丙泊酚或异氟醚麻醉下头低位二氧化碳气腹对脑氧供需平衡及能量代谢的影响
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摘要
CO_2气腹时由于腹膜吸收CO_2可能引起脑血管扩张，形成脑过度灌注；另一方面，胸、腹压力的升高使颅内静脉回流受阻，形成脑淤血，加之妇科腹腔镜手术常取头低脚高位，进一步加重脑淤血，其结果可能使颅内压(ICP)明显升高。研究证实丙泊酚及低浓度异氟醚有脑保护作用，头低位气腹条件下以丙泊酚或异氟醚诱导及维持麻醉时，脑氧供需平衡及能量代谢有何改变，目前报道罕见。本研究通过观察颈静脉球压力、血气、血糖及乳酸等结果的变化，探讨丙泊酚或异氟醚麻醉下头低位气腹期间颅内压、脑氧供需平衡及能量代谢的改变。
方法
24例ASAⅠ～Ⅱ级妇科腹腔镜手术患者，年龄20～59岁，随机均分为丙泊酚组和异氟醚组。两组均局麻下行颈内静脉逆行穿刺置管达颈静脉球，行挠动脉置管，动、静脉备采血及测压。分别以丙泊酚和异氟醚麻醉诱导及维持，术中维持通气条件不变(潮气量7ml/kg，频率14次／分)。记录麻醉前(T_1)、气腹前(T_2)、气腹10min(T_3)、20min(T_4)及60min(T_5)时挠动脉及颈静脉球血压、血气、血糖、乳酸以及呼末CO_2(PetCO_2)等，计算脑葡萄糖摄取、乳酸净生成量及摄氧量等，统计学处理采用SPSS10.0软件包进行重复测量设计的方差分析及t检验。
结果
1．丙泊酚组与异氟醚组患者年龄、体重、芬太尼用药量及麻醉前(T_1)各项数据无统计学差异。
2．两组之间比较，其中动脉血糖(Aglu)、脑动、静脉血糖含量差(D_((a-j)glu))、颈静脉球乳酸含量(Jlac)、颈静脉球部压力(JBP)、心率(HR)、气道峰压(PIP)、PaCO_2、PetCO_2、等的变化均无统计学差异；但异氟醚组颈静脉球血氧饱和度(S_jO_2)显著高于丙泊酚组(P＜0.05)，而平均动脉压(MAP)低于丙泊酚组(P＜0.05)。
3.组内与气腹前(T2)相比:两组气腹后(T3、T;、TS)Sj02均显著增高(丙
泊酚组分别为P<0.05;尸<0.01;P<0.05;异氟醚组均P<0.01);丙泊
酚组
D(。)02均显著降低(均P<0.05)，异氟醚组T;、T。之D(，j)02均显著降低
(P<0.01:P<0.05);两组T3、T4、T泣glu水平均明显增高(均P<0.01)，
而D(，J)glu及Jlae无明显变化。两组气腹后PaC氏、PetC仇、JBP及PIP
均显著升高(均尸<0.01)。两组各时点PaC02均未超过45mnlHg。
4.全组中有8例患者(占33%)于气腹且头低位即刻出现窦性心动过缓，其
中3例HR低于50次/分，立即静脉注射阿托品0.5功g后均升高至正常范
围。
结论
丙泊酚或异氟醚麻醉下头低位气腹期间颅内压、脑氧供需平衡及能量代
谢的改变如下。
1.JBP显著升高造成工cP增高，且丙泊酚组与异氟醚组无统计学差异。
2.Sj压升高提示脑氧供大于氧需，脑过度灌注，异氟醚麻醉下脑过度灌注更
明显。
3.两组D。a--J)glu及Jlac均无明显变化提示未出现能量代谢障碍。
4.丙泊酚与异氟醚对C压气腹后脑氧及能量代谢的影响无统计学差异。
Objective The carbon dioxide which may expand the brain vessel could be absorbed from peritoneum when pneumoperitoneum was created. At the same time, the pneumoperitoneum would make abdomen pressure hoist, which would bring the center vessel pressure high. So the cerebral blood circumfluence resistance was enlarged. These above effects induced intracranial pressure high. The propofol and isoflurane have the protection effect of cerebral .How did cerebral oxygen delivery, oxygen consumption and energy metabolism change in gynecologic laparoscopic surgery anesthetized with propofol or isoflurane? This study observed it by jugular bulb blood gas, sugar and lactic.
