急性高容量血液稀释联合瑞芬太尼控制性降压对颅内动脉瘤术患者血流动力学和脑氧代谢的影响

Effects of acute hypervolemic hemodilution combined with remifentanil-induced deliberated hypotension on hemodynamics and cerebral oxygen metabolism in patients undergoing intracranial aneurysm surgery

目的观察颅内动脉瘤夹闭术患者在急性高容量血液稀释(AHH)联合瑞芬太尼控制性降压(CH)后血流动力学和脑氧代谢的变化,评价其可行性。方法选择颅内动脉瘤夹闭术患者40例,随机均分为硝酸甘油组(A组)和瑞芬太尼组(B组)。手术开始时以15～20ml·kg-1·h-1的速率输入4%琥珀酰明胶,使Hct稀释为25%～32%。在剪开硬脑膜后行CH,A组泵入硝酸甘油1～5μg·kg-1·min-1;B组泵入瑞芬太尼12～30μg·kg-1·h-1,使MAP维持在60～65mmHg,动脉瘤夹闭后10min停止CH。记录两组患者AHH前(T0)、AHH后(T1)、降压前(T2)、降压后30min(T3)、动脉瘤夹闭后5min(T4)的MAP、HR、Hb和Hct,分别于T2～T4时采集颈内静脉球部血和桡动脉血作血气分析,检测动、静脉血氧饱和度(SaO2、SjvO2)、动、静脉血氧分压(PaO2、PjvO2)、Hb和Hct,计算动脉氧含量(CaO2)、颈内静脉氧含量(CjvO2)、动脉颈内静脉球部血氧差(Da-jvO2)、颈内静脉球部动脉乳酸差(VADL)和脑氧摄取率(CERO2)。结果与T0时比较,T1～T4时两组Hb和Hct均显著降低(P<0.01)。与T2时比较,T3、T4时两组MAP明显降低,A组HR明显增快,B组的HR明显减慢(P<0.01);T3、T4时B组SjvO2和CjvO2明显高于T2时和A组,Da-jvO2和CE-RO2明显低于T2时和A组(P<0.01)。结论 AHH联合瑞芬太尼CH用于颅内动脉瘤夹闭术中,不但维持血流动力学的相对稳定,而且明显降低脑氧代谢率,较AHH联合硝酸甘油CH更具优越性。

Objective To observe the changes of patient＇s hemodynamics and cerebral oxygen metabolism undergoing intracranial aneurysm surgery after acute hypervolemic hemodilution （AHH） combined with remifentaniI-induced deliberated hypotension and to evaluate the clinical applicatioru Methods Forty patients undergoing intracranial aneurysm surgery were randomly divided into nitroglycerin group （group A, n=20） and remifentanil group（group B, n=20）. At the beginning of the surgery, the patients in both groups received 4% succinylated gelatin at a rate of 15 20 ml.kg-1 .h-1 until Hct was stabled at 25%-32%. After cerebral dura incision, MAP was maintained to 60-65 mm Hg by nitroglycerin （1-5μg.kg-1.min-1 ） in group A and by remifentanil（12-30 μg.kg-1 .h-1 ） in group B until 10 minutes after clamping of the aneurysm. MAP, HR, Hb and Hct were recorded atbaseline （T0）, after AHH（T1）, pre-hypotensiQn（T2 ） ,30 rain after hypotension（T3 ） and 5 min after clamping（T4 ）. SjvO2, PjvO2, SaO2, PaO2, Hb and Hct were measured, and CaO2, CjvO2, Da-jvO2, VADL and CERO2 were calculated from T2 to T4 from radical arterial and bulb of intra jugular vein blood gases. Results Compared with baseline, Hb and Hct decreased significantly from TI to T4 in both groups （P〈0. 01）. Compared with Te, MAP decreased obviously at T3 and T4 in both groups, and HR increased in group A but decreased in group B significantly （P〈0. 01）. SjvO2 and CjvO2 increased but DajvO2 and CERO2 decreased at T3 and T4 than at T2 with more significance in group B （P〈0.01）. Conclusion AHH combined with remifentanil can maintain stable hemodynamics and decrease cerebral oxygen metabolism in intracranial aneurysm surgery.