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1、阻滞药阻滞药在围手术期的应用在围手术期的应用Perioperative Application of -Adrenergic Receptor Blocker李立环李立环LiLihuan北京阜外心血管病医院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Effectof-blockorintreatinghighriskvascularsurgery标准治疗+受体阻滞剂StandardTherapy+-blocker标准治疗组StandardTherapyP值PValue心血管死亡(CardiovascularDeath)3.4%17%=0
2、.02非致死性心梗(NonfatalMyocardialInfarction)0.0%17%0.001致死性心梗(FatalMyocardialInfarction)0.0%17%0.001N 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Retrospectivestudyof-blockerstherapyinacutemyocardialinfarctioninUSACABG:8,482CABG:8,482例例 ；PTCA:13,997PTCA:13,997例
3、例一年死亡率统计一年死亡率统计 (one-yearmortalityrate)(one-yearmortalityrate)( (P0.001)P0.001)： 阻滞剂治疗阻滞剂治疗 (group(groupwithwith-blockertherapy)-blockertherapy)：12.3%12.3% 未未 阻滞剂阻滞剂治疗治疗 (groupwithout-blocker(groupwithout-blockertherapy)therapy)：23.6%23.6%冠脉血管重建冠脉血管重建: : 阻滞剂能明显降低一年死亡率阻滞剂能明显降低一年死亡率; ;CABG:-blockerthe
4、rapysignificantlyCABG:-blockertherapysignificantlydecreaseone-yearmortalitydecreaseone-yearmortality阻滞药围术期心脏的保护作用Heartprotectiveeffectof-blockorinperioperativeperiod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Thedepartmentofanaethesiaofourhospitalhastriedusing-blockortotreatcardiaceventssin
5、ce1990sanditsresultschallengedthetraditionalconceptoftreatingtheseevents.9595年开始美托洛尔渐渐成为年开始美托洛尔渐渐成为CABGCABG围术期处理心围术期处理心脏事件的常用药物脏事件的常用药物MetoprololMetoprololhasbeenbecomingadruginhasbeenbecomingadrugincommonuseintreatingcardiaceventsincommonuseintreatingcardiaceventsinperioperativeperioperativeperiods
6、ince1995.periodsince1995.9696年年6 6月后，月后， 阻滞药开始作为冠心病术前用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用药中广泛应用 -blockor-blockorbegantobeadrugusingbegantobeadrugusingpreoperativelyafterJune1996.Nowadays,itispreoperativelyafterJune1996.Nowadays,itisadministratedbroadlybeforebigcardiacadmi
7、nistratedbroadlybeforebigcardiacoperations.operations. 阻滞药已成为心脏手术中困难复苏非常规处理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的主要药物 -blockor-blockorhasbecomeamaindrugintreatinghasbecomeamaindrugintreatingunsuccessfulresuscitationexceptthegeneralunsuccessfulresuscitationexceptthegeneraltreatments.treatments.病例(case)体外循环下冠脉搭桥(
8、CABGundercardiopulmonarybypass)术前病情偏重，EF约40，未放置漂浮导管;Relativelysevereconditionbeforeoperation,EFabout40%,pulmonaryarterycatheterunlocated;停机时给予0.03ug/kg/min肾上腺素辅助循环;0.03ug/kg/minepinephrinetosupportcirculationstabilityafterstoppingcardiopulmonarybypass;静注鱼精蛋白循环尚稳定;Hemadynamicstabilityduringprotaminei
9、ntravenousadministration;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;Bloodpressuredecreased5minutesafterportamineadministration，elevatedafterincreasingdoseofepinephrine;数分钟后出现下列临床征象Followingsymptomsoccurredfewminuteslater临床症状(clinicalsymptoms)s急性肺水肿，粉红色泡沫样痰Acutepulmonaryedema,pinkfoamingspittles高气道压力Highpressurei
10、nairways心电图ST段明显抬高STsegmentelevatedsignificantlyinECGs反复恶性心律失常：室速室颤Repeatedfatalarrhythmia:ventriculartachycardia,ventricularfibrillations低血压(SBP7075mmHg)Hypotension治疗经过Therapeuticprocesss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34bpmAfter1mgmetoprololadministration,bloodpressure elevated, occurrence of VT ,
11、VFdecreased,heartratereducedby34bpms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After1mgmetoprololadministration,VT,VFvanished,STsegmentloweredtonormalandhemodynamicstablewhenbloodpressureincreasedto808590mmHg阻滞药围术期脑保护作用Brainprotectiveeffectof-blockorinperioperativeperiodNewman：CABG中应用阻滞剂，卒中发
