阻滞药在围手术期的应用

阻滞药 在围手术期的应用 Perioperative Application of -Adrenergic Receptor Blocker,李立环 Li Lihuan 北京阜外心血管病医院 Fu Wai Hospital (Beijing),-阻滞药治疗高危血管外科的疗效 Effect of -blockor in treating high risk vascular surgery,N Engl J Med 1999;341:1789-94,Archives of Internal Medicine 2000, 160:947,美国-阻滞药治疗 急性心梗回顾性研究 Retrospective study of -blocker s therapy in acute myocardial infarction in USA,CABG: 8,482例 ；PTCA: 13,997例 一年死亡率统计 (one-year mortality rate)( P0.001 ) ： 阻滞剂治疗 (group with-blocker therapy) ： 12.3% 未阻滞剂治疗 (group without -blocker therapy)： 23.6% 冠脉血管重建:阻滞剂能明显降低一年死亡率; CABG: -blocker therapy significantly decrease one-year mortality,阻滞药 围术期心脏的保护作用 Heart protective effect of -blockor in perioperative period,北京阜外心血管病医院麻醉科从90年起术中尝试使用阻药处理心脏事件，取得的效果挑战了对心脏事件处理的传统观念 The department of anaethesia of our hospital has tried using -blockor to treat cardiac events since 1990s and its results challenged the traditional concept of treating these events.,95年开始美托洛尔渐渐成为CABG围术期处理心脏事件的常用药物 Metoprolol has been becoming a drug in common use in treating cardiac events in perioperative period since 1995.,96年6月后， 阻滞药开始作为冠心病术前用药。现已在某些瓣膜病、先心病、大动脉瘤术前用药中广泛应用 -blockor began to be a drug using preoperatively after June 1996. Nowadays, it is administrated broadly before big cardiac operations. 阻滞药已成为心脏手术中困难复苏非常规处理的主要药物 -blockor has become a main drug in treating unsuccessful resuscitation except the general treatments.,病例(case),体外循环下冠脉搭桥 (CABG under cardiopulmonary bypass) 术前病情偏重，EF约40， 未放置漂浮导管; Relatively severe condition before operation, EF about 40%,pulmonary artery catheter unlocated; 停机时给予0.03ug/kg/min肾上腺素辅助循环; 0.03ug/kg/min epinephrine to support circulation stability after stopping cardiopulmonary bypass;,静注鱼精蛋白循环尚稳定; Hemadynamic stability during protamine intravenous administration; 鱼精蛋白注毕后约5min血压下降，加大肾上腺素用量血压上升; Blood pressure decreased 5 minutes after portamine administration ，elevated after increasing dose of epinephrine; 数分钟后出现下列临床征象 Following symptoms occurred few minutes later,临床症状(clinical symptoms) 急性肺水肿，粉红色泡沫样痰 Acute pulmonary edema, pink foaming spittle 高气道压力 High pressure in airway 心电图ST段明显抬高 ST segment elevated significantly in ECG 反复恶性心律失常：室速 室颤 Repeated fatal arrhythmia: ventricular tachycardia, ventricular fibrillation 低血压(SBP7075mmHg) Hypotension,治疗经过 Therapeutic process,美托洛尔1mg后血压维持原水平略有上升，室速室颤频率 ，心率减慢约34bpm After 1mg metoprolol administration , blood pressure elevated, occurrence of VT ,VF decreased, heart rate reduced by 34bpm 美托洛尔1mg后血压上升到808590mmHg，室速室颤消失，ST段恢复，循环稳定 After 1mg metoprolol administration ,VT,VF vanished, ST segment lowered to normal and hemodynamic stable when blood pressure increased to 808590mmHg,阻滞药 围术期脑保护作用 Brain protective effect of -blockor in perioperative period,Newman：CABG中应用阻滞剂，卒中发生率为1.9，未用者为4.3 Newman: Among patients using -blockor in CABG, incidence rate of stroke: 1.9; otherwise: 4.3,阻滞剂治疗的病人，意识模糊、谵妄和一过性缺血发作的发生率为3.9，未用者为8.2 Among patients using -blockor , neurological complication : 3.9; otherwise:8.2 比较2575例CABG的转归证实了术中阻滞剂的脑保护作用 Prognosis of 2575 cases experiencing CABG demonstrated the brain protective effect of -blockor administered during operation.,-阻滞剂降低 高危病人手术死亡率 -blockor decreased surgery mortality rate in high risk patients,受体阻滞剂组 安慰剂组 P值 -blockor placebo p value （n=99） （n=101） 总 6个月 0.0% 8.0% 0.001 死 six month 亡 第1年 3.0% 10% =0.005 率 one year Total 第2年 10% 21% =0.019 mortality two year rate N Engl J Med 1996;335:1713-20,-阻滞药 围术期应用现状 Current application of -blockor in perioperative period,北美胸外科协会成人心脏外科数资料 总计629,877例手术 Adult cardiac surgery data from The American Association for Thoracic Surgery: 629,877cases in total,1996年到1999年，手术前-受体阻滞剂的总使用率从50%增加到60%（P0.001） Total utility rate of -blockor before operation increase from 50% to 60% from 1996 to 1999.,JAMA,2002; 287: 2221-2227,各医院的使用率有较大差别（20% 85%） Big difference in utility rate among different hospitals. 