AnesthesiaandtheCardiacPatient麻醉和心脏病患者课件

1、AnesthesiaandtheCardiacPatient麻醉和心脏病患者Pharmacologic Considerations in the Cardiac PatientWayne E. Ellis, Ph.D., CRNAAnesthesiaandtheCardiacPatient麻醉和心脏病患者AnesthesiaandtheCardiacPatient麻醉和心脏病患者Treatment of Ischemia(primary) ASA 325 mg immediately Thrombolytics (Retevase) flow rate than TPA 2 doses 30

2、 min intervals lyse clots through the activation of plasminogenAnesthesiaandtheCardiacPatient麻醉和心脏病患者Primary Treatment Antiplatelet agents(abciximab, eptifibatide, tirofiban, integullin) GPIIb-IIIa antagonists inhibit platelet function by blocking the GPIIb-IIIa receptor, the final pathway of platel

3、et aggregation thereby decreasing thrombi development and prevents arterial vessel occlusion AnesthesiaandtheCardiacPatient麻醉和心脏病患者Percutaneous Coronary Intervention Advantages include: higher recanulazation rates improved blood flow through the infarct-related vessel improved LV function lower in-h

4、ospital mortality rates AnesthesiaandtheCardiacPatient麻醉和心脏病患者Anesthetic TechniqueGoals of Anesthesialoss of consciousnessamnesiaanalgesiasuppression of reflexes (endocrine and autonomic)muscle relaxationAnesthesiaandtheCardiacPatient麻醉和心脏病患者Preoperative PreparationAnginaMedications to control itBlo

5、od pressure controlledDiastolic 95 torrCongestive heart failure treatedDiureticsAfterload reductionBed rest if indicatedControl diabetesAnesthesiaandtheCardiacPatient麻醉和心脏病患者Preoperative MedicationsSedationPrevent tachycardiaHypertensionPrepared for hypoxiaSupplemental oxygenCalcium channel blockers

6、 not protective of perioperative ischemiaAntihypertensives continue on day of surgeryStop DiureticsAnesthesiaandtheCardiacPatient麻醉和心脏病患者Low Molecular Weight Heparin Enoxaparin, Dalteparin Anticoagulant activity by binding to antithrombin III, which further binds and inactivates the coagulation fact

7、ors IIa (thrombin) and Xa Advantages include dosed per body wt. Given q12 sub q. Less trombocytopenia and bleedingAnesthesiaandtheCardiacPatient麻醉和心脏病患者Opioids Advantage relates to the relative lack of myocardial depression Exception Sufenta, Carfentanil, and high dose fentanyl They maintain stable

8、hemodynamics and reduce heart rate A primary opioid technique may be of value in the patient with severe myocardial dysfunctionAnesthesiaandtheCardiacPatient麻醉和心脏病患者OpioidsAdvantagesExcellent analgesiaHemodynamic stabilityBlunt reflexesCan use 100% oxygenAnesthesiaandtheCardiacPatient麻醉和心脏病患者Opioids

9、DisadvantagesMay not block hemodynamic and hormonal responses in patients with good LV functionDo not ensure amnesiaChest wall rigidityRespiratory depressionAnesthesiaandtheCardiacPatient麻醉和心脏病患者Vasoconstrictors are useful in the prevention and treatment of ischemia r/t the ability to increase syste

10、mic BP Phenylephrine improves coronary perfusion pressure, at the expense of increasing afterload and Mv02AnesthesiaandtheCardiacPatient麻醉和心脏病患者Vasoconstrictors At the same time, phenylephrine causes venoconstriction, increasing venous return and left ventricular preload. The increase in CPP more th

11、an offsets the increase in wall tensionAnesthesiaandtheCardiacPatient麻醉和心脏病患者Inhalation AgentsAdvantagesMyocardial oxygen balance altered favorably by reductions in contractility and afterloadEasily titratableCan be administered via CPB machineRapidly eliminatedAnesthesiaandtheCardiacPatient麻醉和心脏病患者

12、Inhalational Agents Disadvantages include myocardial depression systemic hypotension with possible tachycardia lack of postoperative analgesiaAnesthesiaandtheCardiacPatient麻醉和心脏病患者Inhalation AgentsDisadvantagesSignificant hemodynamic variabilityMay cause tachycardia or alter sinus node functionPossi

13、bility of “coronary steal syndrome”AnesthesiaandtheCardiacPatient麻醉和心脏病患者Inhalation AgentsPotential for coronary stealAlters coronary autoregulationAlters regional blood flowLittle influence on outcomeAnesthesiaandtheCardiacPatient麻醉和心脏病患者Coronary StealArteriolar dilation of normal vessels diverts b

14、lood away from stenotic areasCommonly associated with adenosine, dipyridamole, and SNPForane causes steal and new ST-T segment depressionMay not be important since Forane reduces SVR, depresses the myocardium yet maintains COAnesthesiaandtheCardiacPatient麻醉和心脏病患者20Antianginal medicationsBeta-blocker

