血气分析联合麻醉深度监测在老年人腹腔镜下胃癌根治术中的应用体会

随着我国经济和医疗水平的提高,国民的平均寿命明显延长,老年病人占受手术病人的比例稳步增高,很多老年病人又同时患有一些重要器官疾病却不得不进行手术治疗的情况也很常见。老年病人,尤其常合并心血管系统疾病（如冠心病）的老年病人进行非心脏手术时不仅不能改善心脏功能,可能加重心脏负担,难以维持血流动力学的稳定,麻醉风险比进行心脏手术还要大。目前我院接受腹腔镜下胃癌根治术的患者大多数都是老年人,老年人对人工气腹的耐受能力有限,因此,术中经常出现一系列并发症而影响麻醉质量。总结我院完成的100例行腹腔镜下胃癌根治术的老年病例,报道如下。     

老年病人术后精神障碍的临床思维

外科技术和麻醉管理的进步确实降低了老年病人的围术期并发症发生率和病死率。术前合并多种内科疾病的老年病人进行各种复杂手术的机会越来越多，而且手术时间越来越长。中枢神经功能(CNS)不全即术后精神障碍被认为是心脏和非心脏手术后常见的一种并发症，老年病人发病率明显提高。     

老年人心脏病非心脏手术麻醉处理

目的：探讨老年人心脏病非心脏手术麻醉处理的特殊性。方法：总结五年行这类手术麻醉病人150例，术前全面了解各重要器官病变程度及代偿能力，选择适当的术前治疗与准备，合适的麻醉方法、药物、监测及调控措施，预防围术期心肌缺血缺氧、术后疼痛、应激反应及心血管事件发生。结果：术前心肌供血不足发生率居首位，其次是高血压／低血压，心绞痛发生第三位。麻醉方法取决于病情和手术种类。急诊手术需行呼吸支持，稳定循环。择期手术，术前给予相应的极化液、降血糖、抗心律失常、降血压和抗感染等治疗。术后行PCA镇痛。手术麻醉死亡率为零。结论：心脏病非心脏手术老年患者，术前充分的准备，选择合适的麻醉方法，加强麻醉管理和维持心肌氧供需平衡，是降低手术麻醉风险的重要措施。     

高龄患者全身麻醉下行非心脏手术围术期并发症及危险因素分析

目的 探讨在全身麻醉下行非心脏手术的高龄患者围术期并发症发生率,并分析其危险因素。方法 回顾性分析2020年1月至2021年12月于上海市松江区中心医院在全身麻醉下行非心脏手术的427例高龄患者的临床资料,根据是否发生并发症分为发生组（57例）和未发生组（370例）,采用单因素和多因素回归分析明确术后并发症发生的危险因素。结果 57例（13.35%）患者发生术后并发症。发生组患者术中累计低血压时间长于未发生组,入ICU比例、ICU停留时间及住院时间多于未发生组。多因素Logistic回归分析显示,长时间手术、术前肾功能不全、术后入ICU及术后更长的ICU停留时间是术后总体并发症增加的独立危险因素（P<0.05）。结论 全身麻醉行非心脏手术的高龄患者围术期具有较高的并发症发生率。术前肾功能不全、长时间手术、术后入ICU及术后更长的ICU停留时间是导致术后并发症增加的独立危险因素,临床应加以重视。     

老年患者心脏介入手术术前饮食指导的探讨

目的探讨老年患者心脏介入手术术前禁食时间及饮食指导。方法对在我区2003年6月～2005年6月行心脏介入治疗的老年患者共33例（A组）,按常规方法术前禁食,2005年7月～2006年6月行心脏介入治疗的老年患者共40例（B组）按试验方法术前禁食,对两组进行术中、术后并发症的观察。结果A组禁食时间明显长于B组,并发症发生次数明显多于B组（P〈0.01）,B组中憋尿感发生次数高于A组。结论行心脏介入手术的老年患者尽可能的缩短术前禁食及禁水的时间,这样可以减少手术中出现的并发症。     

