冠状动脉旁路移植术围术期麻醉管理专家共识(2025版)

1.心脏功能的评估

推荐意见1:推荐术前对包括右心功能在内的心脏功能进行全面综合评估。(推荐强度:强,证据等级:中)

术前应以患者的症状和检查结果为依据,对心脏功能做出综合评估。症状的关注要点:(1)病史存在的总体时间;(2)心脏症状的特点,以胸背痛还是以胸闷憋气为主;(3)心绞痛的类型;(4)近期心脏症状发作的频率,是否伴有心力衰竭

2.冠状动脉的评估

冠状动脉造影仍是评估冠心病患者冠状动脉狭窄程度的首选方法[5],血流储备分数(fractional flow reserve, FRR)是冠状动脉狭窄严重程度的重要功能学评价指标[6]。冠状动脉病变的严重程度取决于狭窄的类型、位置、程度与累及的支数。相较于局限性病变,相同横截面积的节段性狭窄对血流量影响更大。狭窄位于近端时,则表示更大范围的心肌血供受阻。同一根冠状动脉有多处狭窄时,对血流量的影响可能出现叠加效应。左主干病变是围术期心血管不良事件的独立危险因素[7],前降支和回旋支的开口处或近端同时狭窄应视为左主干病变。右冠状动脉高位闭塞时,手术风险大大增加。此外还应判断狭窄的血管有无侧支供血,冠状动脉病变是否继发心肌损伤及损伤范围,是否伴有缺血型二尖瓣反流等情况。

3.肺功能的评估

推荐意见2:推荐术前从病史、肺功能、呼吸功能训练情况等对肺功能作综合评估。(推荐强度:强,证据等级:中)

术前有吸烟史的患者术后带管时间延长,发生肺部并发症的风险增加,戒烟可有效减轻上述影响[8]。术前合并COPD[9]、睡眠呼吸暂停综合征(sleep apnea syndrome, SAS)[10]等呼吸系统疾病与ICU停留时间、术后肺部并发症的发生率及远期死亡率相关,应在术前充分了解各疾病的发病时间、严重程度、近期发作情况及治疗经过。肺功能检查中,肺活量、第一秒用力呼气容积、一氧化碳弥散量等参数对CABG术后结局具有指示作用[11-12],是术前评估的重要指标。术前进行呼吸功能训练等肺部物理疗法能显著加快术后呼吸肌的功能恢复[13],改善氧合[14]。

4. 血糖和糖化血红蛋白水平的评估

推荐意见3:推荐术前进行血糖医师查开优化血糖管理。 (推荐强度强,证据等级B)

CABG 患者术前糖化血红蛋白水平与术后长期生存率相关[15-16]。术前血糖控制不佳(糖化血红蛋白>8%)可增加搭桥患者术后死亡率及主要心血管不良事件的发生风险[17]。此外,术前严格的血糖控制即较低的糖化血红蛋白水平,可减少术后伤口感染[18]和急性肾损伤的发生率[19]。一项系统评价[20]结果显示,术前伴有高血糖的非糖尿病患者术后1年死亡率是血糖正常患者的2倍,与术前确诊糖尿病患者的1年死亡率相当。推荐CABG患者进行术前血糖筛查并优化血糖管理,严格的血糖管理可能适用于伴有高血糖的非糖尿病患者,糖尿病患者可采取适度的血糖控制。

5.应用抗血小板药物的评估

推荐意见4:推荐接受抗血小板治疗的患者术前不停用低剂量阿司匹林。(推荐强度:强,证据等级:中)

推荐意见5:推荐接受双重抗血小板治疗的患者术前停用替格瑞洛至少3d、氯吡格雷至少5d、普拉格雷至少7d,必要时血小板功能监测可参与优化手术时机的选择。(推荐强度:弱,证据等级:中)