Methods 24 ASA grade I - II patients undergoing gynecologic laparoscopic surgery without known cerebral or cardiovascular system disease were selected. Anesthesia were induced and maintained with propofol (12 cases, group P) or isoflurane (12 cases, group I), fentanyl and vecuronium. Paired, repeated samples of the arterial and jugular bulb blood were analyzed for oxygen, glucose and lactic acid before anesthesiaf before pneumoperitoneum, 10, 20, and 60min after pneumoperitoneum, respectively.
Results Jugular bulb oxygen saturation (SjO2) jugular bulb pressure (JBP) and plasma glucose level increased and cerebral ateriovenous oxygen content difference( D(a-jO2) decreased significantly after pneumoperitoneum, while the cerebral ateriovenous plasma glucose difference(D (a-j) glu) and plasma lactic acid level were constant. Between the two groups there were no significant differents of those above results except SjO2. The SjO2 of group I was higher than group P.
Conclusions Increased SjO2 indicated that cerebral oxygen supply exceeded oxygen consumption. Increased JBP resulted in ICP hoist when pneumoperitoneum was set up. However, brain energy metabolism was not impacted during head-down pneumoperitoneum anesthetized with not only propofol but also isoflurane. Total intravenous anesthesia with propofol is
probably more suitable for this kind of operation because higher SjO2 in group I mean cerebral hyper-perfusion.
方法
24例ASAⅠ～Ⅱ级妇科腹腔镜手术患者，年龄20～59岁，随机均分为丙泊酚组和异氟醚组。两组均局麻下行颈内静脉逆行穿刺置管达颈静脉球，行挠动脉置管，动、静脉备采血及测压。分别以丙泊酚和异氟醚麻醉诱导及维持，术中维持通气条件不变(潮气量7ml/kg，频率14次／分)。记录麻醉前(T_1)、气腹前(T_2)、气腹10min(T_3)、20min(T_4)及60min(T_5)时挠动脉及颈静脉球血压、血气、血糖、乳酸以及呼末CO_2(PetCO_2)等，计算脑葡萄糖摄取、乳酸净生成量及摄氧量等，统计学处理采用SPSS10.0软件包进行重复测量设计的方差分析及t检验。
结果
1．丙泊酚组与异氟醚组患者年龄、体重、芬太尼用药量及麻醉前(T_1)各项数据无统计学差异。
2．两组之间比较，其中动脉血糖(Aglu)、脑动、静脉血糖含量差(D_((a-j)glu))、颈静脉球乳酸含量(Jlac)、颈静脉球部压力(JBP)、心率(HR)、气道峰压(PIP)、PaCO_2、PetCO_2、等的变化均无统计学差异；但异氟醚组颈静脉球血氧饱和度(S_jO_2)显著高于丙泊酚组(P＜0.05)，而平均动脉压(MAP)低于丙泊酚组(P＜0.05)。
3.组内与气腹前(T2)相比:两组气腹后(T3、T;、TS)Sj02均显著增高(丙
泊酚组分别为P<0.05;尸<0.01;P<0.05;异氟醚组均P<0.01);丙泊
酚组
D(。)02均显著降低(均P<0.05)，异氟醚组T;、T。之D(，j)02均显著降低
(P<0.01:P<0.05);两组T3、T4、T泣glu水平均明显增高(均P<0.01)，
而D(，J)glu及Jlae无明显变化。两组气腹后PaC氏、PetC仇、JBP及PIP
均显著升高(均尸<0.01)。两组各时点PaC02均未超过45mnlHg。
4.全组中有8例患者(占33%)于气腹且头低位即刻出现窦性心动过缓，其
中3例HR低于50次/分，立即静脉注射阿托品0.5功g后均升高至正常范
围。
结论
丙泊酚或异氟醚麻醉下头低位气腹期间颅内压、脑氧供需平衡及能量代
谢的改变如下。
1.JBP显著升高造成工cP增高，且丙泊酚组与异氟醚组无统计学差异。
2.Sj压升高提示脑氧供大于氧需，脑过度灌注，异氟醚麻醉下脑过度灌注更
明显。
3.两组D。a--J)glu及Jlac均无明显变化提示未出现能量代谢障碍。
4.丙泊酚与异氟醚对C压气腹后脑氧及能量代谢的影响无统计学差异。
