脑血管疾病颈动脉内膜切除术的麻醉管理ppt课件.ppt

1,AnestheticManagementofCerebrovascularDiseaseCarotidEndarterectomy,脑血管疾病颈动脉内膜切除术的麻醉管理,2,Introduction,Stroke（中风）isthethirdleadingcauseofdeath.carotidarterydisease（劲动脉疾病）isasignificantanestheticissue（麻醉问题）forpatientsover50yearsofage.Astrokeoccursduetoocclusiveorhemorrhagicconditions.Occlusivecerebrovasculardiseasecanbethrombotic,embolic,orstenotic(血栓，栓塞或狭窄)inorigin.(闭塞性或出血性中风的发生是由于闭塞性脑血管疾病，血栓，栓塞或起源于狭窄)Patientswithahistoryofpriorstroke（既往中风史）ortransientischemicattack（短暂性脑缺血发作）haveanincreasedriskofrecurrentperioperativestroke（围术期再次中风的危险）.,简介,3,Majorsymptomsofcarotidarterydiseaseincludechangesinvision,headache,changesinspeech,orfacial(发热)andextremity(四肢)weakness.Signs(体征)suggestiveofcarotidarterydiseaseincludeahigh-pitchedbruit(高亢的杂音)attheorigin(起源)oftheinternalcarotidartery,increaseinsizeandpulsation（强度）oftheipsilateral(同侧)superficialtemporalartery（颞浅动脉）,andchangesintheretinalexamination（眼底检查）.Confirmation（确诊）ofcarotidarterydiseaseisachievedbyvascularimagingwhichmayincludeultrasound,MRangiography,orcatheterangiography.（颈动脉疾病的确认是通过血管成像，其中可能包括超声，磁共振血管造影或导管造影）,4,Introduction,Presently,thereisinsufficient（不足的）informationtoregardingthetimingofsurgery（手术时机）followinganischemicepisode（缺血性发作）.Data（数据）suggeststhereisasmallbutrealincreaseinmorbidity（发病率）ifsurgeryisperformedshortlyaftertheonsetofsymptoms（症状）.（数据表明，如果进行手术后不久出现症状，有一个小，但真正的发病率增加）Riskmaybeassociatedwiththepresence（存在）ofalowdensity（低密度）lesion（病变）onCTscan,vascularterritory（血管壁内）oftheinfarct（梗塞）,brainshift（脑组织移位）,andlevelofconsciousness（意识）.,5,CarotidArteryRevascularization（颈动脉再灌注）,Carotidendarterectomy(CEA)（颈动脉内膜切除术）wasintroducedin1954astreatmentforocclusive（闭塞性）carotidarterydisease.Efficacy（疗效）dataonCEAwaslimiteduntilthe1990s.AnalysisofthreetrialshasdemonstratedthatCEAhasamarginal（微小）benefitinsymptomaticpatientswith50%-69%stenosisofthecarotidartery,andwasofgreatestbenefitinpatientswith70%stenosis.（三项试验分析表明，CEA在狭窄面积为50-69的颈动脉狭窄症状的患者身上收效甚微，在狭窄70的患者收益最大。）,6,CarotidArteryRevascularization（颈动脉再灌注）,Stenting(支架植入术)andangioplasty（血管成形术）ofthecarotidartery(CAS)hasbeenperformedforalmosttwodecades.Potential（潜在）advantagesofCASincludeavoidingcranialnerve（颅神经）damage,woundhematoma（伤口血肿）,andgeneralanesthesia（全身麻醉）.Theanesthetictechniqueforthisprocedureinvolves（涉及）minimalsedation(镇静）.Thisprocedurecancausesevere（严重）bradycardia（心动过缓）andhypotension,andcanresultincerebralhyperperfusion（高灌注）.,7,Anatomic/Physiologic（解剖/生理学）Considerations（注意事项）,Carotidarterydiseaseistypically（通常是）theresultofather-osclerosis（动脉粥样硬化）atthebifurcation（分支）ofthecommoncarotidartery（颈总动脉）ortheorigin（主支）oftheinternalcarotidartery（颈内动脉）.