局部脑氧饱和度联合神经电生理监测指导颈动脉内膜剥脱术中患者血压管理的效果

发布时间：2018-05-13 23:12

本文选题：血压 + 颈动脉内膜剥脱术　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:拟探讨局部脑氧饱和度联合神经电生理监测对颈动脉内膜剥脱术(Carotid Endarterectomy,CEA)中患侧颈动脉阻断期间血压管理的效果,为临床提供参考。方法:择期行CEA患者40例,年龄50~80岁,性别不限,美国麻醉医师协会(ASA)分级II或III级,采用随机数字表法将其分为2组(n=20):对照组(C组)和联合监测组(M组)。C组患者在颈动脉阻断期间依照传统方法升高收缩压,升高幅度为术前基础血压的20%~30%;M组根据局部脑氧饱和度(rSO_2)监测和神经电生理监测调节收缩压,使监测指标维持在临床许可变化范围。患者入室后监测无创血压(NIBP)、心率(HR)、心电图(ECG)、脉搏血氧饱和度(SpO_2)、rSO_2及脑电双频谱指数(BIS),局麻下桡动脉穿刺置管,连接Flo Trac/Vigileo监护仪连续监测并记录有创动脉压(IBP)、心输出量(CO)和每搏量变异度(SVV)。麻醉诱导:依次静脉注射咪达唑仑0.01~0.05 mg/kg、依托咪酯0.1~0.3mg/kg、顺式阿曲库铵0.1~0.2 mg/kg、枸橼酸舒芬太尼0.4~0.6μg/kg和利多卡因60~100 mg。麻醉维持:微量泵持续泵入丙泊酚2~6 mg·kg-1·h-1、瑞芬太尼0.1~0.3μg·kg-1·min-1,BIS值维持在40~60。诱导后由神经电生理医生连接神经电生理监护仪,监测脑电图和体感诱发电位。两组患者均在术前1 d用简易智能状态检查量表(MMSE)评估认知功能,记录年龄,性别,教育程度,术前合并症等。以入院后护士每日清晨(T0)测得的病房平均血压记为基础血压,术中分别记录两组患者入室(T0)rSO_2,插管即刻(T1)血压,麻醉诱导平稳后5 min(T2)血压,阻断颈动脉后5 min(T3)血压稳定值,开放颈动脉后5 min(T4)血压稳定值,拔管即刻(T5)血压和同时刻的rSO_2。记录全麻药物用量,血管活性药物用量及次数,阻断颈动脉时间,苏醒时间,拔管时间,术后并发症等。术后第1天,第3天,第7天采用MMSE评估患者认知功能。结果:1两组患者年龄、性别比例、教育程度、术前合并症等一般情况比较,差异无统计学意义(P0.05)。2两组组间比较T0-2、T4-5时刻血压差异无统计学意义(P0.05),T3有统计学意义(P0.05)。与C组T3血压高于基础血压20%~30%比较,M组有4例患者血压升高10%~20%,11例患者血压升高0%~10%,5例患者血压低于基础血压0%~10%。与T0时刻比较,T2,4-5时血压降低,T1,3时血压升高,差异有统计学意义(P0.05)。3两组组间比较各时刻rSO_2差异无统计学意义(P0.05),与T0时比较,T1时rSO_2值最高,T3时rSO_2值最低,与其余时刻比较差异有统计学意义(P0.05)。T3时C组rSO_2平均下降9.7%,M组rSO_2平均下降10.0%,差异无统计学意义(P0.05)。开放后rSO_2恢复至阻断前水平,稍高于T2并直至T5。4两组术前MMSE评分统计值差异无统计学意义(P0.05),两组术后1和3 d MMSE评分下降,术后7 d基本恢复至术前水平。两组术后认知功能障碍的发生率术后1 d分别为C组20%,M组15%;术后3 d C组10%,M组15%;术后7 d C组5%,M组0%。5与C组比较,M组血管活性药物使用次数和用量减少,阻断期间心肌耗氧量降低(P0.05)。两组全麻药物用量,阻断时间,苏醒时间,拔管时间,术后并发症差异无统计学意义(P0.05)。结论:脑氧饱和度联合神经电生理监测对颈动脉阻断期间的血压管理有指导作用,比传统方法更精确、安全,减少心脏做功,并且不会降低术后认知功能。
[Abstract]:Objective: To explore the effect of local cerebral oxygen saturation combined with neuroelectrophysiological monitoring on the management of blood pressure during the occlusion of carotid artery endarterectomy (Carotid Endarterectomy, CEA), and to provide reference for clinical practice. Methods: 40 cases of CEA patients, age 50~80, sex unlimited, II or III grade of American anesthesiologist Association (ASA) were selected. The random digital table was used to divide it into 2 groups (n=20): the control group (group C) and the joint monitoring group (group M).C patients increased the systolic pressure according to the traditional methods during the occlusion of the carotid artery, the increase was 20%~30% of the pre operation basic blood pressure, and the M group adjusted the systolic pressure according to the local cerebral oxygen saturation (rSO_2) monitoring and the neurophysiological monitoring. The patients were maintained in the range of clinical licensing changes. After the admission, the patients were monitored without invasive blood pressure (NIBP), heart rate (HR), electrocardiogram (ECG), pulse oxygen saturation (SpO_2), rSO_2 and electroencephalogram double spectrum index (BIS), radial artery puncture tube under local anesthesia, continuous monitoring and recording of invasive arterial pressure (IBP), cardiac output (CO) and pacing quantitative change with Flo Trac/Vigileo monitoring instrument. SVV. Induction of anesthesia: intravenous injection of midazolam 0.01~0.05 mg/kg, etomidate 0.1~0.3mg/kg, CIS atracurium 0.1~0.2 mg/kg, sufentanil citrate 0.4~0.6 mu g/kg and lidocaine 60~100 mg. anesthesia maintenance: micropump continued to pump propofol 2~6 mg. 40~60. was induced by electrophysiologists to monitor electroencephalogram and somatosensory evoked potentials. The two groups of patients were assessed the cognitive function by the simple intelligence state Checklist (MMSE) before 1 D, and recorded age, sex, education, and preoperative complication. The average day morning (T0) of nurses after admission was measured. Blood pressure was recorded as basic blood pressure, and two groups of patients (T0) rSO_2, immediate (T1) blood pressure, 5 min (T2) blood pressure after anesthesia induction, 5 min (T3) blood pressure stability after carotid artery occlusion, 5 min (T4) after opening carotid artery were opened, and the amount of drug dosage and vasoactivity of immediate (T5) blood pressure and simultaneous rSO_2. were recorded and vasoactive activity was recorded. Drug dosage and times, occlusion of carotid artery time, awakening time, extubation time, postoperative complications and so on. First days, third days and seventh days after operation were used to evaluate the cognitive function of patients with MMSE. Results: there was no significant difference in age, sex ratio, education level and preoperative complication between group 1 and two groups (P0.05), there was no significant difference between group.2 and two groups of T0-2, The blood pressure difference at T4-5 time was not statistically significant (P0.05), and T3 had statistical significance (P0.05). Compared with the C group, the blood pressure of M group was higher than that of the basic blood pressure 20%~30%, in group M, blood pressure was elevated in 4 patients, and in 11 cases, the blood pressure was higher in 0%~10%, and the blood pressure was lower in the 5 patients than that in the T0. There was no statistical significance (P0.05) between groups of.3 two groups at different times (P0.05). Compared with T0, the rSO_2 value of T1 was the highest and T3 was the lowest at the time of T3. There was a significant difference between T3 and the rest time. (P0.05).T3, the C group decreased by an average of 10%, and the difference was not statistically significant. SO_2 was restored to pre blocking level, slightly higher than T2 and until T5.4 two groups had no statistical significance (P0.05) before operation (P0.05). The 1 and 3 D MMSE scores decreased after operation, and 7 d recovered to the preoperative level after operation. The two groups after operation 1 D were 20% in C group and 15% in M group; 3 D, 10%, 15% and 7 after operation. D C group 5%, group M 0%.5 compared with the C group, the number and dosage of vasoactive drugs in group M decreased and the myocardial oxygen consumption decreased during the blocking period (P0.05). There was no significant difference between two groups of anesthetic dosage, blocking time, time of awakening, extubation time and postoperative complications (P0.05). Conclusion: cerebral oxygen saturation combined with electrophysiological monitoring of carotid artery obstruction (P0.05). The blood pressure management during the period of interruption has a guiding role, which is more accurate and safe than traditional methods, and reduces cardiac work and does not reduce postoperative cognitive function.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614

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