老年患者麻醉管理与脑保护课件.pptx

老年患者麻醉管理与脑保护基于病例的学习,病例报告,患者，男，68岁，64kg，170cm，ASA II级主诉：体检发现右肺占位2个月入院诊断：右肺下叶腺癌（T1bN0M0）高血压II级，极高危2型糖尿病高脂血症脑梗死（右侧丘脑）拟施手术：胸腔镜下肺叶切除术,既往史,高血压25年，最高140/100mmHg，氨氯地平 5mg bid，平时130/90mmHg糖尿病史2年，二甲双胍 0.5g tid，空腹血糖8mmol/L，餐后2h血糖8mmol/L高脂血症15年，阿托伐他汀 10mg QN丘脑梗死1月余，遗留左面部麻木，氯吡格雷 75mg Qd，术前7天改依诺肝素 0.4ml Qd,入院查体,HR 84bpm，BP 125/86mmHg，RR 18次/分，SpO2 96%双肺呼吸音清；心律齐，无杂音及奔马律；心脏浊音界正常左侧三叉神经分布区针刺觉减退，四肢肌力、肌张力正常，病理征（-）,实验室检查,血常规：HB 166g/L，PLT 173 109/L糖化血红蛋白： 6.4% (6.1-7.9%)血气分析：pH 7.42, PaCO2 36.0mmHg, PaO2 83.7mmHg凝血全项：PT 13.5s, APTT 29.5 s, Fib 2.50g/L心电图: 无异常,辅助检查,超声心动：左室壁肥厚，左室舒张功能减低，升主动脉轻度扩张，EF 63%肺功能检查：FEV1 2.35，FEV1/FVC 73%，RV/TLC 39%，DLCO 10.2，通气储备 84%,辅助检查,头颅MRI: 右侧丘脑、双侧脑室旁及双侧放射冠可见散在斑点、斑片状异常信号，提示脑内多发腔隙性脑梗死，脑白质变性颈动脉超声：双侧颈动脉内-中膜不均增厚TCD：未见异常,术前高血压既往脑卒中抗血小板治疗他汀类治疗,Contents,麻醉方法选择麻醉深度维持术中血压维持血糖水平管理,血压与脑卒中死亡率的关系,Lancet. 2002;360:190313,收缩压,舒张压,血压与缺血性心脏病死亡率的关系,Lancet. 2002;360:190313.,收缩压,舒张压,血压与其他血管相关死亡率关系,Lancet. 2002;360:190313.,收缩压,舒张压,血压每增加20/10mmHg，心血管死亡风险加倍,Lancet. 2002;360:1903-1913; JAMA. 2003;289:2560-2572,收缩压下降2 mmHg，心脑血管事件风险降低10%,Lancet.2002;360:1903-1913,美国成年人血压 随年龄、种族的变化,N Engl J Med. 2007;357:789 96,冠心病不良预后风险与年龄、血压关系,Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy. Am J Med. 2010;123:719 26.,年龄与最佳血压,高血压(合并疾病)的治疗,N Engl J Med 2009;361:878-87,末次ACEI/ARB服药时间与术中低血压风险,Anesth Analg 2005;100:636 44,Journal of the American Society of Hypertension 8(9) (2014) 644651,7 RCTs with 571 adults, any type surgery under GABenefits and harms of perioperative ACEIs/ARBs,Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD009210.,Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD009210.,Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD009210.,Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD009210.,No evidence to support that perioperative ACEIs or ARBs can prevent mortality, morbidity, and complications,Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD009210.,高血压病人的围术期治疗,术前规范抗高血压治疗术日晨给予抗高血压药物(ACEI/ARB除外？)术后尽早恢复抗高血压治疗,术前高血压既往脑卒中抗血小板治疗他汀类治疗,Contents,麻醉方法选择麻醉深度维持术中血压维持血糖水平管理,iao,微小脑卒中也会损害脑血流自身调节脑血流自身调节损害不限于卒中侧，而是整个脑脑血流自身调节的变化：脑卒中的前5天进行性恶化随后的1-3个月内逐渐恢复脑血流自身调节损害时，轻度低血压即致脑缺血，但血压过高同样有害,Stroke. 2010;41:2697-2704,Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery,Compared with patients without stroke, a prior stroke within 3 months More major CV events (OR 14.23, 95% CI 11.6117.45)Higher 30-day mortality (OR 3.07, 95%CI 2.304.09),JAMA 2014; 312: 26977,近期脑卒中病人的手术时间选择,择期手术： 推迟至3个月后改善危险因素急诊手术：认真监测、维持血压脑缺血监测 (TCD、EEG、诱发电位),术前高血压既往脑卒中抗血小板治疗他汀类治疗,Contents,麻醉方法选择麻醉深度维持术中血压维持血糖水平管理,停用抗血小板药物增加围术期MACE风险,A retrospective, observational study666 patients with coronary stent(s)MACE = CV death, MI, or stroke,Thromb Haemost 2015; 113: 272282,Thromb Haemost 2015; 113: 272282,MACE,CV death,MI,Stroke,Predictors of 30-day MACE,Thromb Haemost 2015; 113: 272282,持续抗血小板治疗增加围术期出血风险,RCT, a 