老年人非心脏手术并发急性心肌梗死37例临床分析

据调查,非心脏手术人群中,3.9%患有缺血性心脏病,其中16.4%在围术期发生心脏并发症。在老年患者,心肺并发症成为围手术期主要致死性因素,急性心肌梗死的发生更是直接威胁着病人的生命。我院自1986年10月至2005年10月共收治老年人非心脏手术并发急性心肌梗死(AMI)37例,其中死亡1     

老年非心脏手术后心律失常的相关分析及护理

目的:对老年非心脏手术患者的心律失常危险因素进行相关分析,以制定相应护理对策.方法:406例患者分为心律失常和非心律失常组,分别对年龄及性别、手术类型、合并症、血氧饱和度及电解质紊乱进行危险因素相关分析.结果:高龄,男性,胸科手术,合并症多以及术后血氧饱和度低、电解质紊乱者,心律失常组明显多于无心律失常组.结论:对于老年非心脏手术患者的护理,应针对以上危险因素制定相应的护理措施.     

老年患者开胸手术后心血管并发症的护理

老年患者开胸手术后心血管并发症的护理第一军医大学南方医院（广州５１０５１５）杨丽朱志红开胸手术的创伤和麻醉对呼吸和循环系统影响较大，尤其是老年病人表现更明显，故手术后更易发生心血管并发症。手术后病情的观察和得力的护理措施，是抢救病人成功必不可少的条件...     

不同麻醉方法对冠心病非心脏术后病人心脏并发症的影响及监护

我国冠心病发病率呈逐年上升趋势，外科病人合并冠心病需手术的人数越来越多，此类病人围术期主要并发症是心肌缺血和心肌梗死，高发时间是手术当天和术后第1天，而胸部或上腹部手术后心肌梗死的发生率约为其他部位手术的3倍。目前，胸部或上腹部手术的麻醉方法主要有两种，即单纯全身麻醉(GA)与胸段硬膜外阻滞(TEA)复合全麻。我们观察了两种麻醉方法对胸部或上腹部手术的冠心病病人术后心脏并发症的影响，加强术后监护，及时采取有效措施，以降低此类病人围术期心脏并发症的发生率。     

全身麻醉复合硬膜外阻滞对老年胸科术后认知功能的影响

目的探讨全身麻醉复合硬膜外阻滞用于老年患者胸科手术对术后认知功能的影响。方法选择择期行开胸非心脏手术的老年患者186例,随机分为全身麻醉复合硬膜外阻滞组（试验组）和单纯全身麻醉组（对照组）,每组93例。术后24和48 h采用视觉模拟疼痛评分尺评价患者静息和咳嗽时疼痛评分,记录监护室停留时间、术后住院时间、术后并发症的发生情况;分别在术前1 d和术后第3、7天由同一实验者对患者采用简易精神状态量表（MMSE）进行神经精神功能评定。结果试验组镇痛效果明显优于对照组,术后住院时间试验组明显少于对照组,P〈0.05;试验组在术后第3、7天得分均高于对照组,但无明显差异;术后第7天较术后第3天POCD的发生明显减少,试验组两时间发生认知功能障碍的病例数明显少于对照组。结论全身麻醉复合硬膜外阻滞用于老年胸科非心脏手术可明显降低患者术后早期POCD的发生率。     

