[Guideline Consensus] Elderly Perioperative Guidelines (2020 Edition)·Management of Myocardial Ischemia Injury and Stroke

Click on the "blue word" above to find more exciting
.

China, like other countries in the world, faces the problem of population aging.
According to statistics, the aging population has reached more than 10%
.

With the increasing number of elderly operations, statistics report that half of the elderly over the age of 65 have to undergo at least one surgical treatment before they die
.

Due to many factors such as aging, comorbidities (multiplechronic conditions, MCC), frailty and other factors in elderly patients, the risk of adverse events during surgery is significantly increased
.

Therefore, whether the elderly need surgery, how to reduce perioperative risks, reduce complications, and maintain postoperative functional status have become key issues
.

Part III Diagnosis and management of common complications in elderly patients in ICU III.
Myocardial ischemia injury and myocardial infarction 1.
Definition and diagnosis: The diagnosis of postoperative myocardial injury is mainly based on changes in cardiac biomarkers, perioperative cardiac troponin (CTnI) higher than the 99% reference value upper limit (URL) is defined as perioperative myocardial injury [48]
.

Perioperative myocardial injury (PSPMI) with prognostic significance after cardiac surgery is defined as patients whose cTnI is within the upper limit of normal before surgery, and cTnT ≥ 7 × URL or cTnI ≥ 20 × URL within 48 hours after surgery (with or without suggesting myocardial infarction) The main reason is that myocardial injury is common in patients after cardiac surgery, and the increase of minor biochemical indicators is not strongly associated with the prognosis of patients [49]
.

A number of studies have shown that [50-52] that a slight increase in postoperative cTnI (≥20×URL in cardiac surgery patients) is associated with 30-day postoperative mortality and long-term mortality
.

Perioperative myocardial infarction is myocardial necrosis caused by myocardial ischemia.
The diagnosis is based on the clinical manifestations of elevated cTnI and myocardial ischemia or changes in electrocardiogram [48]
.

According to different mechanisms, myocardial infarction can be divided into 5 types, and perioperative myocardial infarction mainly involves type I or type II
.

Type I refers to myocardial necrosis caused by thrombosis or embolism in coronary arteries related to the rupture of atherosclerotic plaque; Type II refers to myocardial necrosis caused by the imbalance of myocardial oxygen supply and demand
.

2.
Incidence and harm: The incidence of myocardial infarction during the perioperative period is different in different surgical populations
.

For example, the incidence rate in patients undergoing non-cardiac surgery is about 0.
1% to 5.
0%, and in the population undergoing major vascular surgery, it is about 2.
9% to 23.
9% [53-54]
.

Perioperative myocardial infarction mainly occurred in the early postoperative period.
74.
1% of perioperative myocardial infarction occurred within 48 hours after surgery, and 65.
3% of patients had no clinical manifestations of myocardial ischemia [55]
.

Old age is one of the main risk factors for myocardial infarction in the perioperative period [53]
.

The incidence of myocardial ischemia injury during the perioperative period is higher [50-52]
.

For example, it is about 11%~72% after non-cardiac surgery [56], while it may be as high as 100% in cardiac surgery patients [50-52]
.

3.
Prevention: All treatment principles for patients with coronary atherosclerotic heart disease (coronary heart disease) should be strictly followed during the perioperative period [57-58]
.

Antiplatelet therapy should weigh the risks of surgical bleeding and thrombosis
.

For patients who are receiving aspirin treatment and the risk of thrombosis is medium to high risk, if non-cardiac surgery is planned, it is recommended to continue taking aspirin during the operation
.

For patients who have placed coronary artery bare metal stents, if surgery is necessary within 6 weeks, it is recommended to continue antiplatelet therapy during the perioperative period
.

For patients who have placed coronary drug-coated stents, it is recommended that the stent be implanted for 6 months before surgery; if surgery is necessary within 6 months, it is recommended to continue antiplatelet therapy during the perioperative period
.

