心臟病人麻醉課件

心臟病人的麻醉心臟手術(shù)非心臟手術(shù)心臟病人的麻醉心臟手術(shù)1先天性心臟病(CongenitalHeartDisease)青紫型非青紫型右→左分流左→右分流肺血少肺血多缺氧、酸中毒血容量先天性心臟病(CongenitalHeartDiseas2獲得性心臟病(AcquiredHeartDisease)瓣膜病變的程度二尖瓣4-6cm2主動(dòng)脈瓣

2.6-3.5cm2

≤2.1cm2＞10Torr

≤1cm2

心肌收縮力損害的程度EF、PH、CVP合并其他臟器病變的程度獲得性心臟病(AcquiredHeartDisease)3二尖瓣狹窄二尖瓣關(guān)閉不全

LVPHRV避免

竇速、房顫快室率

突然心率變慢

低血容量

突然外周阻力增加

過(guò)度輸液

頭低位、心肌抑制低外周阻力

低血容量低氧、低通氣

二尖瓣狹窄二尖瓣關(guān)閉不全LV4主動(dòng)脈瓣狹窄主動(dòng)脈關(guān)閉不全

暈厥心絞痛心力衰竭避免

心動(dòng)過(guò)緩心動(dòng)過(guò)緩(>80次/分)

低血容量突然增加外周阻力突然外周阻力改變心肌抑制主動(dòng)脈瓣狹窄主動(dòng)脈關(guān)閉不全5缺血性心臟病(ischemicHeartdisease)心室功能的判斷病史：活動(dòng)度、心絞痛、心肌梗塞、心力衰竭藥物檢查：心電圖、心胸比例缺血性心臟病(ischemicHeartdisease)6心室功能

好差

EF>60%<40%PAWP<12>18CI>2.8<2.1LVG－HypokinesiadyskinesiaakinesiaaneurysmMI－+CAG－LMLAD，CX，RCADM，HT，Smoking心室功能好7CardiacAnesthesiaPremedicationMorphine10mgScopolamine0.3mgInductionFentanyl3-8g/kg10-20g/kgMidazolam0.02mg/kgEtomidate0.3mg/kgPancuroniumPipecuriumVecuroniumMaintenanceIsofluraneEnfluraneFentanylCardiacAnesthesiaPremed8MonitoringABPCVPPAWPCISpO2ETCO2ABGK+MonitoringABPCVP9MyocardiacProtectionCardioplegiaHypothermiaCrystalloidBloodRetrograde5-11℃K+15-40mEq/LMyocardiacProtectionCardio10LowCardiacOutput

BP<80CVP>15PAWP>18SVRI>2500CI<2.1UO<0.5ml/kg·minUnconsciousnessLowCardiacOutputB11Treatment

PreloadCVP10PAWP15AfterloadNP0.15-10ug/kg·minNTGContractilityDopamine4-6ug/kg·minEpinepherine1-4ug/minDobutamine4-6ug/kg·minAmrinone0.5-1mg/kg5-10ug/kg·minTreatmentPreload12AntiarrhythmiaLidocaine1-1.5mg/kg1-4mg/minVerapamil2.5-10mgDiltiazem0.15mg/kg2ug/kg·minAmiodarone150mg/20min1,200mg/24hrsIsoprerolol1-4ug/minAntiarrhythmiaLidocaine13圍術(shù)期心肌缺血

心肌氧供需失衡冠脈痙攣血栓形成血氧含量前負(fù)荷NO冠脈血流量后負(fù)荷NTG心率心肌收縮力Diltiazem舒張末壓心率Aprotinine

Aspirin圍術(shù)期心肌缺血心肌氧供需失衡冠脈痙攣14心臟病人的麻醉心臟手術(shù)非心臟手術(shù)心臟病人的麻醉心臟手術(shù)15先天性心臟病(CongenitalHeartDisease)青紫型非青紫型右→左分流左→右分流肺血少肺血多缺氧、酸中毒血容量先天性心臟病(CongenitalHeartDiseas16獲得性心臟病(AcquiredHeartDisease)瓣膜病變的程度二尖瓣4-6cm2主動(dòng)脈瓣

2.6-3.5cm2

≤2.1cm2＞10Torr

≤1cm2

心肌收縮力損害的程度EF、PH、CVP合并其他臟器病變的程度獲得性心臟病(AcquiredHeartDisease)17二尖瓣狹窄二尖瓣關(guān)閉不全

LVPHRV避免

竇速、房顫快室率

突然心率變慢

低血容量

突然外周阻力增加

過(guò)度輸液

頭低位、心肌抑制低外周阻力

低血容量低氧、低通氣

二尖瓣狹窄二尖瓣關(guān)閉不全LV18主動(dòng)脈瓣狹窄主動(dòng)脈關(guān)閉不全

暈厥心絞痛心力衰竭避免

心動(dòng)過(guò)緩心動(dòng)過(guò)緩(>80次/分)

低血容量突然增加外周阻力突然外周阻力改變心肌抑制主動(dòng)脈瓣狹窄主動(dòng)脈關(guān)閉不全19缺血性心臟病(ischemicHeartdisease)心室功能的判斷病史：活動(dòng)度、心絞痛、心肌梗塞、心力衰竭藥物檢查：心電圖、心胸比例缺血性心臟病(ischemicHeartdisease)20心室功能

好差

EF>60%<40%PAWP<12>18CI>2.8<2.1LVG－HypokinesiadyskinesiaakinesiaaneurysmMI－+CAG－LMLAD，CX，RCADM，HT，Smoking心室功能好21CardiacAnesthesiaPremedicationMorphine10mgScopolamine0.3mgInductionFentanyl3-8g/kg10-20g/kgMidazolam0.02mg/kgEtomidate0.3mg/kgPancuroniumPipecuriumVecuroniumMaintenanceIsofluraneEnfluraneFentanylCardiacAnesthesiaPremed22MonitoringABPCVPPAWPCISpO2ETCO2ABGK+MonitoringABPCVP23MyocardiacProtectionCardioplegiaHypothermiaCrystalloidBloodRetrograde5-11℃K+15-40mEq/LMyocardiacProtectionCardio24LowCardiacOutput

BP<80CVP>15PAWP>18SVRI>2500CI<2.1UO<0.5ml/kg·minUnconsciousnessLowCardiacOutputB25Treatment

PreloadCVP10PAWP15AfterloadNP0.15-10ug/kg·minNTGContractilityDopamine4-6ug/kg·minEpinepherine1-4ug/minDobutamine4-6ug/kg·minAmrinone0.5-1mg/kg