术前应用阿司匹林有助于稳定病情和减少围末期血栓形成的风险,同时可能增加出血性并发症的发生率。以往的指南[21]中推荐CABG术前持续使用低剂量阿司匹林,但在其心血管和出血风险方面,近年的研究[22-25]证据仍不统一。术前应综合评估其收益风险比,必要时可在术中通过输注血小板逆转阿司匹林的作用,减少严重出血性并发症的发生[26]。双重抗血小板治疗时,需要在持续使用阿司匹林的前提下,适时停用P2Y12受体拮抗剂[27],建议术前停用替格瑞洛至少3d、氯吡格雷至少5d、普拉格雷至少7d[28]。目前尚无公认的血栓弹力图等血小板功能监测决定用药策略的定量指标,可在权衡抗血栓收益与出血风险的同时,于血小板功能监测的辅助下缩短停药时间[29]。

问题2:CABG术中血流动力学的管理。

推荐意见6:推荐术中通过控制心率、合理的容量管理和血管活性药的使用维持血流动力学稳定。(推荐强度:强,证据等级:高)

血流动力学管理的核心是维持心肌氧供与氧耗的平衡。心肌氧供取决于冠状动脉的灌注压、血管阻力和动脉血氧含量。术中氧供不足的主要原因有:贫血、$SpO_2$下降、心脏前负荷不足、后负荷升高、心肌收缩力下降、冠状动脉阻力增加等。氧耗则取决于心率、室壁张力以及室壁厚度。术中控制心率可以降低氧耗并能保证心脏充足的舒张时间。对心率的调控目标应以术前患者基础状态下的心率水平作为参考,采取个体化管理。一定程度的心率增快,可能是危重患者对心输出量不足的代偿反应,此时机械性地降低心率可能造成循环崩溃。维持术中适宜的容量状态是血流动力学管理的重要环节,应在适当的血流动力学监测方法的指导下进行。在CABG术的循环维持中,应根据实际情况合理使用血管活性药,正性肌力药可以增加心肌收缩力,升高血压,增加心输出量,同时也会加快心率,增加心肌耗氧,术中应衡量收益谨慎使用。

在非心肺转流(cardiopulmonary bypass, CPB)下CABG术(off-pump coronary artery bypass grafting, OPCABG)中,搬动心脏以及心脏固定装置的使用,常引发术中低血压(intra-operative hypotension, IOH)。除患者自身因素外,导致IOH发生的诱因大致分为外科因素和术中管理因素。常见的外科因素有:(1)搬动或固定时心脏扭转角度过大;(2)与心脏接触的气体或液体温度过低;(3)冠状动脉内误入气体;(4)多支病变时血运重建顺序不当;(5)移植血管狭窄或闭塞;(6)出血。术中管理因素包括:(1)容量不足或负荷过大;

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(2)心率控制不良引起心肌氧耗增加或心输出量不足;(3)血管活性药使用不当;(4)麻醉深度过深或过浅;(5)内环境紊乱;(6)贫血;(7)低体温等。及时预防以及低血压发生时快速准确的鉴别并排除诱因,是管理此类IOH事件的前提和关键。当诱因无法在短时间内解除或解除后IOH仍不能纠正时,可给予血管活性药以维持心肌灌注,同时密切观察生命体征变化,必要时行IABP辅助或转为CPB下手术。应尽可能在适当的术中监测方法指导下,依照患者静息状态下血压的基线水平进行个体化管理。由于IOH与术后多种器官并发症相关[30],因此除了维持心脏功能外,进行血压调控时还应充分考虑相应器官的组织灌注。

问题3:CABG术中特殊情况的预防和处理。

1.冠状动脉痉挛

推荐意见7:推荐围术期积极预防冠状动脉痉挛的发生,钙离子拮抗药可用于桥血管痉挛的预防和治疗。(推荐强度:强,证据等级:高)

