TAVI手术麻醉准备及要点.ppt

**TAVI手术麻醉准备及要点

TAVI适应征：有症状的严重主动脉瓣狭窄(瓣膜口面积1cm2);欧洲心脏手术风险评分（EuroSCORE）≥8。临床入选病人绝大多数为高龄（70岁）、存在严重合并症而不能行外科开胸手术的患者。EuroSCORE：心脏团队（cardiacgroup）TAVI手术路径TransfemoralTransapicalTransaorticTrans-subclavianTransaxillary解剖结构手术特点：球囊扩张主动脉瓣及置入主动脉瓣时主动脉无前向血流。方法：1)快速心室起搏（Rapidventricularpacing，RVP)140-180次/分2)时间平均12sAnestheticmanagementforpercutaneousaorticvalveimplantation:anoverviewofworldwideexperiences-HSRProceedingsinIntensiveCareandCardiovascularAnesthesia2012;4(1):40-46TAVI麻醉准备（全麻）１麻醉监测五导联ECG、有创动脉压、SpO2、CVP、温度TEE备体外除颤电极２药物麻醉药物麻醉诱导：力月西、舒芬太尼、依托咪酯、罗库溴铵/阿曲库铵麻醉维持：七氟醚、瑞芬太尼血管活性药物血管活性药物：肾上腺素、去甲肾上腺素、麻黄素、间羟胺等AnestheticManagementofPatientsUndergoingTranscatheterAorticValveImplantation.JCardiothoracVascAnesth.2013Dec5.pii:S1053-0770(13)00414目前华西医院TAVI麻醉流程（全麻）全身麻醉：心功能3级以上，建议气管插管全麻心功能2-3级以上，可选用喉罩+镇静全麻所有设备和抢救药物按心脏外科手术准备心室起博、球囊扩张、放置瓣膜时，麻醉医师应密切注意循环和心脏跳动术中麻醉维持sevoflurane（1%-2%)+remifentanil（0.025-0.2μg/kg/min）术后回CCU拔管或在手术间拔出喉罩全程体外循环备机TAVI麻醉准备（不插管全麻）１麻醉监测五导联ECG、有创动脉压、SpO2、CVP、温度TEE备体外除颤电极２药物麻醉药物麻醉诱导：力月西、舒芬太尼麻醉维持：右旋美托嘧啶血管活性药物：肾上腺素、去甲肾上腺素、麻黄素、间羟胺等AnestheticManagementofPatientsUndergoingTranscatheterAorticValveImplantation.JCardiothoracVascAnesth.2013Dec5.pii:S1053-0770(13)00414目前华西医院TAVI麻醉流程（不插管全麻）全身麻醉：入室力月西、舒芬、右美所有设备和抢救药物按心脏外科手术准备心室起博、球囊扩张、放置瓣膜时，麻醉医师应密切注意循环和心脏跳动术中麻醉维持右美+必要时符合异丙酚术后回CCU全程体外循环备机MAC：MonitoredAnesthesiaCareWhitePF.etalAnesthAnalg.1997;85(3):566-72.AnesthesiologistsPreservationofMarginalCardiovascularandRespiratoryFunctionSedation:NoRecallAnalgesia:Nociceptivereflex,BPandHRstableNon-disturbedProcedureAdvancedLifeMonitorandSupportStimulusIntensityinPercutaneousTAVIHowDeepinPercutaneousTAVI?RamsayMAetal.BMJ1974,2:656-659BIS:50~70MinimalCardiovascularIn