Objective The carbon dioxide which may expand the brain vessel could be absorbed from peritoneum when pneumoperitoneum was created. At the same time, the pneumoperitoneum would make abdomen pressure hoist, which would bring the center vessel pressure high. So the cerebral blood circumfluence resistance was enlarged. These above effects induced intracranial pressure high. The propofol and isoflurane have the protection effect of cerebral .How did cerebral oxygen delivery, oxygen consumption and energy metabolism change in gynecologic laparoscopic surgery anesthetized with propofol or isoflurane? This study observed it by jugular bulb blood gas, sugar and lactic.
Methods 24 ASA grade I - II patients undergoing gynecologic laparoscopic surgery without known cerebral or cardiovascular system disease were selected. Anesthesia were induced and maintained with propofol (12 cases, group P) or isoflurane (12 cases, group I), fentanyl and vecuronium. Paired, repeated samples of the arterial and jugular bulb blood were analyzed for oxygen, glucose and lactic acid before anesthesiaf before pneumoperitoneum, 10, 20, and 60min after pneumoperitoneum, respectively.
Results Jugular bulb oxygen saturation (SjO2) jugular bulb pressure (JBP) and plasma glucose level increased and cerebral ateriovenous oxygen content difference( D(a-jO2) decreased significantly after pneumoperitoneum, while the cerebral ateriovenous plasma glucose difference(D (a-j) glu) and plasma lactic acid level were constant. Between the two groups there were no significant differents of those above results except SjO2. The SjO2 of group I was higher than group P.
Conclusions Increased SjO2 indicated that cerebral oxygen supply exceeded oxygen consumption. Increased JBP resulted in ICP hoist when pneumoperitoneum was set up. However, brain energy metabolism was not impacted during head-down pneumoperitoneum anesthetized with not only propofol but also isoflurane. Total intravenous anesthesia with propofol is
probably more suitable for this kind of operation because higher SjO2 in group I mean cerebral hyper-perfusion.
引文
1. Hodgson C, McClelland RM, Newton JR. Some effects of the peritoneal insufflation of carbon dioxide at laparoscopy. Anaesthesia. 1970 Jul; 25(3): 382-90.
2. Fujii Y, Tanaka H, Tsuruoka SH, et al. Middle cerebral arterial blood flow velocity increases during laparoscopic cholecystectomy. Anesth Analg, 1994, 78: 80-83.
3. Erkan N, Gokmen N, Goktay AY, et al. Effects of CO_2 pneumo-peritoneum on the basilar artery. Surg Endosc, 2001, 15(8): 806-11.
4. Huettemann E, Terborg C, Sakka SG, et al. Preserved CO_2 reactivity and increase in middle cerebral arterial blood flow velocity during laparoscopic surgery in children. Anesth Analg, 2002, 94(2): 255-8.
5. Hanel F, Blobner M, Bogdanski R, et al. Effects of carbon dioxide pneumoperitoneum on cerebral hemodynamics in pigs. J Neurosurg Anesthesiol, 2001, 13(3): 222-6.
