手术室平台潜在风险自查报告讲解课件.ppt

* 从药理机制上来说，依托咪酯对心肌收缩力、外周压力感受器和外周血管均没有影响。而丙泊酚在抑制心肌收缩力，抑制外周压力感受器的同时扩张外周血管，势必会导致血压显著下降。在临床运用过程中部分医生利用镇痛不足，插管或手术刺激让使用丙泊酚的患者的血压维持在看似正常的水平，并不代表患者的心肌收缩力和外周压力感受器没有受到影响。对于有心血管潜在风险的患者，比如老年、有心血管病史和家族史、肥胖等患者的，可能会无形中增加心血管风险。 * 在全麻过程中，诱导期是对心血管稳定要求最高的阶段，这一阶段患者不但要经过从清醒状态进入到镇静麻醉状态，还要经过气管插管这一有明显性血管反射的特殊阶段。与丙泊酚比较福尔利导时不会引起血压下降，研究表明两者对于插管反射时引起的血压增高的绝对值无显著差别，而阿片受体抑制剂如芬太尼家族则是解决插管反射时血压增高的经典而科学的选择。因此多数熟悉福尔利的专家认同福尔利的心血管稳定性不仅仅对于危重患者有不可替代的价值，对于普通患者来说同样具有更加安全的意义。 * 心血管疾病患者在心血管系统不稳定时，患者的风险会更大。如图所示2007年的芬兰学者Bendel S 等研究发现丙泊酚诱发主动脉瓣狭窄患者的低血压发生率是依托咪酯的两倍，而有瓣膜病的患者，常常会在血压下降时引起更加显著的心肌和全身供血不足而导致患者猝死。 Propofol causes more hypertension than etomidate in patients with severe aortic stenosis: a double-blind, randomized study comparing propofol and etomidate. BACKGROUND: Vasodilatation and hypotension are thought to be harmful in patients with severe aortic stenosis. Etomidate is preferred to propofol for anaesthesia induction in haemodynamically unstable patients, but may disturb cortisol synthesis. We assessed the haemodynamic effects of etomidate vs. propofol as anaesthesia induction agents, and the effects of these drugs on cortisol concentrations, in patients with severe aortic stenosis. The main end-point of the study was the incidence of hypotension. METHODS: Sixty-six patients with severe aortic stenosis scheduled for elective aortic valve replacement were enrolled in the study. The patients were randomized to receive either propofol or etomidate for induction of anaesthesia. Haemodynamic parameters, i.e. mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP) and cardiac index (CI), were measured. If MAP decreased below 70 mmHg for more than 30 s, phenylephedrine was administered. Serum cortisol concentrations were also measured. RESULTS: MAP decreased in all patients (P 0.001). MAP decreased to a greater extent in patients receiving propofol than in those receiving etomidate (P = 0.006). Patients receiving propofol needed phenylephedrine more often than those receiving etomidate (