咪达唑仑全凭静脉麻醉在颅内动脉瘤介入栓塞术中的应用

目的探讨咪达唑仑全凭静脉麻醉在颅内动脉瘤介入栓塞术中的应用效果。方法将40例择期在全身麻醉下实施颅内动脉瘤介入栓塞术患者采用随机数字表随机分为咪达唑仑组和静吸复合组，每组20例。咪达唑仑组静脉注射咪达唑仑0．3mg／kg、静吸复合组静脉注射丙泊酚1．5mg／kg诱导后，置入LMASupreme喉罩行机械通气。咪达唑仑组应用0．1—0．2mg／（kg·h）咪达唑仑持续输注，静吸复合组1％～3％七氟醚持续吸入。2组均分别静脉持续输注瑞芬太尼0．2—0．4ug/（kg·min）、罗库溴铵0．15mg／（kg·h）维持麻醉。记录2组患者诱导前（T0）、置入喉罩前1min（T1）、置入喉罩即刻（T2）、股动脉穿刺时（T3）、动脉瘤栓塞时（T4）、拔除喉罩即刻（T5）、拔除喉罩后10min（T6）的生命体征；记录患者自主呼吸恢复时间、意识恢复时间和拔除喉罩时间；评估患者拔除喉罩后改良Geller和Freye清醒评分情况。结果与T0比较，2组患者T1～T4时平均动脉压（MAP）和心率明显下降咪达唑仑组（78±10）、（76±13）、（77±9）、（79±11）mmHg（1mmHg=0．133kPa）比（97±11）mmHg；（71±6），（69±5）、（70±9）、（72±10）次／min比（83±10）次／min；静吸复合组（70±12）、（73±12）、（73±15）、（72±12）mmHg比（98±10）mmHg；（69±9），（70±6）、（70±8）、（71±5）次／min比（80±9）次／min]（均P〈0．05），与静吸复合组比较，T1时咪达唑仑组MAP升高（78±10）mmHg比（70±12）mmHg]（P〈0．05），心率变化差异无统计学意义；2组患者自主呼吸恢复时间比较差异无统计学意义，咪达唑仑组睁眼时间、拔除喉罩时间以及清醒评分达6分时间明显短于静吸复合组（2．9±0．6）min比（7．1±1．3）min、（4．1±1．2）min比（12．7±2．2）min、（6．1±1．4）min比（15．3±3．1）min]（P〈0．05），拔除喉罩后清醒评分咪达唑仑组低于静吸复合组（0．3±0．1）分比（0．6±0．1）分，P〈0．05]。结论咪达唑仑静脉麻醉在颅内动脉瘤介入栓塞术中的应用使患者血流动力学平稳，可控性好，苏醒快速、完全、平稳。

Application of midazolam intravenous anesthesia in interventional embolization of intracranial aneurysms

Objective To investigate the effect of the total intravenous anesthesia（TIVA） with midazolam for the interventional embolization of intracranial aneurysm. Methods Forty patients who were about to receive scheduled interventional embolization of intracranial aneurysm were randomly assigned into two groups ： midazolam group （total intravenous anesthesia with midazolam, n = 20）and group C（ general anesthesia with inhale and intravenous drugs,n = 20）. Anesthesia was inducted in the midazolam group with midazolam 0.3 mg/kg, sufentanil 0.3 ug/kg, rocuranium 0.6 mg/kg; in group C anesthesia was induced with propofol 1.5 mg/kg, respectively. When the depth of anesthesia was enough then inserted laryngeal mask mechanical ventilatior. Maintenance of anesthesia： in the midazolam group patients were infused with midazolam 0.1-0.2 mg/（ kg . h）, remifentanil 0.2- 0.4 ug/（ kg . h）and rocuranium 0.15 mg/（ kg . h）. In group C, the patients received inhaled sevoflurane with inspired concentration of 1%-3% via breathing circuit and continuous infusion of remifentanil 0.2-0. 4 ug/（kg . min）, rocuranium 0.15 mg/（kg . h）. At the end of the operation, neostigmine 2 mg and atropine 1 mg were gave to patients in both groups intravenously. Furthermore midazolam group gave flumazenil 1 mg intrrvenously. In group C, adjudst the flow of fresh gas larger than 6 L/min. Hemodynamic change was recorded at the time of before induction（ T0 ）, 1 minute before insertion of laryngeal mask（ T1 ）, insertion of laryngeal mask（ T2 ） puncture of the femoral artery（T3 ） embolization of the aneurysm（ T4 ）, extraction of the laryngeal mask（ T5 ）, and 10 minutes after the extubation（T6 ）. And the time needed of the return of spontaneous respiration, recovery of the consciousness and extraction of the laryngeal mask（T6 ）were recorded. Results The mean arterial pressure （MAP） and heart rate decreased significantly compared with To to T1-T4 in each group midazolam group（78 ± 10）, （76 ± 13）, （77 ± 9 ）, （79 ± 11 ） mmHg vs （97 ± 11 ） mmHg ; （71 ± 6 ）, （69 ± 5 ）, （70 ± 9）, （ 72 ± 10） times/min vs （ 83 ± 10） times/ rain; group C（70 ± 12）, （73 ± 12）, （73 ± 15）, （72 ± 12） mmHg vs （98 ± 10）mmHg; （69 ± 9）, （70 ±6）, （70 ± 8）, （71 ±5）times/min vs （80 ±9）times/min] （P 〈 0.05）. There were no significant differences among Ts, T6 and T0. MAP was increased in midazolam group when compared to group C at T1 （78 ± 10 ） mmHg vs （70 ± 12） mmHg] （P 〈 0.05 ）, but heart rate change had no significant difference. The time needed to return spontaneous respiration had no difference in two groups. But the time of recovery consciousness, extubating the laryngeal mask and reaching the level of consciousness score at 6 in midazolam group was significantly shorter than group C （2.9±0.6）minvs （7.1 ±1.3）min,（4.1 ±1.2）min vs （12.7 ±2.2）min,（6.1 ±1.4）min vs （15.3 ± 3.1 ） min ] （P 〈 0.05 ）. The alertness score after laryngeal mask extubation in midazolam group was lower than that in group C （0.3 ± 0.1 ） scores vs （0.6 ± 0.1 ） scores ] （ P 〈 0.05 ）. Conclusion The application of the TIVA with midazolam for the lnterventional embolization of intracranial aneurysm has good hemodynamic stability, excellent controllability, and the patients can quickly and safely wake up from anesthesia.