術前全身評価（５月１６日 担当：板井先生）

術前の全身評価についてアップデートしました。

術前プレゼンテーションの時に「心・肺・肝・腎、異常ありません。」で済まされる症例の少なくなって来た昨今では、外科医は何を基準に術前状態の把握を行い、手術適応を決定すればよいのでしょうか？











































今日勉強した中で、心機能評価に関する内容は、下記論文に詳述されています。
Eur Heart J. 2009 Nov;30(22):2769-812. doi: 10.1093/eurheartj/ehp337. Epub 2009 Aug 27.
Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery.

この中に、今日discussionした内容も詳しく書かれていたので、下記に抜粋します。

１．EFの評価
Assessment of left ventricular function
Resting LV function can be evaluated before non-cardiac surgery by radionuclide ventriculography, gated single photon emission computed tomography (SPECT) imaging, echocardiography, magnetic resonance imaging (MRI), or multislice computed tomography (CT), with similar accuracy. Routine echocardiography is not recommended for the pre-operative evaluation of LV function, but may be performed in asymptomatic patients undergoing high-risk surgery. A meta-analysis of the available data demonstrated that an LV ejection fraction of <35% had a sensitivity of 50% and a specificity of 91% for prediction of perioperative non-fatal MI or cardiac death.　The limited predictive value of LV function assessment for perioperative outcome may be related to the failure to detect severe underlying IHD. Recommendations for the pre-operative evaluation of (asymptomatic) patients with cardiac murmurs are discussed in the section on VHD.


２．心機能と腹腔鏡下手術
Laparoscopic procedures have the advantage of causing less tissue trauma and intestinal paralysis compared with open procedures, resulting in less incisional pain and diminished post-operative fluid shifts related to bowel paralysis. On the other hand, the pneumoperitoneum used in these procedures results in elevated intra-abdominal pressure and a reduction in venous return. It will result in a decrease in cardiac output and an increase in systemic vascular resistance. <strong>Therefore, cardiac risk in patients with heart failure is not diminished in patients undergoing laparoscopy compared with open surgery, and both should be evaluated in the same way. This is especially true in patients undergoing interventions for morbid obesity.

ついでに、BNP値などもBiomarkerとして有用との事です。
ご一読を。