β阻滞药在围手术期的应用.ppt
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1、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 Retrospecti
2、ve 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
3、 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 co
4、ncept 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. Nowaday
5、s, 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 befo
6、re 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;
7、 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
8、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
9、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 perioperati
10、ve 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
11、 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% =
12、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
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