（颈动脉疾病通常是颈内动脉主支和颈总动脉分支粥样硬化的结果）Ischemiaismostoftenembolicinoriginbutmayalsohaveahemodynamicbasis.（缺血最常见的起源于栓塞，但可能也有血液动力学基础）Therearethreephases（阶段）oftheresponseofvariouscerebralvariables（脑变量）toprogressive（进展的）carotidarterydisease.（颈动脉疾病的进展在脑变量的反应上分三阶段）Duringischemia（缺血）,collateralflow（侧支循环）isacornerstone（基础）ofcerebralbloodflow(CBF)compensation（补偿）.,8,Anatomic/Physiologic（解剖/生理学）Considerations,TheprincipalpathwaysofcollateralflowaretheCircleofWillis（侧支循环的主要途径是Willis环）,extracranialanastomoticchannels（颅外吻合通道）,andleptomeningeal（脑膜）communicationsthatbridge“watershed”（分水岭）areasbetweenmajorarteries.DuringCEA,theriskofischemiaisrelatedtothedependencyofthecirculationontheipsilateral（同侧）internalcarotid（颈内）artery,andthecerebrovascular（脑血管）reserve（储备）ofthecontralateral（对侧）hemisphere（半球）.,9,PreoperativeConcerns（术前关注点）,CEAhasaninherent（固有）riskofperioperative（围手术期）strokeandcardiovascular（心血管）events.（CEA存在着围术期中风和心血管事件的固有风险）Insymptomaticpatients,thereisa6.5%rateofstrokeanddeathassociatedwithCEA;whilethereportedstrokeanddeathrateforpatientswithasymptomaticdiseaseis2.3%.TheriskforstrokefollowingCEAismoststronglyassociatedwithanactiveneurologic（神经）process（活动）priortosurgicalintervention（手术干预）.,10,Otherfactorswhichhavebeenreportedtoincreaseneurologicalriskinclude:（其他有报道的增加神经系统风险的因素包括）,hemisphericversusretinaltransientischemicattack（半球与视网膜短暂性脑缺血发作）anurgentprocedure（紧急手术）aleftsidedprocedure（左侧手术）ipsilateralischemiclesiononcomputerizedtomography（电脑断层扫描同侧缺血性病变）contralateralcarotidocclusionorpoorcollaterals（对侧的颈动脉闭塞或者侧支循环差）impairedconsciousness（意识障碍）anirregularorulceratedipsilateralplaque（不规则或者破溃的同侧斑块）,11,Medicalcomplicationsoccurabout10%ofthetimeafterCEAandareassociatedwiththefollowing:（CEA后并发症的发生还与下列有关）,Hypertension(HTN)（高血压病）：theincidence（发病率）ofaneurologicdeficit（神经功能缺损）isgreaterinpatientswithuncontrolled（未控制的）HTNpreoperatively（术前）andpostoperativeHTN（术后高血压）.（术前未控制的高血压和术后高血压的神经功能缺损的发病率更高）Cardiac（心脏病）：acardiacassessment（心脏评估）isindicatedinpatientswhopresentforCEA.Diabetes（糖尿病）：dataindicate（表明）thatCEAcanbeperformedsafelyinpatientswithdiabetes（糖尿病人可以安全的进行CEA）Renalinsufficiency（肾功能不全）：patientswithrenalinsufficiencyhaveanoverall（整体）increased（增加）riskforstroke,death,andcardiacmorbidity（发病率）,associatedwithCEA,12,Monitoring（监控）,BasicMonitoring：thisshouldincludebasicASAmonitoringandintra-arterialbloodpressuremonitoring.