cardiovascular complications related to anesthesia课件

Cardiovascular Complications related to Anesthesia,Wanawimol Saengchote M.D. Department of Anesthesiology, Ramathibodi Hospital, Mahidol U,Anesthetic Goals,SAFETY,Anesthesia Incident Monitoring Study January to June 2007. 200,000 cases, 2537 incidents A standardized incident report form was developed in order to fill in what, where, when, how, and why it happened,THAI AIMS J Med Assoc Thai 2008; 91 (7): 1011-9,Arrhythmia 25% Desaturation 24% Death within 24 hrs. 20% Cardiac arrest 14%,Common CVS Complications,inexperience, lack of vigilance, inadequate preanesthetic evaluation, inappropriate decision, emergency condition, haste, inadequate supervision, ineffective communication.,Important Factors related to Incidents,DO2 = CO x 10 x CaO2 Tissue O2 delivery = cardiac output x arterial O2 content CO = SV x HR SV preload, contractility, afterload CO = EF x LVEDV x SVR x HR,Basic CVS physiology,Patients comorbid : controllability? Anesthetic management : drugs, techniques, process, anesthesia personnel Surgical procedure,Factors contributing to CVS complications,A. HYPOTENSION,Preoperative,Intraoperative & PO.,Hypovolemia Preop NPO Trauma-fractures Peritonitis N/v, diarrhea Bowel prep Diuretics,Blood loss Major fluid shift Tissue edema Effusion Diuresis (concealed blood loss),Tachycardia Peripheral vasoconstriction Low systolic blood pressure Narrow pulse pressure Cold ,clammy skin and extremities Low urine output (anemia not apparent in acute loss without adequate volume replacement) With beta blocker effect, no tachycardia detected,Symptoms & Signs of Hypovolemia,Clinical Classes of Severity of Hypovolemic Shock,Alert to environment, notice surgeons (and team) expression Good communication Adequate volume loading is all the time necessary (crystalloid colloid) Blood and blood component as required Critical perfusion pressure should be maintained (MAP 65 mmHg) Concern about distribution of regional blood flow,Intraoperative management,Accessory for fast IV infusion,Colloids availability,1. Drug effect : nearly all anesthetic agents depress myocardial contractility Potent inhalation agents Nitrous oxide in compromised heart Intravenous : thiopental , propofol, ketamine Opioid : pethidine ( arrhythmogenic effect to be discussed later),B.Impaired myocardial contractility,Coronary artery disease Myocardial ischemia / infarct Cardiogenic shock Valvular heart disease Congestive heart failure most common rheumatic heart disease : mitral, aortic , tricuspid valve,B. IMC : Pumping failure,Acute ischemic episode large or significant myocardial loss serious ventricular arrhythmia, pulmonary congestion , hypotension . Hemodynamic support : inotropes , antiarrhythmic , mechanical device Cardiac markers : troponin I, AST, LDH, CK-MB cTnT 2 x normal),Ischemic heart disease,Obstruction to heart, cardiac chambers or great vessels reduced stroke volume Causes : 1.Cardiac tamponade from injury, post cardiac surgery, cardiac catheterization * 2.Tension pneumothorax * 3. Pulmonary embolism * 4. Surgical manipulation in chest, esophageal, cardiac surgery 5. Supine hypotensive syndrome,B. Obstructive lesions,Acute onset of pulmonary embolism,C.Decreased afterload,20% of population with hypertensive diseases Causes of intraoperative HTN Response to laryngoscopy and intubation Light anesthesia Hypercarbia Hypoxemia Drug effect Hypervolemia Specific surgical procedure,D.HYPERTENSION,Causes of HTN postop and at emergence 1. Stimuli from endotracheal & extubation 2. Pain 3. Hypoventilation, airway obstruction 4. Hypothermia,shivering 5. Acidosis 6. Full bladder 7. Antihypertensive withdrawal,HYPERTENSION,Risk Factors Hypertension Diabetes mellitus Underlying heart disease : CAD, VHD Liver disease, renal disease Head injury Sepsis Carbon monoxide poisoning (elderly, malnutrition, hypoalbuminemia),HYPERVOLEMIA, pulmonary edema,A 62 yr-old female suspected CBD stone, scheduled for ERCP , plan for post procedural admission. Anesthetic time 1 hr 15 mins. ,uneventful an. and surgical procedure After extubation, ? Abn. breathing pattern, occ. fine crepitations BLL. Later SPO2 drop IV fluid 800 mL, minimal blood loss Diuretic given, PACU 2 hrs. At ward SBP drop, intubate ventilate,on dopa,Interesting Case,1. Physiological disturbances during anesthesia Anesthetics modify body mechanism + vagal dominant, acidosis, hypoxia/ hypercarbia, electrolyte disorder, hypovolemia 2. Pathological disturbances CAD : heart block, PVC, Thyrotoxicosis, MH, pheochromocytoma 3. Pharmacological causes :ketamine, NMB 4. Anesthesia procedures : IT, CVP, SA,