6. Schob OM, Allen DC, Benzel E, et al. A comparison of the pathophysiologic effects of carbon dioxide, nitrous oxide, and helium pneumoperitoneum on intracranial pressure. Am J Surg. 1996, 172(3): 248-53.
7. Rosenthal RJ, Hiatt JR, Phillips EH, et al. Intracranial pressure. Effects of pneumoperitoneum in a large-animal model. Surg Endosc, 1997, 11(4): 376-80.
8. Lentschener C, Leveque JP, Mazoit JX, et al. The effect of pneumoperitoneum on intraocular pressure in rabbits with alpha-chymotrypsin-induced glaucoma. Anesth Analg. 1998 Jun; 86(6): 1283-8.
9．单闯，祝建刚，刘诚，等．腹腔镜胆囊切除术中二氧化碳气腹对脑血流的影响．中华麻醉学杂志，2000，20(7)：411-412．
10. de Waal EE, de Vries JW, Kruitwagen CL, et al. The effects of
low-pressure carbon dioxide pneumoperitoneum on cerebral oxygenation and cerebral blood volume in children. Anesth Analg, 2002, 94(3): 500-5.
11. Moncure M, Salem R, Moncure K, et al. Central nervous system metabolic and physiologic effects of laparoscopy. Am Surg, 1999, 65(2): 168-72.
12. Kitajima T, Okuda Y, Yamaguchi S, et al. Response of cerebral oxygen metabolism in the head-up position during laparoscopic cholecystectomy. Surg Laparosc Endosc, 1998, 8(6): 449-52.
13．王恩真主编．神经外科麻醉学．北京：人民卫生出版社，2000．74．
14. Rosenthal RJ, Friedman RL, Chidambaram A, et al. Effects of hyperventilation and hypoventilation on PaCO_2 and intracranial pressure during acute elevations of intraabdominal pressure with CO_2 pneumoperitoneum: large animal observations. J Am Coll Surg, 1998, 187(1): 32-8.
15．王涛，赵继宗，赵元立，等．血液稀释对颅脑肿瘤手术患者颈内静脉血气和压力的影响．北京医学，2002，24(2)：77-79．
16. Cooke SJ, Paterson-Brown S. Association between laparoscopic abdominal surgery and postoperative symptoms of raised intracranial pressure. Surg Endosc. 2001, 15(7): 723-5.
17. Aoki T, Tanii M, Takahashi K, et al. Cardiovascular changes and plasma catecholamine levels during laparoscopic surgery. Anesth Analg, 1994, 78: S8-10.
18. Bullock R, Stewart L, Rafferty C, et al. Continuous monitoring of jugular bulb oxygen saturation and the effect of drugs acting on cerebral metabolism. Acta Neurochir Suppl (Wien). 1993; 59: 113-8.
19. Oshima T, Karasawa F, Satoh T. Effects of propofol on cerebral blood flow and the metabolic rate of oxygen in humans. Acta Anaesthesiol Scand. 2002 Aug; 46(7): 831-5.
20. Werner C, Standl T, Thiel H, et al. Propofol-alfentanil reduced cerebrovascular CO_2 reactivity in comparison with isoflurane.
Anaesthesist. 1995 Jun; 44(6): 417-22.
21. Jansen GF, van Praagh BH, Kedaria MB, et al. Jugular bulb oxygen saturation during propofol and isoflurane/nitrous oxide anesthesia in patients undergoing brain tumor surgery. Anesth Analg. 1999 Aug; 89(2): 358-63.
22. Cenic A, Craen RA, Lee TY, et, al. Cerebral blood volume and blood flow responses to hyperventilation in brain tumors during isoflurane or propofol anesthesia. Anesth Analg. 2002 Mar; 94(3): 661-6;
23. Petersen KD, Landsfeldt U, Cold GE, et al. Intracranial pressure and cerebral hemodynamic in patients with cerebral tumors: a randomized prospective study of patients subjected to craniotomy in propofol-fentanyl, isoflurane-fentanyl, or sevoflurane-fentanyl anesthesia. Anesthesiology. 2003 Feb; 98(2): 329-36.
