心脏病人非心脏手术术前评估与术中管理-课件.ppt

1、心脏病人非心脏手术术前评估与术中管理 心脏病人非心脏手术术前评估与术中管理 ppt课件1Impact Factor 9.275心脏病人非心脏手术术前评估与术中管理 ppt课件2The Preambleu Guidelines and recommendations should help physicians and other healthcare providers to make decisions in their daily practice.However,the physician in charge of his/her care must make the ultimate

2、judgement regarding the care of an individual patient 心脏病人非心脏手术术前评估与术中管理 ppt课件3心脏病人非心脏手术术前评估与术中管理 ppt课件4IntroductionThe present guidelines focus on the cardiological management of patients undergoing non-cardiac surgery,i.e.patients where heart disease is a potential source of complications during s

3、urgery major non-cardiac surgery is associated with an incidence of cardiac death of between 0.5 and 1.5%,and of major cardiac complications of between 2.0 and 3.5%心脏病人非心脏手术术前评估与术中管理 ppt课件5Impact of the ageing Impact of the ageing populationpopulation It is estimated that elderly people require surg

4、ery four times more often than the rest of the population 心脏病人非心脏手术术前评估与术中管理 ppt课件6Pre-operative evaluation Surgical risk for cardiac events:the urgency,magnitude,type,and duration of the procedure,as well as the change in body core temperature,blood loss,and fluid shifts 心脏病人非心脏手术术前评估与术中管理 ppt课件7心脏

5、病人非心脏手术术前评估与术中管理 ppt课件8心脏病人非心脏手术术前评估与术中管理 ppt课件9Functional capacity Functional capacity is measured in metabolic equivalents(METs)Exercise testing provides an objective assessment of functional capacity Without testing,functional capacity can be estimated by the ability to perform the activities of

6、daily living 心脏病人非心脏手术术前评估与术中管理 ppt课件10 4 METs indicates poor functional capacity and is associatedwith an increased incidence of post-operative cardiac events 心脏病人非心脏手术术前评估与术中管理 ppt课件11Risk indices Goldman(1977),Detsky(1986),Lee(1999)The Lee index,to be the best currently available cardiac risk pre

7、diction index in non-cardiac surgery 心脏病人非心脏手术术前评估与术中管理 ppt课件12Six independent clinical determinants(The Lee (The Lee index)index)a history of IHD a history of cerebrovascular disease heart failure insulin-dependent diabetes mellitus impaired renal function High-risk type of surgery 心脏病人非心脏手术术前评估与术中

8、管理 ppt课件13The Lee indexThe Lee index All factors contribute equally to the index(with 1 point each)the incidence of major cardiac complications is estimated at 0.4,0.9,7,and 11%in patients with an index of 0,1,2,and 3 points,respectively 心脏病人非心脏手术术前评估与术中管理 ppt课件14心脏病人非心脏手术术前评估与术中管理 ppt课件15Biomarkers

9、Biomarkers Cardiac troponins T and I(cTnT and cTnI)are the preferred markers for the diagnosis of MI because they demonstrate sensitivity and tissue specificity superior to other available biomarkers 心脏病人非心脏手术术前评估与术中管理 ppt课件16Plasma BNP and NT-proBNPPlasma BNP and NT-proBNP important prognostic indi

10、cators in patients with heart failure additional prognostic value for long-term mortality and for cardiac events 心脏病人非心脏手术术前评估与术中管理 ppt课件17Non-invasive testingthree cardiac risk markers:LV dysfunction myocardial ischaemia heart valve abnormalities 心脏病人非心脏手术术前评估与术中管理 ppt课件18心脏病人非心脏手术术前评估与术中管理 ppt课件19

11、Echocardiography Echocardiography A meta-analysis of the available data demonstrated that an LV ejection fraction of 100 mmHg 心脏病人非心脏手术术前评估与术中管理 ppt课件25心脏病人非心脏手术术前评估与术中管理 ppt课件26心脏病人非心脏手术术前评估与术中管理 ppt课件27Nitrates:Nitroglycerin Nitrates:Nitroglycerin 心脏病人非心脏手术术前评估与术中管理 ppt课件28心脏病人非心脏手术术前评估与术中管理 ppt课件

12、29心脏病人非心脏手术术前评估与术中管理 ppt课件30DiureticsDiuretics心脏病人非心脏手术术前评估与术中管理 ppt课件31AspirinAspirin心脏病人非心脏手术术前评估与术中管理 ppt课件32Anticoagulant therapy Anticoagulant therapy 心脏病人非心脏手术术前评估与术中管理 ppt课件33心脏病人非心脏手术术前评估与术中管理 ppt课件34心脏病人非心脏手术术前评估与术中管理 ppt课件35心脏病人非心脏手术术前评估与术中管理 ppt课件36RevascularizationRevascularization心脏病人非心

13、脏手术术前评估与术中管理 ppt课件37心脏病人非心脏手术术前评估与术中管理 ppt课件38Specific diseases Specific diseases Arterial hypertension Valvular heart disease Aortic stenosis Mitral stenosis AR and MR prosthetic valve(s)心脏病人非心脏手术术前评估与术中管理 ppt课件39Arterial hypertensionArterial hypertension antihypertensive medications should be cont

