您当前的位置:首页 > 主题内容 > 临床麻醉 > 基础与临床研究

神经外科手术中脑电双频指数反馈调控丙泊酚靶控输注的研究

时间:2010-08-24 11:31:02  来源:  作者:

Feedback Target-Controlled Infusion of Propofol with Bispectral Index in Neurosurgical Anesthesia<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

彭宇明  首都医科大学2001级硕士研究生
王保国   教授 
中国医学科学院首都医科大学附属北京天坛医院麻醉科,北京100050
Yuming PengMD and Baoguo WangMD
Department of Anesthesiology, Beijing Tiantan Hospital, Capital University of Medical Science, Chinese Academy of Medical Sciences, Beijing100050, China

ABSTRACT

Objective: Bispectral index (BIS) is generally regarded as a measurement of depth of sedation and anesthesia. The aims of the study were to investigate the feasibility of propofol TCI for craniotomy using BIS as a feedback control and the suitable propofol TCI target concentrations at different anesthetic and surgical stages.
Methods: Fifteen ASA Ⅰ~Ⅱpatients for elective craniotomy were anesthetized with TCI propofol. The initial plasma target concentration CpTof propofol was set at 4μg/ml and the feedback control started when the patient lost consciousness (LOC) . The BIS value was automatically and manually maintained in the range of ±5% of 5 below the LOC point during anesthesia. The calculated plasma concentration (CpCALC) and the calculated effect-site concentration (CeCALC) were recorded at different stages of operation. BIS, mean arterial pressure (MAP), heart rate (HR), doses of adjunctive drugs, time for recovery, awareness during operation was observed. 
Results: There was a statistical difference between CpCALC or CeCALC and CpT during anesthesia of before operation (3.2±0.7 3.2±0.6 VS 3.6±0.4μg/ml), skull opening (2.9±0.83.0±0.8 VS 3.3±0.6μg/ml), and intracranial procedure (2.8±0.82.8±0.8 VS 3.0±0.8μg/ml) (p<0.05). BIS values were linearly correlated  with CpCALC or CeCALC
Conclusion: It is feasible that propofol TCI for neurosurgical anesthesia using BIS as a feedback control. The recommended plasma or effect-site target concentrations of propofol TCI during anesthetic induction, before skin incision, skull opening, intracranial procedure and skull closing were 3.2μg/ml, 3.2μg/ml, 3.2μg/ml, 3.0μg/ml and 3.2μg/ml, respectively.
Key words: Feedback; Target-controlled infusion; Effect-site compartment; Intravenous anesthesia.
 

       靶浓度控制输注(Target-controlled infusionTCI)系统使得静脉麻醉更加便利,但药代动力学存在个体差异性,并且不同手术,甚至不同手术步骤中靶控浓度也不一样,有关神经外科手术应用TCI的研究很少。脑电双频指数(BIS)可以反映丙泊酚麻醉状态下的睡眠深度,成为个体化麻醉深度的监测指标。本研究探讨BIS反馈调控丙泊酚TCI用于神经外科开颅手术的可行性,并寻找不同手术步骤时适宜的丙泊酚TCI靶浓度。

               材料与方法
  选择ASA III级择期颅脑手术病人15例,年龄1855岁,术前不使用镇痛剂和镇静药。入室后,开放下肢静脉输液。头部局部皮肤用乙醇脱脂后,放置一次性EEG电极,用HXD-I型数量化脑电监测仪(华翔公司,中国哈尔滨)监测 EEG,皮肤阻抗小于5KΩ,采样频率为2.5秒,经缚丽叶转换处理后自动显示BIS值。用Datex多功能监测仪(Datex CardiocapⅡ,Finland)监测无创血压(NIBP)、心率(HR)和脉搏血氧饱和度(SpO2)。用图片记忆法观察对麻醉诱导期和恢复期事件的记忆情况(图片的图案分别为瓶子、警察、树叶、足球、剪刀和鸽子共6张)。用气体监测仪(Datex UltimaFinland)持续监测麻醉后呼气末CO2分压(PETCO2,呼吸频率(RR)。

