眼科手术患者流行病学情况调查及心血管病患者围手术安全性分析
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摘要
目的 眼科手术对全身创伤虽小，但术前、术中的用药、紧张情绪、手术刺激、疼痛、麻醉、眼心反射等均能增加手术危险性。随着医疗技术的进步，决定眼科手术安全性的关键因素不再是手术本身，而是患者伴有的全身疾病情况，如心血管病、糖尿病等。另外流行病学模式的转变、人口老龄化和人类疾病谱的改变在眼科手术患者中同样产生深刻的影响。因此，有必要对目前眼科手术患者并发全身病情况进行探讨，并对目前国内广泛开展的较新型眼科手术，即白内障超声乳化和视网膜玻璃体手术的安全性进行评估，探讨在并发心血管病患者中两种手术对血压、眼心反射及心电图等的影响，评估不同麻醉方法及术前、术中用药等因素对手术的安全性。以期对选择手术适应症、制定合理的围手术期处理措施提供依据。
方法 1. 回顾性分析十年间我院眼科手术患者流行病学变化情况。 2. 比较白内障超声乳化手术中心血管病患者与对照组、表面麻醉组与球后麻醉组血压、眼心反射、心电图变化情况。3. 比较玻璃体视网膜手术中心血管病组与对照组、麻醉中使用与不使用肾上腺素血压、眼心反射、心电图变化情况。4. 随访心血管病组与对照组术后视力恢复情况。
结果 1. 1989年、2000年眼科手术患者年龄分别为35.4±23.4岁和56.7±19.5岁，十年间患者年龄增高非常显著 (P<0.01)；患者并发心血管系统疾病的比例从18.9%上升到68.6%，上升幅度非常显著(P<0.01)。2. 白内障超声乳化手术术中各阶段平均收缩压水平与术前相比，心血管病组升高6.9～18.2mmHg,对照组升高8.3～13.4mmHg；心血管病组在手术切口和超声乳化时收缩压升高显著(P<0.05)，对照组除麻醉外其余各时段收缩
压升高均显著(P<0.05)；另外在切口、超声乳化、I/A时球后麻醉组舒张压升高较表面麻醉组显著(P<0.05)；但患者都能安全经历手术。视网膜玻璃体手术平均时间164分钟，明显长于白内障超声乳化手术21分钟的平均术时，但术中血压变化不大；在手术麻醉时运用肾上腺素组舒张压升高较显著(P<0.05)。3. 白内障超声乳化手术术中OCR发生率为17%～18%，视网膜玻璃体手术术中发生率为33%～44%，差异非常显著(P<0.01)；白内障超声乳化手术术中表面麻醉组与球后麻醉组OCR发生率分别为13%和23%，差异显著(P<0.05)。4. 术中新出现心电异常多为短时或一过性，球后麻醉时发生率36%，表面麻醉时发生率17%，差异显著(P<0.05)。5. 白内障超声乳化手术术后随访3月，心血管病组视力恢复情况较差，与对照组比较差异显著(P<0.05)。
结论 1. 眼科手术患者合并全身病情况符合流行病学模式的改变，与1989年相比老龄、心血管病和糖尿病人群增加。该人群在白内障手术患者中的比例呈上升趋势。2. 手术可引起患者术中血压升高，与术前是否合并心血管病无必然关系。术前运用镇静剂或强化麻醉对维持术中血压的稳定有益。表面麻醉运用于白内障超声乳化手术较球后麻醉更安全。麻醉中使用的小剂量肾上腺素对血压影响不大，偶可引起心动过速，在心血管病患者中应当慎用。3. 术中OCR发生与是否合并心血管病无关，而复杂的手术操作和手术刺激是术中OCR发生增高的原因。OCR大都是一过性，可自行缓解，但要注重手术全过程的监护，作好急救准备。表面麻醉、术中操作轻柔可减少OCR的发生。4. 术前心电图正常者术中仍有出现心电图异常改变的可能，因此无论合并心血管病与否，有条件术中尽量运用心电监护；术中新出现心电异常与麻醉、情绪、药物等因素相关，大都是偶发或一过性。5. 作为目前国内开展较多的眼科手术，白内障超声乳化手术和视网膜脱离玻璃体切割手术在心血管病患者中开展是安全和可靠的。
Objective Although ophthalmologic operation had a little influence on the systemic body of patient, it would increase operation risk that medications, stress, operative stimulus, pain, anesthesia, oculocardiac reflex(OCR) and so on. With the development of medicine and technique, the committed safe factor to the ophthalmologic operation was not operation itself, but the concomitant diseases of the patient, such as cardiovascular disease, diabetes mellitus. Moreover, the transition in patterns of epidemiology, aging and change of disease pedigree in mankind would influence on the concomitant diseases of patient deeply. Therefore, it was necessary to research the change of concomitant diseases of ophthalmologic operation at present. In addition, ophthalmologist should evaluate safety and reliability of phacoemulsification and vitreoretinal operation which were carried out widely, and research the change of blood pressure, OCR and electrocardiogram(ECG) in the two kinds of operations above which were performed on the patient with cardiovascular disease, so as to provide evidence for the management in the peri-operation period.
