外科病人手術前後心血管風險評估及內科處理

Perioperative Risk Evaluations and Medical Managements in Surgical Patients-An Update

林廷燦(Ting-Tsan Lin) ； 朱文洋(Wen-Yang Chu) ； 劉怡君(Yi-Chun Liu) ； 鍾瑞嶂(Rei-Jahn Juhn)

《內科學誌》 23卷6期 (2012/12) Pp. 403-421

https://doi.org/10.6314/JIMT.2012.23(6).05

摘要

任何手術，重大創傷或其他外科原因而住院的病人，皆可能發生內科相關的合併症，這不僅帶來更多的痛苦與不適，也可能為病人的生命帶來潛在的危險。因此，外科病人手術前後風險評估及內科處理，包括手術或創傷時生理機轉，以及後續之全身性發炎反應症候群或多發性器官失全症候群，皆需密切處理。一言以蔽之，手術的風險及效應，對於內外科醫護同仁皆是一門重要的課題。另外，心血管疾病在國人死亡原因中早已名列前十大原因。因此在非心臟性外科手術中危險度的分類（分成高，中，低度危險群) 及處理：包括臨床上預測因子或臨床指標（主要，中間或次要）皆需要有一明確的指引及規範。這對評估任何手術的危險度相當重要。平心而論，外科領域會碰到內科常見的問題，吾人把它們歸類成四大類。第一類：內科問題惡化而轉往外科；第二類：外科問題因無關的內科問題而更加複雜；第三類：先前的內科問題因麻醉／手術而惡化。第四類：先前的內科潛在問題因麻醉／手術之壓力而快速呈現。以實證醫學觀點而言，決定手術與否就是風險及效益評估之最終結果。因此無論任何手術（計畫安排／緊急手術）每位醫師皆應設法平衡風險及效益。以目前醫療現況，內外細專科分工精細，因此我們將回顧國內外大型研究及文獻並參照我們本土的經驗，冶為一爐。將各種評估方式重點介紹，如美國麻醉學會之分類以及高曼氏心臟風險指數逐一介紹。並將手術前後預防心血管重大事件（心肌梗塞，心衰竭，死亡）以及相關所有的內科問題及處置（包括藥物）作深入淺出的回顧及整理。希冀此一回溯性論文，會對臨床內外科醫護同仁有所助益。

關鍵字

手術前後的風險評估 ； 全身性發炎反應症候群 ； 多重器官功能全失症候群 ； 非心臟外科手術 ； 高曼氏心臟風險指數 ； 心血管重大事件

並列摘要

Any patients who suffered from major trauma or surgery face potential life-threatening hazards. No questions were doubtful concerning any type of surgery which maybe complicated with medical problems during the hospital course may bring more painful and discomfortable feelings to the patients. Thus, periopertive risk evaluations and medical managements present an important issue for patient's safety and life quality. Moreover,pathophysiology of subsequent systemic inflammatory response syndrome (SIRS) as well as multiple organ dysfunction syndrome (MODS) should be closely follow-up because of its developing catastrophic events. In facts, risks and benefits of surgery raised an important issues to either medical or surgical staffs. Additionally, the cardiovascular disease such as stroke, myocardial infarction, and cardiac death still standed the top ten priority of the leading cause of death in Taiwan. On the top of this issue, cardiac risk evaluations may be divided into 3 different (high, intermediate, and low) based on clinical indicators and predictors during the non-cardiac surgery. All of these should provide clear and distinctive clinical regulations. Thus, any surgical risk can be assessed and evaluated according to the evidences of medicine. Frankly speaking, medical problems could be revealed in four category presentations in the field of surgery as follows: the first, medical issues got worse, then referred to surgical ward for cure; the surgical problems got more complexed owing to irrelevant medical issue; the third, previous medical issue got more trouble due to surgical and anesthetic procedures, the last one, previous potential medical problems quickly emerged resulting from surgical and medical oxidative stress. On the viewpoints of evidence-based medicine, either surgical or medical solution is the bottom line of final balance of benefits and risks. The ultimate outcome of any elective or emergency surgery will be justified based on risks and benefits of surgical outcome. Thus, perioperative risk assessments and medical managements still remained the cornerstone of the hot topic to the medical and surgical staffs. Briefly speaking, in this review article, we will introduce ASA classification as well as Goldmans cardiac risk index but also review the new AHA and JACC guidelines and managements. Worthy of comments, we will focus on the recent update for perioperative cardiovascular evaluations for noncardiac surgery in addition to medical update managements. Hopefully, it may bring us the new conceps and help us handle these important issues for the current medical practice.

並列關鍵字

Perioperative risk evaluations ； Systemic inflammatory response syndrome ； Multiple organ dysfunction syndrome ； Noncardiac surgery ； Goldman cardiac risk index ； Major cardiovascular events