Elderly Anesthesia Cloud Rounds 6.29 Perioperative management notes for multi-level vertebral fusion in elderly patients after mitral valve replacement

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Thanks to Ling Jun for supporting the new column.
Thanks to Professor Wang Tianlong of Xuanwu Hospital.
Thanks to the Chinese Gerontology Group for building such a good learning platform.
Notes I hope everyone will study hard and participate in the discussion.
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cn/#/meeting_notice_detail?meeting_id=48075 Problem In 2020, 250 million elderly people (over 60 years old is defined as the elderly) In 2025, more than 300 million elderly people will enter the ranks of elderly people.
In 2025-2030, there will be more than 100 million elderly people over 80 years old.
Therefore, anesthesia management of elderly patients is a big challenge.
6.
29 Case discussion Screenshot of the perioperative management course of multi-level vertebral body fusion in elderly patients after mitral valve replacement 01 How to bridge long-term warfarin anticoagulation and antiplatelet therapy in patients with atrial fibrillation after mitral valve replacement ? How to carry out individualized management of coagulation function in the perioperative period? First of all, we need to understand the coagulation function status during the use of anticoagulants and the coagulation function status of patients during low molecular weight heparin anticoagulation bridging therapy
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Personalized assessment is the only way to have personalized management
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Xue: Anticoagulation and antithrombotics are not the same concept.
Antithrombotics include: anticoagulation, antiplatelet, and thrombolysis; warfarin is an anticoagulant drug, aspirin and Plavix are antiplatelet drugs; TPA, streptokinase, and urokinase are Suppository medication
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Perioperative management of patients taking antithrombotic drugs: assessing the risk of perioperative thromboembolism: any patient after mitral valve replacement is the highest risk and extremely high risk category of patients; after aortic valve replacement, bicuspid Aortic valve replacement, without other complications, belongs to intermediate-risk patients with thromboembolism, and if combined with chronic heart failure, it belongs to high-risk patients
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1.
The clinical use of anticoagulants and antithrombotic drugs are mainly divided into three categories: ① patients after valve replacement; ② patients with atrial fibrillation; ③ patients with thromboembolism
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2.
We need to decide whether and when to discontinue the drug according to the risk of embolism and the risk of surgical bleeding
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For patients taking warfarin, there is a risk of major bleeding during surgery, and warfarin should be stopped 5 days before surgery according to the pharmacokinetics of warfarin
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3.
Whether or not to bridge: patients after mitral valve replacement need bridge because of the high risk of embolism
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Bridging was performed two days after warfarin was discontinued
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4.
How to deal with emergencies: patients with oral warfarin, spleen rupture in car accident emergency, how to deal with it? 02 There is a view that taking ACEI/ARB drugs 24 hours before surgery will increase the risk of intraoperative hypotension and cardiovascular events.
What is the consideration for this patient taking ARB drugs on the day of surgery? Professor: Stop
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The patient took three types of antihypertensive drugs, the three drugs interacted, and did not take it that morning, so that the blood pressure would not be too high
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Mental stress, susceptibility to high blood pressure, initial administration of sedative and analgesic induction, if not, low-dose intravenous antihypertensive drugs
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Avoid hypotension during induction
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Vasodilation, relatively insufficient blood volume, expansion; at the same time vasopressin, a receptor agonist, against hypotension caused by ACEI ARB
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Xue: We are not afraid of low blood pressure and high blood pressure during the operation, but it is difficult to control the high blood pressure after the operation
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Professor: Low blood pressure or high blood pressure can be corrected to normal values, but the damage caused by it has already occurred
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Professor Tianlong: It is recommended to stop taking ACEI ARB for 24 hours, and other antihypertensive drugs are recommended to continue taking them in the morning.
After stopping the drug, blood pressure fluctuates greatly
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Refractory hypotension occurred after induction, and norepinephrine 0.
1ug was pumped before induction
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Xue: Beijing Jiangya No.
0, reserpine, the principle is: depletion of vesicles
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Indirect vasopressors are ineffective, ephedrine is ineffective, but norcine can be used
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Our thoughts: It is better to stop the drug; keep it, the operation can continue, and prepare the vasoconstrictor drug for prevention
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Small supplement: Beijing Jiangya No.
