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Attachment: The choice of anesthesia method and anesthesia drug in the text part The choice of anesthesia method mainly depends on the operation method and operation site
.
Regional anesthesia, including spinal anesthesia, peripheral nerve block, etc.
, is recommended to be preferred under the conditions that the surgical needs can be met
.
A study of patients undergoing knee and hip replacement showed that general anesthesia was an independent risk factor for postoperative stroke (OR 3.
54, 95%CI 1.
01-12.
39); The incidence of stroke and 30-day postoperative mortality were significantly reduced in patients with intratubal anesthesia
.
Although no studies have confirmed the advantages of regional anesthesia in other types of surgery, regional anesthesia is recommended in extremity surgery to reduce the risk of perioperative stroke in patients
.
Whether anesthesia drugs affect the occurrence of perioperative stroke remains controversial
.
Patients undergoing carotid endarterectomy, cerebral aneurysm surgery, and hypothermic cardiopulmonary bypass surgery are prone to cerebral ischemia, but there is no evidence from clinical studies that general anesthetics have neuroprotective effects
.
There are also insufficient clinical studies to demonstrate the advantages and disadvantages of intravenous anesthetics, inhalation anesthetics, or combined intravenous and inhalation drugs in brain protection or perioperative stroke reduction
.
It is currently believed that on the basis of ensuring cerebral perfusion, anesthetic drugs themselves will not affect the risk of perioperative stroke
.
【Recommendations】Patients undergoing extremity surgery are recommended to choose regional anesthesia to reduce the risk of perioperative stroke
.
Intraoperative beta-blocker use increases perioperative stroke risk in patients undergoing noncardiac surgery with intraoperative metoprolol
.
Although intraoperative hypotension was associated with perioperative stroke, there was no linear association between metoprolol and hypotension
.
On the other hand, intraoperative use of esmolol or labetalol did not increase the risk of stroke
.
Therefore, if necessary, it is recommended to use short-acting beta-blockers such as esmolol during surgery
.
[Recommendation] It is recommended to use short-acting beta-blockers such as esmolol when necessary during surgery, and avoid the use of metoprolol
.
Intraoperative hypotension is common in perioperative blood pressure management
.
Studies have shown that intraoperative hypotension is significantly associated with postoperative stroke, and the risk of stroke increases with the duration of hypotension
.
Therefore, intraoperative blood pressure management is the focus of preventing perioperative stroke, and maintaining intraoperative blood pressure between the basal level and 20% above the basic value can help reduce the incidence and mortality of stroke
.
The use of goal-directed fluid therapy in combination with vasoconstrictors helps maintain blood pressure at ideal levels
.
Indicators to guide goal-directed fluid management under mechanical ventilation include stroke volume variation (SVV), pulse pressure variation (PPV), and pleth variability index (PVI)
.
SVV or PPV > 13% indicates insufficient cardiac preload and requires accelerated infusion
.
Non-mechanical ventilation patients can use the fluid shock test to guide volume therapy, that is, a rapid infusion of 3ml/kg (standard body weight) of crystalloid or colloid within 5 minutes, and the increase in stroke volume (SV) (ΔSV) exceeds 10% as fluid shock If the test is positive, a second liquid shock test can be performed until ΔSV<10%
.
Over-reliance on fluid infusions to maintain blood pressure may result in fluid overload, and single or continuous infusion of low-dose vasoconstrictors can maintain hemodynamic stability
.
In the head-high position such as the beach chair position, patients are prone to insufficiency of cerebral blood supply.
When monitoring blood pressure, it should be noted that the zero point of the arterial pressure transducer should be adjusted to the level of the external auditory canal
.
[Recommendation] Rational use of vasoconstrictor drugs, goal-directed fluid therapy, and maintenance of intraoperative blood pressure from the baseline value to 20% above the baseline value
.
For the surgery in the beach chair position, continuous intraoperative arterial pressure monitoring is recommended, and the zero point of the transducer is placed at the level of the external auditory canal
.
Intraoperative bleeding and blood transfusion therapy Intraoperative bleeding and anemia are associated with an increased risk of postoperative stroke, especially in cardiac surgery patients
.
Perioperative use of beta-blockers with intraoperative anemia (hemoglobin <9.
0 g/dL) increases the risk of stroke
.
Therefore, for patients who have been taking beta-blockers and have undergone non-cardiac, non-neurosurgery operations, hemoglobin should be maintained at 9.
