小剂量去甲肾上腺素复合目标导向液体治疗在颅内肿瘤切除术患者中的应用

发布时间：2018-03-09 20:31

  本文选题：颅内肿瘤切除术　切入点：麻醉　出处：《河北医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:颅内肿瘤是神经外科的常见病,手术切除是其目前主要的治疗方法。术中需维持正常脑组织灌注和氧供,优化手术条件便于肿瘤切除,确保病人从麻醉中迅速恢复以利于进行神经功能评估。本研究对接受目标导向液体治疗的颅内肿瘤切除术患者,在麻醉期间输注小剂量去甲肾上腺素,观察术中动静脉血氧含量差(Ca-jvO2)、脑氧摄取率(CERO2)和脑乳酸生成率(LacPR)等脑氧代谢指标的改变,测定颈内静脉球部血液S100B蛋白含量的变化,记录术中生命体征,探讨小剂量去甲肾上腺素对接受目标导向液体治疗的颅内肿瘤切除术患者的影响。方法:择期全麻下行颅内肿瘤切除术患者40例,年龄18~65岁,性别不限,美国麻醉医师协会(American Society of Anesthesiologist,ASA)分级Ⅱ~Ⅲ级,Glasgow评分(GCS)15分,无心肺功能障碍,无肝肾疾病、心律失常、周围动脉广泛性闭塞性疾病及凝血异常等。经过签订知情同意书,将其随机分为两组(n=20):目标导向液体治疗组(G组)和目标导向液体治疗复合小剂量去甲肾上腺素组(N组)。所有患者均监护心电、无创血压、脉搏血氧饱和度和体温,建立外周静脉液路。局部麻醉后在左侧桡动脉处穿刺置管,通过Flo Trac传感器与Vigileo监测仪(Edwards公司,美国)连接。诱导用咪达唑仑0.04mg/kg、丙泊酚2mg/kg、罗库溴铵0.6mg/kg和舒芬太尼0.5μg/kg,满足插管条件后置入气管导管,连接麻醉机进行机械通气。设定潮气量为8~10ml/kg,维持呼气末二氧化碳分压(PETCO2)在30~40mmHg之间。在右股静脉处穿刺置管;在右颈内静脉处逆行穿刺置管至颈内静脉球部。以3~6mg/(kg·h)速率输注丙泊酚和0.1~0.3μg/(kg·h)速率输注瑞芬太尼维持麻醉。G组当每搏量变异度(stroke volume variation,SVV)高于13%超出5分钟时,指示患者体内有效循环血容量不足,需要补液以使其低于13%;当SVV降低至13%以下时,以1~2ml/(kg·h)的速度补充维持所需液体。n组在麻醉诱导后开始静脉输注小剂量去甲肾上腺素,速度为0.01~0.03μg/(kg·min),维持平均动脉压(map)≥65mmhg,其他同g组。两组术中均维持hb8g/dl。在两组中分别于麻醉诱导后(t1)、打开硬脑膜时(t2)、开硬脑膜1h(t3)、术毕(t4),抽取桡动脉血和颈内静脉球部血进行血气分析,计算ca-jvo2、cero2、脑血流/脑氧代谢率比值(cbf/cmro2比值)和lacpr。取颈内静脉球部静脉血2ml至试管静置后离心,采用酶联免疫吸附法(elisa)测定血清中s-100b蛋白的含量。记录并统计术中总液体量、晶体液入量、胶体液入量、出血量和尿量。结果:1两组患者的性别构成比、年龄、asa分级构成比、体质指数(bmi)和麻醉时长(min)等相比差异无统计学意义(p0.05)。2两组各时点心率(hr)相比差异无统计学意义(p0.05)。n组的map在t4时点与g组相比显著升高(p0.05)。g组的map在不同时点差异无统计学意义(p0.05);n组的map在t4较t1~t3时点明显升高(p0.05);其余时点间差异无统计学意义。3n组的总液体量和晶体液入量低于g组,差异有统计学意义(p0.05)。两组尿量相比差异无统计学意义(p0.05)。4两组在各时点的ca-jvo2值组间比较差异无统计学意义(p0.05)。g组在t3、t4较t1时点明显下降;n组的ca-jvo2值在t2较t1时点明显下降(p0.05);其余时点差异无统计学意义。5在t3、t4时点g组的cero2与n组相比显著降低(p0.05)。g组在t4较t1、t2时点明显下降(p0.05);n组的cero2在t3较t2时点明显升高(p0.05);其余时点差异无统计学意义。6两组各时点lacpr相比差异无统计学意义(p0.05)。7g组的cbf/cmro2在t3较t1时点明显升高(p0.05);n组在t2较t1时点明显升高(p0.05);其余时点差异无统计学意义。8两组各时点血清s100b蛋白含量相比差异均无统计学意义(p0.05)。n组在t4时点较t1明显下降,差异有统计学意义(p0.05)。结论:对接受目标导向液体治疗的颅内肿瘤切除术患者,在麻醉期间输注小剂量去甲肾上腺素,可减少术中输液量,维持内环境稳定,增加肾脏的灌注和尿量;可维持血流动力学稳定,改善脑灌注和脑氧供需关系。
[Abstract]:Objective: intracranial tumor is a common disease in Department of Neurosurgery, surgery is the main treatment. To maintain normal brain tissue perfusion and oxygen supply in the operation, optimization of operation conditions for tumor resection, ensure the patient from anesthesia rapid recovery of neurological function assessment to intracranial tumors. This study of goal-directed fluid therapy surgical patients in anesthesia during infusion of small doses of norepinephrine, observed in arterial venous oxygen content