胸腹主动脉瘤手术中脑脊液引流对脊髓的保护作用

目的探索胸腹主动脉瘤手术患者脑脊液引流(CSFD)对脊髓的保护作用。方法将2008年12月至2009年8月北京安贞医院的30例胸腹主动脉瘤手术患者,按照术中是否行CSFD,采用计算机随机法分为CSFD组(15例,其中男12例,女3例;平均年龄45.0岁)和对照组(15例,其中男11例,女4例;平均年龄45.8岁),进行升主动脉和主动脉弓部置换+降主动脉支架植入或胸腹主动脉联合置换术,部分患者同时行Bentall手术或半弓置换手术,CSFD组行CSFD。术中和术后固定时间点采取血清样本,测定其血清S100B蛋白、神经胶质原纤维酸性蛋白、神经元特异性烯醇化酶,术前、术后72 h和出院时按美国国立卫生研究院卒中量表和脊髓损伤神经学分类国际标准评分。结果对照组4例出现中枢神经系统(CNS)并发症:1例发生脑损伤和脊髓损伤而死亡;1例发生脊髓损伤,早期行CSFD等治疗,截瘫有所恢复后出院;2例患者发生脑损伤,其中1例死亡,另1例同时出现肾功能衰竭和呼吸衰竭等并发症,经治疗后恢复出院。CSFD组仅1例因呼吸衰竭继发多器官功能衰竭而死亡,其余患者恢复良好出院。随访3个月无死亡。CSFD组患者血清S100B(F=7.153,P=0.012)、神经胶质原纤维酸性蛋白(F=3.263,P=0.082)和神经元特异性烯醇化酶(F=4.927,P=0.035)值均低于对照组,且差异有统计学意义。结论脑脊液选择性引流具有明确的脊髓保护作用,在胸腹主动脉瘤手术中安全、有效并可行。     

Systemic Naloxone Infusion May Trigger Spasticity in Patients With Spinal Cord Injury: Case Series

Abstract

Background/Objective: Three patients with spinal cord injury (SCI) and 3 able-bodied (AB) patients were infused with naloxone during a study to examine their neuroendocrine function. An unanticipated side effect occurred during the naloxone infusion. All 3 patients with SCI, but none of the AB patients, experienced profoundly increased spasticity during the naloxone infusion. Our report describes this side effect, which has potential implications for the clinical treatment or scientific evaluation of individuals with SCI.

Methods: All patients were in good general health and medication free for 11 days or longer before the study. Each patient was placed on a 30-hour protocol to analyze pulsatile release of gonadotropins. Physiologic saline was intravenously infused on day 1 to serve as a control period for naloxone infusion on day 2.

Results: AB patients experienced no muscle spasm activity or any other side effects at any time during the study. In contrast, all 3 patients with SCI experienced a profoundly increased frequency and duration of spasticity in muscles innervated by the nerve roots caudal to their level of injury. In all 3 patients with SCI, spasticity increased only during the period of naloxone infusion. Within 1 hour of stopping naloxone, spasticity returned to baseline levels.

Conclusions: Naloxone infusion produced a differential effect on the muscle activity of men with SCI compared to AB men with intact spinal circuits. Consistent with previous studies, the results of this study indicate a relationship between opioid neuromodulation and spasticity after SCI.     

The Incidence of Spinal Cord Ischaemia Following Thoracic and Thoracoabdominal Aortic Endovascular Intervention