Methods 1. Analyzing retrospectively the transition of epidemiology on the ocular surgery patients in ten years. 2. Patients in phacoemulsification were divided into cardiovascular disease group and control group, topical anesthesia group and retrobulbar anesthesia group, and comparing the changes of blood pressure, OCR and ECG among all groups. 3. Patients in vitreoretinal operation were divided into cardiovascular disease group and control group, anesthesia with epinephrine group and without group.
Comparing the changes of blood pressure, OCR and ECG among all groups. 4. Following-up the visual acuity in the cardiovascular disease group and control group after operation.
Results 1. Age of patients were 35.4±23.4 and 56.7±19.5 in 1989 and 2000 respectively, ratio of patients with cardiovascular disease was from 18.9% to 68.6% in ten years, it was significant difference (P<0.01). 2. Compared with the mean systolic blood pressure at preoperative phase in phacoemulsification, cardiovascular disease group rose 6.9～18.2mmHg and control group rose 8.3～13.4mmHg during operation. Cardiovascular disease group had a significant rise in systolic blood pressure(P<0.05) at incision and phacoemulsification, the same as control group at all phases beside anesthesia. Compared with topical anesthesia group, retrobulbar anesthesia group had a significant rise in diastolic blood pressure(P<0.05) at incision , phacoemulsification and Irrigation/Aspiration(I/A). The mean time of vitreoretinal operation was 164 minutes which was longer than that of phacoemulsification, but the blood pressure had a little change, and diastolic blood pressure in anesthesia with epinephrine group rose significantly(P<0.05) at anesthesia phase. 3. Ratio of OCR was 17～18% in phacoemulsification and 33～44% in vitreoretinal operation, moreover, it was 13% in topical anesthesia group and 23% in retrobulbar anesthesia group, and the difference was significant. 4. There were new and transient ECG abnormalities during operation, which did not necessarily associate with the preoperative ECG and occurred in retrobulbar anesthesia group mostly. 5. Patients have been followed-up for three months after phacoemulsification, cardiovascular disease group had a worse visual acuity than control group, the difference was significant(P<0.05).