（基本监控应包括基础麻醉的监测和动脉内血压监测）CNSMonitoring：nospecialcerebralmonitorisrequiredinawakepatientswithregionalanesthesia.specialcerebralmonitor（脑监测）isemployed（用于）whengeneralanesthesia（全麻）.,13,Monitoring（监控）,Electrophysiological（电生理）Monitoring:The16-channelEEG（脑电图）remainsasensitiveindicator（指标）ofinadequate（不足）cerebralperfusion（脑灌注）.Ipsilateral（单）orbilateral（双）attenuation（降低）ofhighfrequencyamplitude（高频压力）ordevelopment（增长）oflowfrequencyactivityseenduringcarotidcross-clampingisindicativeofinadequatecerebralperfusion.IntraoperativeneurologiccomplicationshavebeenshowntocorrelatewellwithEEGchangesindicativeofischemia.（同侧或双侧高频衰减幅度或开发低频活动期间看到颈动脉交叉夹紧是反映脑灌注不足，术中已显示出良好的相关性脑电图改变，预示缺血的神经系统并发症）,14,MoststudiessuggestthatSSEPsareusefulformonitoringcerebralperfusionduringcross-clampingandhavesimilarorsuperiorsensitivityandspecificitytoconventionalEEG.(SSEPs在监测夹闭动脉的脑灌注上有类似或优于常规脑电图的敏感性和特异性）StableanesthesiamustbemaintainedtominimizetheinfluenceofanestheticsontheSSEPamplitude.Ingeneral,50%reductionofamplitudeofthecorticalcomponentisconsideredtobeasignificantindicatorofinadequatecerebralperfusion.IncontrasttoconventionalEEG,SSEPmonitorsthecortexaswellasthesubcorticalpathwaysintheinternalcapsule,anareanotreflectedinthecorticalEEG.（必须维持麻醉平稳麻醉药对体感诱发电位的振幅的影响减到最小。在一般情况下，减少50的振幅皮质成分被认为是脑灌注不足一个重要的指标。与常规脑电图相反，体感诱发电位监测皮层和皮层下通路，而没有反映在皮层脑电图,15,Monitoring（监控）,MeasurementofStump（残端）Pressure:SinceoneimportantdeterminantofCBFisperfusionpressure,itseemsreasonabletoassumethatthedistal（远端）arterialpressureintheipsilateral（同侧）hemisphere（半球）duringcarotidocclusion（颈动脉闭塞）wouldprovidesomeindication（迹象）ofcollateral（侧枝的）CBF.Stumppressureinvolvesdirectmeasurementoftheretrogradeinternalcarotidarterypressurefollowingocclusionofthemoreproximalcommonandexternalcarotidarteries.（由于CBF的一个重要的决定因素是灌注压，这似乎是合理的假设，在同侧半球在颈动脉闭塞远端动脉压会提供一些补偿，CBF树桩压力涉及直接测量闭塞的逆行颈内动脉的近端压力和颈外动脉压力）TranscranialDoppler（经颅多普勒超声）(TCD):TCDhasbeenutilized（利用）asamonitoring（监控）toolbymeasuringbloodflowvelocity（速度）inthemiddlecerebralartery（中脑动脉）duringCEA.（TCD被用来作为监测工具，通过测量CEA过程中大脑中动脉血流速度）,16,AnestheticManagement,Generalanesthesiaispreferredinpatientswithanatomy/pathologythatmaymakethesurgicalconditionsdifficult.（全麻是那些在解剖/病理学上有手术困难的患者的首选）Onecaveatthatisoftennotappreciatedregardsnitrousoxide.Itisverydifficulttoplaceashuntinthecarotidartery,ortoreleasethecarotidarterycross-clamp,withoutexposingthedistalcerebralcirculationtoairbubbles.（需要注意的一点是氧化亚氮是不被推荐的。放置颈动脉分流器或释放颈动脉交叉钳时不暴露前端而使气泡进入到脑循环，这是非常困难的）,17,AnestheticManagement,SevofluraneanddesfluranehavebeenshowntoresultinquickerextubationtimesandrecoveryprofilesafterCEA,comparedtoisoflurane,withnosignificantperioperativedifferenceincardiacmorbidity.