0 is a compound preparation, and its main components are hydrochlorothiazide, triamterene, dihydralazine sulfate, and reserpine
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The duration of discontinuation depends on the pharmacokinetics of reserpine
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The time to discontinue reserpine depends on the half-life of the drug
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The availability (F) of reserpine is about 30% to 50%; the peak plasma concentration is reached 2 to 4 hours after the drug, and the plasma protein binding rate is as high as 96%
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The onset is slow, it takes several days to three weeks, and the peak blood pressure is reached in 3 to 6 weeks
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Metabolism is slow, and the effect can last for 1 to 6 weeks after drug withdrawal.
The half-life of distribution phase (t1/2β) and the half-life of elimination phase (t1/2β) are 4.
5 hours and 45 to 168 hours, respectively, so the preoperative withdrawal time should be earlier
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There are too many discussion articles about reserpine.
The most authoritative one should be the current consensus on the clinical management of Chinese experts in non-cardiac surgery during perianesthesia for cardiac patients.
2020 You can also poke the previous article to see the hot discussion in the group 0805 Lixue Flat and catheter fixation [Sunday] Hot discussion in the group 2021030703 Surgeons in this type of surgery emphasize controlled blood pressure to reduce bleeding, while anesthesiologists emphasize that elderly patients need to maintain baseline blood pressure to ensure systemic organ perfusion, how to conduct volume and blood pressure and circulatory and anti-stress management to meet the surgical and anesthesia requirements of multi-level lumbar fusion in elderly patients? Tianlong: Controlled blood pressure is not suitable for elderly patients
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Maintain organ perfusion while meeting surgical needs
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First, tranexamic acid was used; secondly, alpha receptor agonists combined with goal-directed fluid therapy to reduce the amount of bleeding
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Bleeding in spinal surgery is a slow cumulative and gradual bleeding, which is greatly affected by the tension of venous blood vessels
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If the blood pressure is controlled and we want to maintain the volume, it will cause too much fluid infusion, which will increase the venous vascular tension, resulting in increased bleeding
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Xue: Is tranexamic acid used for patients after mitral valve replacement? Tianlong: used half the amount, 500mg
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At present, 15-20mg/kg is commonly used in spine surgery, and we use less than 10mg/kg
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There is sufficient evidence internationally that the use of tranexamic acid does not increase the risk of thrombosis in these patients
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Xue: Controlled blood pressure reduction is to reduce arterial bleeding, suitable for total hip replacement, sinus surgery, shoulder surgery
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For liver surgery, controlled blood pressure is ineffective due to hepatic venous hemorrhage
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Bleeding in spinal surgery: some arterial, some venous, and venous bleeding accounts for more, and cannot be completely controlled by blood pressure
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How to reduce venous bleeding: 1⃣️ Positioning is very important to avoid compression of the inferior vena cava caused by abdominal compression, affecting venous return, and increased spinal vena cava pressure leading to increased bleeding
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2⃣️Keep warm, improve blood coagulation and reduce bleeding
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3⃣️Cell saver autologous blood recovery
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4⃣️ Tranexamic acid
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Controlled blood pressure is not required to reduce bleeding
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04How accurate is the functional hemodynamic monitoring of LiDCO/MostCare/Weijie flow in patients with coexisting left and right atrial enlargement and atrial fibrillation after mitral valve replacement? Is it possible to implement goal-directed fluid management? How to implement perioperative volume and circulation management in such patients? LiDCO/MostCare/Vijieflow are parameters derived from the calculation of arterial waveforms, and are implemented on the basis of a complete thoracic cage, mechanical ventilation of more than 8ml/kg, no arrhythmia, and good cardiac function
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Not available for patients with atrial fibrillation
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This patient could not use ppv and svv as parameters for goal-directed fluid therapy
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However, in patients with atrial fibrillation, the use of sv stroke volume as a monitoring is accurate
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05What are the clinical considerations for TEE monitoring for non-cardiac surgery after heart valve replacement? Will peripheral functional hemodynamic monitoring combined with TEE become the standard for combined monitoring of non-cardiac surgery with significant changes in cardiac structure and function? It is beneficial to monitor the cardiac function of patients after valve replacement: understand the functional status and size of the left ventricle in patients after valve replacement, whether there is thrombus, and understand the baseline status of preoperative management as a reference for intraoperative management
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Comprehensive assessment of ventricular structural changes
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Combined with peripheral hemodynamic monitoring, the two complement each other
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Xue: Considering the lack of relevant monitoring methods in grassroots hospitals, and clinically critical patients are often in grassroots hospitals, there may only be direct arterial pressure measurement, so is it possible to carry out such operations? Wang: Literature indicates that only about 30% of high-risk patients use tee monitoring during surgery
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Conditions available
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Xue: For a patient after mitral valve replacement, it is more important to clarify the patient's hemodynamic goals, what level should blood pressure/heart rate be maintained, the heart rate of atrial fibrillation patients should be controlled at 70-90bpm, and the myocardial contractility of the patient should be understood.