ObjectivesTo determine the incidence and risk factors for spinal cord ischaemia (SCI) following thoracic and thoracoabdominal aortic intervention.MethodsA prospective database of all thoracic and thoracoabdominal aortic interventions between 2001 and 2009 was used to investigate the incidence of SCI. All elective and emergency cases for all indications were included. Logistic regression was used to investigate which factors were associated with SCI.Results235 patients underwent thoracic aortic stent grafting; 111(47%) thoracic aortic stent-grafts alone, with an additional 14(6%) branched or fenestrated thoracic grafts, 30(13%) arch hybrid procedures and 80(34%) visceral hybrid surgical and endovascular procedures. The global incidence of SCI for all procedures was 23/235 (9.8%) and this included emergency indications (ruptured TAAA and acute complex dissections) but the incidence varied considerably between types of procedures. Of the 23 cases, death occurred in 4 patients but recovery of function was seen in 6. Thus, permanent paraplegia occurred in 13/235 (5.5%) patients. Of the nine pre-specified factors investigated for association with SCI, only percentage of aortic coverage was significantly associated with the incidence of SCI; adjusted odds ratio per 10% increase in aorta covered = 1.78[95% CI 1.18–2.71], p = 0.007. The procedures in patients who developed SCI took longer (463.5 versus 307.2 minutes) and utilised more stents (4 versus 2).ConclusionSCI following thoracic and thoracoabdominal aortic endovascular intervention is associated with the proportion of aorta covered. The degree of risk varies between different types of procedure and this should be carefully considered in both selection and consenting of patients.     

Spinal Cord Protection during Aortic Cross Clamping: Retrograde Venous Spinal Cord Perfusion,Distal Aortic Perfusion,and Cerebrospinal Fluid Drainage

Objective - We investigated retrograde venous spinal cord perfusion (RVP), with the established adjuncts cerebrospinal fluid drainage (CSFD), and distal aortic perfusion (DAP) in the canine model. We then examined the clinical feasibility of RVP, DAP, and CSFD. Design - Canine study : Twenty dogs were randomized to four treatment groups. All animals underwent 60 min of complete aortic cross-clamp. Group 1 was the control and received only aortic cross-clamp; group 2 DAP and CSFD; group 3 DAP, CSFD, and RVP; and group 4 CSFD plus RVP. Human study : Five patients underwent aortic graft replacement of the descending or thoracoabdominal aorta, while receiving CSFD, DAP, and RVP. Results - Canine study : All animals in groups 1 and 4 awoke paralyzed. One animal each in groups 2 and 3 were paraparetic, with the remaining dogs neurologically intact. Groups 2 and 3 differed from groups 1 and 4 at p < 0.0001. Human study : No mortality or permanent complications were observed in this group. Conclusion - While RVP did not reduce neurologic injury, neither did it increase morbidity. In humans the method is technically feasible and free from major problems. Further animal studies and randomized trials are underway at our center.     

Strategies for Spinal Cord Protection during Descending Thoracic and Thoracoabdominal Aortic Surgery: Up-to-date Experimental and Clinical Results - A review

Abstract

Objectives. Stroke following cardiac surgery may occur either in association with surgery (early) or occur postoperatively (delayed). The hemispheric distribution of lesions may provide information about embolic routes, which was analyzed here. Design. In 10,809 patients undergoing cardiac surgery, early (n = 223) and delayed stroke (n = 116) were explored. Symptoms and computed tomography findings were evaluated to categorize hemispheric distributions. This was compared with pre- and intra-operative characteristics and survival, using logistic regression and Kaplan-Meier statistics. Results. Early stroke had preponderance for the right rather than the left hemisphere (P = 0.009), whereas delayed stroke had a uniform distribution. Several intraoperative variables predicted the development of bilateral stroke compared with its unilateral counterpart. At multivariable analysis, the use of tranexamic acid was associated with bilateral stroke (P = 0.017), but was also associated with right rather than left-hemispheric stroke (P = 0.001). Bilateral lesions dramatically impaired survival versus those with unilateral lesions (P < 0.001). There was no survival difference between left and right-hemispheric stroke. Conclusions. When stroke, after cardiac surgery, is subdivided into early and delayed forms, it becomes evident that early, but not delayed stroke, demonstrates a hemispheric side difference. The preponderance for right-hemispheric lesions may indicate embolic mechanisms routed via the brachiocephalic trunk.     

