神经外科手术期间地氟烷复合丙泊酚控制性降压的临床研究

Clinical study of controlled hypotension induced with combination of propofol and desflurane in neurosurgical procedure

目的：探讨地氟烷复合丙泊酚控制性降压应用于颅脑手术的有效性及安全性。方法：35例择 期开颅手术病人，术中分离切除瘤体时通过增加地氟烷和丙泊酚用量使平均动脉压(MAP)较术前下降 30%～40%，维持30～45 min。监测降压前，降压中和升压前，升压过程地氟烷浓度和丙泊酚输注速度、 血流动力学和脑脊液压(CSFP)以及降压前、中、后脑氧代谢等指标的变化，并观察麻醉苏醒恢复情况。结 果：降压初期心率一过性增加(P＜0． 05) ，CSFP 在脑膜剪开后呈进行性下降，降压期间维持在较低水平 (P＜0． 05) 。与降压前比较，降压期间 SjvO_2。显著性升高，脑氧摄取率(ERO_2) 和 D(a-jv)O_2显著性下降(P ＜0． 05) ，而 CaO_2和 CjvO_2无明显变化(P＜0． 05) 。结论：地氟烷复合丙泊酚控制性降压，可有效降低血 压，可控性好。降压期间脑脊液压力维持较低水平，脑氧代谢降低，两者复合，既可避免高浓度地氟烷 吸入，又能减轻丙泊酚剂量，是一种比较理想的神经外科手术控制性降压方法。

Objective： To investigate the effect and reliability of controlled hypotension induced with combination of propofol and desflurane in cranlotomy. Methods： Thirty-five ASA Ⅰ-Ⅱpatients undergoing elective cranlotomy were randomly selected. Anesthesia was maintained with infusion of propofol and inhalation of desflurane. The propofol infusion rate and desflurane inhalation concentration were raised during isolation and resection of the tumors so that the mean arterial pressure was reduced by 30%-40%, and maintaind at this level for 30-45min. After the resection of tumor, the propofol infusion rate and desflurane inhalation concentration were reduced so as to let the MAP increase to normal level. MAP, heart rate（HR）, cerebrospinal fluld pressure（CSFP）, propofol infusion rate, and inhalation concentration of desflurane were recorded before controlled hypotension, during the procedure of controlled hypotension and just before the increase of blood pressure and after controlled hypotension. The awakening status was observed. Arterial and jugular bulb venous blood samples were collected before, during, and after hypotension and the arterial to jugular bulb venous oxygen content difference [D（a-jv）02] and cerebral oxygen extraction rate （ER02） were measured. Results： HR increased significantly in the initial stage and returned to baseline value after 3-14 min during the controlled hypotension. CSFP decreased significantly after incision of dura mater of brain and during controlled hypotension （P〈0.05）. the recovery time after weaning from propofol infusion and desflurane inhalation until eye opening in response to order and autonomous breathing was （15 ± 9）min. the SjvO2 was increased significantly, and D（a-jv）O2 and ERO2 were decreased significantly during hypotension, （P〈0.05）. CaO2 and CjvO2 remainded unchanged throughout the process of hypotension（P〉0.05）. Conclusion： Controlled hypotention with propofol plus desflurane can reduce blood pressure effectively.rapid recovery after weaning from propofol infusion and desflurane inhalation.a short recovery time from anesthesia, and decreased CSFP and brain oxygen metabolism, controlled hypotension with propofol infusion and desflurane inhalation is suitable to incranial surgery.