Conclusions 1. The concomitant diseases of the ocular surgery patients accorded with the changing of epidemiology. Old people with cardiovascular
disease would be the important group in the ophthalmologic operation, especially in cataract surgery. 2. Blood pressure had a rise tendency during operation. It was beneficial for maintaining stability of blood pressure to apply anesthesia with reinforcement in a long time operation. Topical anesthesia was reliable in cataract phacoemulsification. Proper dosage of epinephrine with anesthesia gave a little influence on blood pressure, but i
方法 1. 回顾性分析十年间我院眼科手术患者流行病学变化情况。 2. 比较白内障超声乳化手术中心血管病患者与对照组、表面麻醉组与球后麻醉组血压、眼心反射、心电图变化情况。3. 比较玻璃体视网膜手术中心血管病组与对照组、麻醉中使用与不使用肾上腺素血压、眼心反射、心电图变化情况。4. 随访心血管病组与对照组术后视力恢复情况。
结果 1. 1989年、2000年眼科手术患者年龄分别为35.4±23.4岁和56.7±19.5岁，十年间患者年龄增高非常显著 (P<0.01)；患者并发心血管系统疾病的比例从18.9%上升到68.6%，上升幅度非常显著(P<0.01)。2. 白内障超声乳化手术术中各阶段平均收缩压水平与术前相比，心血管病组升高6.9～18.2mmHg,对照组升高8.3～13.4mmHg；心血管病组在手术切口和超声乳化时收缩压升高显著(P<0.05)，对照组除麻醉外其余各时段收缩
压升高均显著(P<0.05)；另外在切口、超声乳化、I/A时球后麻醉组舒张压升高较表面麻醉组显著(P<0.05)；但患者都能安全经历手术。视网膜玻璃体手术平均时间164分钟，明显长于白内障超声乳化手术21分钟的平均术时，但术中血压变化不大；在手术麻醉时运用肾上腺素组舒张压升高较显著(P<0.05)。3. 白内障超声乳化手术术中OCR发生率为17%～18%，视网膜玻璃体手术术中发生率为33%～44%，差异非常显著(P<0.01)；白内障超声乳化手术术中表面麻醉组与球后麻醉组OCR发生率分别为13%和23%，差异显著(P<0.05)。4. 术中新出现心电异常多为短时或一过性，球后麻醉时发生率36%，表面麻醉时发生率17%，差异显著(P<0.05)。5. 白内障超声乳化手术术后随访3月，心血管病组视力恢复情况较差，与对照组比较差异显著(P<0.05)。
结论 1. 眼科手术患者合并全身病情况符合流行病学模式的改变，与1989年相比老龄、心血管病和糖尿病人群增加。该人群在白内障手术患者中的比例呈上升趋势。2. 手术可引起患者术中血压升高，与术前是否合并心血管病无必然关系。术前运用镇静剂或强化麻醉对维持术中血压的稳定有益。表面麻醉运用于白内障超声乳化手术较球后麻醉更安全。麻醉中使用的小剂量肾上腺素对血压影响不大，偶可引起心动过速，在心血管病患者中应当慎用。3. 术中OCR发生与是否合并心血管病无关，而复杂的手术操作和手术刺激是术中OCR发生增高的原因。OCR大都是一过性，可自行缓解，但要注重手术全过程的监护，作好急救准备。表面麻醉、术中操作轻柔可减少OCR的发生。4. 术前心电图正常者术中仍有出现心电图异常改变的可能，因此无论合并心血管病与否，有条件术中尽量运用心电监护；术中新出现心电异常与麻醉、情绪、药物等因素相关，大都是偶发或一过性。5. 作为目前国内开展较多的眼科手术，白内障超声乳化手术和视网膜脱离玻璃体切割手术在心血管病患者中开展是安全和可靠的。
Objective Although ophthalmologic operation had a little influence on the systemic body of patient, it would increase operation risk that medications, stress, operative stimulus, pain, anesthesia, oculocardiac reflex(OCR) and so on. With the development of medicine and technique, the committed safe factor to the ophthalmologic operation was not operation itself, but the concomitant diseases of the patient, such as cardiovascular disease, diabetes mellitus. Moreover, the transition in patterns of epidemiology, aging and change of disease pedigree in mankind would influence on the concomitant diseases of patient deeply. Therefore, it was necessary to research the change of concomitant diseases of ophthalmologic operation at present. In addition, ophthalmologist should evaluate safety and reliability of phacoemulsification and vitreoretinal operation which were carried out widely, and research the change of blood pressure, OCR and electrocardiogram(ECG) in the two kinds of operations above which were performed on the patient with cardiovascular disease, so as to provide evidence for the management in the peri-operation period.
