第一讲：心脏病人接受非心脏手术患者围术期评估与处理要点解析课件 (1)VIP免费

心脏病人接受非心脏手术评估与处理基于2014ACC/AHA指南的要点解析www.pumch.cn朱斌北京协和医院麻醉科BinZhu,PUMCHospital麻醉医生围术期的责任FromMiller麻醉学1.麻醉医生是手术室内科医生2.麻醉学是围术期医学术中核心任务：手术配合（麻醉）生命支持3循环支持麻醉医生术中的核心任务437例心跳骤停原因解析：①呼吸问题（130例）：气道丢失；中枢抑制②循环问题（284例）：AMI+容量绝对或相对不足围术期心脏问题的核心指南414新版趋复杂，更加强调个体化、专业化、多学科交流及共同决策5两版指南区别：14版vs07版ActiveCardiacConditionsforWhichthePatientShouldUndergoEvaluationandTreatmentBeforeNoncardiacSurgery(ClassI,LevelB)1.不稳定冠脉综合症2.失代偿心力衰竭3.严重心律失常4.严重的瓣膜病关于“左主干病变”07VS146两版指南区别：14版vs07版14新版趋复杂，更加强调个体化、专业化、多学科交流及共同决策7两版指南区别：14版vs07版14新版趋复杂，更加强调个体化、专业化、多学科交流及共同决策2.Thecornerstoneofperioperativeevaluationisacollaborative“perioperativeteamapproach”thatreliesoncommunicationbetweenallrelevantparties(i.e.,surgeon,anesthesiologist,primarycaregiver,andconsultants).Suchpartnershipshouldinvolvethepatient,incorporatehis/herpreferencesandgoals,andfacilitateshareddecisionmaking.8Managementoftheperioperativeantiplatelettherapyshouldbedeterminedbyaconsensusofthesurgeon,anesthesiologist,cardiologist,andpatientweighingtherelativeriskofbleedingversuspreventionofstentthrombosis(ClassI,LevelofEvidence:C).10keypointsabout2014指南@http://www.cardiosource.org/Science-And-Quality/Journal-Scan/2014/08/2014-ACC-AHA-Guideline-on-Perioperative-CV-Evaluation.aspx提纲1.评估2.处理3.引申问题与思考4.病例PartⅠ术前评估1.心血管风险的临床评估(合并疾患风险)2.外科手术对心血管风险的影响（手术风险）3.心血管风险评估流程（评估策略）高度心血管风险-严重的心脏疾患应在非心脏手术前进行评估和处理1.不稳定冠脉综合症2.失代偿心力衰竭3.严重心律失常4.严重的瓣膜病心血管风险的临床评估推荐级别与证据强度:ClassⅠLevelB1.心肌梗死（≤30d）2.不稳定心绞痛3.严重心绞痛(Ⅲ&Ⅳ)高度心血管风险-1:不稳定冠脉综合症心血管风险的临床评估1.恶化或新出现的心衰2.心功能Ⅳ级高度心血管风险-2:失代偿心力衰竭ClassDescription(NYHA分级)INolimitationisexperiencedinanyactivities;therearenosymptomsfromordinaryactivities.IISlight,mildlimitationofactivity;thepatientiscomfortableatrestorwithmildexertion.IIIMarkedlimitationofanyactivity;thepatientiscomfortableonlyatrest.IVAnyphysicalactivitybringsondiscomfort;symptomsoccuratrest.心血管风险的临床评估有症状HF：EF正常orEF降低or舒张功能异常无症状HF：EF降低or舒张功能异常14心血管风险的临床评估心力衰竭HF@2014版指南Itshouldbenotedthatthe2011appropriateusecriteriaforechocardiographystatesitis“inappropriate”toassessventricularfunctioninpatientswithoutsignsorsymptomsofcardiovasculardiseaseinthepreoperativesetting尴尬之处在于：1.RestrictiveCardiomyopathies2.HypertrophicObstructiveCardiomyopathy3.ArrhythmogenicRightVentricular(RV)Cardiomyopathyand/orDysplasia（致心律失常性右心室心肌病）4.PeripartumCardiomyopathy15心血管风险的临床评估心肌病①了解疾病的病理生理过程②了解病人症状、体征和MET；③心脏结构（超声）④专科会诊意见⑤维持CO总体原则1.CO为前负荷和心率依赖2.避免容量严重不足3.避免心率过慢过快4.避免房颤房扑16心血管风险的临床评估RestrictiveCardiomyopathies1.避免外周阻力过低；2.避免容量不足3.避免过度利尿4.慎用正性肌力药物HypertrophicObstructiveCardiomyopathy1.致死性室性心律失常/猝死2.ICD植入17心血管风险的临床评估ArrhythmogenicRVCardiomyo...