Risk of noncardiac surgical procedures in patients with aortic stenosis

Although severe aortic stenosis has been reported to increase the risk of noncardiac operation, recent advances in anesthetic management may alter this risk. We reviewed the perioperative course of 48 consecutive patients (mean age, 73 years) with significant aortic stenosis who underwent a noncardiac operation or diagnostic procedure between 1985 and 1987. Twenty-five patients had local anesthesia with intravenous sedation, 22 (17 with severe and 5 with moderate aortic stenosis) underwent general anesthesia, and 1 had spinal anesthesia. Of the 48 patients, 36 (75%) had symptoms--congestive heart failure in 24, angina in 19, and syncope in 7. Doppler echocardiography, performed in all 48 patients, revealed a mean peak instantaneous gradient of 76 mm Hg and a calculated aortic valve area (in 22 patients) of 0.61 cm2. In the 20 patients who also underwent preoperative cardiac catheterization, the calculated mean aortic valve area was 0.59 cm2. Seven patients had one or more perioperative events, including intraoperative hypotension in five; all except one of these events were transient and without major sequelae. No intraoperative deaths occurred. Selected patients with severe aortic stenosis can undergo noncardiac procedures at a reasonably low risk with careful monitoring of anesthesia.     

AANA Journal course: Update for nurse anesthetists--Part 4--preoperative cardiac evaluation

This AANA Journal course discusses the American College of Cardiology (ACC) and American Heart Association (AHA) guideline on perioperative cardiovascular evaluation for noncardiac surgery. The intent of the ACC/AHA guideline is to assist clinicians in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, and prevention of cardiac diseases. Optimizing the anesthetic management of the cardiac patient undergoing noncardiac surgery is becoming increasingly important: as the percentage of Americans older than 65 years continues to grow, so does the prevalence of cardiac disease in this population. Simply accepting a preoperative cardiology clearance for the cardiac patient undergoing noncardiac surgery provides little information that can be used for risk assessment and management of anesthesia. While national practice patterns vary significantly, there is an important need to standardize cost-effective preoperative cardiac evaluation. By using evidence-based studies, the ACC/AHA guideline delineates methods to objectively categorize cardiovascular risk and use data from the cardiology consultation to refine anesthetic management. Use of the guideline can lead to more efficient evaluation of the noncardiac patient with cardiac disease, which can decrease morbidity, mortality, and cost.     

重型颅脑损伤急诊手术的麻醉方法研究

目的研究分析重型颅脑损伤患者急诊手术中的麻醉方法。方法选取我院急诊手术治疗的重型颅脑损伤患者共40例,回顾性分析急诊手术中的麻醉方法和麻醉效果。结果患者HR、SBP、DBP术后水平分别为104.25±6.49次/min、13.08±3.94KP、6.52±0.84KP,均较术前得到改善(P0.01);25例术中异氟烷维持麻醉患者,未见死亡,术中至苏醒过程未见明显血压波动,并发症1例;15例术中丙泊酚维持麻醉的患者,1例死亡(因脑部并发症死亡),4例术中至苏醒血压等明显波动。异氟烷术中维持麻醉效果优于丙泊酚术中维持麻醉,差异显著(P0.05)。40例患者住院时间为20.4±2.7d,术后切口疼痛时间为2.2±0.4d;术中死亡率为2.5%,术中并发症发生率为2.5%。结论重型颅脑损伤患者急诊手术在维持呼吸通畅、供氧、抗休克、扩容同时,灵活结合病情选择麻醉方式与麻醉用药,可有效降低病死率、缩短住院时间和术后切口疼痛时间。     

脊柱侧弯矫形手术术中采用神经电生理功能监测838例效果分析

目的探讨脊柱侧弯矫形手术术中采用神经电生理功能监测的临床效果。方法使用十通道神经电生理功能监测系统,共对838例手术患者进行了术中神经电生理功能监测,分析838例脊柱侧弯矫形手术中应用体感诱发电位(SEP)监测脊髓和运动诱发电位的效果和体会。结果 838例患者中,19例患者术中神经电生理功能监测出现了SEP异常,波幅值下降50%或潜伏期延长超过10%。19例患者中术中SEP波幅恢复至基线的有8例,波幅好转11例。838例患者中有11个患者术中SEP没有变化,但是术后反而下肢有症状,假阳性率为1.4%。结论脊柱侧弯矫形手术术中联合应用SEP能够通过为术者实时监测脊髓功能,已达到了解神经系统功能状态的目的,最大限度地避免脊髓的损伤风险,为手术的安全性提供了一定的保障,降低了手术的致残率,应成为脊柱侧弯矫形手术的常规监测项目。     