2-by-2 factorial trial design10,010 patients preparing for noncardiac surgery and at risk for vascular complicationsAspirin (initiation: 200 mg before, 100 mg/d * 30 d; continuation: 100 mg/d * 7 d, continue) PlaceboDeath or major vascular complications at 30 days,N Engl J Med 2014;370:1494-503,Primary Composite Outcome,N Engl J Med 2014;370:1494-503,Risk of Life-Threatening or Major Bleeding,N Engl J Med 2014;370:1494-503,围术期小心使用抗血小板药物出血风险小：继续使用出血风险大、CV风险小：停止使用出血风险大、CV风险大：停止使用，LMWH,术前高血压既往脑卒中抗血小板治疗他汀类治疗,Contents,麻醉方法选择麻醉深度维持术中血压维持血糖水平管理,5 RCTs with 178 participantsPerioperative short-term statin therapy and outcomes,Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD009971,Evidence was insufficient to conclude that statin use resulted in either a reduction or an increase in any of the outcomes examined,Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD009971,17 RCTs with 2138 participants, on-/off-pump myocardial revascularisationEffectiveness of preoperative statin therapy,Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD008493.,Preoperative statin therapy Reduces postop AF, shortens LOS in ICU and hospital No influence on periop mortality, stroke, MI or RF,Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD008493.,如果病人在服用他汀类治疗，继续,术前高血压既往脑卒中抗血小板治疗他汀类治疗,Contents,麻醉方法选择麻醉深度维持术中血压维持血糖水平管理,An overview of 9 Cochrane systematic reviewsNeuraxial block +/- GAGA alone,Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD010108,Postoperative mortality (0-30 days),RA vs. GA,Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD010108,Postoperative mortality (0-30 days),RA + GA vs. GA,Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD010108,Postoperative pneumonia (0-30 days),RA + GA vs. GA,RA vs. GA,Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD010108,P=0.07,Postoperative MI (0-30 days),RA vs. GA,RA + GA vs. GA,Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD010108,P=0.11,高危病人尽可能选择区域阻滞麻醉,术前高血压既往脑卒中抗血小板治疗他汀类治疗,Contents,麻醉方法选择麻醉深度维持术中血压维持血糖水平管理,Meta-analysis39 RCTs, 16,082 participantsNon-pharmacological or pharmacological interventions for preventing delirium,Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD005563.,BIS-guided anaesthesia vs BIS-blinded anaesthesia,Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD005563.,Light propofol sedation vs deep propofol sedation,Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD005563.,Retrospective cohort study4087例恶性肿瘤手术病人麻醉期间BIS45累积时间手术时恶性肿瘤分期术后2年死亡率,Anesth Analg 2009;108:508 12,BIS45时间与术后远期死亡风险,TBIS 45持续时间与2年死亡率明显相关,Anesth Analg 2009;108:508 12,A pilot RCT125 patients ASA III-IV, aged 60 years, surgery 2 hours, and receiving general anesthesia “Low” group: BIS/SE target 35“High” group: BIS/SE target 50,Anesth Analg 2014;118:9816,Anesth Analg 2014;118:9816,Postoperative Outcomes,Anesth Analg 