Ho Michael C, Beathe Jonathan C, Sharrock Nigel E
Department of Anesthesiology, Hospital for Special Surgery, New York, NY 10021, USA.
Reg Anesth Pain Med. 2008 Mar-Apr;33(2):129-33. doi: 10.1016/j.rapm.2007.09.008.
The use of conduction anesthesia and induced hypotension are traditionally contraindicated in patients with aortic stenosis. This hypothesis-generating observational pilot study details the clinical outcomes in patients with aortic stenosis undergoing hypotensive epidural anesthesia for total hip replacement.
From a database of 1,947 consecutive patients undergoing total hip replacement under hypotensive epidural anesthesia performed from 1994 to 2005, 22 patients were identified with aortic stenosis. Chart review was performed. All patients were monitored with central venous pressure and radial arterial catheters. Cardiovascular and renal outcomes, thromboembolic events, and blood loss and transfusion were assessed.
Twenty-two patients were identified: 19 patients (86%) were American Society of Anesthesiologists classification III, and 3 patients (14%) were American Society of Anesthesiologists classification IV. The mean age was 75 years (range: 58-92). No patient suffered from preoperative angina, syncope, or resting dyspnea. Valve areas ranged from 0.9 to 1.8 cm(2) and peak gradient from 12 to 64 mm Hg. Systolic blood pressure was maintained at 60 to 100 mm Hg. The mean duration of hypotension was 91 minutes (range: 50-200). Heart rate was maintained at a mean (+/-SD) of 70 +/- 11. Central venous pressure was maintained at baseline value. Mean intraoperative crystalloid administered was 1,695 mL (range: 900-4,000), and mean estimated blood loss was 234 mL (range: 100-1,500). There were no deaths, myocardial infarctions, cerebrovascular accidents, or pulmonary embolic events. No patient developed renal dysfunction.
We report the absence of complications (with calculated upper limit 95% confidence interval of approximately 13.6%) when hypotensive epidural anesthesia was performed in 22 patients with noncritical asymptomatic aortic stenosis.
传统上，主动脉瓣狭窄患者禁忌使用传导麻醉和诱导性低血压。这项产生假设的观察性试点研究详细阐述了接受全髋关节置换术的主动脉瓣狭窄患者在进行低血压硬膜外麻醉后的临床结局。
从1994年至2005年接受低血压硬膜外麻醉下全髋关节置换术的1947例连续患者的数据库中，识别出22例主动脉瓣狭窄患者。进行病历审查。所有患者均通过中心静脉压和桡动脉导管进行监测。评估心血管和肾脏结局、血栓栓塞事件以及失血量和输血情况。
识别出22例患者：19例（86%）为美国麻醉医师协会分级III级，3例（14%）为美国麻醉医师协会分级IV级。平均年龄为75岁（范围：58 - 92岁）。无患者术前患有心绞痛、晕厥或静息性呼吸困难。瓣口面积范围为0.9至1.8 cm²，峰值压差为12至64 mmHg。收缩压维持在60至100 mmHg。低血压的平均持续时间为91分钟（范围：50 - 200分钟）。心率维持在平均（±标准差）70 ± 11。中心静脉压维持在基线值。术中平均输注晶体液量为1695 mL（范围：900 - 4000 mL），平均估计失血量为234 mL（范围：100 - 1500 mL）。无死亡、心肌梗死、脑血管意外或肺栓塞事件发生。无患者出现肾功能障碍。
我们报告了22例非重度无症状主动脉瓣狭窄患者在进行低血压硬膜外麻醉时未出现并发症（计算得出的95%置信区间上限约为13.6%）。