非心脏手术围手术期心脏事件预测的超声心动图研究现状

对非心脏手术病人进行准确的术前心脏事件危险性评估可以帮助临床采取预防性保护措施并制定合理的治疗方案,降低围手术期心脏事件的发生.采用何种合适的术前检测方法和恰当的术前风险评估一直是临床关注的研究热点.超声心动图,特别是负荷超声心动图通过对非心脏病人术前心脏各指标的检测,可以对围手术期心脏事件的危险性进行分级,被认为是有潜在价值的评估非心脏手术病人心脏事件发生的有效方法.     

硬膜外阻滞复合浅全麻用于老年高血压病患者开胸手术

目的观察硬膜外阻滞复合浅全麻对老年高血压患者开胸手术血流动力学变化、术中知晓及苏醒时间的影响。方法择期开胸手术的老年高血压患者60例,随机分为单纯全麻组（Ⅰ组）和浅全麻复合硬膜外阻滞组（Ⅱ组）,监测两组患者术中的血流动力学变化和ECG的变化及全麻药用量和苏醒时间。结果Ⅰ组出现明显的心血管反应,尤以插管及拔管时显著高于基础值（P〈0．05）,Ⅱ组各时点血流动力学稳定,与I组比较有显著差异（P〈0．05）,心肌缺血有所改善,全麻药用量明显少于Ⅰ组（P〈0．01）,术后清醒及气管拔管时间与Ⅰ组比较明显缩短（P〈0．01）。结论硬膜外阻滞复合浅全麻可减轻应激反应,循环状态稳定,全麻用药量减少,苏醒快,是老年高血压患者开胸手术的首选麻醉方法。     

罗库溴铵靶控输注用于老年患者腹腔镜手术效果观察

目的探讨罗库溴铵靶控输注(TCI)用于老年患者腹腔镜手术的效果。方法择期行腹腔镜手术老年患者84例,美国麻醉医师协会(对患者的病情和体格情况评估标准)(ASA)Ⅱ级,年龄65～83岁,随机分为A、B、C 3组,每组28例,将A、B、C 3组诱导插管时静脉注射罗库溴铵0.6mg/kg,术中维持效应室靶浓度分别为0.6、0.8、1.0mg/L。观察各组诱导插管起效时间、气管插管条件、术中骨骼肌松弛条件和术后骨骼肌松弛恢复情况。结果 A、B、C 3组均可顺利完成气管插管,术中A组骨骼肌松弛条件满意率低于B组和C组;与B组比较,C组罗库溴铵用药量大,术中肌肉阻滞程度较深,术后恢复时间延长,差异有统计学意义(P<0.05)。结论老年患者腹腔镜手术诱导插管时以罗库溴铵0.6mg/kg进行骨骼肌松弛维持,术中效应室靶浓度维持在0.8mg/L,可以实现诱导插管顺利、术中骨骼肌松弛满意和术毕迅速恢复。     

Etomidate vs propofol in coronary heart disease patients undergoing major noncardiac surgery: A randomized clinical trial

