术中唤醒在颅脑术中预防肢体功能障碍的临床研究

Clinical research of intraoperative wake - up on the prevention of limb dysfunction in brain surgery

目的探讨唤醒后颅内病变切除术在颅脑手术中预防重要功能区损伤的有效性。方法2005年1月至2010年1月完成52例术中唤醒后颅内病变切除术，术前对患者进行唤醒训练。术中维持丙泊酚血药浓度为3．5—4．0mg／L，泵注雷米芬太尼0．15ug/（kg·min），吸入50％N2O和50％O2的气流2L／min。唤醒前30min停用肌肉松弛药，丙泊酚靶浓度渐降至0．5～1．5mg／L，雷米芬太尼减至0．05～0．100ug/（kg·min）。唤醒前15～20min停用丙泊酚和吸入麻醉药，维持雷米芬太尼用量不变；当呼吸恢复后唤醒患者，嘱其按指令活动双侧手指、足趾。然后吸入6％七氟醚、50％N2O与50％O2的新鲜气流5L／min。监测麻醉药最低肺泡有效浓度（MAC）达1．25～1．50时停用吸入麻醉药。记录唤醒所需时间和指令动作恢复时间，术后随访患者对唤醒过程有无记忆。结果唤醒结果满意。颅内病变切除过程中唤醒时间为30～60min。术后4例患者轻微躁动，所有患者无重要功能障碍，术后无痛苦、恐惧等心理体验，对唤醒试验无记忆。结论唤醒后颅内病变切除能较早观察到重要功能损伤，是保证手术安全的有效方法之一。

Objective To investigate the value of awaking between the operation of resection of intracalvarium process in protecting damage of important domain in brain surgery. Methods From January 2005 to January 2010, 52 patients undergoing the awaking between the operation of resection of intracalvarium process at our department. Preoperative for patients with awake training. Intraoperative maintained blood drug level of Propofol for 3.5 -4. 0 ms/L and remyfentanyl injection for 0. 15 ug / （kg · min）, inhaled 50% N2O and 50% O2 airflow for 2 L/min. For 30 min before awaking discontinuing muscle relaxation medicine; the target eoncentrations of propofol injection gradually reduced to 0.5 - 1.5 mg/L, remyfentanyl reduced to 0. 05-0. 100 ug/（kg · min）. 15 -20 min before awaking discontinuation propofol and inhaled anesthetics, maintained remyfentanyl dosage unchanged; After the respiratory recovery, to instructed the patients activity their bilateral fingers and toes according to the instructions. Then inhaled 6% sevoflurane, 50% N2O and 50% O2 fresh air 5 L/min. Monitored anesthetics minimum alveolar effective concentration （MAC） amounted to 1.25 - 1.5 when inhaled anesthetics. Stop 1.50 record awaking needed time and instructions action recovery time, follow - up of patients to awaken process without memory. Results The awake time of waking between the operation of resection of intracalvarium process was from 30 to 60 min. Postoperative four patients were slight restless. All of the patients had no functional disturbance, and there was no memory for postoperative pain and fear. Conclusions Awaking between the operation of resection of intracalvarium process which can early observe damage of important domain for ensuring safe operation is one of the effective approaches.