Methods 1. Analyzing retrospectively the transition of epidemiology on the ocular surgery patients in ten years. 2. Patients in phacoemulsification were divided into cardiovascular disease group and control group, topical anesthesia group and retrobulbar anesthesia group, and comparing the changes of blood pressure, OCR and ECG among all groups. 3. Patients in vitreoretinal operation were divided into cardiovascular disease group and control group, anesthesia with epinephrine group and without group.
Comparing the changes of blood pressure, OCR and ECG among all groups. 4. Following-up the visual acuity in the cardiovascular disease group and control group after operation.
Results 1. Age of patients were 35.4±23.4 and 56.7±19.5 in 1989 and 2000 respectively, ratio of patients with cardiovascular disease was from 18.9% to 68.6% in ten years, it was significant difference (P<0.01). 2. Compared with the mean systolic blood pressure at preoperative phase in phacoemulsification, cardiovascular disease group rose 6.9～18.2mmHg and control group rose 8.3～13.4mmHg during operation. Cardiovascular disease group had a significant rise in systolic blood pressure(P<0.05) at incision and phacoemulsification, the same as control group at all phases beside anesthesia. Compared with topical anesthesia group, retrobulbar anesthesia group had a significant rise in diastolic blood pressure(P<0.05) at incision , phacoemulsification and Irrigation/Aspiration(I/A). The mean time of vitreoretinal operation was 164 minutes which was longer than that of phacoemulsification, but the blood pressure had a little change, and diastolic blood pressure in anesthesia with epinephrine group rose significantly(P<0.05) at anesthesia phase. 3. Ratio of OCR was 17～18% in phacoemulsification and 33～44% in vitreoretinal operation, moreover, it was 13% in topical anesthesia group and 23% in retrobulbar anesthesia group, and the difference was significant. 4. There were new and transient ECG abnormalities during operation, which did not necessarily associate with the preoperative ECG and occurred in retrobulbar anesthesia group mostly. 5. Patients have been followed-up for three months after phacoemulsification, cardiovascular disease group had a worse visual acuity than control group, the difference was significant(P<0.05).
Conclusions 1. The concomitant diseases of the ocular surgery patients accorded with the changing of epidemiology. Old people with cardiovascular
disease would be the important group in the ophthalmologic operation, especially in cataract surgery. 2. Blood pressure had a rise tendency during operation. It was beneficial for maintaining stability of blood pressure to apply anesthesia with reinforcement in a long time operation. Topical anesthesia was reliable in cataract phacoemulsification. Proper dosage of epinephrine with anesthesia gave a little influence on blood pressure, but i
引文
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2. Eustis HS, Eiswirth CC, Smith DR.Vagal responses to adjustable sutures in strabismus correction. Am J Ophthalmol, 1992,114:307-12.
3. Smith RB.Death and the oculocardiac reflex. Can J Anaesth, 1994,41:760-1.
4. Badrinath S. S.Ophthalmic surg. Lasers, 1995,26:535-8.
5. WHO-ISH Hypertension Guidelines Committee.1999 World Health Organizational Society of Hypertension Guidelines for the Management of Hypertension.J Hypertension, 1999, 17:151-2.
6. Halstead SB.Dengue In the Health Transition, Kao-Hsiung-I-Hsush-Ko- Hsueh-Tsa-Chih, 1994,10:S2-14.
7. WHO.The World Health Report 1997, Conquering suffering, Enriching Humanity, Geneva:WHO, 1997.
8. Jamison DT.Disease Control Priorities in Developing Countries. Oxford Medical Publications, 1993:31-33.
9. 饶克勤. 中国主要城市人口疾病死亡模式变化的理论模型和趋势预测.世界医药与医疗设备专家论坛，1995，1(1)：62-64.
10. Aziz ES, Samra A. Prospective evaluation of deep topical fornix nerve block versus peribulbar nerve block in patients undergoing cataract surgery using phacoemulsification. Br-J-Anaesth, 2000, 85(2): 314-6.
11. Johnston RL, Whitefield LA, Giralt J, et al. Topical versus peribulbar anesthesia, without sedation, for clear corneal phacoemulsification. J-Cataract-Refract-Surg, 1998,24(3): 407-10.
12. Roman S, Pietrini D, Auclin F. Phacoemulsification and topical anesthesia. Apropos of 40 cases. J-Fr-Ophtalmol, 1996,19(1): 32-8.
13. Chen L, Li MG.Clinical investigation of phacoemulsification through a clear corneal incision in advanced aged patients with cataract. Chin Ophthal Res, 1999, 4:294-6.
14. Modarres M, Parvaresh MM, Hashemi M, et al. Inadvertent globe perforation during retrobulbar injection in high myopes. Int-Ophthalmol, 1997-98, 21(4): 179-85.
15. Bullock JD, Warwar RE, Green WR. Ocular explosion during cataract surgery: a clinical, histopathological, experimental, and biophysical study. Trans-Am-Ophthalmol-Soc, 1998, 96243-76:276-81.
16. Watkins R, Beigi B, Yates M, et al. Intraocular pressure and pulsatile ocular blood flow after retrobulbar and peribulbar anaesthesia. Br-J-Ophthalmol, 2001, 85(7): 796-8.
17. Hunter DG, Lam GC, Guyton DL. Inferior oblique muscle injury from local anesthesia for cataract surgery. Ophthalmology, 1995,102(3): 501-9.
18. Strobel I, Huhnermann M. Eyedrop anesthesia in cataract surgery. Ophthalmologe, 1996, 93(1): 68-72.
19. Newman DK. Visual experience during phacoemulsification cataract surgery under topical anaesthesia. Br-J-Ophthalmol, 2000,84(1): 13-5.
20. Fiore PM, Cinotti AA. Systemic effects of intraocular epinephrine during cataract surgery. Ann-Ophthalmol, 1988, 20(1): 23-5.
21. 周承逵. 眼心反射引起心跳停搏1例.实用眼科杂志，1983，1：173-4.
22. Vrabec MP, Preslan MW, Kushner BJ.Oculocardiac reflex during manipulation of adjustable sutures after strabismus surgery. Am J Ophthalmol, 1987,104:61-67.
23. 于秀敏，王利华.不同麻醉方法下眼外肌手术的眼心反射.中华眼科杂志，1991，27：34-35.
24. 高磊，陶志刚，王卿，等.老年性白内障术中的眼心反射.中华眼科杂志，1997，33：334-35.
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27. Heuermann T, Anders N, Rieck P. Peribulbar anesthesia versus topical anesthesia in cataract surgery: comparison of the postoperative course. Ophthalmologe, 2000,97(3): 189-93.
28. Eke T, Thompson JR. The National Survey of Local Anaesthesia for Ocular Surgery. II. Safety profiles of local anaesthesia techniques. Eye, 1999,13 ( Pt 2):196-204.
29. Kim MS, Cho KS, Woo H. Effects of hand massage on anxiety in cataract surgery using local anesthesia. J-Cataract-Refract-Surg, 2001, 27(6): 884-90.
30. Harman DM. Combined sedation and topical anesthesia for cataract surgery. J-Cataract-Refract-Surg, 2000,26(1): 109-13.
31. Rosenfeld SI, Litinsky SM, Snyder DA, et al. Effectiveness of monitored anesthesia care in cataract surgery. Ophthalmology, 1999,106(7): 1256-60, discussion 1261.
32. Jayamanne DG, Gillie RF. The effectiveness of peri-operative cardiac monitoring and pulse oximetry. Eye, 1996,10 ( Pt 1)130-2.
2. Eustis HS, Eiswirth CC, Smith DR.Vagal responses to adjustable sutures in strabismus correction. Am J Ophthalmol, 1992,114:307-12.
3. Smith RB.Death and the oculocardiac reflex. Can J Anaesth, 1994,41:760-1.
4. Badrinath S. S.Ophthalmic surg. Lasers, 1995,26:535-8.
5. WHO-ISH Hypertension Guidelines Committee.1999 World Health Organizational Society of Hypertension Guidelines for the Management of Hypertension.J Hypertension, 1999, 17:151-2.
6. Halstead SB.Dengue In the Health Transition, Kao-Hsiung-I-Hsush-Ko- Hsueh-Tsa-Chih, 1994,10:S2-14.
7. WHO.The World Health Report 1997, Conquering suffering, Enriching Humanity, Geneva:WHO, 1997.
8. Jamison DT.Disease Control Priorities in Developing Countries. Oxford Medical Publications, 1993:31-33.
9. 饶克勤. 中国主要城市人口疾病死亡模式变化的理论模型和趋势预测.世界医药与医疗设备专家论坛，1995，1(1)：62-64.
10. Aziz ES, Samra A. Prospective evaluation of deep topical fornix nerve block versus peribulbar nerve block in patients undergoing cataract surgery using phacoemulsification. Br-J-Anaesth, 2000, 85(2): 314-6.
11. Johnston RL, Whitefield LA, Giralt J, et al. Topical versus peribulbar anesthesia, without sedation, for clear corneal phacoemulsification. J-Cataract-Refract-Surg, 1998,24(3): 407-10.
12. Roman S, Pietrini D, Auclin F. Phacoemulsification and topical anesthesia. Apropos of 40 cases. J-Fr-Ophtalmol, 1996,19(1): 32-8.
13. Chen L, Li MG.Clinical investigation of phacoemulsification through a clear corneal incision in advanced aged patients with cataract. Chin Ophthal Res, 1999, 4:294-6.
14. Modarres M, Parvaresh MM, Hashemi M, et al. Inadvertent globe perforation during retrobulbar injection in high myopes. Int-Ophthalmol, 1997-98, 21(4): 179-85.
15. Bullock JD, Warwar RE, Green WR. Ocular explosion during cataract surgery: a clinical, histopathological, experimental, and biophysical study. Trans-Am-Ophthalmol-Soc, 1998, 96243-76:276-81.
16. Watkins R, Beigi B, Yates M, et al. Intraocular pressure and pulsatile ocular blood flow after retrobulbar and peribulbar anaesthesia. Br-J-Ophthalmol, 2001, 85(7): 796-8.
17. Hunter DG, Lam GC, Guyton DL. Inferior oblique muscle injury from local anesthesia for cataract surgery. Ophthalmology, 1995,102(3): 501-9.
18. Strobel I, Huhnermann M. Eyedrop anesthesia in cataract surgery. Ophthalmologe, 1996, 93(1): 68-72.
19. Newman DK. Visual experience during phacoemulsification cataract surgery under topical anaesthesia. Br-J-Ophthalmol, 2000,84(1): 13-5.
20. Fiore PM, Cinotti AA. Systemic effects of intraocular epinephrine during cataract surgery. Ann-Ophthalmol, 1988, 20(1): 23-5.
21. 周承逵. 眼心反射引起心跳停搏1例.实用眼科杂志，1983，1：173-4.
22. Vrabec MP, Preslan MW, Kushner BJ.Oculocardiac reflex during manipulation of adjustable sutures after strabismus surgery. Am J Ophthalmol, 1987,104:61-67.
23. 于秀敏，王利华.不同麻醉方法下眼外肌手术的眼心反射.中华眼科杂志，1991，27：34-35.
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