（与异氟烷相比，七氟烷和地氟烷被证明CEA术后更快的拔管时间、更好的苏醒质量，而无围术期心脏事件发生率的不同。）Propofolandnarcoticsmaybeassociatedwithbetterhemodynamicstabilitythanisoflurane,andremifentanil/propofolmayhavelessevidenceofmyocardialischemiathanisoflurane/fentanyl.（与异氟烷相比，丙泊酚和阿片类可能有更好的血流动力学稳定性，瑞芬太尼/丙泊酚与异氟烷/芬太尼相比可能更少的心肌缺血发生）,18,AnestheticManagement,AregionaltechniqueforCEArequiresanesthesiaofcervicalnerves2-4.（CEA的区域麻醉需要麻醉颈神经2-4）Superficialcervicalplexusblock,deepcervicalplexusblock,epiduralanesthesia,straightlocal,andcombinationsofthesetechniqueshaveallbeenusedsuccessfully.（颈浅神经丛阻滞、颈深神经丛阻滞、硬膜外麻醉、单纯局麻或以上技术的结合都被成功的使用过）Untilrecently,non-randomizedstudiessuggestedthattheuseofaregionaltechniquemaybeassociatedwithreductions(approximately50%)intheoddsofstroke,death,myocardialinfarctionandpulmonarycomplications.（直到最近，非随机研究提示区域性技术可能与术后中风、死亡、心肌梗死、肺部并发症的减少（近50%）相关。）,19,ModalitiesofCerebralProtection脑保护的方式,Surgical（外科）：ashuntisplacedtomaintainCBFduringcross-clamping（分流在颈动脉夹闭时用于维持脑血流）.Mostoften,placementoftheshuntisdependentonthedataofacerebralmonitor.（大多数情况下，是否放置分流取决于脑功能监测的数据）Ashuntentailstherisksofembolizationandcarotidintimaldissection，andlimitssurgicalexposure.（分流意味着栓塞和颈动脉内膜剥脱的风险，并限制了外科暴露）ThereisinsufficientevidencefromrandomizedcontrolledtrialstosupportorrefutetheuseofroutineorselectiveshuntingduringCEA.（没有足够随机对照实验证据支持或拒绝在CEA中常规或选择性分流）,20,Physiologic:（生理）1.Hypothermia（低温）-muchhasbeenstudiedaboutthebeneficial（有益）effectofmildhypothermia（低温）oncerebralischemia（脑缺血）.Accordingly,istheconcernthatifhypothermiaisemployedasacerebralprotectantforCEA,manypatientsmaysufferfromshiveringduringrecovery;andaconsequentincreaseinmyocardialoxygenconsumptionwhichmayprecipitatemyocardialischemia.Thus,routineemploymentofhypothermiaisnotrecommendedforpatientsundergoingCEA.Conversely,hyperthermiashouldbeavoided.（很多研究已经表明低温对脑缺血的有利，但是，如果采用低温作为CEA术中的脑保护剂，许多患者可出现在恢复过程中寒战发抖以及心肌耗氧量的增加可能诱发心肌缺血，因此，不建议常规对接受CEA的患者进行低温麻醉，相反，应避免高温）,21,2.Hyperglycemia（高血糖）-shouldbeavoided（避免）andtreated（处理）whenpossible.3.Hypertension（高血压）-duringischemia,autoregulation（自动调节）isimpairedandCBFisdependentonperfusionpressure（灌注压）.Itisadvisabletomaintainnormaltohigharterialpressureinmostsituations.（缺血过程中，自动调节受损，脑血流是依赖于灌注压力以维持正常的动脉血压，在大多数情况下，这是可取的）4.Hemodilution（血液稀释）-usinghemodilutiontoimproveCBFisdependentupontherationale（原理）thatCBFisinverselyrelatedto（负相关的）hematocrit（血细胞比容）.（使用血液稀释改善CBF是根据CBF负相关于血细胞比容的原理）5.CarbonDioxide（二氧化碳）-normocarbia（正常二氧化碳分压）shouldbethegoal.