0 g/dL to reduce the risk of stroke
.
For patients with risk factors for cardiovascular disease, a restrictive blood transfusion strategy (transfusion when hemoglobin <8.
0 g/dL) does not increase the risk of postoperative stroke in non-cardiac and non-neurosurgery patients, and intraoperative hemoglobin should be maintained at 7.
0.
g/dL or more
.
[Recommendation] Non-cardiac and non-neurosurgery patients taking beta-blockers should maintain hemoglobin above 9.
0 g/dL
.
For patients with cardiovascular disease, hemoglobin should be maintained above 7.
0 g/dL
.
Intraoperative ventilation strategies There is currently limited evidence on the association of low intraoperative PaCO2 or EtCO2 with stroke
.
Intraoperative hyperventilation has multiple hazards, including: decreased lung compliance and oxygenation (ventilation/flow mismatch and increased shunt), increased myocardial oxygen demand and decreased blood supply (coronary vasoconstriction), arrhythmia risk increase and decrease in cerebral blood flow
.
Among nonsurgical patients, stroke patients with hypocapnia have a worse prognosis than normoventilated patients
.
To date, no studies have demonstrated that changing ventilation strategies can reduce the risk of postoperative stroke
.
However, patients with risk factors for stroke should avoid hypocapnia
.
[Recommendation] Patients at high risk of stroke should avoid hypocapnia
.
Intraoperative blood glucose management For patients prone to intraoperative cerebral ischemia such as cardiovascular surgery and carotid endarterectomy, hyperglycemia (> 11.
1 mmol/L) will increase the risk of postoperative stroke
.
However, intensive intraoperative insulin therapy (with a blood glucose control target of 4.
4 to 5.
6 mmol/L) was also associated with an increased risk of postoperative stroke and death
.
There is no clear evidence for the optimal level of intraoperative glycemic control
.
Blood sugar levels should be monitored during surgery to avoid hyperglycemia or hypoglycemia.
High-risk patients are advised to control blood sugar between 7.
8 and 10.
0 mmol/L
.
[Recommendation] Avoid hyperglycemia or hypoglycemia during surgery, and control blood sugar between 7.
8 and 10.
0 mmol/L in high-risk patients
.
Graphic arrangement: Wu Xiaobin
.
Regional anesthesia, including spinal anesthesia, peripheral nerve block, etc.
, is recommended to be preferred under the conditions that the surgical needs can be met
.
A study of patients undergoing knee and hip replacement showed that general anesthesia was an independent risk factor for postoperative stroke (OR 3.
54, 95%CI 1.
01-12.
39); The incidence of stroke and 30-day postoperative mortality were significantly reduced in patients with intratubal anesthesia
.
Although no studies have confirmed the advantages of regional anesthesia in other types of surgery, regional anesthesia is recommended in extremity surgery to reduce the risk of perioperative stroke in patients
.
Whether anesthesia drugs affect the occurrence of perioperative stroke remains controversial
.
Patients undergoing carotid endarterectomy, cerebral aneurysm surgery, and hypothermic cardiopulmonary bypass surgery are prone to cerebral ischemia, but there is no evidence from clinical studies that general anesthetics have neuroprotective effects
.
There are also insufficient clinical studies to demonstrate the advantages and disadvantages of intravenous anesthetics, inhalation anesthetics, or combined intravenous and inhalation drugs in brain protection or perioperative stroke reduction
.
It is currently believed that on the basis of ensuring cerebral perfusion, anesthetic drugs themselves will not affect the risk of perioperative stroke
.
【Recommendations】Patients undergoing extremity surgery are recommended to choose regional anesthesia to reduce the risk of perioperative stroke
.
Intraoperative beta-blocker use increases perioperative stroke risk in patients undergoing noncardiac surgery with intraoperative metoprolol
.
Although intraoperative hypotension was associated with perioperative stroke, there was no linear association between metoprolol and hypotension
.
On the other hand, intraoperative use of esmolol or labetalol did not increase the risk of stroke
.
Therefore, if necessary, it is recommended to use short-acting beta-blockers such as esmolol during surgery
.
[Recommendation] It is recommended to use short-acting beta-blockers such as esmolol when necessary during surgery, and avoid the use of metoprolol
.
Intraoperative hypotension is common in perioperative blood pressure management
.
Studies have shown that intraoperative hypotension is significantly associated with postoperative stroke, and the risk of stroke increases with the duration of hypotension
.
