AnesthesiaandtheCardiacPatient麻醉和心脏病患者.ppt

PharmacologicConsiderationsintheCardiacPatient WayneE Ellis Ph D CRNA 3 26 2020 TreatmentofIschemia primary ASA325mgimmediatelyThrombolytics Retevase flowratethanTPA2doses 30minintervalslyseclotsthroughtheactivationofplasminogen 3 26 2020 PrimaryTreatment Antiplateletagents abciximab eptifibatide tirofiban integullin GPIIb IIIaantagonistsinhibitplateletfunctionbyblockingtheGPIIb IIIareceptor thefinalpathwayofplateletaggregationtherebydecreasingthrombidevelopmentandpreventsarterialvesselocclusion 3 26 2020 PercutaneousCoronaryIntervention Advantagesinclude higherrecanulazationratesimprovedbloodflowthroughtheinfarct relatedvesselimprovedLVfunctionlowerin hospitalmortalityrates AnestheticTechnique GoalsofAnesthesialossofconsciousnessamnesiaanalgesiasuppressionofreflexes endocrineandautonomic musclerelaxation PreoperativePreparation AnginaMedicationstocontrolitBloodpressurecontrolledDiastolic 95torrCongestiveheartfailuretreatedDiureticsAfterloadreductionBedrestifindicatedControldiabetes PreoperativeMedications SedationPreventtachycardiaHypertensionPreparedforhypoxiaSupplementaloxygenCalciumchannelblockersnotprotectiveofperioperativeischemiaAntihypertensivescontinueondayofsurgeryStopDiuretics 3 26 2020 LowMolecularWeightHeparin Enoxaparin DalteparinAnticoagulantactivitybybindingtoantithrombinIII whichfurtherbindsandinactivatesthecoagulationfactorsIIa thrombin andXaAdvantagesincludedosedperbodywt Givenq12subq Lesstrombocytopeniaandbleeding 3 26 2020 Opioids AdvantagerelatestotherelativelackofmyocardialdepressionExceptionSufenta Carfentanil andhighdosefentanylTheymaintainstablehemodynamicsandreduceheartrateAprimaryopioidtechniquemaybeofvalueinthepatientwithseveremyocardialdysfunction Opioids AdvantagesExcellentanalgesiaHemodynamicstabilityBluntreflexesCanuse100 oxygen Opioids DisadvantagesMaynotblockhemodynamicandhormonalresponsesinpatientswithgoodLVfunctionDonotensureamnesiaChestwallrigidityRespiratorydepression 3 26 2020 Vasoconstrictors areusefulinthepreventionandtreatmentofischemiar ttheabilitytoincreasesystemicBPPhenylephrineimprovescoronaryperfusionpressure attheexpenseofincreasingafterloadandMv02 3 26 2020 Vasoconstrictors Atthesametime phenylephrinecausesvenoconstriction increasingvenousreturnandleftventricularpreload TheincreaseinCPPmorethanoffsetstheincreaseinwalltension InhalationAgents AdvantagesMyocardialoxygenbalancealteredfavorablybyreductionsincontractilityandafterloadEasilytitratableCanbeadministeredviaCPBmachineRapidlyeliminated 3 26 2020 InhalationalAgents Disadvantagesincludemyocardialdepressionsystemichypotensionwithpossibletachycardialackofpostoperativeanalgesia InhalationAgents DisadvantagesSignificanthemodynamicvariabilityMaycausetachycardiaoraltersinusnodefunctionPossibilityof coronarystealsyndrome InhalationAgents PotentialforcoronarystealAlterscoronaryautoregulationAltersregionalbloodflowLittleinfluenceonoutcome CoronarySteal ArteriolardilationofnormalvesselsdivertsbloodawayfromstenoticareasCommonlyassociatedwithadenosine dipyridamole andSNPForanecausesstealandnewST TsegmentdepressionMaynotbeimportantsinceForanereducesSVR depressesthemyocardiumyetmaintainsCO 3 26 2020 WEEllis 20 Antianginalmedications Beta blockersCalciumChannelBlockersNitratesNitropastemorningofsurgery 3 26 2020 Nitrates Nitroglycerin venodialator reducesvenousreturn decreaseswalltension Mv02 alsoacoronaryarterialdialator DrugofchoiceforcoronaryvasospasmAlthoughprimarilyisasystemicvenodialator athighdosescausesarterialdilatationandsystemichypotension Cardioactivedrugs NitroglycerinLowerLVEDPVasodilatorPoorventricularfunction 3 26 2020 BetaBlockers Betablockersreducemyocardialworkload Mv02 andoxygenconsumption V02 byreducingHR BP andcontractility andtheyincreasethethresholdforventricularfibrillation Indicationsforbetablockersinclude sinustachycardia supraventriculardysrhythmiasandhyperdynamicstates BetaBlockers