14、inued during the perioperative period.In patients with grade 3 hypertension(systolic blood pressure 180 mmHg and/or diastolic blood pressure 110 mmHg),the potential benefits of delaying surgery to optimize the pharmacological therapy should be weighed against the risk of delaying the surgical proced

15、ure 心脏病人非心脏手术术前评估与术中管理 ppt课件40Valvular heart diseaseValvular heart disease higher risk Echocardiography should be performed 心脏病人非心脏手术术前评估与术中管理 ppt课件41Aortic stenosisAortic stenosis Severe AS:aortic valve area 1 cm2 1.5 cm2)and in asymptomatic patients with significant MS(valve area 1.5 cm2)and systo

16、lic pulmonary artery pressure 50 mmHg control of heart rate Strict control of fluid overload anticoagulation AF心脏病人非心脏手术术前评估与术中管理 ppt课件43AR and MR AR and MR Non-significant AR and MR(low risk)asymptomatic patients with severe AR and MR and preserved LV function(low risk)Symptomatic patients and LV E

17、F30%(High risk,only if necessary,optimization of pharmacological therapy)心脏病人非心脏手术术前评估与术中管理 ppt课件44prosthetic valve(s)prosthetic valve(s)no evidence of valve or ventricular dysfunction(without additional risk)endocarditis prophylaxis anticoagulation regimen modification 心脏病人非心脏手术术前评估与术中管理 ppt课件45Bra

18、dyarrhythmiasBradyarrhythmias Temporary cardiac pacing is rarely required,even in the presence of pre-operative asymptomatic bifascicular block or CLBBB The indications for temporary pacemakers are generally the same as those for permanent pacemakers 心脏病人非心脏手术术前评估与术中管理 ppt课件46Pacemaker/implantable P

19、acemaker/implantable cardioverter defibrillatorcardioverter defibrillator unipolar electrocautery represents a significant risk be avoided by positioning the ground plate Keeping the electrocautery device away from the pacemaker,giving only brief bursts and using the lowest possible amplitude心脏病人非心脏

20、手术术前评估与术中管理 ppt课件47 The implantable cardioverter defibrillator should be turned off during surgery and switched on in the recovery phase before discharge to the ward 心脏病人非心脏手术术前评估与术中管理 ppt课件48Perioperative monitoringPerioperative monitoring V5(75%),V4(61%),V5+V4(90%),V5+V4+II(96%)Continuous automate

21、d ST trending monitors(sensitivity and specificity of 74 and 73%)ECG心脏病人非心脏手术术前评估与术中管理 ppt课件49心脏病人非心脏手术术前评估与术中管理 ppt课件50Transesophageal Transesophageal echocardiographyechocardiography心脏病人非心脏手术术前评估与术中管理 ppt课件51Right heart catherizationRight heart catherization both a large observational study and a

22、randomized multicentre clinical trial did not show a benefit associated with the use of right heart catheterization no difference in mortality and hospital duration /a higher incidence of pulmonary embolism心脏病人非心脏手术术前评估与术中管理 ppt课件52Disturbed glucose Disturbed glucose metabolismmetabolism promotes at

23、herosclerosis,endothelial dysfunction,and activation of platelets and proinflammatory cytokines 心脏病人非心脏手术术前评估与术中管理 ppt课件53心脏病人非心脏手术术前评估与术中管理 ppt课件54Intraoperative anaesthetic Intraoperative anaesthetic managementmanagement proper organ perfusion pressure Spinal and epidural anaesthesia(T4)One meta-a

24、nalysis reported significantly improved survival and reduced incidence of post-operative thromboembolic,cardiac and pulmonary complications with neuraxial blockade compared with general anaesthesia 心脏病人非心脏手术术前评估与术中管理 ppt课件55Putting the puzzle together心脏病人非心脏手术术前评估与术中管理 ppt课件56心脏病人非心脏手术术前评估与术中管理 ppt课

25、件57心脏病人非心脏手术术前评估与术中管理 ppt课件58心脏病人非心脏手术术前评估与术中管理 ppt课件59患者和外科特殊因素决定治疗策略，不需进一步心脏检查和治疗，请求会诊以加强术中管理，监测心脏事件和拟定长期药物治疗方案多学科会诊以决定最佳治疗方案，如能推迟手术则可进行CABG、球囊成形术、支架植入术明确危险因素、进行手术治疗、提供正确的生活方式和适当的药物治疗，以改善术后长期生存质量明确心功能状态、进行手术治疗、适当的术前药物治疗（他汀类，受体阻滞剂）适当的术前药物治疗（他汀类，受体阻滞剂）、左室收缩功能障碍者（ACE-inhibitors）、进行进行手术治疗手术治疗、围术期ECG监测心脏病人非心脏手术术前评估与术中管理 ppt课件60适当的术前药物治疗（他汀类，受体阻滞剂）、左室收缩功能障碍者（ACE-inhibitors）non-invasive stress test Revascularization bridging therapy心脏病人非心脏手术术前评估与术中管理 ppt课件61