Optimizing Nicorandil for Spinal Cord Protection in a Murine Model of Complex Aortic Intervention

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Continuous Infusion of Ropivacaine for Pain Relief after Iliac Crest Bone Grafting for Shoulder Surgery

Background: The aim of the study was to compare the efficacy of either ropivacaine or placebo through an iliac crest (IC) catheter after Bankart repair with IC bone grafting.

Methods: With approval of the local ethics committee and after written informed consent was obtained, 36 patients had an interscalene catheter placed preoperatively. Intraoperatively, the surgeon placed a catheter at the IC donor site. At the end of surgery, 30 ml ropivacaine, 0.5% (ropivacaine group), or 30 ml NaCl, 0.9% (placebo group), was administered. Ropivacaine, 0.2%, was started 6 h after the initial block through the interscalene catheter for 48 h (t48) in all patients. At t0, the patient received either 5 ml/h ropivacaine, 0.2% (ropivacaine group), or 5 ml/h NaCl, 0.9% (placebo group), for 48 h through the IC catheter. All patients received an intravenous morphine patient-controlled analgesia device. Pain scores at the shoulder and at the IC donor site were assessed at rest and during motion every 8 h for 48 h and after 3 months. Plasma concentrations of total and unbound ropivacaine, morphine consumption, and patient satisfaction were assessed.

Results: At the IC donor site, pain was significantly lower in the ropivacaine group compared with the placebo group at rest and during motion at any time. Total and unbound plasma concentrations of ropivacaine were below the toxic threshold in both groups. Morphine consumption was significantly lower in the ropivacaine group after 24 and 48 h. Patient satisfaction was significantly higher in the ropivacaine group. At 3 months, pain at the IC during motion was significantly lower in the ropivacaine group.     

腹主动脉瘤腔内修复与开腹切除术的麻醉管理比较

目的比较腹主动脉瘤腔内修复与开腹切除术的麻醉管理特点。方法 2010年2月~2011年1月,70例ASAⅡ~Ⅳ级,肾下型腹主动脉瘤行腔内修复术52例（腔内修复组）,开腹切除术18例（开腹切除组）。开腹切除组采用气管内插管全身麻醉。腔内修复组采用的麻醉方法包括气管内插管全身麻酔、全凭静脉麻醉（喉罩通气）和监护麻醉。气管内插管全身麻醉采用快速顺序静脉诱导,气管插管后机械控制呼吸,静吸复合方式维持麻醉;全凭静脉麻醉（喉罩通气）采用丙泊酚靶控静脉输注,经喉罩行机械通气控制呼吸;监护麻醉保留自主呼吸,适当镇静镇痛。结果开腹切除组在气管内插管全身麻醉下完成手术,术中均需要使用血管活性药物控制血压。腔内修复组有57.7%（30/52）的患者采用气管内插管全身麻醉、34.6%（18/52）的患者采用全凭静脉麻醉（喉罩通气）和7.7%（4/52）的患者在监护麻醉下完成手术。与开腹切除组相比,腔内治疗组术中血压较平稳,麻醉时间[（90±27）min vs.（210±44）min,t=13.668,P=0.000]、手术时间[（45±22）min vs.（187±36）min,t=-19.811,P=0.000]、术中输注晶体液[（750±178）ml vs.（1896±367）ml,t=17.486,P=0.000]、胶体液[（349±147）ml vs.（1257±266）ml,t=18.034,P=0.000]、异体血[（50±34）ml vs.（898±154）ml,t=-37.615,P=0.000]、术后返ICU患者比例（15.4%vs.66.7%,χ2=17.231,P=0.000）及术后住院时间[（8.5±2.1）d vs.（15.2±4.3）d,t=8.700,P=0.000]均明显降低。结论腹主动脉瘤腔内修复术的麻醉手术时间、液体出入量及血管活性药物应用水平远低于腹主动脉瘤开腹切除术,且监护麻醉、全凭静脉麻醉适用于该术式。