氯胺酮和丙泊酚持续颈内静脉输注对脑损伤患者围术期脑保护效应的临床研究

Clinical research of Ketamine and Propofol internal carotid vein continuous infusion on brain protective effect in patients with craniocerebral injury during perioperative period

目的探讨氯胺酮和丙泊酚持续颈内静脉输注对脑损伤患者围术期脑保护效应。方法选择临床中型脑损伤患者适当病例60例行颅内血肿清除术,随机分三组,各20例。A组:对照组,围术期未特殊处理;B组:围术期氯胺酮/丙泊酚1:1混合0.5 mg/(kg·h)微泵持续颈内静脉输注;C组:围术期氯胺酮/丙泊酚1:1混合1 mg/(kg·h)微泵持续颈内静脉输注。三组患者分别于手术开始前和术毕12、24、48 h不同时间点取对侧颈内静脉血5 mL,采用酶联免疫法(ELISA)测定血清星状细胞胶质蛋白S-100β(S-100β蛋白)和神经元性烯醇化酶(NSE)浓度,并记录不同时间点各组患者神经反射变化和意识恢复情况,6个月后随访60例患者并进行简短精神状态检查(MMSE)。结果与A组比较,B、C组随时间延长S-100β蛋白和NSE浓度显著降低,差异有高度统计学意义(P<0.01),其作用效应有剂量依赖性。B组S-100β蛋白浓度术毕24 h为(2.26±0.52)μg/L,术毕48 h为(1.25±0.35)μg/L;C组S-100β蛋白浓度术毕24 h为(1.12±0.25)μg/L,术毕48 h为(0.69±0.11)μg/L。B组NSE蛋白浓度术毕24 h为(7.26±1.12)μg/L,术毕48 h为(5.36±0.58)μg/L;C组NSE蛋白浓度术毕24 h为(6.02±0.65)μg/L,术毕48 h为(4.78±0.81)μg/L。与A组比较,B组和C组患者神经反射和意识恢复快,脑神经并发症低,差异有统计学意义(P<0.05)。B组意识恢复时间为(26.5±6.9)h,C组意识恢复时间(27.3±4.7)h;B组神经功能缺损评分为(12.8±1.9)分,C组神经功能缺损评分为(12.3±0.9)分。6个月后随访进行MMSE评分,A组MMSE评分为(17.1±3.2)分,低于B组[(23.7±4.5)分]和C组[(25.5±4.7)分](P<0.05),但B组和C组差异无统计学意义(P>0.05)。手术结束24 h患者血清S-100β蛋白和NSE浓度越高对应其6个月后随访MMSE评分就越低,血清S-100β蛋白与MMSE评分呈明显负相关(r=-0.618,P<0.05)。结论氯胺酮和丙泊酚联合应用对脑损伤围术期有明显的治疗和神经保护作用,术后随访无不良反应或副作用。

Objective To investigate Ketamine and Propofol internal carotid vein continuous infusion on brain protec tive effect in patients with cranioeerebral injury during perioperative period. Methods Clinical 60 patients with medium craniocerebral injury were randomly divided into 3 groups, with 20 cases in each group. Group A： control group, with out any special treatments; group B： mixture of Ketamine and Propofol by 1：1 were pumped to the carotid vein by a continuous infusion of 0.5 mg/（kg, h） in perioperative; group C： mixture of Ketamine and Propofol by 1：1 were pumped to the carotid vein by a continuous infusion of 1 mg/（kg-h） in perioperative. 5 mL blood samples were taken at initiation of the surgery, 12 h, 24 h and 48 h after operation from contralateral carotid vein of the three groups. Concentration of both S-10013 and NSE in serum of patients was measured bv enzvme-linked immunosorbent （FIIA Aria changes and recovery of consciousness of patients in each group at different time points were recorded. 60 patients were followed up six months later and the minimental state examination （MMSE） was performed andrecorded. Results Compared with group A , S-100 protein and NSE were significantly lower （P 〈 0.01） in group B and C with time, with role in a dose-dependent effect, and patients recover faster reflex and consciousness, while lower cranial nerve complications than the control group. The S-10013 levels in group B after operation 24 h and 48 h were （2.26±0.52） μg/L and （1.25±0.35） txg/L, the S-10013 levels in group C after operation 24 h and 48 h were （1.12±0.25） μg/L and （0.69±0.11） μg/L respectively. The NSE levels in group B after operation 24 h and 48 h were （7.26±1.12） μg/L and （5.36±0.58） μg/L, the NSE levels in group C after operation 24 h and 48 h were （6.02±0.65）μg/L and （4.78±0.81） μg/L respectively. The consciousness recover time in group B and C were （26.5±6.9） h and （27.3±4.7） h, the clinical neurological functional deficiency score （CNFDS） in group B and C were （12.8±1.9） points and （12.3±0.9） points re spectively. The MMSE score after 6 months follow-up visits in group B [（23.7±4.5） points] and group C [（25.5±4.7） points] were higher than that in control group [（17.1±3.2） points] （P 〈 0.05）. There was negative association between S100[5 in serum and MMSE score （r = -0.618, P 〈 0.05）. Conclusion The application of Ketamine and Propofol has significant therapeutic and neuroprotective effects during cerebral surgery, with no adverse reactions or side effects after postoperative follow-up visits.