A Clinical Observation on the General and Local Anesthesia for Mini-invasive Aspiration and Drainage of Intracerebral Hematoma
王力甚  王年云
李圣平  沈述威
湖北省荆州市中心医院麻科, 荆州 434020  
Lishen Wang,  Nianyun Wang,  Shengping Li and Shuwei Shen
Central Hospital of Jinzhou, Hubei 434020, China


　　　　　　　　　　　ABSTRACT     
　Objective: To approach the anesthetic technique for the mini-invasive drainage and aspiration of intracerebral hematoma.
　Methods: 18 cases of patients with hypertensive intracerebral hemorrhage were studied. Local anesthesia with lidocaine was done at the puncture site through the scalp followed by intravenous injection of propofol until the patients had no limb movements. Bolus propofol was added during operation. SpO₂ and the vital signs were monitored.
　Results: Anesthesia was satisfactory in all patients during surgery (35～55min) and the dosage of propofol was 100～280mg. The heart rate in only one patient decreased to 51 beats per minute but returned to normal  after intravenous atropine; SpO₂ in 4 cases reduced transiently to below 90% but recovered soon after proper treatment. No patients needed tracheal intubation.
　Conclusion: Intravenous propofol plus local anesthesia used for the mini-invasive aspiration and drainage of intracerebral hematoma possesses such advantages as reliability, convenient adjustment and control, few adverse effects and reduced intracranial pressure. Therefore it's a good method for this kind of operation.
　Key words: Intracerebral hematoma; Surgery; Anesthesia; Propofol
　Corresponding author: Lishen Wang; slw_wls2000@yahoo.com.cn


    高血压并发脑出血时常会导致严重后果，如昏迷、颅内压升高，甚至脑疝等，需紧急救治。本文观察了局麻加异丙酚用于颅内血肿微创清除术的情况，效果良好。报道如下。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

一、资料与方法     

　　高血压性脑出血患者23例，男性18例，女性5例。年龄45～62岁。所有病例均有高血压病史，并经CT确诊为脑出血而急诊入院，估计出血量为10～50ml。
　　手术在神经内科病房内进行。麻醉前30min常规肌注阿托品、鲁米那或安定。根据CT等资料在头部穿刺点定位后，以利多卡因作头皮全层直至骨膜的局部麻醉。经鼻氧管常规吸氧。手术开始前缓慢静注异丙酚5～15ml直至无肢体活动，必要时适量追加。保留自主呼吸。术中出现上呼吸道梗阻致SpO₂下降时，托起患者下颌或置入口咽通气道，无效时经面罩加压给氧。
　　麻醉完善后，用电钻将预定深度的引流针钻入颅内病灶处。适当调整深度，直至引流或抽吸出陈旧性血液或血块。以生理盐水反复冲洗后，注入尿激酶1～2万单位，保留引流管2～3天，观察至病情稳定。
　　　　　　　　　　　　　二、结　果     
　　所有病例麻醉效果满意。手术时间35～55min，异丙酚用量100～280mg。1例术中心率降至51次/分，静注阿托品后好转。11例注药后出现鼾睡，其中4例SpO₂下降至90％以下，经处理很快回升。无一例患者需行气管插管。所有患者均如期出现苏醒反应。手术效果良好，除1例因脑疝于术后18小时死亡外，其余22例均在手术2天后逐渐清醒。

　　　　　　　　　　　　　三、讨　论    
　　脑出血微创引流术是微创技术在神经内科的应用。手术对镇痛要求不高，但患者头部不应随意摆动，以免妨碍手术操作或造成损伤，因此必须给予适当麻醉。局麻可减轻患者穿刺部位疼痛，加上全麻，可让患者在麻醉中平稳接受手术，有利于操作和术中病人的安全。
　　异丙酚是起效快、作用时间短的全麻药。静脉持续输注无明显蓄积作用，且可保持血流动力学的稳定。研究证实^[1,2]，异丙酚对心脏传导、左室功能和心肌收缩力无明显抑制作用。本研究中出现的一例心率减慢，可能与颅内压增高有关。由于作用时间短，因此，异丙酚具有苏醒快、恢复早和可控性强的特点，比传统的强效吸入麻醉药地氟醚具有更多的优点^[3]。
　　颅内压增高是脑出血患者常常面临的严重问题。除静注甘露醇外，冲洗的压力不应过高，引流或抽吸的压力则不应过低，以防继发性出血。此外，异丙酚能增加脑血管张力，维护其自身调节功能，因而不影响脑血流量^[4]，有利于降低颅内压。异丙酚亦可降低脑糖代谢率^[5]，有利于早期恢复。
　　异丙酚无明显镇痛作用，在此类手术中需辅助局部麻醉来完成手术。其副作用包括注射过快或剂量过大时，可减慢自主呼吸、抑制膈肌收缩，甚至导致呼吸暂停，有的需行辅助呼吸^[6] 。上呼吸道梗阻造成的鼾睡，是异丙酚麻醉中较常见的并发症。本研究中即有11例出现鼾睡。此时可抬起下颌，或用面罩加压给氧，往往收到明显的效果^[7]。预防的方法是缓慢推药、密切观察，并备妥急救插管设备。

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