培训课件--风湿病的围手术期处理.pptVIP

* A common issue that arises in patients who are treated chronically with corticosteroids is the perioperative supplementation with stress dose steroids. Although it is commonly done, there is scant evidence to support this practice * Four studies evaluated stopping or continuing methotrexate one or more weeks before elective orthopaedic surgery in RA. In one RCT, no differences in postoperative complications were observed between patients who continued or stopped methotrexate (mean dose 10 mg/week).99 In a second RCT, patients who continued methotrexate (mean dose 10 mg/week) reported significantly fewer RA flares than patients who stopped methotrexate.100 In contrast, in a prospective cohort study postoperative infections occurred in 30% of patients who continued methotrexate compared with none of the patients who stopped methotrexate, without postoperative flares of RA in either group.101 However, a multivariate analysis in another cohort study showed that the perioperative use of methotrexate was not associated with wound morbidity (p=0.84) and significantly reduced RA flares.102 Although these studies suggest that methotrexate can be safely continued in the perioperative period of elective orthopaedic surgery, no studies were found regarding (non-)elective non-orthopaedic surgery. 风湿性疾病的围手术期处理 Dept. of Rheumatology Wang Qian 概 述 手术相关：预防并发症 手术指征和风险评估：急诊/择期/限期 并发症预防：感染（IE、人工关节）、伤口愈合、出血、血栓 原发病相关： 疾病活动性评估 脏器功能和损伤评估 合并症处理：妊娠、粒缺/淋巴细胞缺乏、机会性感染 药物相关：围手术期药物调整 糖皮质激素 免疫抑制剂 NSAIDs 新型生物制剂：抗TNF-α，etc 围手术期药物的处理策略 －糖皮质激素（GC） 皮质激素的生理学机制 生理状态 考的松 5.7 mg/m2/d； ～口服氢化可的松10-12 mg/m2/d 应激状态：正常成年人 小手术： cortisol ～50 mg/24h 大手术：75～100 mg/24h 分泌增加并非均匀：主要与诱导麻醉相关 术后24h内考的松分泌很少超过200 mg 长期服用GC者的病理生理 GC对调控血管张力和血压起“允许作用” 抑制血管内皮及其它细胞产生PGI2 肾上腺功能抑制：由于激素治疗引起肾上腺功能异常，但无临床表现，如低血压； 继发性肾上腺功能不全：由于激素治疗导致ACTH缺乏，引起临床表现，如低血压 盐皮质激素不会引起继发性肾上腺功能不全 调节醛固酮的分泌：ACTH＜＜RAS 肾上腺功能抑制＞＞继发性肾上腺功能不全，但在手术应激状态下（全麻、手术打击）有发展为后者的可能。需引起关注 问题的普遍性 2001,美国 34,124,000 张激素处方，4大激素 局部应用、吸入激素也可能导致肾上腺功能不全 围手术期肾上腺功能不全比较少见 全因：0.01% (1