冠状动脉痉挛可以发生在CABG围术期的各个阶段,是术中紧急事件的常见诱因,主要表现为心电图上ST段和T波的改变、严重心律失常或其他不能解释原因的突然发生的血流动力学波动。引起冠状动脉痉挛发生的诱因主要有:(1)麻醉诱导前患者紧张和焦虑情绪;(2)麻醉过浅、疼痛刺激、应激增强;(3)严重的内环境紊乱;(4)缺氧或二氧化碳蓄积;(5)低体温;(6)冠状动脉低灌注;(7)鱼精蛋白过敏;(8)外科因素等。冠状动脉痉挛应以预防为主,如充分镇痛、抑制应激反应、避免低体温、维持适当的灌注压等。术中一旦出现冠状动脉痉挛,应立刻鉴别并解除诱因,同时给予钙离子拮抗药或硝酸酯类药物解痉治疗。荟萃分析[31]显示,连续静脉输注地尔硫草和硝酸甘油都能增加桥血管血流量并改善患者预后,与后者相比,地尔硫草能够更有效地降低术后心肌梗死和房颤的发生率。而一项队列研究[32]认为,地尔硫草在改善搭桥患者术后短期和长期结局方面并无显著优势。

2. IABP的应用

推荐意见8:推荐危重患者在术中应用IABP进行循环支持。(推荐强度:弱,证据等级:中)

对于CABG的高危患者术前植入IABP的收益,目前仍存在争议。一些研究[33]认为,IABP可以降低危重患者术前急性心血管事件的发生率,维护术中血流动力学平稳并改善预后,早期放置的效果优于术后应用[34-35]。而另一项多中心研究[36]显示,左主干受累的患者术前植入IABP,会导致机械通气时间和ICU停留时间延长,且不能降低心源性死亡率和院内并发症的发生风险。如CABG术中出现常规方法难以纠正的心功能障碍或CPB后停机困难,IABP仍是改善循环的备选方案之一,但其确切应用指征和应用时机则有待进一步研究。

问题4:CABG麻醉诱导的特点。

推荐意见9:推荐麻醉诱导期间积极控制心率和应激反应,力求气管插管前后循环稳定。(推荐强度:强,证据等级:高)

手术当天,由于禁饮禁食等因素会导致部分患者内环境紊乱,易在麻醉诱导期间引发心律失常和循环波动。因此,入室后可进行血气分析,必要时应在诱导前纠正电解质及酸碱平衡紊乱。对于心功能较好的患者,诱导前可适当给予快速补液,有助于维持患者诱导期的循环稳定。

CABG 麻醉诱导的目标是在尽可能维持血流动力学平稳的基础上,获得适当的麻醉深度,充分控制应激反应,为气管插管的顺利进行提供有利条件。诱导中最常用的阿片类药物为芬太尼和舒芬太尼,镇静药常选用咪达唑仑、丙泊酚和依托咪酯。丙泊酚可以使心排量轻度增加,心肌耗氧下降,但大剂量快速推注会引发严重心肌抑制和低血压,对于重症患者应谨慎使用。依托咪酯对心肌收缩力、心率、心排量均无明显影响,辅以适当剂量的阿片类药物可用于心功能较差的患者[37]。麻醉诱导期间静脉泵注右美托咪定,可有效减轻插管后心动过速的发生率,适用于冠心病患者的麻醉诱导[38-39]。研究[40]表明,七氟醚对于CABG的患者具有心脏保护作用,并且起效快、对血流动力学影响小,可以代替丙泊酚用于该类患者的麻醉诱导。除药物的配伍选择和剂量外,对于病情危重的患者,应特别注意从小剂量开始间断、缓慢、交替给药,使麻醉药物充分起效,避免用药过量,还能为心血管系统的自身调节提供充足的时间。

问题5:CABG的术中监测方法。

所有行CABG的患者均应进行基本的生命体征监测,包括常规建立5导联心电监测 $SpO_2$、$P_{ET}CO_2$、体温、有创动脉血压、中心静脉压(central venous pressure, CVP)监测等。

