甲氧明在缺血性脑卒中伴冠心病患者全身麻醉神经介入手术中的应用

Application of methoxamine in neurointerventional treatment under general anesthesia for patients with ischemic stroke associated with coronary heart disease

目的 探讨持续静脉泵注射甲氧明和多巴胺对全身麻醉神经介入手术治疗缺血性脑卒中伴冠心病患者脑组织氧饱和度(SctO_(2))和血流动力学的影响.方法 80例择期拟在全身麻醉下行介入手术治疗的缺血性脑卒中伴冠心病患者[40~75岁,美国麻醉医师协会(ASA)分级Ⅱ~Ⅲ级],按数字表法随机分为甲氧明组(A组)和多巴胺组(B组),每组40例.两组患者于手术麻醉诱导完成后至支架植入时分别持续静脉泵注射甲氧明(0.5~3μg/kg^(-1).min^(-1))、多巴胺(0.5~10μg/kg^(-1).min^(-1)),使血压波动幅度不超过基础值20%.围术期采用Fore-Sight脑部血氧饱和度监护仪监测SctO_(2),ICON无创心输出量测量仪监测心肺功能.观察两组患者麻醉诱导前(T0)、麻醉诱导完成后(T1)、气管插管即刻(T2)、气管插管后5 min(T3)、手术开始时(T4)、手术开始10 min(T5)、球囊置入时(T6)、支架植入时(T7)、手术结束时(T8)的SctO_(2)、平均动脉压(MAP)、心率(HR)、心输出量(CO)、心脏搏出量(SV)、系统血管阻力(SVR)、每搏变异(SVV)、收缩力指数(ICON)、射血前期(PEP)时间、收缩时间比(STR)变化以及术中不良反应发生情况.结果 两组患者一般情况、T0~T8时点SctO_(2)、MAP、SVV,T2~T7时点CO、SV差异均无统计学意义(P>0.05).B组T3~T7时点HR高于A组(P<0.05);两组间T1时点SVR均低于T0时点,且T2~T6时点A组SVR高于B组(P<0.05);两组间T1时点ICON值较T0时点减少,PEP时间、STR较T0时点增高(P>0.05),T2~T8时点ICON、PEP时间、STR差异均无统计学意义(P>0.05).A组心律失常、心肌缺血发生率均低于B组(P<0.05).结论 静脉泵注射甲氧明和多巴胺,均可维持全身麻醉下接受神经介入手术治疗缺血性脑卒中伴冠心病患者SctO_(2)和血流动力学平稳,但甲氧明能增加外周血管阻力,提高冠状动脉血流,降低HR,减少心脏做功,降低心脏并发症发生,对冠心病患者更有利.

Objective To investigate the effect of continuous pumping of methoxamine and dopamine on cerebral oxygen saturation(SctO2)and hemodynamics in patients with ischemic stroke combined with coronary heart disease undergoing neurointerventional treatment under general anesthesia.Methods A total of 80 patients with ischemic stroke complicated by coronary heart disease(40-75 years old and ASAⅡ-Ⅲgrade),who were scheduled to receive neurointerventional surgery under general anesthesia,were randomly divided into group A(n=40,receiving methoxamine)and Group B(n=40,receiving dopamine).Between the completion of surgical induction anesthesia and the time of stent implantation,continuous pumping of methoxamine(0.5-3ug/kg-1.min-1)and dopamine(0.5-10)μg/kg-1.min-1)was given to patients of group A and group B respectively,so as to keep the blood pressure fluctuation amplitude not exceeding 20%of the base values.During the perioperative period,the Fore-Sight cerebral oxygen saturation monitor was used to monitor the patient’s SctO2,ICON non-invasive cardiac output measurement apparatus was used to monitor the patient’s cardio-pulmonary functions.The SctO2,mean arterial pressure(MAP),heart rate(HR),cardiac output(CO),cardiac stroke volume(SV),systemic vascular resistance(SVR),stroke volume variation(SVV),contractility index(ICON),pre-ejection phase(PEP)time,changes of contractile time ratio(STR),and the occurrence of intraoperative adverse reactions were recorded at each of the following time points:before induction anesthesia(T0),completion of anesthesia induction(T1),starting tracheal intubation(T2),5 minutes after T2(T3),starting surgery(T4),10 minutes after T4(T5),balloon implantation(T6),stent implantation(T7)and completion of surgery(T8).Results There were no statistically significant differences in general conditions,in SctO2,MAP and SVV measured at T0-T8,and in CO and SV measured at T2-T7 between the two groups(P>0.05).The HRs measured at T3-T7 in group B were significantly higher than those in group A(P<0.05).The SVR measured at T1 was obviously lower than that measured at T0 in both groups,but the SVR values measured at T2-T7 in group A were strikingly higher than those in group B(P<0.05).In both groups,the ICON value at T1 was lower than that at T0,the PEP and STR at T1 were higher than those at T0(P>0.05).The differences in ICON,PEP and STR measured at T2-T8 between the two groups were not statistically significant(P>0.05).The incidences of both arrhythmia and myocardial ischemia in group A were remarkably lower than those in group B(P<0.05).Conclusion Intravenous pumping of methoxamine or dopamine can maintain the SctO2 and hemodynamic stability in patients with ischemic stroke and coronary heart disease undergoing neurointerventional surgery under general anesthesia,but methoxamine can increase peripheral vascular resistance,improve the coronary artery blood flow,reduce cardiac work,and reduce the incidence of cardiac complications,which is more favorable for patients with coronary heart disease.