Intraoperative or short-term use of beta-blockers to control heart rate can significantly reduce the incidence of postoperative myocardial infarction, but it will increase the risk of perioperative hypotension, which in turn will increase the incidence of stroke and lead to an increase in overall mortality.
[57]
.

Patients who have previously received β-blocker therapy should continue to use it; but starting the administration shortly (within 1 week) before surgery may increase the incidence of adverse events [57,59]
.

For patients who have used statins in the past, the established treatment should be continued during the perioperative period, because stopping the drug will increase the risk of cardiovascular complications [57]
.

Prophylactic administration of anticoagulants may reduce the incidence of myocardial injury, but the risk of bleeding needs to be vigilant
.

Studies have shown [60-61] that perioperative administration of dabigatran or rivaroxaban can reduce the incidence of myocardial injury after non-cardiac surgery
.

The use of aspirin during the perioperative period may not benefit the patient and may increase the risk of bleeding [62]
.

In addition, good perioperative anesthesia management is the fundamental guarantee to reduce postoperative myocardial ischemia/myocardial infarction
.

4.
Treatment: The prerequisite for effective treatment is to differentiate between type Ⅰ or type Ⅱ acute myocardial infarction
.

Type I myocardial infarction can benefit from active anticoagulation, antiplatelet and early coronary recanalization, while type II will benefit from rapid correction of the balance of oxygen supply and demand, such as volume expansion during hypotension or blood transfusion during anemia [48]
.

Considering that most patients with perioperative myocardial ischemia/myocardial infarction lack characteristic clinical manifestations, some scholars suggest that high-risk patients should monitor troponin levels daily for the first 3 days after surgery to detect myocardial injury/myocardial infarction in time [ 56]
.

Perioperative myocardial infarction should follow the treatment principles of cardiology [58, 63-64]
.

There is no treatment recommendation for myocardial ischemia injury, but the treatment principles of myocardial infarction can be referred to, including: oxygen inhalation, optimization of hemoglobin level, administration of aspirin and/or clopidogrel, statins, anticoagulation therapy, if necessary Give nitroglycerin and/or morphine; patients with stable hemodynamics may consider b-blockers, patients with unstable hemodynamics should first deal with hypotension and arrhythmia, and then consider b-blockers after the circulation is stable Receptor blockers; consider angiography and interventional therapy if necessary
.

[Recommendations] People who have taken beta blockers and statins should continue to be used in the perioperative period
.

Perioperative antithrombotic therapy should weigh the risks and benefits
.

Treatment should be based on different pathogenesis, with different focuses
.

4.
Transient ischemic attack (TIA) and stroke 1.
Definition and diagnosis: The definition of stroke refers to focal or extensive neurological deficits due to cerebrovascular causes, and the duration exceeds 24 h or 24 h The patient died within
.

Stroke is divided into ischemic stroke and hemorrhagic stroke
.

The perioperative period is mainly ischemic stroke, and hemorrhagic stroke accounts for less than 1% [65-66]
.

TIA is traditionally defined as an acute focal loss of brain or visual function, with symptoms lasting less than 24 hours, often caused by embolism or thrombosis
.

Later, the definition was revised to include transient neurological events without evidence of acute infarction in imaging studies
.

This is due to strokes confirmed by many imaging examinations (especially MRI), the duration of clinical symptoms is shorter than 24 hours, or even no clinical manifestations
.

The diagnosis of perioperative stroke or TIA is mainly based on clinical symptoms, signs and imaging findings
.

The clinical manifestations are often sudden onset and depend on the site of ischemia or infarction.
Asymmetric facial and (or) limb numbness, weakened muscle strength, communication difficulties, visual impairment, loss of balance or coordination, and severe inability may occur.
Explain the symptoms of headache, unexplained nausea and vomiting
.

When suspicious symptoms occur, timely consultation with specialists and imaging examinations are helpful for early detection and treatment [65-67]
.

