主动脉夹层手术的麻醉课件整理

主动脉夹层手术的麻醉皖南医学院弋矶山医院麻醉科王立鹏LOGO主动脉夹层手1Contents1.主动脉夹层病理生理特点2.麻醉前访视与评估3.麻醉诱导与维持4.麻醉管理重点Contents2主动脉夹层定义主动脉内膜和中层弹力膜发生撕裂,血液进入主动脉中层形成壁间假腔,并与主动脉真腔相交通,称为主动脉夹层。致病因素:高血压病史(约80%患者)性别(男性居多)结缔组织病(马凡氏综合征)先天性心脏病主动脉夹层定义3分型StanfordA型StanfordB型累及升主动脉仅累及降主动和弓部主动脉脉起始以远的,约占60%部位,约占7525%-40%分型4A型夹层升主动脉全弓置换+升主动脉Bental人工血管象鼻支架置换置换术置入术sun氏术A型夹层5主动脉夹层病理生理特点高血压波动幅度多中心临床与动物实验发现:1.80%以上的主动脉夹层患者患有高血压,部分患者主动脉囊性中层坏死2.高血压并非是囊性坏死的原因,但可促进其进展。3.血压波动的幅度而不是血压值高度与主动脉夹层分裂相关研究表明:血压波动的幅度破坏了主动脉血管的自我调节性和代偿能力主动脉夹层病理生理特点6主动脉夹层病理生理特点主动脉通道功能严重受损:真腔血流受阻+裂开的夹层形成双腔主动脉。主动脉通道功能丧失:冠状A、头臂干/左颈总A、肾A等血管断流→心、脑、肾重要脏器缺血主动脉夹层病理生理特点7主动脉夹层病理生理特点心脏压塞、心律失常等心脏并发症主动脉夹层破裂脑、肾等循环衰竭多器官缺血主动脉夹层病理生理特点8Circulation2019se281221312839.d101181RCULATIONAHA109.92942.:20198013.ImportanceofrefractorypainandhypertensioninacutetypeBaorticdissection:insightsfromtheInternationalRegistryofAcuteAorticDissection(IRADIPrimarchs,Ee,,既如,SP出chansonS!RamnoldivGrassi,9ossoneE距m啪A,TsaiTT,FroehlichJB,Coopery,MontgomeryD,MeinhardG,MyrmelT,UnchurchGR,SundtTIn,IsselbacherEMInternationalRegistryofAcuteAortic4AuthorintormationAbstractBACKGROUND:InpatientswithacutetypeBarticdissection,presenceDfrecurrentorretractorypainand/orrefractoryhypertensionmedicaltherapyissometimesusedasanindicationfarimvasletreatmentTheInternationalRegistyofAcuteAorticdissectionIRAD)wasusedtoinvestgatetheimpactofrefractorypainandrorrefractoryrypertensionontheoutcomesofacutetypeBaortCdissectionMETHODSANDRESULTS:Threehundredsity-fivepatientsaffectedbyuncomplicatedacutetypeBaorticdissection,enrolledinRADtom2019to200,werecategorizedaccordingtonskprotleinto2groupsPatientsworthrecurrentandorrefractorypainorretractoryypertension(groupln=69andpatentswithoutclinicalcomplicatonsatpresentation(grouplln=296)werecompared."High-riskIatientsmthclassiccomplicationswereExcludedfromthisanalysis.Theoverallin-hospitalmortalityMras6.5%and'nasincreasedingroupIcomparedwithgroupll(17.49versus4.0%P=0.000S).Thein-hospitalmortalityaftermedicalmanagementwrassignifcantlyicreasedingroupIcomparedwithgroupl[356%versus16%P=.0003)Mortalityratesaftersurgical[20versus28%P=0.74)ement(S.7%versus9.1%5P=0.50)didnotdiffersignificantybetweengrauplandgroupI,respectively.Aulbvariablelogisticregressionmodelconfirmedthatrecurrentandorrefractorypainorrefractoryhypertensionwasapredictorofinkhospitalmortality[oddsratio,3.31:95%confidenceinterval,1.04to10.45,P=0.041]CONCLUSIONS:Recurrentpainandrparticularlywhenmanagedmedically.Theseobservationssuggestthataorticintervention,suchasviaanendovascularapproachmaybeindicatedinthisintermediate-riskgroupCirculation2019se281221312839.9jac,201日.01.064PresentingSystolicBloodPressureandoutcomesinPatientsWithAcuteAorticDissection.BossoneE1GorlaR,LaBountyThd3Suzuki,GilonD5,straussc5BallottaA'PatelHJB,EvangelistaA9.EhrlichMp10.Hutchison511,Kllne-Rogers三aktAuthorintormationAbstractBACKGROUND:Presentingsystolicbloodpressure(SBP)isapowerfulpredictorofmortalityinmamycardiovascularsettings,includingOBJECTIVES:ThisstuctyevaluatedtheassociationofpresentingSEPwithin-hosptaloutcomes.specificallyalk-causemortality.inMETHODS:Thestudyincluded6,23Bconsecutivepatients(4,167wothbypeAand2.071wnthtypeBAAD)enrolledintheInternationalRegIstyofAcuteaortiton.Patientswerestabledin4groupsaccordingtopresentingsBP:SBP>150,5BP101to150,SBPse0mmHdRESULIS:TherelationshipbeteenpresentingSBPandin-hospitalmortalitydisplayedaJ-curveassociation,unthsignifcantyhigtmortalityratesinpatientswi'thvelBP[26.3%forsBP>180mmHgintypeAAAD,13.3%5forsBP>200mmHgintypeBAAD0.005andp=0.018,respective)aswellasinthosesuitSBP$100mmHg(29.9%ointypeA,22.4intypeB,p=0.035andp=0.015,respectivelyl.Thisrelationshipwasmainlyfromincreasedratesofin-hospitalcamplications(acuterenalfailurE,coma,andmesentericischemiaanfarctioninpatientswthsBP>15DmmHg:stroke,coma,cardiactamponade,myocardialischemia/nfarctionandacuterenalfailureinpatientswithSBPs80mmHg).NotablypresentingSEPsBUmmHgmasindependentlyassociatedwithin-ospitalmortalityinbothtpeA[p=0.001)andtypeBAAD(p=0.003)CONCLUSIONS:PresentingSEPshowedaclearJ-curverelationshipwithin-hospitalmortalityinpatientswithAAD.Althoughthisssociabonwasrelatedtoincreasedratesofcomorbidconditionsattheedgesofthecurve,SaPsadmrmHgwasanindependet'elateoTin-nospltalmortalitjac,201日.01.06410主动脉夹层手术的麻醉课件整理11主动脉夹层手术的麻醉课件整理12主动脉夹层手术的麻醉课件整理13主动脉夹层手术的麻醉课件整理14主动脉夹层手术的麻醉课件整理15主动脉夹层手术的麻醉课件整理16主动脉夹层手术的麻醉课件整理17主动脉夹层手术的麻醉课件整理18主动脉夹层手术的麻醉课件整理19主动脉夹层手术的麻醉课件整理20主动脉夹