15、sCalcium Channel BlockersNitratesNitropaste morning of surgeryAnesthesiaandtheCardiacPatient麻醉和心脏病患者Nitrates Nitroglycerin = venodialator, reduces venous return, decreases wall tension(Mv02) also a coronary arterial dialator. Drug of choice for coronary vasospasm Although primarily is a systemic ven

16、odialator, at high doses causes arterial dilatation and systemic hypotensionAnesthesiaandtheCardiacPatient麻醉和心脏病患者Cardioactive drugsNitroglycerinLower LVEDPVasodilatorPoor ventricular functionAnesthesiaandtheCardiacPatient麻醉和心脏病患者Beta Blockers Beta blockers reduce myocardial workload(Mv02), and oxyg

17、en consumption(V02) by reducing HR,BP, and contractility, and they increase the threshold for ventricular fibrillation. Indications for beta blockers include: sinus tachycardia, supraventricular dysrhythmias and hyperdynamic statesAnesthesiaandtheCardiacPatient麻醉和心脏病患者Beta BlockersNegative inotropic

18、 effectsWithdrawal following stoppage of beta blockerUnstable anginaMyocardial infarctionAnesthesiaandtheCardiacPatient麻醉和心脏病患者Beta Blockers Propranolol (non-selective) t1/2 = 4-6 hours Metoprolol (B1 selective) t 1/2 = 4-6 hours Labatelol (1:7 ratio) t 1/2 = 2-4hours Esmolol (Beta1 selective) t1/2

19、= 9.5 minutesAnesthesiaandtheCardiacPatient麻醉和心脏病患者EsmololControl heart rate and blood pressureInductionEmergenceAnesthesiaandtheCardiacPatient麻醉和心脏病患者LabetalolMixed alpha and betaControl hypertensionHeart rate managementAnesthesiaandtheCardiacPatient麻醉和心脏病患者Ca Channel Blockers Evidence for benefici

20、al effects post mi is less compelling Nifedipine treatment is associated with a trend towards increased mortality and reinfarction Verapamil does not reduce mortality or reinfarction Verapamil - useful for slowing the ventricular response in atrial fibrillation/flutterAnesthesiaandtheCardiacPatient麻

21、醉和心脏病患者Ca Channel Blockers Cardizem- in pts with non-Q wave infarction seems to reduce the reinfarction rate during the 1st 6 months after the infarction, but incidence of late infarction was similar to a placebo. Cardizem increases cardiac events in pts with LVEF3.37 mmol/1AnesthesiaandtheCardiacPa

22、tient麻醉和心脏病患者ClonidineLess hypertensionDecreased anesthesia requirementsAnesthesiaandtheCardiacPatient麻醉和心脏病患者Anesthetic ManagementRegional vs. generalAnesthetic management skills more important than techniqueSafest technique is the one the practitioner does bestAnesthesiaandtheCardiacPatient麻醉和心脏病患

23、者Regional AnesthesiaMonitor patient more accuratelyControl sympathetic responsesFluidsEsmololAnesthesiaandtheCardiacPatient麻醉和心脏病患者General anesthesiaAvoids sympathectomyRisks with intubationSympathetic stimulationHypoxiaIncreased catecholaminesLoss of subjective monitorChest painIschemiaAnesthesiaan

24、dtheCardiacPatient麻醉和心脏病患者General Anesthesia requiredNarcoticsEffective control of catecholaminesRespiratory depressionProlonged ventilationAnesthesiaandtheCardiacPatient麻醉和心脏病患者LidocaineBlunt effects of intubation1.5 mg/kg 4-6 minutes prior to intubationAnesthesiaandtheCardiacPatient麻醉和心脏病患者Nitrous

25、 OxideRarely used due to:increased PVRdepression of myocardial contractilitymild increase in SVRair expansionAnesthesiaandtheCardiacPatient麻醉和心脏病患者Induction DrugsBarbituratesBenzodiazepinesKetamineEtomidateAnesthesiaandtheCardiacPatient麻醉和心脏病患者Avoid KetamineHypertensionTachycardiaUse in traumaAnesth

26、esiaandtheCardiacPatient麻醉和心脏病患者EtomidatePainful to injectMore CV stabilityAnesthesiaandtheCardiacPatient麻醉和心脏病患者BarbiturateDirect depressantExtended duration of activitySmaller doses1-2 mg/kgAdd benzodiazepines and narcoticAnesthesiaandtheCardiacPatient麻醉和心脏病患者BenzodiazepinesQuell anxietyHemodynami

27、c stabilityExtended duration of actionPotential for hypoxiaLidocaineEsmololAnesthesiaandtheCardiacPatient麻醉和心脏病患者Muscle RelaxantsUsed to:facilitate intubationprevent shiveringattenuate skeletal muscle contraction during defibrillationAnesthesiaandtheCardiacPatient麻醉和心脏病患者Muscle RelaxantsAvoid pancuroniumTachycardiaST segment changes consistent with ischemiaDoxacurium Duration similar to pancuroniumNo cardiovascular effectsAnesthesiaandtheCardiacPatient麻醉和心脏病患者