  患者安静10min后测BISNIBPHR作为基础值,并向病人展示第一张图片。面罩吸氧,开始TCI丙泊酚(Grasby 3500微量泵,英国;Marsh药代动力学参数;最高限速600ml/h)诱导,初始靶浓度为4μg/ml,每10秒钟呼唤病人一次或推摇病人肩部一次,当病人警觉/镇静观察评定(Observer's assessment of alertness/sedation, OAA/S)分级达到3级(对大声或/和重复呼名有反应;讲话速度明显减慢或吐字含糊不清;面部表情明显松弛;目光呆滞,睑下垂≥1/2)时向其展示第二张图片,直到意识丧失(Loss of consciousnessLOC)。此时启动反馈环路,以LOC时的BIS值下调5作为反馈调节界定值,当实测BIS>界定值时系统自动持续输注;当BIS<=界定值时则停止输注;若BIS值大于该界限值的5%持续5min,则手动上调靶浓度0.5μg/ml;而小于该界限值的5%持续5min(此时微量泵处于停止状态),则手动下调靶浓度0.5μg/ml,以维持BIS值在界限值的±5%的范围里。此外,术中BIS监测受干扰较多(尤其是电凝、电刀),系统设置脑电抗干扰的时间范围为10秒钟,即在停止输注时脑电受持续干扰在10秒钟之内,系统不启动给药。神志消失后给予芬太尼(Fentanyl 2μg/kg,维库溴胺(Vecuronium0.1mg/kg,面罩辅助呼吸,应用肌松监测模块(华翔公司,中国哈尔滨), 于定标后持续监测四连串刺激-肌收缩反应。待T4/T1T1/Tc均达到0时行气管插管。插管后,以潮气量10ml/kg,呼吸频率12/min行机械通气,氧流量为1L/min,丙泊酚TCI维持麻醉。手术刺激较强(上头架、切皮和钻骨)时静注Fentanyl 1-2μg/kg,颅内操作期不再给予Fentanyl ,在缝完硬膜时给予Fentanyl-2μg/kg。术中根据肌松监测的结果间断辅助维库溴胺诱导量的半量(0.5mg/kg)维持肌松(T4/T1<25%)。

<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

  低血压(平均动脉压MAP<基础值的20%,并持续达5min)时,加快输液速度,静脉给予麻黄碱6mg,必要时重复同样剂量的麻黄碱。心动过缓(心率<55次/min,持续5min)时,静脉给予阿托品0.5mg, 必要时重复同样剂量。高血压(MAP>基础值的10%,持续 5min)和心动过速(心率>90次/min,持续5min)时,艾司洛尔200mg,佩尔地平4mg稀释至20ml持续泵入进行控制。
  术中记录诱导期(开始丙泊酚TCI至气管插管)、术前期(气管插管后至上头架)、开颅期(上头架、切皮、钻骨的即刻、3min、5min和10min)、颅内操作期(间隔10min)、关颅期(缝硬膜、盖骨瓣、缝皮的即刻、5min)的丙泊酚实调靶浓度(CpT)、血浆计算浓度(CpCALC)、效应室计算浓度(CeCALC)、使用剂量和持续时间,BIS、MAP、HR、RR的变化,以及各辅助用药次数、剂量。计算不同时期各参数的平均值和95%可信区间。手术结束时,停止TCI丙泊酚。必要时用新斯的明和阿托品拮抗肌松作用。记录呼吸恢复、拔管、呼之睁眼、定向力恢复的时间。于病人定向力恢复时和离开手术室时分别向病人展示第三张和第四张图片。记录病人的出血量、尿量、输血量和输液量。术后第一日随访病人术中是否知晓,若有知晓则记录其知晓的内容。随访时上述6张图片全部展示给患者,让其辨认出曾看过的图片。

     
应用SPSS10.0软件进行数据统计处理。计量数据以均值±标准差表示,采用方差分析(ANOVA),两两比较用q检验。P<0.05认为有统计学意义。

      总之,在神经外科手术中,应用BIS值反馈调控丙泊酚靶控输注是可行的,麻醉维持平稳,血流动力学波动小,术后恢复快。从中我们也得到了神经外科手术不同阶段血浆靶控输注和效应室靶控输注靶控点的推荐值,二者在实际临床应用的特点有待进一步研究。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

 


1 Anthony R. Absalom, Nicholas Sutcliffe, et al. Closed-loop Control of Anesthesia   Using Bispectral Index. Anesthesiology, 2002, 96: 67-73.
2 Anez C, Papaceit J, Sala JM, et al. The effect of encephalogram bispectral index monitoring during total intravenous anesthesia with propofol in outpatient surgery. Rev Esp Anesthesiol Reanim, 2001, 48: 264-269.
3 Leonard IE, Myles PS. Target-controlled intravenous anaesthesia with bispectral index monitoring for thoractomy in a patient with severely impaired left ventricular function. Anaesth intensive care, 2000, 28: 318-321.
4 Glass PS, Bloom M, Kearse L, et al. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology , 1997, 86: 836-47.
5
李海燕,吴新民,等. 双频指数反馈调控靶控输注时丙泊酚学药浓度的变化-闭合环路靶控输注的可行性研究. 麻醉与监护论坛,20029: 15-17.
6 Doi M, Gajraj RJ, Mantzaridis H, et al. Relationship between calculated blood concentration of propofol and electrophysiological variables during emergence from anaesthesia: comparison of bispectral index, spectral edge frequency,

7 median frequency and auditory evoked potential index. Br J Anaesth, 1997, 78: 180-4.
8 Kearse LA, Rosow C, Zaslavsky A, et al. Bispectral analysis of the electroencephalogram predicts conscious processing of information during propofol sedation and hypnosis. Anesthesiology, 1998, 88: 25-34

来顶一下
返回首页
返回首页

本周热点文章

站内搜索: 高级搜索
关于我们 | 主编信箱 | 广告查询 | 联系我们 | 网站地图 |