（必须维持正常的二氧化碳分压）,22,ModalitiesofCerebralProtection,Anesthetics:（麻醉药）1.Barbiturates（巴比妥类药物）-asawhole,theevidencedoesnotsupporttheuseofbarbituratesasacerebralprotectantforpermanentfocalischemia.(总的来说，证据不支持使用巴比妥类药物作为永久性局灶性脑缺血脑保护剂)2.VolatileAnesthetics（挥发性麻醉药）-generalanesthesiawithisofluraneandsevofluraneisassociatedwithalowercriticalCBF(thatatwhichEEGevidenceofischemiawaspresent)comparedtohalothaneandenflurane（与氟烷、安氟醚相比，全身麻醉中使用异氟醚和七氟醚更少出现危险的脑血流（脑电图证实的脑缺血）3.Etomidate（依托咪酯）-etomidateisnotrecommendedforuseasacerebralprotectant.（依托咪酯，不建议用做脑保护剂）4.Propofol（异丙酚）-theamasseddatabaseisnotaslargeasthatforbarbiturates（数据有限）5.Dexmedetomidine（右美托咪啶）-itshouldbepointedoutthatinhumanvolunteersdexmedetomidinedecreasesCBFbutdoesnotincreasetheincidenceofshuntplacementduringawakeCEA（应该指出的是，在人类志愿者，右旋美托咪啶降低脑血流，但是在清醒麻醉下的CEA中不增加分流率）,23,ThePostoperativePeriod（术后）,Concernsintheimmediatepostoperativeperiodinclude:（术后即刻应关注的是：）1.HTN（高血压）-HTNmayworsenneurologicoutcomebyexacerbatingthehyperperfusionsyndromewithresultantintracerebralhemorrhage（高血压可能加剧高灌注综合征，导致脑出血，使预后恶化）2.Hyperperfusion（高灌注）Normotensionshouldbemaintainedinpatientsatriskforhyperperfusion.（有高灌注危险的患者应保持患者正常灌注）3.Hypotension（低血压）-Regionalanesthesiamaybeassociatedwithahigherincidenceofpostoperativehypotensionwhilegeneralanesthesiaismoreoftenassociatedwithpostoperativehypertension（区域麻醉可能伴随术后高发生率的低血压，而全麻往往与术后高血压相关）4.MyocardialInfarction（心梗）-themostfrequentcauseofmorbidityandmortality（心梗是发病率和死亡率的最常见的原因，）5.Stroke（中风）-mostoftenembolicinorigin.（中风常源于栓塞）,24,6.Bleeding-airwayobstructionhasbeenattributedtoneckhematomathatisworsenedbyhypertension.（气道阻塞已被归因于高血压恶化导致的颈部血肿）7.CranialNerveInjury-Damagetotherecurrentlaryngealnervemaycompromiseprotectivereflexesaswellascauseairwayobstruction.Bilateralinjuriescanresultinupperairwayobstruction.（喉返神经的损伤除了可能引起气道梗阻，还可能损害保护性反射。双侧损伤可能会导致上呼吸道阻塞。）8.CarotidBodyDamageresultsinreducedventilatoryresponsetohypoxemiaandhypercapnia.Patientsundergoingsecond-sideCEAmeritcloseobservation.（颈动脉体损伤导致对低氧血症和高碳酸血症的通气反应降低，患者接受第二侧CEA应密切观察。）9.CNSDysfunction（中枢神经系统功能障碍）,25,Conclusions,Approximatelyonethirdofperioperativestrokesarehemodynamicinnature.（围术期中风大约有三分之一源于血流动力学的变化）Itisreasonablethattightphysiologicmanagementmightaffectthissubsetofpatients.（严格的生理管理可能影响这一部分患者，这是合理的）PatientswhohaveundergoneCEAhaveincreasedriskofaperioperativemyocardialevent.（接受过CEA的患者围术期心肌事件的风险增加）ThereisnodemonstrableadvantageofaspecificanesthetictechniqueforpatientsundergoingCEA.（没有一种特别的麻醉技术对CEA患者有明显的优势）Whicheveranesthetictechniqueisemployed,itisimperativethatCBFisoptimizedth