Therefore, intraoperative blood pressure management is the focus of preventing perioperative stroke, and maintaining intraoperative blood pressure between the basal level and 20% above the basic value can help reduce the incidence and mortality of stroke
.
The use of goal-directed fluid therapy in combination with vasoconstrictors helps maintain blood pressure at ideal levels
.
Indicators to guide goal-directed fluid management under mechanical ventilation include stroke volume variation (SVV), pulse pressure variation (PPV), and pleth variability index (PVI)
.
SVV or PPV > 13% indicates insufficient cardiac preload and requires accelerated infusion
.
Non-mechanical ventilation patients can use the fluid shock test to guide volume therapy, that is, a rapid infusion of 3ml/kg (standard body weight) of crystalloid or colloid within 5 minutes, and the increase in stroke volume (SV) (ΔSV) exceeds 10% as fluid shock If the test is positive, a second liquid shock test can be performed until ΔSV<10%
.
Over-reliance on fluid infusions to maintain blood pressure may result in fluid overload, and single or continuous infusion of low-dose vasoconstrictors can maintain hemodynamic stability
.
In the head-high position such as the beach chair position, patients are prone to insufficiency of cerebral blood supply.
When monitoring blood pressure, it should be noted that the zero point of the arterial pressure transducer should be adjusted to the level of the external auditory canal
.
[Recommendation] Rational use of vasoconstrictor drugs, goal-directed fluid therapy, and maintenance of intraoperative blood pressure from the baseline value to 20% above the baseline value
.
For the surgery in the beach chair position, continuous intraoperative arterial pressure monitoring is recommended, and the zero point of the transducer is placed at the level of the external auditory canal
.
Intraoperative bleeding and blood transfusion therapy Intraoperative bleeding and anemia are associated with an increased risk of postoperative stroke, especially in cardiac surgery patients
.
Perioperative use of beta-blockers with intraoperative anemia (hemoglobin <9.
0 g/dL) increases the risk of stroke
.
Therefore, for patients who have been taking beta-blockers and have undergone non-cardiac, non-neurosurgery operations, hemoglobin should be maintained at 9.
0 g/dL to reduce the risk of stroke
.
For patients with risk factors for cardiovascular disease, a restrictive blood transfusion strategy (transfusion when hemoglobin <8.
0 g/dL) does not increase the risk of postoperative stroke in non-cardiac and non-neurosurgery patients, and intraoperative hemoglobin should be maintained at 7.
0.
g/dL or more
.
[Recommendation] Non-cardiac and non-neurosurgery patients taking beta-blockers should maintain hemoglobin above 9.
0 g/dL
.
For patients with cardiovascular disease, hemoglobin should be maintained above 7.
0 g/dL
.
Intraoperative ventilation strategies There is currently limited evidence on the association of low intraoperative PaCO2 or EtCO2 with stroke
.
Intraoperative hyperventilation has multiple hazards, including: decreased lung compliance and oxygenation (ventilation/flow mismatch and increased shunt), increased myocardial oxygen demand and decreased blood supply (coronary vasoconstriction), arrhythmia risk increase and decrease in cerebral blood flow
.
Among nonsurgical patients, stroke patients with hypocapnia have a worse prognosis than normoventilated patients
.
To date, no studies have demonstrated that changing ventilation strategies can reduce the risk of postoperative stroke
.
However, patients with risk factors for stroke should avoid hypocapnia
.
[Recommendation] Patients at high risk of stroke should avoid hypocapnia
.
Intraoperative blood glucose management For patients prone to intraoperative cerebral ischemia such as cardiovascular surgery and carotid endarterectomy, hyperglycemia (> 11.
1 mmol/L) will increase the risk of postoperative stroke
.
However, intensive intraoperative insulin therapy (with a blood glucose control target of 4.
4 to 5.
6 mmol/L) was also associated with an increased risk of postoperative stroke and death
.
There is no clear evidence for the optimal level of intraoperative glycemic control
.
Blood sugar levels should be monitored during surgery to avoid hyperglycemia or hypoglycemia.
High-risk patients are advised to control blood sugar between 7.
8 and 10.
0 mmol/L
.
[Recommendation] Avoid hyperglycemia or hypoglycemia during surgery, and control blood sugar between 7.
8 and 10.
0 mmol/L in high-risk patients
.
Graphic arrangement: Wu Xiaobin
