脉旁路移植术(CABG)6例,主动脉瓣置换术1例。全部患者均经股动静脉插管建立ECMO辅助。结果:7例患者CPR时间40～65 min,平均(53±7)min,建立ECMO辅助后全部患者均恢复自主心律,ECMO辅助时间36～128 h,平均(85±26)h,监护室停留时间2～8d,平均(5±1)d。辅助24h后患者平均动脉压(MBP)、血乳酸(Lac)及正性肌力药物评分(IS)均明显改善。6例(85.7%)患者成功撤离ECMO辅助,其中3例(42.9%)存活出院,1例患者因无法脱机而死亡,3例成功脱机后因感染及中枢神经系统并发症死亡;4例患者同时应用主动脉内球囊反搏(IABP),3例进行肾替代治疗(CRRT)。结论:体外膜肺心肺复苏(ECPR)可以提供紧急生命支持,挽救部分常规方法复苏困难的心脏术后心脏骤停患者的生命。     

Abdominal surgery in patients 90 years of age and older at a provincial general hospital

Background:   It has been commonly accepted that age itself is never an absolute contraindication for surgical treatment in the elderly. Some of the many problems with the oldest old could be solved by surgical intervention. However, there are quite a few issues to be resolved for the surgical treatment of patients aged in their nineties. We therefore investigated cases of abdominal operations performed during the past decade, and wish to give our point of view on the indication, significance, merits and demerits of conducting surgical operations in this age-group of patients.
Methods:   We studied perioperative status, postoperative morbidity/mortality, and short- and long-term outcomes of abdominal surgery in patients 90 years of age and older who underwent abdominal surgical operation at a provincial general hospital.
Results:   Seven patients had elective operations and six patients underwent emergency operations. The postoperative morbidity was fairly high after both elective and emergency operations. Major complications occurred in one patient who died of multiple organ failure 20 days after the operation. One patient stayed in the hospital and died there 240 days after gastrectomy. Three patients survived more than 4 years after surgery. No definite relationship was revealed between the risk score and postoperative morbidity/mortality. No evident change was recognized in the performance status in patients who received abdominal surgical operations.
Conclusion:   The results indicate that more meticulous consideration as well as more precise decision about the indication for surgical intervention, and more intensive perioperative management will be necessary in order to secure more favorable outcomes of therapy and quality of life for high-risk patients aged in their nineties.     

高龄心血管外科的现状与进展

随着社会的老龄化和心血管疾病发病率的增高,70岁以上高龄患者心血管外科手术日益增多。尽管与70岁以下患者相比,高龄患者往往具有更多的高危因素,术后脑卒中的发生率增高,但目前高龄冠状动脉外科和主动脉瓣膜外科的近远期效果满意,微创和杂交技术是高龄患者心血管手术的发展趋势。     

Good outcomes from cardiac surgery in the over 70s

OBJECTIVE: To determine the early mortality and major morbidity associated with cardiac surgery in the elderly. DESIGN: Retrospective case record review study of 575 patients >/= 70 years old who underwent cardiac surgery at the Manchester Heart Centre between January 1990 and December 1996. SETTING: Regional cardiothoracic centre. SUBJECTS: Patients >/= 70 years old who underwent cardiac surgery. MAIN OUTCOME MEASURES: Comparison of 30 day mortality and incidence of major morbidity between patients >/= 70 years old and patients < 70 years old. RESULTS: Of 4395 cardiac surgical operations, 575 operations (13.1%) were in patients aged >/= 70 years (mean (SD) 73.1 (3.2) years). The proportion of elderly patients rose progressively from 7.9% in 1990 to 16.5% in 1996. 334 patients (58.1%) had coronary artery bypass grafting alone, 91 patients (15.8%) had valve surgery alone, and 129 patients (22.4%) had combined valve surgery and bypass grafting. For isolated coronary artery bypass grafting, 30 day mortality in patients >/= 70 years was 3.9% compared with 1.3% in patients < 70 years (p < 0.001). 30 day mortality for isolated valve surgery in patients >/= 70 years was 7.7%. Isolated aortic valve replacement was the most common valvar procedure in patients >/= 70 years and carried the lowest mortality (4.3%). Additional coronary artery bypass grafting increased the mortality rate in patients >/= 70 years to 9.3% for all valve surgery and to 8.0% for aortic valve replacement. Major morbidity in patients >/= 70 years was low for all procedure types (stroke 1.9%, acute renal failure requiring dialysis 1.6%, perioperative myocardial infarction 0.5%). CONCLUSIONS: Early mortality and major morbidity is low for cardiac surgery in elderly patients. Concerns over the risk of cardiac surgery in the elderly should not prevent referral, and elderly patients usually do well. However, unconscious rationing of health care may affect referral patterns, and studies that assess the cost effectiveness of cardiac surgery versus conservative management in such patients are lacking.     