12、生率为1.9，未用者为4.3Newman:Amongpatientsusing-blockorinCABG, 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性缺血发作的发生率为3.93.9，未用者为，未用者为8.28.2AmongpatientsusingAmongpatientsusing-blockor-blockor,neurological,neurologicalcomplication:3.9complication:3.9;otherwise
13、:8.2;otherwise:8.2比较比较25752575例例CABGCABG的转归证实了术中的转归证实了术中 阻滞剂阻滞剂的脑保护作用的脑保护作用Prognosisof2575casesexperiencingCABGPrognosisof2575casesexperiencingCABGdemonstratedthebrainprotectiveeffectofdemonstratedthebrainprotectiveeffectof-blockorblockoradministeredduringoperation.administeredduringoperation.-阻滞剂降低
14、高危病人手术死亡率-blockordecreasedsurgerymortalityrateinhighriskpatients受体阻滞剂组安慰剂组P值-blockorplacebopvalue（n=99）（n=101）总6个月0.0%8.0%0.001死sixmonth亡第1年3.0%10%=0.005率oneyearTotal第2年10%21%=0.019mortalitytwoyearrateN Engl J Med 1996;335:1713-20 -阻滞阻滞药围术期期应用用现状状 Current application of -blockor in perioperative per
15、iod北美胸外科协会成人心脏外科数资料总计629,877例手术AdultcardiacsurgerydatafromTheAmericanAssociationforThoracicSurgery:629,877casesintotal1996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）Totalutilityrateof-blockorbeforeoperationincreasefrom50%to60%from1996to1999.JAMA,2002; 287: 2221-2227各医院的使用率有较大差别（各医院的使用率有较大差别（20%85%240mg
16、/dL(6.2mmol/L)(serumtotalcholesterol240mg/dL)5.有糖尿病但尚未需要胰岛素治疗者(diabeteswithoutreceivinginsulintherapy)围术期使用受体阻滞剂结论conclusion1.1.围术期预防性使用围术期预防性使用 阻滞剂能减少心肌缺血、降低心阻滞剂能减少心肌缺血、降低心肌梗死发生率和总死亡率，冠心病患者和高危患者效肌梗死发生率和总死亡率，冠心病患者和高危患者效果尤其明显果尤其明显ProphylacticusingProphylacticusing-blockor-blockorininperioperationperi
17、operationperiodperiodmayreduceincidencerateofmyocardialischemia,mayreduceincidencerateofmyocardialischemia,decreaseincidencerateandtotalmortalityrateofdecreaseincidencerateandtotalmortalityrateofmyocardialinfarction,especiallyinpatientswithCHDmyocardialinfarction,especiallyinpatientswithCHDandinhigh
18、riskpatients.andinhighriskpatients.2.2.择期手术的高危患者，术前应尽早择期手术的高危患者，术前应尽早 阻滞剂治疗阻滞剂治疗HighriskpatientsreadytotakeselectiveoperationHighriskpatientsreadytotakeselectiveoperationshouldbegivenshouldbegiven-blockor-blockorasearlyaspossiblebeforeasearlyaspossiblebeforeoperation.operation.3.3.调整剂量使静息心率维持在调整剂量使静
19、息心率维持在5060bpm5060bpm（70bpm)70bpm)AdjustthedosetomaintainrestingheartrateatAdjustthedosetomaintainrestingheartrateat5060bpm5060bpm（lessthan70bpm)lessthan70bpm)4.4.如有需要，应在麻醉诱导前静脉给药，控制心如有需要，应在麻醉诱导前静脉给药，控制心率率Ifnecessary,giveintravenouslybeforeIfnecessary,giveintravenouslybeforeanaesthesiaanaesthesiaindu
20、ctiontocontrolHRinductiontocontrolHR5.5.手术后继续使用至少手术后继续使用至少7 7天（不能口服者应静脉天（不能口服者应静脉给药）给药）ContinueusingforatleastsevendaysafterContinueusingforatleastsevendaysafteroperation(intravenousadministrationtothoseoperation(intravenousadministrationtothoseunabletotakeorally)unabletotakeorally)6.6.冠心病只要没有禁忌证，应该
21、无限期使用冠心病只要没有禁忌证，应该无限期使用 阻阻滞剂滞剂InpatientswithCADshouldbelong-termusedInpatientswithCADshouldbelong-termusedunlesscontraindicationexistsunlesscontraindicationexistsThe Evidence Is In, Now the Work Begins”Physicians can no longer accept the argumentthat absence of adequate knowledge is a reasonfor underuse of beta-blockers. The data are overwhelming and they have been published inleading medical journals.”Califf RM, OConnor CM. Editorial, JAMA 2000;283:1335-1337RM RM CaliffCaliff, CM OConnor. Editorial, JAMA:, CM OConnor. Editorial, JAMA:
