颅内动脉瘤夹闭术中七氟烷复合瑞芬太尼控制性降压
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摘要
[目的]通过七氟烷复合瑞芬太尼用于颅内动脉瘤夹闭术中的控制性降压，探讨七氟烷复合瑞芬太尼控制性降压的可行性及效果。
[方法]选择期行颅内动脉瘤夹闭术患者36例，随机分为A组（七氟烷组n=18）和B组（硝酸甘油组n=18），A组以七氟烷作为控制性降压药物，B组以硝酸甘油作为控制性降压药物。
[结果]七氟烷复合瑞芬太尼控制性降压安全用于颅内动脉瘤夹闭术，且术后随访未见麻醉并发症。
[结论]七氟烷复合瑞芬太尼行控制性降压可以做到满意的效果。它具有降压及恢复血压平稳、易于控制、麻醉苏醒快、降压期间对组织代谢影响轻，可用于神经外科手术的控制性降压麻醉，值得推广。
[Objective] To explore the feasibility and anesthetic effect ofDeliberate Hypotension Induced by Sevoflurane-RemifentanilCompounded Anesthesia in the Clamp Operation of IntracranialAneurysm
[Methods] Thirty-six ASA I~II patients undergoing electiveclipping surgery of intracranial aneurysm were randomly divided into2 groups(n=18each): Group A deliberated hypotension withsevoflurane inhalation (sevoflurane group); group B deliberatedhypotension with nitroglycerin administration (nitroglycerin group).Transfuseing 10~15ml/kg colloid fluid in 30~40min. Monitoring BP,ECG, SpO2, PETO2, invasive BP (arteriopuncture after inducing).Setting respiratory parameter: VT 8~12ml/kg, frequency 10~12/min,inspiratory/expiratory 1:2. All the patients were induced withmadazolam 2mg, fentanyl 3~5μg/kg, etomidate 0.3mg/kg, vecuronium0.08~0.1mg/kg. In group A anesthesia was maintained withremifentanil 8μg/ml + sevoflurane (initial concentration 0.5MAC,increase 0.5MAC every 3 respirations till the inhalation concentrationreach to 1.0~1.5MAC); in group B with remifentanil 8μg/ml +propofol 6~8mg/(kg·h), interruptable intravenous injection ofvecuronium was administrated as needed. Regulating theconcentration of sevoflurane and the pumping speed of propofol ineach group depending on the vital signs. After the dura was opened, gradually increased the inhalation concentration of sevoflurane (1~3MAC) in group A and started to pump nitroglycerin at a speed of 3μg/(kg·min)in group B to make SBP go down 25%~40% and maintain the MAP at a level about 60mmHg, the MAP shoule be further decreased at the time of clipping the intracranial aneurysm. Decreased the inhaled concentration of sevoflurane(0.5~1MAC) in group A and stopped pumping the nitroglycerin in group B after clipping to recover BP as the level that before Deliberate Hypotension. Stopped the application of sevoflurane and propofol in each groups 20mins before the completion of surgery. Remifentanil should be stopped using at the time of suturing the skin. The patients were extubated and breathing spontaneously with SPO2>93% and could open eyes on verbal command before being transferred to wards. Recorded the urinary volume, transfusion volume, losing volume of blood; Noted the BP and HR before and after Deliberate Hypotension. Blood gas analysis was undertaken at 5 time points: T0 (started to Deliberate Hypotension)、T1(20min after Deliberate Hypotension)、T2(40min after Deliberate Hypotension)、T3(60min after Deliberate Hypotension)and T4 (the end of the surgery). The duration time of achieving Deliberate Hypotension and recovering from it were recorded. The data of time lasting from complecation of surgery to extubation should also be recorded.
[Results] The urinary volume of both groups were in normal range(>1ml/(kg·h)), the effect of Deliberate Hypotension in tow groups was stabile and satisfied. The duration time of achieving Deliberate Hypotension and recovering from it in group B is shorter than that of group A, HR became decreased after Deliberate Hypotension in group A(no statistical significance, P>0.05)while that became increased in group B(statistical significance, P<0.05 ).There was statistical significance between T3 and T0 in pH value(P<0.05), and the statistical significances were also shown at the time point of T0, T3 and T2 in BE and T-CO2(P<0.05). On the other hand, the blood gas analysis results in group A were all in normal range and no statistical significances. The comparation between tow groups at the same time point shows that there was statistical significances at T3 in pH and T2, T3 in BE, T-CO2 (P<0.05).
[Conclusion] The effect of Deliberate Hypotension Induced by Sevoflurane-Remifentanil Compounded Anesthesia is satisfied without combining with other hypotension drug. Moreover, the controllability of sevoflurane is better than that of nitroglycerin according to the more stable variety of BP, costing shorter time to recovery from anesthesia and more gentle influence to the tissue metabolism our trail. Thus, sevoflurane-remifentanil Compounded Anesthesia Inducing Deliberate Hypotension is a suitable method for neurosurgery.
[方法]选择期行颅内动脉瘤夹闭术患者36例，随机分为A组（七氟烷组n=18）和B组（硝酸甘油组n=18），A组以七氟烷作为控制性降压药物，B组以硝酸甘油作为控制性降压药物。
[结果]七氟烷复合瑞芬太尼控制性降压安全用于颅内动脉瘤夹闭术，且术后随访未见麻醉并发症。
[结论]七氟烷复合瑞芬太尼行控制性降压可以做到满意的效果。它具有降压及恢复血压平稳、易于控制、麻醉苏醒快、降压期间对组织代谢影响轻，可用于神经外科手术的控制性降压麻醉，值得推广。
[Objective] To explore the feasibility and anesthetic effect ofDeliberate Hypotension Induced by Sevoflurane-RemifentanilCompounded Anesthesia in the Clamp Operation of IntracranialAneurysm
[Methods] Thirty-six ASA I~II patients undergoing electiveclipping surgery of intracranial aneurysm were randomly divided into2 groups(n=18each): Group A deliberated hypotension withsevoflurane inhalation (sevoflurane group); group B deliberatedhypotension with nitroglycerin administration (nitroglycerin group).Transfuseing 10~15ml/kg colloid fluid in 30~40min. Monitoring BP,ECG, SpO2, PETO2, invasive BP (arteriopuncture after inducing).Setting respiratory parameter: VT 8~12ml/kg, frequency 10~12/min,inspiratory/expiratory 1:2. All the patients were induced withmadazolam 2mg, fentanyl 3~5μg/kg, etomidate 0.3mg/kg, vecuronium0.08~0.1mg/kg. In group A anesthesia was maintained withremifentanil 8μg/ml + sevoflurane (initial concentration 0.5MAC,increase 0.5MAC every 3 respirations till the inhalation concentrationreach to 1.0~1.5MAC); in group B with remifentanil 8μg/ml +propofol 6~8mg/(kg·h), interruptable intravenous injection ofvecuronium was administrated as needed. Regulating theconcentration of sevoflurane and the pumping speed of propofol ineach group depending on the vital signs. After the dura was opened, gradually increased the inhalation concentration of sevoflurane (1~3MAC) in group A and started to pump nitroglycerin at a speed of 3μg/(kg·min)in group B to make SBP go down 25%~40% and maintain the MAP at a level about 60mmHg, the MAP shoule be further decreased at the time of clipping the intracranial aneurysm. Decreased the inhaled concentration of sevoflurane(0.5~1MAC) in group A and stopped pumping the nitroglycerin in group B after clipping to recover BP as the level that before Deliberate Hypotension. Stopped the application of sevoflurane and propofol in each groups 20mins before the completion of surgery. Remifentanil should be stopped using at the time of suturing the skin. The patients were extubated and breathing spontaneously with SPO2>93% and could open eyes on verbal command before being transferred to wards. Recorded the urinary volume, transfusion volume, losing volume of blood; Noted the BP and HR before and after Deliberate Hypotension. Blood gas analysis was undertaken at 5 time points: T0 (started to Deliberate Hypotension)、T1(20min after Deliberate Hypotension)、T2(40min after Deliberate Hypotension)、T3(60min after Deliberate Hypotension)and T4 (the end of the surgery). The duration time of achieving Deliberate Hypotension and recovering from it were recorded. The data of time lasting from complecation of surgery to extubation should also be recorded.
[Results] The urinary volume of both groups were in normal range(>1ml/(kg·h)), the effect of Deliberate Hypotension in tow groups was stabile and satisfied. The duration time of achieving Deliberate Hypotension and recovering from it in group B is shorter than that of group A, HR became decreased after Deliberate Hypotension in group A(no statistical significance, P>0.05)while that became increased in group B(statistical significance, P<0.05 ).There was statistical significance between T3 and T0 in pH value(P<0.05), and the statistical significances were also shown at the time point of T0, T3 and T2 in BE and T-CO2(P<0.05). On the other hand, the blood gas analysis results in group A were all in normal range and no statistical significances. The comparation between tow groups at the same time point shows that there was statistical significances at T3 in pH and T2, T3 in BE, T-CO2 (P<0.05).
[Conclusion] The effect of Deliberate Hypotension Induced by Sevoflurane-Remifentanil Compounded Anesthesia is satisfied without combining with other hypotension drug. Moreover, the controllability of sevoflurane is better than that of nitroglycerin according to the more stable variety of BP, costing shorter time to recovery from anesthesia and more gentle influence to the tissue metabolism our trail. Thus, sevoflurane-remifentanil Compounded Anesthesia Inducing Deliberate Hypotension is a suitable method for neurosurgery.
引文
1. 庄心 ,曾因明,陈伯銮 . 代麻 学[M]. 第三版. 北京: 人民卫生 版 , 2004.419~420
2. 方久. 麻酔の代謝と臓 障害. 本臨床麻酔学会会誌, 1993,13: 504
3. 陈 华, 俞文 , 马维玲等. 颅 外科麻 控制 降 对脑代谢和颅内 影 . 中华麻 学杂志, 1997,17:459~461
4. 志 , 曾因明. 吸入 麻 对脑缺血脑保护 验 究进展. 外医学(麻 学与复苏分 ), 2003,24(3):140~143
5. Faberowski LW, Raizada MK, Sumners C. Hypoxia-and ischemia-induced neuronal apoptosis is decreased by halothane and isoflurane (abstract) J Neurosurg Anesthesiol, 1999,11:307
6. Bin Zhu. Isoflurane and the Brain Protection Research. Knowledge Lecture FAM. 2005,6:386~388
7. Payne RS, Akca O, Roewer N, et al.Sevoflurane-induced Preconditioning protects against cerebral ischemic neuronal damage in rats. Brain Res, 2005,1034:147~152
8. Moe MC, Berg-Johnsen J, Larsen GA, et al. The effect of isoflurane and sevoflurane on cerebrocortical presynaptic Ca2+ and protein kinase C activity.J Nerrosurg Anesthesiol, 2003, 15:209~214
9. Engelhard K, Werner C, Eberspacher E, et al. Sevoflurane andpropofol influence the expression of apoptosis-regulating proteins after cerebral ischaemia and reperfusion in rats. Eur J Anaesthesiol, 2004,21:530~537
10. 胡亚兰, 英, 申红亚等. 动脉旁路 心因 预 和治疗[J]. 中 误诊学杂志, 2003, 3(1):111~112
11. 俊杰, 赵俊, . 代麻 学[M]. 北京: 人民卫生 版,1992, 164~166
12. 如 , 大林等. 异 控制 降 对颅内动脉 夹闭血 中 SIOOB 量 影 . 临 床 麻 学 杂 志 , 2004, 20(1):13~15
13. 秋筠, 孟 云, 顺 等. 七 控制 降 对脑代谢 影. 中华麻 学杂志, 2005,20(5):271~273
14. Bernard JM, Wouters PF, Doursout PH, et al. Effects of sevoflurane and isoflurane on cardiac and coronary dynamics in chronically instrumented dogs. Anesthesiology, 1990,72: 659~662
15. 枢, , 海峰. 丙泊 复合异 控制 降 对脑 代谢 影 . 临床麻 学杂志, 2005,21(8):522~524
16. 庄心 , 曾因明, 陈伯 . 代麻 学. 第 3 版. 北京: 人民卫生 版 , 2004.443
17. 毛卫 , 俊杰. 控制 降 对脑循环和代谢 影 . 外医学麻 学与复苏分 , 1990,11:321~324
18. Hatakeyam N, Momose Y. lto Y. Effects of sevoflurane on contractile responses and electrophysiologic properties in canine single cardiac myocytes. Anesthesiology, 1995,82:559~565
19. 秋筠, 孟 云, 顺 等. 七 控制 降 对脑代谢 影. 中华麻 学杂志, 2005,20(5):271~273
20. 庄心 , 曾因明, 陈伯銮 . 代麻 学[M]. 第三版. 人民卫生 版 , 2004.443~448
21. 崔 , 汉花, 艳 . 异 、异丙 、艾司洛尔、硝酸油 开颅 控制 降 中 应用. 中 误诊学杂志, 2005,5 (3):464~465
22. McEwan AI, Anaes FC, Smith C, et al. Isoflurane minimum alveolar concentration reduction by fentanyl. Anesthesiology, 1993, 78:864~869
23. 庄心 , 曾因明, 陈伯銮 . 代麻 学[M]. 第三版. 北京: 人民卫生 版 , 2004.525
24. 葛云 , 钟泰迪, 倪卫 . 瑞 尼 合七 内窥镜中 控 制 降 . 科 医 学 临 床 与 教 , 2006, 4(2):118~120,137
25. 华, 新, 贺 莉. 瑞 尼和 尼用于神经外科麻 较. 中 代医 杂志, 2006,8(12):88~89
26. 郁葱, 丽霞. 瑞 尼和 尼用于老年 人麻较. 中 矿医学, 2007,20(2):20~21
1. 庄心 , 曾因明, 陈伯 . 代麻 学. 第 3 版. 北京:人民卫生 版 , 2004.1689~1709
2. Sperry RJ, Monk CR, Durieux ME, et a1. The influence of hemorrhage on organ perfusion during deliberate hypotension in rats.Anesthesiology, 1992,77(5):1171~1177
3. 俊杰. 赵俊, . 代麻 学[M]. 第 l 版. 北京: 人民卫生版 , 1996.681~688
4. Mookherjee S, Fuleihan D, Wamer RA, et al. Effects of sublingual nitroglycerin on resting pulmonary gas exchange and haemodynamics in man. Circulation. 1978,57(1):106~110
5. 方久. 麻酔の代謝と臓 障害. 本臨床麻酔学会会誌, 1993,13: 504
6. 梁启 , 肖广 , 兰, 等. 七 醚 维持麻 对心脏人血 动力学 影 . 中华麻 学杂志,1997, 17(10):594
7. 英. 心脏 臵 中七 醚复合麻 对血 动力学 影. 中华麻 学杂志,1994,14(3):212
8. Trwersky RS, Jamerson B,et al.Hemodynamics and emergence profile of remifentanil versus fentanyl prospectively compared in a large population of surgical patients. J Clin Anesth, 2001,13(6): 407~416
9. 毛瑞 , 高秀 . 同剂量 瑞 尼对 麻 者血 动力学 影 . 中 心血 究杂志, 2004,2,(12):967~968
10. Tuncali B, Karci A, Bacakoglu AK, et al. Controlled hypotension and minimal inflation pressure a new approach for pneumatic toumiquet application in upper limb surgery [J]. Anesth Analg, 2003,97(5)1529~1532
11. 郁葱, 丽霞. 瑞 尼和 尼用于老年 人麻 较[R614.2]中 矿医学. 2007,20(2):20~21
12. Payne RS, Akca O, Roewer N, et al. Sevoflurane-induced preconditioning protects against cerebral ischemic neuronal damage in rats. Brain Res, 2005,1034:147~152
13. 周 生等. 七 醚对人大脑中动脉血 影 . 临床麻学杂志. 2001,17(7):391
14. 秋筠等. 七 醚控制 降 对脑代谢 影 . 中华麻 学杂志,2000,20(5):270~273
15. 庄心 , 曾因明, 陈伯銮 . 代麻 学[M]. 第三版. 人民卫生 版 ,2004.443~448
2. 方久. 麻酔の代謝と臓 障害. 本臨床麻酔学会会誌, 1993,13: 504
3. 陈 华, 俞文 , 马维玲等. 颅 外科麻 控制 降 对脑代谢和颅内 影 . 中华麻 学杂志, 1997,17:459~461
4. 志 , 曾因明. 吸入 麻 对脑缺血脑保护 验 究进展. 外医学(麻 学与复苏分 ), 2003,24(3):140~143
5. Faberowski LW, Raizada MK, Sumners C. Hypoxia-and ischemia-induced neuronal apoptosis is decreased by halothane and isoflurane (abstract) J Neurosurg Anesthesiol, 1999,11:307
6. Bin Zhu. Isoflurane and the Brain Protection Research. Knowledge Lecture FAM. 2005,6:386~388
7. Payne RS, Akca O, Roewer N, et al.Sevoflurane-induced Preconditioning protects against cerebral ischemic neuronal damage in rats. Brain Res, 2005,1034:147~152
8. Moe MC, Berg-Johnsen J, Larsen GA, et al. The effect of isoflurane and sevoflurane on cerebrocortical presynaptic Ca2+ and protein kinase C activity.J Nerrosurg Anesthesiol, 2003, 15:209~214
9. Engelhard K, Werner C, Eberspacher E, et al. Sevoflurane andpropofol influence the expression of apoptosis-regulating proteins after cerebral ischaemia and reperfusion in rats. Eur J Anaesthesiol, 2004,21:530~537
10. 胡亚兰, 英, 申红亚等. 动脉旁路 心因 预 和治疗[J]. 中 误诊学杂志, 2003, 3(1):111~112
11. 俊杰, 赵俊, . 代麻 学[M]. 北京: 人民卫生 版,1992, 164~166
12. 如 , 大林等. 异 控制 降 对颅内动脉 夹闭血 中 SIOOB 量 影 . 临 床 麻 学 杂 志 , 2004, 20(1):13~15
13. 秋筠, 孟 云, 顺 等. 七 控制 降 对脑代谢 影. 中华麻 学杂志, 2005,20(5):271~273
14. Bernard JM, Wouters PF, Doursout PH, et al. Effects of sevoflurane and isoflurane on cardiac and coronary dynamics in chronically instrumented dogs. Anesthesiology, 1990,72: 659~662
15. 枢, , 海峰. 丙泊 复合异 控制 降 对脑 代谢 影 . 临床麻 学杂志, 2005,21(8):522~524
16. 庄心 , 曾因明, 陈伯 . 代麻 学. 第 3 版. 北京: 人民卫生 版 , 2004.443
17. 毛卫 , 俊杰. 控制 降 对脑循环和代谢 影 . 外医学麻 学与复苏分 , 1990,11:321~324
18. Hatakeyam N, Momose Y. lto Y. Effects of sevoflurane on contractile responses and electrophysiologic properties in canine single cardiac myocytes. Anesthesiology, 1995,82:559~565
19. 秋筠, 孟 云, 顺 等. 七 控制 降 对脑代谢 影. 中华麻 学杂志, 2005,20(5):271~273
20. 庄心 , 曾因明, 陈伯銮 . 代麻 学[M]. 第三版. 人民卫生 版 , 2004.443~448
21. 崔 , 汉花, 艳 . 异 、异丙 、艾司洛尔、硝酸油 开颅 控制 降 中 应用. 中 误诊学杂志, 2005,5 (3):464~465
22. McEwan AI, Anaes FC, Smith C, et al. Isoflurane minimum alveolar concentration reduction by fentanyl. Anesthesiology, 1993, 78:864~869
23. 庄心 , 曾因明, 陈伯銮 . 代麻 学[M]. 第三版. 北京: 人民卫生 版 , 2004.525
24. 葛云 , 钟泰迪, 倪卫 . 瑞 尼 合七 内窥镜中 控 制 降 . 科 医 学 临 床 与 教 , 2006, 4(2):118~120,137
25. 华, 新, 贺 莉. 瑞 尼和 尼用于神经外科麻 较. 中 代医 杂志, 2006,8(12):88~89
26. 郁葱, 丽霞. 瑞 尼和 尼用于老年 人麻较. 中 矿医学, 2007,20(2):20~21
1. 庄心 , 曾因明, 陈伯 . 代麻 学. 第 3 版. 北京:人民卫生 版 , 2004.1689~1709
2. Sperry RJ, Monk CR, Durieux ME, et a1. The influence of hemorrhage on organ perfusion during deliberate hypotension in rats.Anesthesiology, 1992,77(5):1171~1177
3. 俊杰. 赵俊, . 代麻 学[M]. 第 l 版. 北京: 人民卫生版 , 1996.681~688
4. Mookherjee S, Fuleihan D, Wamer RA, et al. Effects of sublingual nitroglycerin on resting pulmonary gas exchange and haemodynamics in man. Circulation. 1978,57(1):106~110
5. 方久. 麻酔の代謝と臓 障害. 本臨床麻酔学会会誌, 1993,13: 504
6. 梁启 , 肖广 , 兰, 等. 七 醚 维持麻 对心脏人血 动力学 影 . 中华麻 学杂志,1997, 17(10):594
7. 英. 心脏 臵 中七 醚复合麻 对血 动力学 影. 中华麻 学杂志,1994,14(3):212
8. Trwersky RS, Jamerson B,et al.Hemodynamics and emergence profile of remifentanil versus fentanyl prospectively compared in a large population of surgical patients. J Clin Anesth, 2001,13(6): 407~416
9. 毛瑞 , 高秀 . 同剂量 瑞 尼对 麻 者血 动力学 影 . 中 心血 究杂志, 2004,2,(12):967~968
10. Tuncali B, Karci A, Bacakoglu AK, et al. Controlled hypotension and minimal inflation pressure a new approach for pneumatic toumiquet application in upper limb surgery [J]. Anesth Analg, 2003,97(5)1529~1532
11. 郁葱, 丽霞. 瑞 尼和 尼用于老年 人麻 较[R614.2]中 矿医学. 2007,20(2):20~21
12. Payne RS, Akca O, Roewer N, et al. Sevoflurane-induced preconditioning protects against cerebral ischemic neuronal damage in rats. Brain Res, 2005,1034:147~152
13. 周 生等. 七 醚对人大脑中动脉血 影 . 临床麻学杂志. 2001,17(7):391
14. 秋筠等. 七 醚控制 降 对脑代谢 影 . 中华麻 学杂志,2000,20(5):270~273
15. 庄心 , 曾因明, 陈伯銮 . 代麻 学[M]. 第三版. 人民卫生 版 ,2004.443~448