24. Kirkinen P, Hirvonen E, Kauko M, etal. Intracranial blood flow during laparoscopic hysterectomy. Acta Obstet Gynecol Scand. 1995 Jan; 74(1): 71-4.
25. Boccara G, Mann C, Pouzeratte Y, et al. Improved postoperative analgesia with isoflurane than with propofol anaesthesia. Can J Anaesth. 1998 Sep; 45(9): 839-42.
26. Heine J, Jaeger K, Osthaus A, et al. Anaesthesia with propofo decreases FMLP-induced neutrophil respiratory burst but not phagocytosis compared with isoflurane. BrJ Anaesth. 2000; 85(3): 424-30.
27. Schneider G, Elidrissi C, Sebel PS. Bispectral index-guided administration of anaesthesia: comparison between remifentanil/propofol and remifentanil/isoflurane. Eur J Anaesthesiol. 2003; 20(8): 624-30.
28. Mowafi HA, Al-Ghamdi A, Rushood A. Intraocular pressure changes during laparoscopy in patients anesthetized with propofol total
intravenous anesthesia versus isoflurane inhaled anesthesia. Anesth Analg. 2003; 97(2): 471-4,
29．孙来宝，肖亮灿，黄文起，等．允许性高碳酸血症在腹腔镜手术麻醉中的应用．广东医学，2001，21(3)：211-212．
2. Fujii Y, Tanaka H, Tsuruoka SH, et al. Middle cerebral arterial blood flow velocity increases during laparoscopic cholecystectomy. Anesth Analg, 1994, 78: 80-83.
3. Erkan N, Gokmen N, Goktay AY, et al. Effects of CO_2 pneumo-peritoneum on the basilar artery. Surg Endosc, 2001, 15(8): 806-11.
4. Huettemann E, Terborg C, Sakka SG, et al. Preserved CO_2 reactivity and increase in middle cerebral arterial blood flow velocity during laparoscopic surgery in children. Anesth Analg, 2002, 94(2): 255-8.
5. Hanel F, Blobner M, Bogdanski R, et al. Effects of carbon dioxide pneumoperitoneum on cerebral hemodynamics in pigs. J Neurosurg Anesthesiol, 2001, 13(3): 222-6.
6. Schob OM, Allen DC, Benzel E, et al. A comparison of the pathophysiologic effects of carbon dioxide, nitrous oxide, and helium pneumoperitoneum on intracranial pressure. Am J Surg. 1996, 172(3): 248-53.
7. Rosenthal RJ, Hiatt JR, Phillips EH, et al. Intracranial pressure. Effects of pneumoperitoneum in a large-animal model. Surg Endosc, 1997, 11(4): 376-80.
8. Lentschener C, Leveque JP, Mazoit JX, et al. The effect of pneumoperitoneum on intraocular pressure in rabbits with alpha-chymotrypsin-induced glaucoma. Anesth Analg. 1998 Jun; 86(6): 1283-8.
9．单闯，祝建刚，刘诚，等．腹腔镜胆囊切除术中二氧化碳气腹对脑血流的影响．中华麻醉学杂志，2000，20(7)：411-412．
10. de Waal EE, de Vries JW, Kruitwagen CL, et al. The effects of
low-pressure carbon dioxide pneumoperitoneum on cerebral oxygenation and cerebral blood volume in children. Anesth Analg, 2002, 94(3): 500-5.
11. Moncure M, Salem R, Moncure K, et al. Central nervous system metabolic and physiologic effects of laparoscopy. Am Surg, 1999, 65(2): 168-72.
12. Kitajima T, Okuda Y, Yamaguchi S, et al. Response of cerebral oxygen metabolism in the head-up position during laparoscopic cholecystectomy. Surg Laparosc Endosc, 1998, 8(6): 449-52.
