心脏病人非心脏手术

心脏病人非心脏手术指南

2023ACC/AHAGuideline术中麻醉管理部分第1页麻醉药物和麻醉技术ClassIIa1.Useofeitheravolatileanestheticagentortotalintravenousanesthesiaisreasonableforpatientsundergoingnoncardiacsurgery,andthechoiceisdeterminedbyfactorsotherthanthepreventionofmyocardialischemiaandMI(LevelofEvidence:A)LandoniG,FochiO,BignamiE,etal.Cardiacprotectionbyvolatileanestheticsinnon-cardiacsurgery?Ametaanalysisofrandomizedcontrolledstudiesonclinicallyrelevantendpoints.HSRProcIntensiveCareCardiovascAnesth.2023;1:34-43.LuratiBuseGAL,SchumacherP,SeebergerE,etal.Randomizedcomparisonofsevofluraneversuspropofoltoreduceperioperativemyocardialischemiainpatientsundergoingnoncardiacsurgery.Circulation.2023;126:2696-704.第2页文献报告文献1第3页2768toTIVAand3451receivingdesfluraneorsevofluraneintheiranesthesiaplanVolatileanestheticdosagevariedacrossstudies,ranging0.33-2MACinthe609patientsreceivingdesfluraneand0.25-2MACinthe2842patientsreceivingsevofluraneHospitalstaywasidenticalbetweengroups(WMD0.01days[-0.06,0.07],pforeffect=0.88,pforheterogeneity=0.48,I2=0%with1201includedpatients

Noauthorreportedanypostoperativemyocardialinfarctionordeathamongthestudypopulation,noranysignificantcardiacadverseeventPostoperativerenalorrespiratoryfailureandreleaseofcardiacbiomarkerswerenotreported第4页心律失常第5页文献2第6页第7页第8页在心脏手术中22includedtrialsincluded1,922randomlyassignedpatients(904toTIVAand1018receivingdesfluraneorsevofluraneintheiranesthesiaplan)Volatileanestheticdosagevariedacrossthestudies,butwasalways>0.15MACandrangedfrom0.15-2MACinthe475patientsreceivingdesfluraneand0.25-4MACinthe543patientsreceivingsevofluraneMINERVAANESTESIOL2023;75:269-73第9页volatileanestheticsreducedtheriskofMI(24/979[2.4%]inthevolatileanestheticsgroupvs.45/874[5.1%]incontrols,OR=0.51[0.32-0.84],Pforeffect=0.008),

all-causemortalitywasalsoreduced(4/977[0.4%]vs.14/872[1.6%],OR=0.31[0.12-0.80],Pforeffect-0.02asignificantdecreaseincTnIpeakrelease(WMD-2.35ng/dl[-3.09,-1.60],Pforeffect<0.00001,Pforheterogeneity<0.00001,I2=94.1%with1,463includedpatients)andtheneedforinotropicsupport(170/679[25.0%]vs.203/562[36.1%],OR=0.47[0.29,0.76],Pforeffect<0.002,Pforheterogeneity=0.008,I2=53.1%with1,241includedpatients).ashorterICUstay(WMD=-7.10hours[-11.47;-2.73],Pforeffect<0.001,Pforheterogeneity<0.00001,I2=76.6%with1,433includedpatients),timetohospitaldischarge(WMD=-2.26days[-3.83;-0.68],Pforeffect=0.005,with1,593includedpatients)

timeonmechanicalventilation(WMD=-0.49hours[-0.97;-0.02],Pforeffect=0.04,pforheterogeneity0.03,I2=44.1%with1,846includedpatients).Finally,onlytwostudiesreportedoneyearfollow-updataconcerningmajorcardiacevents(definedascardiacdeath,non-fatalMI,unstableangina,intercurrentcoronaryangioplasty,CABG,arrhythmiasrequiringhospitalizationandnewepisodesofcongestiveheartfailure第10页ClassIIa2.NeuraxialanesthesiaforpostoperativepainreliefcanbeeffectiveinpatientsundergoingabdominalaorticsurgerytodecreasetheincidenceofperioperativeMI(LevelofEvidence:B)NishimoriM,LowJHS,ZhengH,etal.Epiduralpainreliefversussystemicopioid-basedpainreliefforabdominalaorticsurgery.CochraneDatabaseSystRev.2023;7:CD005059.第11页文献报告15trialsthatinvolved1297patients(633patientsreceived

epidural

analgesiaand664received

systemic

opioidanalgesia)Thepostoperativedurationoftrachealintubationandmechanicalventilationwassignificantlyshorter,byabout48%,inthe

epidural

analgesiagroup.Theoveralleventratesofmyocardialinfarction,acuterespiratoryfailure(definedasanextendedneedformechanicalventilation),gastrointestinalcomplications,andrenalcomplicationsweresignificantlylowerintheepidural

analgesiagroup.

第12页ClassIIb1.Perioperativeepiduralanalgesiamaybeconsideredtodecreasetheincidenceofpreoperativecardiaceventsinpatientswithahipfracture

(LevelofEvidence:B)第13页文献Anesthesiology2023;98:156–63第14页术中管理ClassIIa1.Theemergencyuseofperioperativetransesophagealechocardiogramisreasonableinpatientswithhemodynamicinstabilityundergoingnoncardiacsurgerytodeterminethecauseofhemodynamicinstabilitywhenitpersistsdespiteattemptedcorrectivetherapy,ifexpertiseisreadilyavailable.(LevelofEvidence:C)第15页ClassIIb1.Maintenanceofnormothermiamaybereasonabletoreduceperioperativecardiaceventsinpatientsundergoingnoncardiacsurgery(150,151).(LevelofEvidence:B)2.Useofhemodynamicassistdevicesmaybeconsideredwhenurgentoremergencynoncardiacsurgeryisrequiredinthesettingofacuteseverecardiacdysfunction(i.e.,acuteMI,cardiogenicshock)thatcannotbecorrectedbeforesurgery.(LevelofEvidence:C)3.Theuseofpulmonaryarterycatheterizationmaybeconsideredwhenunderlyingmedicalconditionsthatsignificantlyaffecthemodynamics(i.e.,HF,severevalvulardisease,combinedshockstates)cannotbecorrectedbeforesurgery.(LevelofEvidence:C)第16页FrankSM,FleisherLA,BreslowMJ,etal.Perioperativemaintenanceofnormothermiareducestheincidenceofmorbidcardiacevents.Arandomizedclinicaltrial.JAMA.1997;277:1127-34CgrouphypothermicPT35.4+/-0.136.7+/-0.1<0.01Postoperativeventriculartachycardia2.4%7.9%;P=.04morbidcardiacevents1.4%6.3%;P=.02第17页Perioperativehypothermia(33degreesC)doesnotincreasetheoccurrenceofcardiovasculareventsinpatientsundergoingcerebralaneurysmsurgery:findingsfromtheIntraoperativeHypothermiaforAneurysmSurgeryTrial.Anesthesiology.2023;113:327-42第18页ClassIII:NoBenefit1.Routineuseofpulmonaryarterycatheterizationinpatients,eventhosewithelevatedrisk,isnotrecommended(LevelofEvidence:A)2.Prophylacticintravenousnitroglycerinisnoteffectiveinreducingmyocardialischemiainpatientsundergo