, how to control the front and rear load
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It is even more important to understand the goals of hemodynamic control in patients with various types of heart disease
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Tianlong added: The patient's SBP was 100-110 after induction of anesthesia in the supine position, and the patient's volume was still ok from a PPV of 8%
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However, through the use of TEE intraoperatively, it was found that the left ventricular volume was smaller, and blood pressure was improved by rehydration of 300-400ml
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Therefore, TEE has certain advantages in judging whether to choose volume optimization or vasoconstrictor drugs
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But more importantly, we need to understand the state of long-term compensation hemodynamic parameters in preoperative patients with heart disease, and not deviate from the physiological indicators established by long-term compensation
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06How to use peripheral nerve block/local anesthetic wound infiltration analgesia for intraoperative anti-stress management? Spinal surgery pain is complex and severe.
How to do multimodal analgesia to avoid preoperative pain from turning into chronic pain
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The cornerstone of multimodal analgesia Local analgesia control preoperative pain: Oral NSAIDs, commonly used diclofenac sodium, Celebrex Gabapentin and pregabalin Oral 3-5 days before surgery Intraoperative surgeon: wound local infiltration Anesthesia physician: vertical Spinal muscle block, intubation can be used for postoperative analgesia methadone, NMDA receptor antagonists plus μ receptor agonists, to prevent hyperalgesia and avoid conversion to chronic pain Postoperative analgesia acetaminophen NSAIDS opioid combination, as little as possible How to implement brain protection strategies to prevent postoperative brain complications with opioid 07? Neural electrophysiological monitoring of hemodynamic maintenance Xue brain and spinal cord, blood pressure-dependent, auto-regulation; metabolic-dependent, acidosis, hypoxia, CO2 accumulation, increased blood flow ①Maintain circulatory stability, MAP is more important, not lower than baseline 20 %; ② stable internal environment; ③ correction of anemia
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Blindness prevention ischemic optic neuropathy massive blood loss body placement; colloid infusion has certain benefits, reducing the blindness rate
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The depth of anesthesia monitoring varies greatly among individuals to avoid the use of dexmedetomidine in the operation of excessive anesthesia, reduce the use of related anesthetic drugs, avoid restlessness during recovery, and reduce postoperative complications
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08How to implement lung protection strategies during surgery to ensure rapid endotracheal tube extubation after surgery? How to protect lungs with prone position ventilation, prone position ventilation itself is a kind of protective ventilation ① no peep is added to avoid affecting reflux; ② avoid excessive tidal volume, 8ml/kg, regular lung expansion, 30cm H2O for 15-30s ③ appropriate amount of muscle Looseness, prevention of postoperative pulmonary complications Guidance for perioperative anesthesia management in Chinese elderly patients (2020 version) (1) Guidance for perioperative anesthesia management in Chinese elderly patients (2020 version) (2) Expert consensus: Chinese elderly Guiding Opinions on Perioperative Anesthesia Management of Patients (2020 Edition) (3) Expert Consensus: Guiding Opinions on Perioperative Anesthesia Management of Chinese Elderly Patients (2020 Edition) (4) Expert Consensus: Guiding Opinions on Perioperative Anesthesia Management in Chinese Elderly Patients (2020) Edition) (5) [Wednesday] Perioperative Guidelines for the Elderly (2020 Edition) (6) Chinese Experts' Consensus on Clinical Management of Non-cardiac Surgery Peri-anesthesia for Special Elderly Patients with Anesthesia and Heart Disease