2014;118:9816,深麻醉累积时间与术后病人预后的关系有待研究,麻醉医生倾向于维持过深麻醉常规麻醉深度监测，避免全身麻醉过深,术前高血压既往脑卒中抗血小板治疗他汀类治疗,Contents,麻醉方法选择麻醉深度维持术中血压维持血糖水平管理,Lancet 2008; 371: 183947,RCT8351 patients with, or at risk of, atherosclerotic disease who were undergoing non-cardiac surgeryExtended-release metoprolol (n=4174)Placebo (n=4177)Started 24 h before surgery and continued for 30 days,Myocardial infarction,Death,Stroke,Cardiovascular deathNon-fatal MINon-fatal CA,Lancet 2008; 371: 183947,低血压导致围术期脑卒中风险增加,Lancet 2008; 371: 183947,巢式病例对照研究48,241例病人，非心脏、非神外手术42例围术期脑卒中 (0.09%)252例对照病人(年龄、手术种类),Anesthesiology 2012; 116:65864,术中低血压时间与围术期脑卒中,Anesthesiology 2012; 116:65864, Statistically significant in multiple testing,术中低血压幅度与围术期脑卒中,Anesthesiology 2012; 116:65864,Intraop hypotension and POD,An observational cohort study734 patients, on-pump cardiac surgery99 patients (13%) developed POD,British Journal of Anaesthesia, 2015, 42733,ORs for the association between AUC of intraoperative hypotension and occurrence of POD,British Journal of Anaesthesia, 2015, 42733,0.05,Intraop hypotension and POD,Systematic review11 studies, 1427 patients, GI surgeryRisk factors for PoD,BJS 2016; 103: e21e28,Intraop hypotension associated with POD,术中血压(SBP/MBP)不低于基础血压20%术中最佳血压？,术前高血压既往脑卒中抗血小板治疗他汀类治疗,Contents,麻醉方法选择麻醉深度维持术中血压维持血糖水平管理,Detrimental effects of elevated glucose in stroke,Stroke. 2004;35:363-364.,血糖升高伴随脑卒中病人预后恶化,Anesthesiology 2012;116:2445,129 patients with acute ischemic stroke treated with endovascular therapy,Predictors of good neurologic outcome,Intraop tight glucose control,RCT198 adult patients undergoing cardiac surgeryTight intraop glucose control (80-110 mg/dl)Standard therapy (150 mg/dl),Anesthesiology 2015; 122:1214-23,Anesthesiology 2015; 122:1214-23,Patients with tight glucose control were more likely to develop delirium (26/93 tight control vs. 15/105 routine; P = 0.03),Anesthesiology 2015; 122:1214-23,RCT6104 adult patients, ICU treatment 3 days 3054 intensive control (4.5-6.0 mmol/L)3050 conventional control ( 10.0 mmol/L),N Engl J Med 2009;360:1283-97.,N Engl J Med 2009;360:1283-97.,术中血糖水平维持 8-10 mmol/L,围术期管理,麻醉前管理,意识状态：清醒合作生命体征：ECG 窦律，BP 135/95mmHg，HR 80bpm，RR 16次/分，SpO2 95%，T 36.1 桡动脉置管接mostcare监护仪：SVV、SVRI、dp/dt、CI 等参数BIS监测麻醉深度用保温毯、暖风机保温,麻醉管理,麻醉诱导依托醚酯10mg+舒芬太尼20g+罗库溴铵60mg双腔气管插管（左双腔37F），纤支镜定位麻醉维持全凭静脉麻醉+椎旁阻滞丙泊酚 34mg/kg/h（BIS）+右美托咪啶（0.2 g/kg/h ）+瑞芬太尼（0.20.3g/kg/min）,麻醉管理,血流动力学插管后：BP 100/72mmHg, HR 70bpm术中维持：去甲肾上腺素（0.050.1g/kg/min )将血压维持在120140/7585mmHg之间呼吸功能VT 450ml，f 12次/分，FiO2 100%，SpO2维持在99100%，恢复双肺通气后，多次手法肺复张,麻醉总结,手术时间269min，麻醉时间348min术中晶体液1000ml，胶体液1000ml，出血量240ml，尿量1000ml椎旁阻滞：诱导后0.4%罗哌卡因 20mlPCIA：羟考酮50mg+昂丹司琼16mg100ml，PCA 2mg，锁定10min，Limit 6mg/h术毕5min拔管；ICU停留43h，术后7天出院围术期未见脑、心、肾等重要脏器系统并发症,总 结,高血压病人术前良好控制血压择期手术推迟至脑卒中3个月之后围术期谨慎使用抗血小板药物他汀类药物围术期可继续尽可能选择区域阻滞麻醉全身麻醉避免麻醉过深围术期血压不低于基础血压20%血糖水平8-10mmol/L时给予胰岛素,感谢关注!,