右美托咪定联合目标导向液体治疗对脑动脉瘤夹闭术患者血流动力学和脑氧供的影响

Effect of dexmedetomidine combined with goal-directed fluid therapy on hemodynamics and cerebral oxygen supply in patients undergoing cerebral aneurysm clipping

目的观察右美托咪定联合目标导向液体治疗(goal-directed fluid therapy,GDFT)对脑动脉瘤夹闭术患者血流动力学和脑氧供的影响。方法选取2021年1月至2022年12月于金华市中心医院行脑动脉瘤夹闭手术的78例患者,根据随机数字表法将其分为对照组与观察组,每组各39例。对照组患者接受常规液体治疗,观察组患者接受右美托咪定泵注+GDFT。比较两组患者不同时点[麻醉诱导前(T_(0))、气管插管即刻(T_(1))、手术开始(T_(2))、切开脑膜(T_(3))、动脉瘤夹闭即刻(T_(4))、手术结束(T_(5))、术后24h(T_(6))、术后72h(T_(7))]的平均动脉压(mean arterial pressure,MAP)、心率(heart rate,HR)、心脏指数(cardiac index,CI)、脑代谢指标、神经元特异性烯醇化酶(neuron specific enolase,NSE)、S100β水平和简易精神状态检查量表(mini mental status examination,MMSE)评分及液体出入量。结果观察组患者T_(1)~T_(4)时点的MAP均显著高于对照组,T_(1)~T_(3)时点的CI均显著高于对照组(P<0.05)。观察组患者的胶体量、总输液量、尿量均显著大于对照组(P<0.05)。两组患者T_(5)~T_(7)时点的血清NSE、S100β水平均显著高于本组T_(0)(P<0.05);观察组患者T_(5)、T_(6)时点的血清NSE、S100β水平均显著低于对照组(P<0.05)。对照组患者T_(1)~T_(4)时点的颈静脉血氧含量(oxygen content in jugular venous blood,CjvO2)显著低于T_(0)(P<0.05);两组患者T_(1)时点的脑氧摄取率均显著高于本组T_(0)(P<0.05);观察组患者T_(3)~T_(4)时点的CjvO2显著高于对照组(P<0.05)。T_(6)、T_(7)时点,两组患者的MMSE评分均显著低于本组T_(0)(P<0.05);观察组患者T_(6)时点的MMSE评分显著高于对照组(P<0.05)。结论脑动脉瘤夹闭术患者接受右美托咪定联合GDFT可有效改善前负荷和脑功能,稳定术中循环功能,提高患者术后的早期认知功能。

Objective To observe the effect of dexmedetomidine combined with goal-directed fluid therapy(GDFT)on hemodynamics and cerebral oxygen supply of patients undergoing cerebral aneurysm clipping.Methods A total of 78 patients undergoing cerebral aneurysm clipping surgery in Jinhua Municipal Central Hospital from January 2021 to December 2022 were selected and divided into control group and observation group according to random number table method,with 39 cases in each group.The patients in control group received conventional fluid therapy,and the patients in observation group received dexmedetomidine pump+GDFT.Mean arterial pressure(MAP),heart rate(HR),cardiac index(CI),brain metabolic markers,neuron specific enolase(NSE),S100βlevels and mini mental status examination(MMSE)scores at different time points[before anesthesia induction(T_(0)),immediately after tracheal intubation(T_(1)),beginning of surgery(T_(2)),opening meninges(T_(3)),immediately after aneurysm clipping(T_(4)),end of surgery(T_(5)),24h after surgery(T_(6)),72h after surgery(T_(7))],and fluid intake and outflow of two groups were compared.Results MAP at T_(1)-T_(4)and CI at T_(1)-T_(3)in observation group were significantly higher than those in control group(P<0.05).The colloid volume,total infusion volume and urine volume in observation group were significantly higher than those in control group(P<0.05).The serum levels of NSE and S100βat T_(5)-T_(7)were significantly higher than those at T_(0)in both groups(P<0.05).The levels of serum NSE and S100βat T_(5)and T_(6)in observation group were significantly lower than those in control group(P<0.05).The oxygen content in jugular venous blood(CjvO2)at T_(1)-T_(4)was significantly lower than that at T_(0)in control group(P<0.05).Cerebral oxygen extraction ratio at T_(1)was significantly higher than that at T_(0)in both groups(P<0.05).CjvO2 at T_(3)-T_(4)in observation group were significantly higher than those in control group(P<0.05).At T_(6)and T_(7),MMSE scores in two groups were significantly lower than at T_(0)in this group(P<0.05).MMSE score at T_(6)of observation group was significantly higher than that of control group(P<0.05).Conclusion Dexmedetomidine combined with GDFT can effectively improve preload and brain function,stabilize intraoperative circulatory function,and improve early postoperative cognitive function in patients undergoing cerebral aneurysm clipping.