BACKGROUNDThe ideal depth of general anesthesia should achieve the required levels of hypnosis, analgesia, and muscle relaxation while minimizing physiologic responses to awareness. The choice of anesthetic strategy in patients with coronary heart disease (CHD) undergoing major noncardiac surgery is becoming an increasingly important issue as the population ages. This is because general anesthesia is associated with a risk of perioperative cardiac complications and death, and this risk is much higher in people with CHD. AIMTo compare hemodynamic function and cardiovascular event rate between etomidate- and propofol-based anesthesia in patients with CHD. METHODSThis prospective study enrolled consecutive patients (American Society of Anesthesiologists grade II/III) with stable CHD (New York Heart Association class I/II) undergoing major noncardiac surgery. The patients were randomly allocated to receive either etomidate/remifentanil-based or propofol/remifentanil-based general anesthesia. Randomization was performed using a computer-generated random number table and sequentially numbered, opaque, sealed envelopes. Concealment was maintained until the patient had arrived in the operating theater, at which point the consulting anesthetist opened the envelope. All patients, data collectors, and data analyzers were blinded to the type of anesthesia used. The primary endpoints were the occurrence of cardiovascular events (bradycardia, tachycardia, hypotension, ST-T segment changes, and ventricular premature beats) during anesthesia and cardiac troponin I level at 24 h. The secondary endpoints were hemodynamic parameters, bispectral index, and use of vasopressors during anesthesia.RESULTSThe final analysis included 40 patients in each of the propofol and etomidate groups. The incidences of bradycardia, hypotension, ST-T segment changes, and ventricular premature beats during anesthesia were significantly higher in the propofol group than in the etomidate group (P < 0.05 for all). The incidence of tachycardia was similar between the two groups. Cardiac troponin I levels were comparable between the two groups both before the induction of anesthesia and at 24 h after surgery. When compared with the etomidate group, the propofol group had significantly lower heart rates at 3 min after the anesthetic was injected (T₁) and immediately after tracheal intubation (T₂), lower systolic blood pressure at T₁, and lower diastolic blood pressure and mean arterial pressure at T₁, T₂, 3 min after tracheal intubation, and 5 min after tracheal intubation (P < 0.05 for all). Vasopressor use was significantly more in the propofol group than in the etomidate group during the induction and maintenance periods (P < 0.001). CONCLUSIONIn patients with CHD undergoing noncardiac major surgery, etomidate-based anesthesia is associated with fewer cardiovascular events and smaller hemodynamic changes than propofol-based anesthesia.     

Anesthetic maintenance during myocardial revascularization in patients over 70 years of age

The authors performed a comparative retrospective analysis of preoperative and intraoperative periods in 50 patients aged 70-83 years with coronary heart disease (CHD). A control group comprised the similar patients aged 40-59 years. The geriatric patients showed a higher incidence of arterial hypertension, respiratory and central nervous system diseases, cardiac arrhythmias, and anemia as an outcome. In CHD patients aged 70-80 years, balanced general anesthesia based on lower-dose midazolam and fentanyl, on subnarcotic-dose ketamine during the metered use of isoflurane and adequate infusion therapy provided reasonable hemodynamic stability during the induction of anesthesia and the preperfiusion period without administering cardiotonic agents. Intraoperatively, there was a more pronounced reduction in pulmonary oxygenizing function, body temperature and more needs for cardiotonic and diuretic therapy and erythrocyte mass after the basic stage of surgery.     

Perioperative Cardiac Risk Reduction in Noncardiac Surgery

Major adverse cardiovascular events are a significant source of morbidity and mortality in the perioperative setting, estimated to occur in approximately 5% of patients undergoing nonemergent noncardiac surgery. To minimize the incidence and impact of these events, careful attention must be paid to preoperative cardiovascular assessment to identify patients at high risk of cardiovascular complications. Once identified, cardiovascular risk reduction is achieved through optimization of medical conditions, appropriate management of medication, and careful monitoring to allow for early identification of—and intervention for—any new conditions that would increase the risk of adverse cardiovascular outcomes. The major cardiovascular and anesthesiology societies in the United States, Europe, and Canada have published guidelines for perioperative management of patients undergoing noncardiac surgery. However, since publication of these guidelines, there has been a practice-changing evolution in the medical literature. In this review, we attempt to reconcile the recommendations made in these 3 comprehensive guidelines, while updating recommendations, based on new evidence, when available.