靶控输注瑞芬太尼复合吸入异氟醚控制性降压对开颅手术患者血液动力学的影响

EFFECTS OF CONTROLLED HYPOTENSION WITH REMIFENTANIL BY TCI COMBINED WITH ISOFLURANE INHALATION ON HEMODYNAMICE IN PATIENTS UNDERGOING NEUROSURGERY

目的探讨靶控输注（target continue infusion，TCI）瑞芬太尼复合吸入异氟醚控制性降压对开颅手术患者血液动力学的影响。方法择期开颅手术患者30例，ASAⅡ～Ⅲ级，随机分为2组：异氟醚控制性降压组（ISO组）和瑞芬太尼复合异氟醚控制性降压组（RF组），每组15例。2组麻醉诱导后至打开硬脑膜前均吸入1％异氟醚维持麻醉，打开硬脑膜后ISO组逐渐增加异氟醚吸入浓度，RF组开始TCI瑞芬太尼行控制性降压，使平均动脉压（mean arteriah pressure，MAP）降至术前的70％，维持30min后，IS0组降低异氟醚吸入浓度，RF组停止TCI瑞芬太尼，终止降压。采用CO2复吸入法无创心肺功能监护系统（NICO2^TM）连续监测心率（heartrate，HR）、心排血量（cardiac output，CO）、心指数（cardiac index，CI）、每搏输出量（stroke volume，SV），分别于手术前（T0）、降压前（T1）、达到目标血压即刻（T2）、5min（T3）、10min（T4）、20min（T5）、30min（T6）及停止降压5min（T7）、10min（T8）、30min（T9）时记录MAP、HR、C0、CI、SV并计算外周血管阻力（systemic vascular resistance，SVR）。结果与降压前比较；ISO组T2～5时SVR降低，T6，7时SV降低（P〈0．05），RF组T2-8时HR减慢、CO、CI、SVR降低（P〈0．05），SV各时点差异无统计学意义；与ISO组比较，RF组T2～8时HR减慢、CO、CI降低（P〈0．05），降压达到目标血压及血压恢复时间短（P〈0．05）。结论开颅手术TCI瑞芬太尼复合吸入异氟醚控制性降压，达到目标血压时间短，效果确切，可控性好，并且降压期间不增快心率，不抑制心肌收缩力。

Objective To investigate the effects of controlled hypotension with remifentanil by target continue infusion （TCI） combined with isoflurane inhalation on hemodynamics in patients undergoing neurosurgery. Methods Thirty ASA Ⅱ-Ⅲ patients undergoing intracranial surgery were randomly divided into 2 groups （ n =15 each）,group ISO （controlled hypotension with isoflurane） and group RF （controlled hypotension with remifentanil and isoflurane）. Anesthesia was induced with fentanyl 3-5μg/kg and propofol 2 mg/kg, tracheal intubation was facilitated with rocuronium 0.9 mg/kg. Anesthesia was maintained with 1% isoflurane inhalation before opening the dura. Starting from opening the dura mean arteriah pressure （MAP） was reduced to 70% of baseline by inhalation of isoflurane （in group ISO） or TCI remifentanil （in group RF） and hypotension was maintained for 30 min. Heart rate（HR）, cardiac output （CO）, cardiac index （CI）, stroke volume （SV） were continuously monitored by NICO2 which was noninvasive. MAP, HR, CO, CI, SV were recorded before and during and after controlled hypotension and systemic vascular resistance （SVR） was calculated. Results SVR was significantly decreased from T2 to T8 and SV was significantly decreased at T6,7in group ISO HR, CO,CI and SVR were significantly decreased from T2 to T8 as compared with the baseline values before controlled hypotension in group RF. The induced and recovery time of controlled hypotension were shorter in group RF than in group ISO. Conclusion Remifentanil by TCI combined with isoflurane inhalation can be used to induce and sustain controlled hypotension during neurosurgery,without HR increasing and myocardial contractility depression.