2.
Incidence and harm: The incidence of perioperative stroke is different in different surgical populations
.

Open heart surgery is 4.
8%~9.
7%, carotid endarterectomy is 4.
4%~8.
5%, and non-cardiac and non-extraoperative surgery is 0.
08%~0.
90% [65, 67-68]
.

Perioperative stroke increases the incidence of postoperative complications and mortality, and is an important cause of postoperative disability [65, 67-68]
.

Studies have shown [68-71] that the incidence of perioperative TIA is about 1% to 7%, and the incidence in patients undergoing carotid artery vascular surgery is as high as about 50%
.

3.
Risk factors: Risk factors can be divided into patient's own factors, type of surgery and perioperative management
.

The patient’s own risk factors include advanced age (>70 years old), female, obesity (body mass index between 35-40 kg/m2), history of stroke or TIA, carotid artery stenosis (especially those with symptoms), ascending aortic atheroma Sclerosis (patients undergoing cardiac surgery), hypertension, diabetes, renal insufficiency, smoking, COPD, peripheral vascular disease, atrial fibrillation, left ventricular systolic dysfunction [left ventricular ejection fraction (LVEF) <40%], sudden preoperative Stop antithrombotic drugs and have a history of myocardial infarction within 6 months before surgery
.

In terms of surgical types, open heart surgery and carotid endarterectomy have the highest risk, followed by closed heart surgery and major head and neck surgery, and non-cardiac and non-neural surgery have lower risks
.

In terms of perioperative management, prolonged surgery, general anesthesia, severe blood pressure fluctuations, severe blood glucose fluctuations, and atrial fibrillation may increase the occurrence of neurological complications [65-67, 69-72]
.

4.
Prevention: Preventive measures are mainly aimed at changeable risk factors
.

For patients with recent stroke (<3 months), elective surgery should be postponed until 3 months later, and treatments to improve risk factors should be given at the same time; emergency surgery should be careful to maintain blood pressure stability and monitor the occurrence of cerebral ischemia, including transcranial Doppler (TCD), electroencephalogram (EEG), evoked potentials [65, 67, 73]
.

If carotid artery stenosis is >70% and symptomatic, revascularization surgery (stent placement/endarterectomy) can be considered first, followed by elective surgery; if stenosis is <50%, recanalization surgery is not required; if stenosis >60% but asymptomatic, the current treatment is still controversial, and secondary prevention is an acceptable option [67, 73]
.

For patients with preoperative atrial fibrillation, heparin should be given after stopping anticoagulant (warfarin) treatment before surgery; antiarrhythmic drugs or heart rate control drugs should be continued during the perioperative period, and attention should be paid to correct postoperative electrolytes and Fluid balance disorder; anticoagulant therapy should be resumed as soon as possible after operation (early use of heparin, and gradually overuse warfarin) [65, 67, 73-74]
.

For patients who use anticoagulation (warfarin) or antiplatelet therapy before surgery, if the risk of surgical bleeding is low-risk, warfarin treatment can be continued; if the risk of thromboembolism after stopping the drug is low-risk, Huafarin can be discontinued before surgery Farin: If there is a risk of bleeding if the drug is not stopped, but there is a risk of thrombosis after the drug is stopped, short-acting anticoagulant drugs (such as low molecular weight heparin) can be given excessively after the drug is stopped [65, 67, 73-75]
.

There is no consensus on the target value of blood pressure management
.

Generally, patients can tolerate a 25% to 35% lower blood pressure than the baseline level.
However, for patients with severe internal carotid artery stenosis/occlusion, incomplete Willis circle, or right shift of the cerebral blood flow self-regulation range, hypotension may lead to a watershed area Infarction, the current recommendation is that the perioperative blood pressure reduction in such patients should not exceed 20% of the basal blood pressure [76-78]
.

There is currently no consensus on the target value of blood glucose management
.

In principle, hyperglycemia or hypoglycemia should be avoided.
Critically ill patients are recommended to maintain blood glucose levels at 7.
8-10.
0 mmol/L [67, 73, 79]
.