difference (Ca-jvO2), cerebral oxygen uptake rate (CERO2) and cerebral lactate production rate (LacPR) and cerebral oxygen metabolism index changes, changes in determination of internal jugular vein blood S100B protein content, vital signs during the recording, to explore the effect of low dose of norepinephrine for goal-directed fluid therapy of the patients with intracranial tumor resection. Methods: 40 cases of patients with intracranial tumor resection under general anesthesia, age 18 ~65 years of age, sex, American Society of anesthesiologists (American Society of Anesthesiologist, ASA) grade II or III (GCS), Glasgow score of 15 points, no pulmonary dysfunction, no liver and kidney disease, arrhythmia, peripheral arterial extensive occlusive disease and abnormal coagulation. After signing the informed consent, they were divided into two groups (n=20): goal-directed fluid therapy group (G group) norepinephrine treatment combined with small dose and goal oriented liquid (N group). All patients were monitoring ECG, non-invasive blood pressure, oxygen saturation and temperature, the establishment of peripheral intravenous route after local anesthesia in the left radial. Artery catheterization, through the Flo Trac sensor and Vigileo monitor (Edwards company, USA). The connection was induced with midazolam 0.04mg/kg, 2mg/kg propofol, rocuronium 0.6mg/kg and sufentanil 0.5 g/kg, to meet the post intubation conditions into the endotracheal tube. Mechanical ventilation with anesthesia machine. The tidal volume was set to 8~10ml/kg, to maintain the end tidal carbon dioxide partial pressure (PETCO2) in 30~40mmHg. In the right femoral vein puncture catheter in right internal jugular vein; retrograde catheterization of internal jugular vein. To 3~6mg/ (kg - H) the rate of infusion of propofol and 0.1~0.3 g/ (kg h) the rate of infusion of remifentanil anesthesia in.G group when the stroke volume variation (stroke volume, variation, SVV) more than 13% more than 5 minutes, indicating the patient effective circulating blood volume, need rehydration so that it is less than 13%; when the SVV decreased to below 13%, with 1~2ml/ (kg. H) the speed of maintain the required liquid group.N intravenous infusion of small doses of norepinephrine after anesthesia induction and speed of 0.01~0.03 g/ (kg min), to maintain the mean arterial pressure (map) other than 65mmhg, with the G group. The two groups were maintained in hb8g /dl. in the two groups respectively. Anesthesia 璇卞�煎悾�

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