术前-阻滞剂使用率越高的医院，围手术期死亡率越低 More higher the utility rate was , more lower mortality rate was.,Sohmidt等调查中发现：158例非心脏手术，67例应该给予阻滞剂，但仅37%(25例)得到治疗 In a study, Sohmidt found that among 158 cases of noncardiac surgery, 67 cases should have been given -blockor ,but only 37 percent of all cases (25 cases) received it.,加拿大麻醉医师的调查：93%认为阻滞剂对冠心病人有利，但仅57%医师在术中应用。只有34%能坚持术后应用 An investigation in Canadan anaesthetists showed 93 percent of them believed -blockor would be beneficial to patients with CHD, but only 57 percent of them used it during operation and only 34 percent continued using it after postoperation.,-阻滞药的认识及围术期的应用不够充分，许多病人不能受益 Many patients cant take advantage of it because of insufficient knowledge about -blockor and its application in perioperative period.,麻醉医师 -阻滞药方面面临的问题 problems faced to anaesthetists about -blockor,静息心率控制在5060bpm的理念是否安全 Whether it is safe to control resting heart rate at 5060bpm? 术前是否需要停药 Whether it need to stop using the medicine before operation? 术中和术后是否需要继续应用？剂量 Whether it need to keep taking it during and after operation? How much the dose is? 是否对预后有不利影响 Whether it has disadvantage to prognosis.,围术期应用 -阻滞药的作用 Results of -blockors perioperative application,显著减少围术期高危患者心肌缺血 Significantly decrease occurrence of myocardial ischemia in high risk patients in perioperative period 显著减少围术期高危患者心肌梗死 Significantly decrease occurrence of myocardial infarction in high risk patients in perioperative period,显著减少围术期高危患者心律失常 Significantly decrease occurrence of arrhythmia in high risk patients in perioperative period 显著减少围术期高危患者心源性死亡 Significantly decrease occurrence of cardiac death in high risk patients in perioperative period 显著减少围术期高危患者总死亡率 Significantly decrease total mortality rate in high risk patients in perioperative period,围术期哪些高危人群 需要应用-阻滞药 Indication in perioperative period,缺血性心脏病(ischemic heart disease) 心肌梗死、心绞痛、运动试验阳性、舌下含服硝甘、 ECG上有Q 波、PCI、CABG等病史 脑血管病(cerebrovascular disease) TIA、卒中发作病史,需胰岛素治疗的糖尿病 (diabetes undergoing insulin therapy) 慢性肾功能不全(chronic renal failure)（血肌酐2.0mg/Dl, 177mol/L） 外科高风险手术(high risk surgery)（胸腹腔和大血管手术等）,无明确心肌缺血病史但有以下2条或以上高危因素者 (without history of myocardial ischemia but have more than two risk factors of following) 1.年龄65岁或以上者 (65 years old or older) 2.高血压 (hypertension) 3.吸烟者 (smoker) 4.血清总胆固醇240mg/dL(6.2mmol/L) (serum total cholesterol 240mg/dL) 5.有糖尿病但尚未需要胰岛素治疗者 (diabetes without receiving insulin therapy),围术期使用受体阻滞剂 结论 conclusion,1.围术期预防性使用阻滞剂能减少心肌缺血、降低心肌梗死发生率和总死亡率，冠心病患者和高危患者效果尤其明显 Prophylactic using -blockor in perioperation period may reduce incidence rate of myocardial ischemia, decrease incidence rate and total mortality rate of myocardial infarction, especially in patients with CHD and in high risk patients. 2.择期手术的高危患者，术前应尽早阻滞剂治疗 High risk patients ready to take selective operation should be given -blockor as early as possible before operation. 3.调整剂量使静息心率维持在5060bpm（70bpm) Adjust the dose t