A number of studies have shown [42, 80-81] that the use of statins during the perioperative period can reduce the incidence of perioperative stroke, but its conclusions have not been determined
.

For patients who have used β-blockers for a long time before surgery, sudden discontinuation of the drug before surgery will increase the mortality rate [82]
.

However, patients who have not used β-blockers for a long time before surgery are not recommended to use large doses during the perioperative period, otherwise it may increase the incidence of stroke and mortality
.

Other perioperative management that should be paid attention to include avoiding hyperventilation, maintaining normal body temperature, and maintaining adequate hemoglobin levels
.

5.
Treatment: For non-surgical patients, intravenous administration of recombinant tissue-type plasminogen activator (rtPA) thrombolytic therapy within 3 hours of stroke can improve the prognosis of patients [73-74]
.

However, there is no experience in the therapeutic effect of intravenous thrombolytic therapy on perioperative stroke patients, because the history of major surgery within 14 days is an absolute contraindication for intravenous thrombolytic therapy
.

In theory, if the operation is small and the benefits of thrombolytic therapy far outweigh the risks, intravenous thrombolytic therapy can also be considered
.

Because intravenous thrombolytic therapy is contraindicated in patients with perioperative stroke, intra-arterial thrombolytic therapy is an option to consider
.

Two cohort studies reported the effect of intra-arterial thrombolysis (rtPA or urokinase) within 6 hours after perioperative stroke.
Some patients have improved neurological function, but the incidence of bleeding complications is high [83-84]
.

For other treatments, please refer to the routine neurological stroke treatment [66]
.

[Recommendation] Stroke in the perioperative period can be prevented, and optimizing the perioperative management can reduce the incidence of stroke
.

The treatment of perioperative stroke is recommended to refer to the routine treatment of neurological stroke
.

END ●Guiding Opinions on Perioperative Anesthesia Management for Chinese Elderly Patients (2020 Edition) (1) ●Guiding Opinions on Perioperative Anesthesia Management for Chinese Elderly Patients (2020 Edition) (2) ●Expert Consensus: Guidance on Perioperative Anesthesia Management for Chinese Elderly Patients Opinions (2020 Edition) (3) Expert Consensus: Guiding Opinions on Perioperative Anesthesia Management for Chinese Elderly Patients (2020 Edition) (4) Expert Consensus: Guiding Opinions on Perioperative Anesthesia Management for Chinese Elderly Patients (2020 Edition) (5) [Wednesday 】Guidelines for the Elderly Perioperative Period (2020 Edition) (6) Anesthesia for Special Elderly Patients 【Wednesday】Guidelines for the Elderly Perioperative Period (2020 Edition) (7) Management of the Elderly Patients during the Recovery Period 【New Year Twenty-Nine】Guidelines for the Elderly Perioperative Period (2020 Edition) (8) Treatment of Acute Postoperative Pain in Elderly Patients [Sixth day of the sixth day] Elderly perioperative guidelines (2020 version) (9) Post-anaesthesia recovery room (PACU) management for elderly patients [Wednesday] Elderly perioperative guidelines (2020 Edition) (10) Comprehensive Management of Elderly Patients in Intensive Care Unit (ICU) [Wednesday] Elderly Perioperative Guide (2020 Edition) (11) Comprehensive Management of Elderly Patients in Intensive Care Unit (ICU) [Wednesday] Elderly Perioperative Guidelines (2020 Edition) (12) Diagnosis and Treatment of Common Complications in ICU Elderly Patients ●Anesthesia Guidelines and Expert Consensus Study day18 Chinese Elderly Hip Fracture Perioperative Anesthesia Management Guidelines ICAA WACA Elderly Hip Surgery Anesthesia-Precise and Individualized Yes Real or dream? Consensus notes study day30 Elderly hip fracture anesthesia and perioperative guidance.
The summary post you want is here! ! ～～Reprinted in the 2021 updated version is a kind of motivation, sharing is a kind of virtue