1.麻醉深度监测

推荐意见10:推荐术中进行麻醉深度监测。(推荐强度:强,证据等级:中)

麻醉深度监测可预防术中知晓,防止因麻醉过深或过浅对患者转归产生不良影响,为患者提供个体化的麻醉管理。BIS基于脑电图(electroencephalogram, EEG)频率谱和功率谱的非线性分析方法,能够较好地反映大脑皮质的功能状态。研究[41-42]指出,CABG患者围术期行BIS监测可同时减少麻醉药物和正性肌力药的用量,但并未增加术中知晓的风险。OPCABG期间由于心脏搬动导致的循环波动可能引起脑灌注不足,从而诱发术后谵妄(postoperative delirium, POD)或术后神经认知障碍(postoperative neurocognitive disorder, PNCD),其间BIS会发生显著变化[43]。此外,BIS还能为颈动脉狭窄患者CABG术中脑灌注不足提供诊断依据[44]。

研究[45]发现,对60岁以上心脏手术患者进行EEG监测并尽量减少术中EEG抑制,结果并没有降低POD的发生率。荟萃分析[46]结果提示,术中使用EEG监测对接受心脏手术患者POD的发生率没有影响,但可降低术后3个月内神经系统并发症的发生率。在CABG术中采用熵指数指导麻醉管理,可以显著减少麻醉药用量,缩短患者机械通气时间[47]。本共识推荐术中进行麻醉深度监测,以便提高麻醉质量,并减少麻醉药用量,从而改善患者预后。

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2. 脑氧饱和度监测

推荐意见11:推荐术中进行局部氧饱和度($rSO_2$)监测。(推荐强度:弱,证据等级:中)

心血管手术围术期脑卒中的发生率显著高于其他手术[48],术中脑血管低灌注是心脏手术患者术后发生脑卒中和认知功能障碍的主要原因[49]。研究[50]表明,术中监测$rSO_2$并采取积极干预措施将$rSO_2$维持在基线值的75%以上可降低CABG患者死亡率、重要器官功能不全的发生率,并缩短ICU停留时间。此外,通过及时干预尽量减少$rSO_2$累计阈值下的曲线下面积(area under the curve, AUC),可降低术后相关并发症的发生率。Harillall 等[51]发现在接受CABG手术的患者中,高龄和术前合并症是术后脑卒中和其他围术期不良结局的危险因素,建议术中监测$rSO_2$并在$rSO_2$下降时进行积极干预。最新研究[52]显示,在OPCABG术中行多部位组织氧监测,可有效维持术中患者的组织氧水平,但并未降低术后30 d并发症的复合结局,其在特定高风险患者和某些特定结局中的潜在应用价值有待进一步研究。已发布的指南[49]建议在心脏手术中使用$rSO_2$监测来识别急性脑缺血缺氧事件并指导术中管理,且$rSO_2$监测可能会缩短术后ICU停留时间。$rSO_2$值沿个体化基线水平(如在麻醉诱导前建立的基线)的变化趋势可能比$rSO_2$的绝对值提供更多信息[53]。建议在术前测量$rSO_2$基线值,与术中的测量值进行比较,同时结合手术不同阶段的特点及其他生理指标对$rSO_2$的变化进行个体化解读。

3. 经食管超声心动图(transesophageal echocardiography, TEE)检查

推荐意见12:推荐术中应用TEE检查。(推荐强度:弱,证据等级:高)

以往的指南[54-57]推荐在麻醉诱导后放置 TEE探头,以评估局部室壁运动、收缩和舒张功能以及自体和人工瓣膜等,应考虑在CABG 术中使用。总体上,TEE对局部心室壁运动异常、心室功能和容量状况的评估对于搭桥患者具有重要的临床意义。大样本研究[58-59]发现,术中 TEE检查增加计划外瓣膜手术的几率,降低患者术后死亡率,尤其推荐在高危患者中使用。

