β阻滞药在围手术期的应用.ppt

单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,阻滞药在围手术期的应用,Perioperative Application of-Adrenergic Receptor Blocker,Li Lihuan,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,标准治疗+,受体阻滞剂,Standard Therapy+,-blocker,标准治疗组,Standard Therapy,P值,P Value,心血管死亡,(Cardiovascular Death),3.4%,17%,=0.02,非致死性心梗,(Nonfatal Myocardial Infarction),0.0%,17%,0.001,致死性心梗,(Fatal Myocardial Infarction),0.0%,17%,0.001,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,Retrospective study of-blocker,s therapy in acute myocardial infarction in USA,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 concept 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.Nowadays,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.,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;,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 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,阻滞药围术期脑保护作用,Brain protective effect of-blockor in perioperative 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%=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,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年到1999年，手术前,-受体阻滞剂的总使用率从50%增加到60%（P0.001）,Total utility rate of-blockor before operation increase from 50%to 60%from 1996 to 1999.,JAMA,2002;287:2221-2227,各医院的使用率有较大差别（240,mg/dL(6.2mmol/L),(serum total cholesterol,240,mg/dL),5.,有糖尿病但尚未需要胰岛素治疗者,(diabetes without receiving insulin therapy),围术期使用,受体阻滞剂结论,conclusion,4.如有需要，应在麻醉诱导前静脉给药，控制心率,If necessary,give intravenously before anaesthesia induction to control HR,5.手术后继续使用至少7天（不能口服者应静脉给药）,Continue using for at least seven days after operation(intravenous administration to those unable to take orally),6.冠心病只要没有禁忌证，应该无限期使用,阻滞剂,In patients with CAD should be long-term used unless contraindication exists,The Evidence Is In,Now the Work Begins,”Physicians can no longer accept the argument,that absence of adequate knowledge is a reason,for underuse of beta-blockers.The data are,overwhelming and they have been published in,leading medical journals.”,Califf RM,OConnor CM.Editorial,JAMA 2000;283:1335-1337,RM Califf,CM OConnor.Editorial,JAMA:,