超声多普勒系统联合神经电生理监测技术对颈动脉内膜剥脱术中血压控制及术后认知功能的影响

Effect of TCD combined with neuroelectrophysiological monitoring on individualized blood pressure management and postoperative cognitive function in patients undergoing CEA

目的 探讨经颅超声多普勒系统(transcranial doppler ultrasound, TCD)联合神经电生理监测技术(neurophysiological monitoring, SEP)对颈动脉内膜剥脱术(carotid endarterectomy, CEA)患者术中个体化血压管理、心肌耗氧及术后认知功能的影响。方法 纳入择期行CEA治疗的老年患者120例作为研究对象,根据随机数字表法分为研究组和对照组,每组60例。对照组通过血管活性药物升高血压,研究组术中根据TCD和SEP联合监测结果指导血压调节工作。收集2组麻醉前(T00),麻醉后10 min(T0)、颈动脉阻断前5 min(T1)、颈动脉阻断前后即刻(T2)、解除颈动脉阻断即刻(T3)及解除颈动脉阻断后1 h(T4)时大脑中动脉血流速度(Vm)值和外周动脉收缩压,比较2组术中一般情况(心肌耗氧量、血管活性药物用量等)、术后认知功能障碍(postoperative cognitive dysfunction, POCD)发生率和半年后超声复查结果。结果 研究组术中麻黄碱用量、尼卡地平用量、去甲肾上腺素用量、心肌耗氧量及术中发生心动过缓患者比例均低于对照组(P<0.05)。2组手术侧Vm与外周动脉收缩压呈波动趋势,研究组Vm与外周动脉收缩压的波动幅度小于对照组,组间、时点间、组间·时点间交互作用差异有统计学意义(P<0.05)。2组POCD总发生率差异无统计学意义(P>0.05)。2组C反应蛋白、丙二醛水平呈先升高后降低趋势,超氧化物歧化酶水平呈先降低后升高趋势,研究组C反应蛋白、丙二醛水平明显高于对照组,超氧化物歧化酶水平明显低于对照组,组间、时点间、组间·时点间交互作用差异有统计学意义(P<0.05)。研究组60例患者中有25例术中阻断颈动脉后,TCD监测提示达到流转标准,其中7例患者同时达SEP波幅下降流转标准,给予转流术操作。TCD监测阳性率高于SEP监测(P<0.05),两种手段共同监测达到转流标准的比例一致性一般(Kappa=0.243,P<0.05)。研究组术后半年发生术后再狭窄和形成继发血栓的患者例数均较对照组明显偏少(P<0.05)。结论 TCD联合SEP对CEA患者术中个体化血压管理具有较高的指导价值,可显著减少术中心肌耗氧量,降低术后不良事件的发生风险,其中TCD对CEA术中脑血流高灌注现象监测效果较好,而SEP对术中转流的实施指导意义更高。

Objective To explore the effect of transcranial doppler ultrasound(TCD)combined with neurophysiological monitoring technology sensory evoked potential(SEP)on intraoperative individualized blood pressure management,myocardial oxygen consumption and postoperative cognitive function in patients undergoing carotid endarterectomy(CEA).Methods One hundred and twenty elderly patients undergoing elective CEA were enrolled as research subjects,and divided into research group(n=60)and control group(n=60)according to random number table method.The control group was treated with vasoactive drugs to increase blood pressure,and the research group was guided by the combined monitoring results of TCD and SEP during the operation.Mean velocity of middle cerebral artery(Vm)values and peripheral arterial systolic pressure before anesthesia(T00),at 10 min after anesthesia(T0),at 5 min before carotid artery occlusion(T1),immediately before and after carotid artery occlusion(T2),immediately after carotid artery occlusion(T3)and at 1 h after carotid artery occlusion(T4)were collected.The intraoperative general conditions(myocardial oxygen consumption,dosage of vasoactive drugs),the incidence of postoperative cognitive dysfunction(POCD)and the results of ultrasound reexamination at 6 months after operation were compared between the two groups.Results The consumption of ephedrine,nicardipine and norepinephrine,myocardial oxygen consumption and the proprtion of patients developing intraoperative bradycardia in the research group were lower than those in the control group(P<0.05).Vm and peripheral arterial systolic pressure on the surgical side of the two groups showed a downward fluctuation trend,and the fluctuation range of Vm and peripheral arterial systolic pressure in the research group was smaller than that in the control group;The difference of interaction between groups,time points,and time points between groups were statistically significant(P<0.05).There was no significant difference in the total incidence of POCD between the two groups(P>0.05).The levels of C-reactive protein(CRP)and malondialdehyde in the two groups increased first and then decreased,while the level of superoxide dismutase decreased first and then increased.The levels of CRP and malondialdehyde in the research group were significantly higher than those in the control group,while the level of superoxide dismutase was significantly lower than that in the control group;There were significant differences in interactions between groups,time points,and time points between groups(P<0.05).In 60 patients in the research group,TCD monitoring indicated that 25 patients reached the shunting standard after carotid artery occlusion during operation,and 7 patients reached the shunting standard of decreased SEP amplitude simultaneously and were given shunting operation.The positive rate of TCD monitoring was higher than that of SEP monitoring(P<0.05),and the consistency of the proportion of shunting standards by the two methods was general(Kappa=0.243,P<0.05).The number of patients with postoperative restenosis and secondary thrombosis in the research group was significantly less than that in the control group(P<0.05).Conclusion TCD combined with SEP has a high guiding value for individualized intraoperative blood pressure management in patients with CEA,which can significantly reduce intraoperative myocardial oxygen consumption and reduce the risk of postoperative adverse events.TCD has a better monitoring effect on cerebral blood flow hyperperfusion during CEA,while SEP has a higher guiding significance for the implementation of intraoperative shunting.