多模式监测对缺血型烟雾病血管重建术患者术后恢复的影响

Multimodal intraoperative monitoring on recovery in patients undergoing cerebral revascularization for ischemic moyamoya disease

目的评价应用包含脑氧饱和度(rSO2)和每搏量变异率(SVV)的多模式监测对缺血型烟雾病血管重建术患者术后恢复的影响。方法择期首次行缺血型烟雾病血管重建术患者66例,男34例,女32例,年龄18~60岁,ASAⅡ或Ⅲ级,数字减影血管造影(DSA)烟雾病分期(Suzuki分期)≥3期。采用随机数字表法分为两组:多模式监测组(Mon组)和对照组(Con组),每组33例。Mon组进行rSO2监测,维持rSO2在55%以上且降低幅度不超过基础值20%,根据SVV指导输液,维持SVV<13%。Con组未进行rSO2监测,采用常规补液原则,维持CVP 10~12 mmHg。记录两组患者手术时间、术中胶体量、晶体量、总液体量、尿量和出血量。分别于麻醉诱导前(T0)、血管阻断前(T1)、血管阻断后10 min(T2)、血管吻合-开放后10 min(T3)时检测乳酸(Lac)和Hb。术前1 d和术后5 d采用40项恢复质量评分量表(QoR-40量表)评估患者身体舒适度、情绪状态、自理能力、心理支持和疼痛评分。记录患者术后谵妄、恶心呕吐和脑血管意外的发生情况。结果 Mon组术中胶体量和总液体量明显高于Con组(P<0.05)。与T0时比较,T2和T3时两组Lac明显升高(P<0.05)。T2和T3时Mon组Lac明显低于Con组(P<0.05)。术后5 d Mon组QoR-40量表评分中身体舒适度评分、情绪状态评分、心理支持评分和总评分明显高于Con组(P<0.05),Mon组术后谵妄和恶心呕吐的发生率明显低于Con组(P<0.05)。结论在缺血型烟雾病血管重建术中应用包含rSO2和SVV的多模式监测,可以指导围手术期氧合及液体管理,有利于维持脑氧平衡及有效脑灌注,提高患者术后恢复质量,降低术后并发症。

Objective To evaluate the effects of multimodal monitoring including regional cerebral oxygen saturation and stroke volume variability on postoperative recovery in patients undergoing cerebral revascularization for ischemic moyamoya disease. Methods Sixty six patients, 34 males and 32 females falling into ASA physical status Ⅱ or Ⅲ, aged 18-60 years, with a BMI of 18-30 kg/m^2,Suzuki ≥ 3,MMSE > 24 scheduled for cerebral revascularization for ischemic moyamoya disease first time, were randomly divided into either refined anesthesia management group(group Mon, n = 33) orcontrol group(group Con, n = 33) using a random number table. In group Mon, regional cerebral oxygen saturation was monitored, rSO2 was maintained above 55% and not below the base value of 20%, and was treated with goal directed fluid therapy, with stroke volume variability(SVV) as a guide, and SVV < 13% was maintained whereas in group Con, no regional cerebral oxygen saturation was monitored and was treated with rehydration principle and CVP 10-12 mmHg was maintained. The operation time, the requirement for crystalloid and colloid solution, total volume of fluid, urine volume and the volume of blood loss were recorded during operation. Lactic acid(Lac) and Hemoglobin(Hb) were recorded before induction of anesthesia(T0), before blood vessel was clamped(T1), 10 min after blood vessel was clamped(T2) and 10 min after anastomosis was completed(T3). At preoperative 1 day and 5 day after surgery, the global QoR-40 aggregate score including physical comfort, emotional state, self-care ability, psychological support and pain scorewas used to assess the quality of patient recovery. Postoperative delirium, nausea and vomiting, cerebrovascular accidents were recorded. Results Compared with group Con, the requirement for colloid solution and total volume of fluid infused were increased during operation in group Mon(P<0.05). Compared with T0, Lac in the two groups increased at T2 and T3, and the Lac in group Con was higher than that in group Mon(P<0.05). Compared with group Con, the QoR-40 scale score includes physical comfort, emotional state, psychological support and overall score at 5 days after surgery was significantly higher in group Mon. Compared with group Con, the incidence of postoperative delirium, nausea and vomiting were significantly lower in group Mon(P<0.05). Conclusion The application of multimodal monitoring of rSO2 and SVV monitoring can guide the perioperative oxygenation and fluid management, which is conducive to maintaining cerebral oxygenbalance and effective cerebral perfusion, improving the quality of postoperative recovery, and reducing postoperative complications in patients undergoing cerebral revascularization for ischemic moyamoya disease.