A Review of Neuroanesthesiology papers in 2006

Zhen-shen Tang¹, Jian-xiong An¹ , Bao-guo Wang²

¹Department of Anesthesiology and Pain Medicine, TsingHua University Yuquan Hospital, Beijing 100049

² Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050

ABSTRACT

    Many papers on neuroanesthesiology have been published in 2006. Some important studies were reviewed in this article and they may benefit our research and clinical work. This review focuses on anesthetic considerations in neurosurgical patients, cerebral hemodynamic, electrophsiological monitoring and neuroprotection.

Keywords：Neurosurgery; Anesthetic consideration; Cerebral hemodynamics; Electrophsiological monitoring ; Neuroprotection

根据部分2006年发表的有关文章，对神经外科麻醉进展作一回顾。

一、神经外科病人的麻醉风险

1.脊髓手术后失明

神经外科病人围术期视觉改变是常见现象，常发生于角膜暴露脱水、角膜磨损、继发性青光眼、视网膜动静脉血流障碍、视神经缺血及脑卒中等一系列病变之后。脊髓手术和其它大手术（如心脏手术）后罕见并发症之一是由于术后视神经缺血或视网膜中心动脉阻塞引起的失明，此并发症发生率很低（Steven等，1997），但后果严重。 Lee等^[1]对ASA收集的93例病例进行分析发现该并发症有以下特点：1） 缺血性神经病变导致的失明占89%，其中视神经缺血性病变引起者占67%；2） 男性占多数，且多数患者身体条件良好（ASA Ⅰ或Ⅱ）；3）择期手术占96%；4）髓核溶解术占89%；5）双侧失明占66%；6）视力部分恢复者仅占42%。因此凡在卧位下进行脊髓手术时必须警惕术后并发失明的可能性。就此ASA颁布了围脊髓手术管理建议^[2]，即具体操作时要特别注意血压控制、容量管理、缩血管药应用、病人体位以及分期手术等，分期手术目的是缩短俯卧位手术时间，这些因素可能都与术后失明有关。

2.神经外科病人术后恶心呕吐

醉后恢复室内PONV总发病率为7.5%，引起PONV的危险因素有：1)植入脂肪防止脑脊液漏；2)腰部放置脑脊液引流管；3)颅咽管瘤。植入脂肪处及植入过程中漏出的脑脊液及从引流管流出的脑脊液均可致颅内压降低，可能是经蝶入路手术PONV的主要原因。

3.神经外科手术病人的气道管理

颈髓前路手术后声带功能异常是罕见但严重的并发症。牵引气管时喉返神经分支可因受压致伤(Apfelbaum等，2000)，气管导管气囊放气随后充气可使气管导管偏离气管壁，而气囊所在部位可出现神经损伤。Audu等^[5]对100例经前路颈髓手术病人气管插管操作方法对声带功能的影响进行研究，声带运动功能由耳鼻喉科医生用纤维光导评估。研究者将病人分为两组，对照组接受标准插管法即气管插管后套囊充气，预先未设定套囊压力，拔管前放气，套囊充气压力凭麻醉医师主观判断；实验组接受对照插管法即气管插管后气囊充气压力调节到20～25cmH₂O，且无漏气。实验组在外科医生牵拉气道后即套囊放气5s，接着用同样压力再次充气。结果术后声带麻痹的发病率两组无差别，但11例经右侧颈部入路手术者中有3例发生声带麻痹，而83例经左侧颈部入路者无一例发生，提示声带麻痹与喉返神经颈部走行存在解剖差异有关。左侧喉返神经位于气管-食管沟内，右侧则位于沟外，本研究提示此类手术声带麻痹与手术有关，而与气管插管无关。

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唐贞申，男，清华大学玉泉医院麻醉与疼痛医学科，主治医师，现为首都医科大学附属北京同仁医院2006级博士研究生。