全凭静脉麻醉和静吸复合麻醉对神经外科术中脑代谢影响的比较

目的 比较丙泊酚复合瑞芬太尼全凭静脉麻醉和地氟醚复合瑞芬太尼静吸复合麻醉在神经外科手术中脑代谢的影响.方法 择期神经外科颅内占位手术患者34例,随机分为2组:A组为丙泊酚复合瑞芬太尼(n=16)和B组为地氟醚复合瑞芬太尼(n=18).入室后局麻B超引导下行右颈内静脉逆行穿刺置管术和动脉穿刺置管术,麻醉诱导:阿托品、丙泊酚、芬太尼、罗库溴铵,常规气管插管后行机械通气.于麻醉前(T1)、手术开始后1 h(T2)、手术开始后2 h(T3)及手术结束后半小时(T4)监测患者的颈静脉球部氧饱和度(jugular bulb venous oxygen saturation,Sjv O2)、颈静脉球部氧分压(jugular bulb venous oxygen partial pressure,Pjv O2)、颈静脉球部血红蛋白(jugular bulb venous hemoglogin,Hbv)、颈静脉球部血乳酸(jugular bulb venous lactate,Ljv)和颈静脉球部葡萄糖值(jugular bulb venous gluxose,Gv)及动脉血氧饱和度(arterial oxygen saturation,Sa O2)、动脉氧分压(arterial oxygen pressure,Pa O2)、动脉血红蛋白(arterin,Hba)、动脉血乳酸(arterial blood lactate,La)和动脉血葡萄糖值(arterial blood gluxose,Ga),计算动脉血氧含量(arterial blood oxygen content,Ca O2)、颈内静脉血氧含量(jugular bulb venous oxygen content,Cjv O2)、动-颈静脉血氧含量差值(arteriovenous oxygen difference,AVDO2)、脑氧摄取率(cerebral extraction of oxygen,CEO2)、乳酸生成率(cerebral lactate production rate,CLP)、葡萄糖摄取率(cerebral glucose uptake rate,CGU).结果 (1)Sjv O2、Pjv O2、Cjv O2、Ca O2B组明显高于A组(P<0.001);AVDO2、CEO2B组低于A组(P<0.05);(2)Gv、Ga B组高于A组(P<0.05);CGU 2组比较无差异(P>0.05);(3)Ljv、La 2组比较无差异(P>0.05);CLP B组低于A组(P<0.05);(4)组内比较Pa O2、Sa O2、Pjv O2、Sjv O22组均随时间而升高(P<0.05),Ca O2、Cjv O2、AVDO2、CEO22组均随时间而下降(P<0.05).结论 (1)静吸复合麻醉和全凭静脉麻醉方式均可降低患者脑氧代谢;(2)对神经外科手术脑保护而言,似乎静吸复合麻醉的作用强于全凭静脉麻醉.

Comparison of Effects on Intraoperative Cerebral Metabolism between Total Intravenous Anesthesia and Intravenous Inhalation Anesthesia in Patients in Neurosurgery

Objective To compare the effect on intraoperative cerebral metabolism between the propofol combined with remifentanil infusion in total intravenous anesthesia and the desflurane combined with remifentanil intravenous inhalation anesthesia in patients in neurosurgery.Methods Thirty-four patients were randomly divided into the propofol combined with remifentanil group(group A,n=16) and the desflurane combined withremifentanil group(group B,n=18).The B-ultrasound under the guide of retrograde catheterization through right internal jugular vein and artery was prepared after the patients entered the operation room.Atropine,propofol,fentanyl, rocuronium were used in the induction of anesthesia.The mechanical ventilation was applied after conventional trachea cannula.Once patients were anesthetized steadily, jugular bulb venous oxygen saturation(Sjv O),jugular2 bulb venous oxygen partial pressure(Pjv O),Jugular2 Bulb venous hemoglogin(Hbv),jugular bulb venous lactate(Ljv),jugular bulb venous gluxose(Gv),arterial oxygen saturation(Sa O),arterial2 oxygen pressure(Pa O2),arterin(Hba),arterial blood lactate(La),arterial blood gluxose(Ga),arterial blood oxygen content(Ca O2), jugular bulb venous oxygen content(Cjv O2), arteriovenous oxygen difference(AVDO2),cerebral extraction of oxygen(CEO2),cerebral lactate production rate(CLP) and cerebral glucose uptake rate(CGU) at different time [before anesthesia induction(T1),1 hours after the start of the operation(T2),2 hours after the start of the operation(T3),half an hour after the operation]were collected.Results(1) The value of Sjv O2,Pjv O2,Cjv O2 and Ca O2 in group B was significantly higher than that in group A(P<0.001);The value of AVDO2 and CEO2in group B was lower than that in group A(P<0.05);(2) The value of Gv and Ga in group B was higher than that in group A(P<0.05);There were no significant differences about CGU in two groups(P>0.05);(3) The value of CLP in group B was lower than that in group A(P<0.05);there were no significant differences about Ljv and La in two groups(P>0.05);(4) Compared with the value at moment of T1 between group A and group B,the value of Pa O2,Sa O2,Pjv O2 and Sjv O2 were increased with time(P<0.05),the value of Ca O2, Cjv O2, AVDO2 and CEO2showed a downward trend(P <0.05).Conclusion(1) Both total intravenous anesthesia and intravenous inhalation anesthesia can reduce the cerebral oxygen metabolism;(2) For the cerebral protection of neurosurgery operation,it seems that the effect of intravenous inhalation anesthesia is more stronger than total intravenous anesthesia.