老年冠心病病人非心脏手术的麻醉.pptVIP

* 血流动力学变化The most common hemodynamic abnormalities observed during ischemic episodes are hypertension and tachycardia. They are almost always a cause rather than the result of ischemia. Hypotension is a late and ominous manifestation of progressive ventricular dysfunction. PA catheters are used less commonly now than in the recent past because several recent observational and randomized studies have noted that such catheters do not improve outcome 经食道超声 TEE 节段性心室壁运动异常（segmental wall motion abnormality, SWMA）较ECG出现早且敏感 Unfortunately, TEE requires expensive equipment and considerable familiarity with the technique to make correct—and rapid—interpretations intraoperatively. TEE在美英等国已经开始常规应用于心脏外科的麻醉，然而其高昂的价格也使得许多医学中心对其望而却步。即便是在发达国家，TEE在非心脏手术中也没能进入常规的监测项目。 * Early ischemic changes are subtle and can often be overlooked. They involve changes in T wave morphology, including inversion, tenting, or both (Figure 20–3). More obvious ischemia may be seen in the form of progressive ST-segment depression. Down-sloping and horizontal ST depression are of greater specificity for ischemia than up-sloping depression. New ST-segment elevations are rare during noncardiac surgery and are indicative of severe ischemia, vasospasm, or infarction. Ischemia may also present as an unexplained intraoperative atrial or ventricular arrhythmia or the onset of a new conduction abnormality. The sensitivity of the ECG in detecting ischemia is related to the number of leads monitored. Studies suggest that the V5, V4, II, V2, and V3 leads (in decreasing sensitivity) are most useful. Ideally, at least two leads should be monitored simultaneously. Usually, lead II is monitored for inferior wall ischemia and arrhythmias and V5 for anterior wall ischemia. An esophageal lead may also be useful in patients with posterior wall ischemia. * Down-sloping and horizontal ST depression are of greater specificity for ischemia than up-sloping depression. New ST-segment elevations are rare during noncardiac surge