NegativeinotropiceffectsWithdrawalfollowingstoppageofbetablockerUnstableanginaMyocardialinfarction 3 26 2020 BetaBlockers Propranolol non selective t1 2 4 6hoursMetoprolol B1selective t1 2 4 6hoursLabatelol 1 7ratio t1 2 2 4hoursEsmolol Beta1selective t1 2 9 5minutes Esmolol ControlheartrateandbloodpressureInductionEmergence Labetalol MixedalphaandbetaControlhypertensionHeartratemanagement 3 26 2020 CaChannelBlockers EvidenceforbeneficialeffectspostmiislesscompellingNifedipinetreatmentisassociatedwithatrendtowardsincreasedmortalityandreinfarctionVerapamildoesnotreducemortalityorreinfarctionVerapamil usefulforslowingtheventricularresponseinatrialfibrillation flutter 3 26 2020 CaChannelBlockers Cardizem inpt swithnon Qwaveinfarctionseemstoreducethereinfarctionrateduringthe1st6monthsaftertheinfarction butincidenceoflateinfarctionwassimilartoaplacebo Cardizemincreasescardiaceventsinpt swithLVEF 40 butdecreasestheirincidenceinpt swithpreservedLVfunction 3 26 2020 CaChannelBlockers AllCablockersdepresscontractility reducecoronaryandsystemictone decreasesino atrialnodefiring andimpedeatrioventricularconduction ThenegativeinatropiceffectisgreatestwithverapamilNifedipine Cardizemareusedinthepreventionofcoronaryvasospasm Nifedipine ControllinghypertensionManagecoronaryarteryspasm 3 26 2020 ACEInhibitors AreeffectiveinreducingischemiceffectsafterMITreatmentshouldbeinstitutedwithinthe1st24hoursofallpt swithacutemicomplicatedbysymptomaticorasymptomaticleftventriculardysfunction 3 26 2020 ACEInhibitors Contraindicatedinpt swithhypotension bilateralrenalarterystenosis historyofacoughorangio edemawithaceinhibitors 3 26 2020 Aspirin ASAbenefitwellestablishedasasecondarypreventionAntiplatelettherapeuticdose 75 325mg day otherantiplateletagentssuchasdipyridamolearenotsupportedintheliteratureexceptinpt swithallergiestoASAwhoarepoorcandidatestooralanticoagulants 3 26 2020 Anticoagulants Studiesofanticoagulanttreatmentaftermishowreductionindeath recurrentMI andthromboemboliticcomplicationsHowever trialscomparingwarafintoASAforsecondarypreventionshownodifferenceinrecurrentinfarctionordeath 3 26 2020 Anticoagulants Areindicatedforpt swithASAintoleranceandforthoseatriskofembolisationfromleftventricularoratrialclot i e persistentatrialfib 3 26 2020 LipidLoweringAgents metaanalysisofclinicaltrialsshowthatlipidloweringagentsproduceareductioninfatalandnon fatalMI sandcardiovasculardeathsShouldbegiventopt swithLDLconcentration 3 37mmol 1 Clonidine LesshypertensionDecreasedanesthesiarequirements AnestheticManagement Regionalvs generalAnestheticmanagementskillsmoreimportantthantechniqueSafesttechniqueistheonethepractitionerdoesbest RegionalAnesthesia MonitorpatientmoreaccuratelyControlsympatheticresponsesFluidsEsmolol Generalanesthesia AvoidssympathectomyRiskswithintubationSympatheticstimulationHypoxiaIncreasedcatecholaminesLossofsubjectivemonitorChestpainIschemia GeneralAnesthesiarequired NarcoticsEffectivecontrolofcatecholaminesRespiratorydepressionProlongedventilation Lidocaine Blunteffectsofintubation1 5mg kg4 6minutespriortointubation NitrousOxide Rarelyuseddueto increasedPVRdepressionofmyocardialcontractilitymildincreaseinSVRairexpansion InductionDrugs BarbituratesBenzodiazepinesKetamineEtomidate AvoidKetamine HypertensionTachycardiaUseintrauma Etomidate PainfultoinjectMoreCVstability Barbiturate DirectdepressantExtendeddurationofactivitySmallerdoses1 2mg kgAddbenzodiazepinesandnarcotic Benzodiazepines QuellanxietyHemodynamicstabilityExtendeddurationofactionPotentialforhypoxiaLidocaineEsmolol MuscleRelaxants Usedto facilitateintubationpreventshiveringattenuateskeletalmusclecontractionduringdefibrillation MuscleRelaxants AvoidpancuroniumTachycardiaSTsegmentchangesconsistentwithischemiaDoxacuriumDurationsimilartopancuroniumNocardiovasculareffects AvoidHistaminereleasingdrugs CurareAtracuriumMivacurium 15mcg kgHypotensionTachycardia NitrousOxide ConstrictscoronaryarteriesAggr