4.肺动脉导管(pulmonary artery catheter, PAC)监测

推荐意见13:推荐高危患者术中应用肺动脉导管PAC监测。(推荐强度:弱,证据等级:中)

早期研究[60]显示,CABG患者不能从PAC的使用中获益,应用PAC可能与死亡率升高相关。后来的研究[61-62]认为,这一结果所基于的证据数量和质量有限,且不排除PAC实际应用指征可能使结果发生偏倚,因此上述结论存在局限性。目前仍然缺乏针对PAC在CABG术中使用的大样本随机对照试验的结果,综合以往的证据,不建议在择期CABG的患者中常规应用PAC。尽管如此,随着监测技术和专业人员水平的提高,PAC监测能够提供除早期压力指标以外更多的数据参数,有助于麻醉科医师对循环和氧供氧耗状态的

掌握。既往的指南$^{[63]}$认为,是否在术中放置PAC,应从患者因素、手术因素、操作人员因素三个方面进行综合评估,推荐在高危手术的高危患者中应用PAC监测。

问题6:CABG 麻醉管理与维持。

推荐意见14:推荐采用静脉或吸入麻醉进行术中麻醉维持。(推荐强度:强,证据等级:高)

推荐意见15:推荐微创直接CABG(minimally invasive direct coronary artery bypass, MIDCAB)采用全麻复合神经阻滞。(推荐强度:弱,证据等级:中)

研究[64]表明,在CABG术中使用吸入麻醉药可降低患者的死亡率。美国心脏病学会和美国心脏协会的指南指出,基于吸入麻醉药可降低患者围术期心肌缺血和梗死风险,建议在CABG术中采用吸入麻醉[57]。此外,与丙泊酚比较,吸入麻醉药维持麻醉可降低接受OPCABG的成年患者的远期死亡率,在心肌保护等方面也优于丙泊酚[65]。然而,大样本随机对照试验[66]发现,CABG患者术中采用吸入麻醉在30d或1年内的死亡率相较于全凭静脉麻醉(total intravenous anesthesia, TIVA)方案并未显著减少。另一项荟萃分析[67]也得到了相似的结果,但吸入麻醉可能会缩短机械通气时间。最新研究[68]显示,吸入麻醉和基于丙泊酚的TIVA在成年心脏手术患者术后30d死亡率、远期死亡率、机械通气时间、ICU和住院时间等方面均无显著差异。依照目前的证据,建议CABG术中采用静脉或吸入麻醉行麻醉维持。

与传统正中开胸手术相比,MIDCAB旨在实现患者快速康复的前提下,不增加术后并发症的发生率和死亡率[69]。但MIDCAB可能引发严重的术后急性疼痛,疼痛控制不佳可能导致严重的术后肺部并发症、ICU停留时间和住院时间的延长[70]。因此,为MIDCAB患者寻找最佳的术后镇痛方法显得至关重要。中大剂量阿片类药物的使用,常引起恶心呕吐、尿潴留、呼吸抑制等不良反应继而阻碍患者的早期康复[71]。由于CABG术中需要肝素化,使用胸部硬膜外镇痛可能会带来严重风险,超声引导下的浅筋膜间平面阻滞可能是一种替代方案[72]。研究[73]发现,对MIDCAB患者采用椎旁神经阻滞(paravertebral nerve block, PVB)可获得与胸部硬膜外镇痛(thoracic epidural analgesia, TEA)相当的镇痛效果,且PVB操作难度更低,安全性更高。超声引导下竖脊肌平面阻滞(erector spinae plane block, ESPB)可降低MIDCAB患者术后疼痛评分,减少术中芬太尼和氢吗啡酮用量,缩短拔管时间和ICU停留时间[74]。胸部局部镇痛是心脏手术围术期多模式疼痛管理的有效组成部分[75],本共识推荐对MIDCAB的患者采用全麻复合超声引导下神经阻滞。