N末端脑钠尿肽原预测老年人腹部手术后心脏事件的价值

目的:探讨术前血浆N末端脑钠尿肽原（NT-proBNP）水平对老年腹部手术患者围手术期严重心血管事件（PMCE）的预测价值。方法: 检测173例拟实施腹部手术老年患者的术前血浆NT-proBNP浓度,通过ROC曲线下面积比较术前血浆NT-proBNP水平和修订心脏风险指数（RCRI）在预测老年腹部手术患者围手术期发生PMCE的价值并找出理想截断点值。结果: 围手术期发生PMCE 12例,PMCE组血浆NT-proBNP浓度显著高于无PMCE组,中位数分别为452.6 ng/L和67.1 ng/L,NT-proBNP-log分别为2.72±0.43和1.82±0.39,P<0.01。术前血浆NT-proBNP的ROC曲线下面积为0.964（95%CI 0.924-0.986,P<0.01）,RCRI的ROC曲线下面积为0.79（95%CI 0.722-0.848,P<0.01）,二者的曲线下面积比较相差0.174,P<0.05。NT-proBNP预测围手术期PMCE的截断点为230.2 ng/L,其诊断灵敏度、特异度和准确度分别为92% 、96%和 96%。结论: 术前血浆NT-proBNP能预测老年腹部手术患者PMCE的发生,可以作为术前风险评估的工具。     

Coronary artery revascularization prior to abdominal nonvascular surgery

BackgroundDoes preoperative revascularization of the myocardium reduce cardiac risk in noncardiac surgery? The aim of this study was to evaluate the clinical effectiveness of preoperative cardioprotection by coronary artery revascularization in abdominal nonvascular surgery under general anesthesia.Materials and methodsThe observational clinical study included 111 consecutive patients with angiographically verified coronary artery disease. Two stratification groups of patients were compared, those with coronary artery revascularization (34 patients, 30.6%) and those without coronary artery revascularization (77 patients, 64.9%), in relation to frequency of perioperative cardiac complications. The patients were followed up until the 30th postoperative day. During operation and in the following 72 postoperative hours, the patients were monitored by continuous ST-T segment recording. Twelve-lead electrocardiography was performed immediately after surgery and on postoperative days 1, 2, and 7 as well as 1 day before discharge. Serum troponin T levels were controlled at 6, 24, and 96 h postoperatively.ResultsThe number of patients with major cardiac complications was 0 (0.0%, n=34) in the revascularized myocardium group and 10 (12.9%, n=77) in the nonrevascularized myocardium group (P<.05). Three patients in the nonrevascularized myocardium group died of acute myocardial infarction, congestive heart failure, and malignant arrhythmias, respectively, with severe coronary artery stenosis verified angiographically.ConclusionsPreoperative cardioprotection by coronary artery revascularization significantly reduces morbidity and mortality in patients who have undergone abdominal nonvascular surgery. Patients with severe coronary artery stenosis and indication for coronary artery revascularization independently of noncardiac surgery should first undergo cardiosurgical intervention prior to elective abdominal nonvascular surgery.     

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