13．王恩真主编．神经外科麻醉学．北京：人民卫生出版社，2000．74．
14. Rosenthal RJ, Friedman RL, Chidambaram A, et al. Effects of hyperventilation and hypoventilation on PaCO_2 and intracranial pressure during acute elevations of intraabdominal pressure with CO_2 pneumoperitoneum: large animal observations. J Am Coll Surg, 1998, 187(1): 32-8.
15．王涛，赵继宗，赵元立，等．血液稀释对颅脑肿瘤手术患者颈内静脉血气和压力的影响．北京医学，2002，24(2)：77-79．
16. Cooke SJ, Paterson-Brown S. Association between laparoscopic abdominal surgery and postoperative symptoms of raised intracranial pressure. Surg Endosc. 2001, 15(7): 723-5.
17. Aoki T, Tanii M, Takahashi K, et al. Cardiovascular changes and plasma catecholamine levels during laparoscopic surgery. Anesth Analg, 1994, 78: S8-10.
18. Bullock R, Stewart L, Rafferty C, et al. Continuous monitoring of jugular bulb oxygen saturation and the effect of drugs acting on cerebral metabolism. Acta Neurochir Suppl (Wien). 1993; 59: 113-8.
19. Oshima T, Karasawa F, Satoh T. Effects of propofol on cerebral blood flow and the metabolic rate of oxygen in humans. Acta Anaesthesiol Scand. 2002 Aug; 46(7): 831-5.
20. Werner C, Standl T, Thiel H, et al. Propofol-alfentanil reduced cerebrovascular CO_2 reactivity in comparison with isoflurane.
Anaesthesist. 1995 Jun; 44(6): 417-22.
21. Jansen GF, van Praagh BH, Kedaria MB, et al. Jugular bulb oxygen saturation during propofol and isoflurane/nitrous oxide anesthesia in patients undergoing brain tumor surgery. Anesth Analg. 1999 Aug; 89(2): 358-63.
22. Cenic A, Craen RA, Lee TY, et, al. Cerebral blood volume and blood flow responses to hyperventilation in brain tumors during isoflurane or propofol anesthesia. Anesth Analg. 2002 Mar; 94(3): 661-6;
23. Petersen KD, Landsfeldt U, Cold GE, et al. Intracranial pressure and cerebral hemodynamic in patients with cerebral tumors: a randomized prospective study of patients subjected to craniotomy in propofol-fentanyl, isoflurane-fentanyl, or sevoflurane-fentanyl anesthesia. Anesthesiology. 2003 Feb; 98(2): 329-36.
24. Kirkinen P, Hirvonen E, Kauko M, etal. Intracranial blood flow during laparoscopic hysterectomy. Acta Obstet Gynecol Scand. 1995 Jan; 74(1): 71-4.
25. Boccara G, Mann C, Pouzeratte Y, et al. Improved postoperative analgesia with isoflurane than with propofol anaesthesia. Can J Anaesth. 1998 Sep; 45(9): 839-42.
26. Heine J, Jaeger K, Osthaus A, et al. Anaesthesia with propofo decreases FMLP-induced neutrophil respiratory burst but not phagocytosis compared with isoflurane. BrJ Anaesth. 2000; 85(3): 424-30.
27. Schneider G, Elidrissi C, Sebel PS. Bispectral index-guided administration of anaesthesia: comparison between remifentanil/propofol and remifentanil/isoflurane. Eur J Anaesthesiol. 2003; 20(8): 624-30.
28. Mowafi HA, Al-Ghamdi A, Rushood A. Intraocular pressure changes during laparoscopy in patients anesthetized with propofol total
intravenous anesthesia versus isoflurane inhaled anesthesia. Anesth Analg. 2003; 97(2): 471-4,
29．孙来宝，肖亮灿，黄文起，等．允许性高碳酸血症在腹腔镜手术麻醉中的应用．广东医学，2001，21(3)：211-212．