心機能と周術期管理

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  • 山浦 健
    九州大学大学院医学研究院麻酔・蘇生学分野

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  • Cardiac Function and Perioperative Management
  • シンキノウ ト シュウジュツキ カンリ

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Heart failure (HF) is associated with postoperative mortality among patients undergoing elective non-cardiac surgery. Postoperative HF has been reported to develop in 9.3% of high-risk patients and in 5.3% of low- or intermediate-risk elderly patients who underwent non-cardiac surgery. Among patients undergoing elective non-cardiac surgery, 7.9% patients have already had a clinical HF with and without symptoms, and in those patients, 60% had documented left ventricular (LV) preserved ejection fraction (EF). Not only LV systolic function but also diastolic dysfunction is reported to be an independent risk factor for adverse cardiovascular morbidities and mortalities in high-risk surgical patients including cardiovascular surgery and sepsis patients. Most surgical patients are commonly at an advanced age, and they often have several comorbidities such as hypertension, ischemic heart disease, diabetes mellitus, atrial fibrillation, chronic kidney disease, anemia, dyslipidemia, and chronic obstructive pulmonary disease. These are risk factor of LV diastolic dysfunction. Therefore, we should know that patients with these comorbidities are at a high risk for diastolic dysfunction, which could contribute to the development of postoperative HF. Anesthetic management for the patients with LV diastolic dysfunction is to avoid fluid overload. Recently, restrictive goal-directed fluid therapy is popular, but it cannot reduce the incidence of acute HF and postoperative pulmonary edema. Postoperative sympathetic activity due to arousal from the anesthesia, pain, shivering, and refilling, venous return and afterload increase, which affects LV diastolic volume and LV diastolic pressure and easily progresses into pulmonary edema in patients with LV diastolic dysfunction even if EF was preserved. Therefore, in perioperative management, it is important to identify patients with impaired LV function, especially those with diastolic dysfunction, to avoid intraoperative fluid overload, and to avoid postoperative pain and shivering.

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