Department of Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
Department of Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA.
Open Heart. 2024 Aug 30;11(2):e002801. doi: 10.1136/openhrt-2024-002801.
Acute intraoperative hypercapnia and respiratory acidosis, which can occur during monitored anaesthesia care (MAC), pose significant cardiopulmonary risks for patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). The goal of the present study is to assess the incidence, risk factors and impact of intraoperative hypercapnia during MAC for patients undergoing transfemoral TAVR.
Data was collected retrospectively from the electronic medical record of 201 consecutive patients with available intraoperative arterial blood gas (ABG) data who underwent percutaneous transfemoral TAVR with MAC using propofol and dexmedetomidine. ABGs (pH, arterial partial pressure of carbon dioxide (PaCO) and arterial partial pressure of oxygen) were performed at the start of each case (baseline), immediately prior to valve deployment (ValveDepl), and on arrival to the postanaesthesia care unit. Data was analysed using Fisher's exact test, unpaired Student's t-test, Wilcoxon rank sum or univariate linear regression as appropriate based on PaCO and pH during ValveDepl (PaCO-ValveDepl, pH-ValveDepl) and change in PaCO and pH from baseline to ValveDepl (PaCO-%increase, pH-%decrease) to determine their association with preoperative demographic data, intraoperative anaesthetic and vasoactive medications and postoperative outcomes.
PaCO increased by a mean of 28.4% and was higher than baseline in 91% of patients. Younger age, male sex, increased weight and increased propofol dose contributed to higher PaCO-ValveDepl and greater PaCO-%increase. Patients with PaCO-ValveDepl>60 mm Hg, pH≤7.2 and greater pH-%decrease were more likely to receive vasoactive medications, but perioperative PaCO and pH were not associated with adverse postoperative outcomes.
Transient significant hypercapnia commonly occurs during transfemoral TAVR with deep sedation using propofol and dexmedetomidine. Although the incidence of postoperative outcomes does not appear to be affected by hypercapnia, the need for vasopressors and inotropes is increased. If deep sedation is required for TAVR, hypercapnia and the need for haemodynamic and ventilatory support should be anticipated.
急性术中高碳酸血症和呼吸性酸中毒可发生在监测麻醉护理（MAC）期间，这对接受经导管主动脉瓣置换术（TAVR）的主动脉瓣狭窄患者的心肺带来重大风险。本研究旨在评估 MAC 期间接受经股 TAVR 患者术中高碳酸血症的发生率、危险因素和影响。
回顾性收集 201 例接受 MAC 下经股 TAVR 患者的电子病历资料，患者术中均有动脉血气（ABG）数据。MAC 采用丙泊酚和右美托咪定。在每个病例开始时（基线）、瓣膜置入前（ValveDepl）和到达麻醉后护理单元时进行 ABG（pH、动脉二氧化碳分压（PaCO ）和动脉氧分压）。根据 ValveDepl 时的 PaCO 和 pH（PaCO-ValveDepl、pH-ValveDepl）以及从基线到 ValveDepl 时 PaCO 和 pH 的变化（PaCO-%increase、pH-%decrease），采用 Fisher 确切检验、配对学生 t 检验、Wilcoxon 秩和检验或单因素线性回归分析，确定其与术前人口统计学数据、术中麻醉和血管活性药物以及术后结果的关系。
PaCO 平均增加 28.4%，91%的患者 PaCO 高于基线。年龄较小、男性、体重增加和丙泊酚剂量增加与 PaCO-ValveDepl 较高和 PaCO-%increase 较大有关。PaCO-ValveDepl>60mmHg、pH≤7.2 和 pH-%decrease 较大的患者更可能接受血管活性药物，但围手术期 PaCO 和 pH 与不良术后结局无关。
在使用丙泊酚和右美托咪定进行深镇静的经股 TAVR 期间，常发生短暂性显著高碳酸血症。尽管高碳酸血症似乎不会影响术后结局的发生率，但血管加压药和正性肌力药的需求增加。如果 TAVR 需要深度镇静，应预期出现高碳酸血症和对血流动力学和通气支持的需求。