问题7:CABG的抗炎抗应激策略。

推荐意见16:推荐术中采取积极抗炎抗应激策略。(推荐强度:弱,证据等级:中)

疼痛刺激及外科操作等因素可触发CABG患者的应激反应和炎症反应。全身炎症水平是引发动脉粥样硬化性心血管疾病患者心血管事件和死亡的决定因素之一[76]，用术

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期实施有效的抗炎抗应激策略,可改善CABG患者的预后,缓解患者的紧张焦虑情绪、抑制疼痛刺激、减少不必要的外科操作影响,可有效减少应激和炎症反应的来源。研究[77-78]显示,一些药物在OPCABG或CABG术中发挥抗炎作用,有助于改善患者术后的肾功能和呼吸功能,减少神经系统并发症的发生风险[79]。研究显示,心脏手术中糖皮质激素的应用既不能降低术后死亡及主要并发症的风险[80-81],也不能减少恢复期的切口疼痛[82]。但也有临床研究[83-84]表明,术中大剂量地塞米松的应用可缩短心脏手术患者的ICU停留时间,但对术后30d内生存时间等其他结局并无显著影响。综上所述,目前尚无充分证据显示术中常规应用糖皮质激素使CABG患者获益。

《冠状动脉旁路移植术围术期管理专家共识(2025版)》

工作组名单(按姓氏汉语拼音排序)

组长

韩建阁(天津大学胸科医院)

执笔人

于建(天津大学胸科医院)

孙朋(天津大学胸科医院)

李云飞(天津大学胸科医院)

翟文倩(天津大学胸科医院)

成员

敖虎山(中国医学科学院阜外医院)

柴云飞(广东省人民医院)

陈世彪(南昌大学第一附属医院)

陈燕桦(广西医科大学第一附属医院)

戴茹萍(中南大学湘雅二医院)

刁玉刚(解放军北部战区总医院)

董榕(上海交通大学医学院附属瑞金医院北部院区)

郭克芳(复旦大学附属中山医院)

郭志刚(天津大学胸科医院)

韩建阁(天津大学胸科医院)

Jiapeng Huang (University of Louisville, USA)

黄立宁(河北医科大学第二医院)

黄维勤(亚洲国际心脏病医院)

黄志勇(中国医学科学院阜外医院深圳医院)

江德斌(福建医科大学附属协和医院)

金沐(首都医科大学附属北京友谊医院)

雷钟(空军军医大学第一附属医院)

雷迁(四川省人民医院)

李斌(郑州大学第一附属医院)

李小刚(西安交通大学第一附属医院)

林洪启(阜外华中心血管病医院)

刘亚涛(兰州大学第一医院)

鲁显福(安徽医科大学第一附属医院)

孟庆涛(武汉大学人民医院)

史宏伟(南京市第一医院)

史 静(贵州医科大学附属医院)

田毅(中南大学湘雅医学院附属海口医院)

汪炜健(温州医科大学附属第一医院)

王 锷(中南大学湘雅医院)

王晟(首都医科大学附属北京安贞医院)

王洪涛(昆明市延安医院)

王洪武(泰达国际心血管病医院)

王伟鹏(上海德达心血管医院)

王永旺(天津医科大学第二医院)

王云(青海省人民医院)

吴剑波(山东第一医科大学第一附属医院)

武庆平(华中科技大学同济医学院附属协和医院)

徐桂萍(新疆维吾尔自治区人民医院)

徐建红(浙江大学医学院附属第四医院)

徐宇玉(香港玛丽医院)

于春华(中国医学科学院北京协和医院)

表莉(青岛大学附属医院)

表 素(中国医学科学院阜外医院)

张林忠(山西医科大学第二医院)

章放香(贵州省人民医院)

曾俊(四川大学华西临床医学院)

钟巍(河南省胸科医院)

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(收稿日期:2025-08-31)

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