發(fā)布時間：2018-03-09 20:31

  本文選題：顱內(nèi)腫瘤切除術(shù)　切入點：麻醉　出處：《河北醫(yī)科大學》2017年碩士論文　論文類型：學位論文

【摘要】：目的:顱內(nèi)腫瘤是神經(jīng)外科的常見病,手術(shù)切除是其目前主要的治療方法。術(shù)中需維持正常腦組織灌注和氧供,優(yōu)化手術(shù)條件便于腫瘤切除,確保病人從麻醉中迅速恢復以利于進行神經(jīng)功能評估。本研究對接受目標導向液體治療的顱內(nèi)腫瘤切除術(shù)患者,在麻醉期間輸注小劑量去甲腎上腺素,觀察術(shù)中動靜脈血氧含量差(Ca-jvO2)、腦氧攝取率(CERO2)和腦乳酸生成率(LacPR)等腦氧代謝指標的改變,測定頸內(nèi)靜脈球部血液S100B蛋白含量的變化,記錄術(shù)中生命體征,探討小劑量去甲腎上腺素對接受目標導向液體治療的顱內(nèi)腫瘤切除術(shù)患者的影響。方法:擇期全麻下行顱內(nèi)腫瘤切除術(shù)患者40例,年齡18~65歲,性別不限,美國麻醉醫(yī)師協(xié)會(American Society of Anesthesiologist,ASA)分級Ⅱ~Ⅲ級,Glasgow評分(GCS)15分,無心肺功能障礙,無肝腎疾病、心律失常、周圍動脈廣泛性閉塞性疾病及凝血異常等。經(jīng)過簽訂知情同意書,將其隨機分為兩組(n=20):目標導向液體治療組(G組)和目標導向液體治療復合小劑量去甲腎上腺素組(N組)。所有患者均監(jiān)護心電、無創(chuàng)血壓、脈搏血氧飽和度和體溫,建立外周靜脈液路。局部麻醉后在左側(cè)橈動脈處穿刺置管,通過Flo Trac傳感器與Vigileo監(jiān)測儀(Edwards公司,美國)連接。誘導用咪達唑侖0.04mg/kg、丙泊酚2mg/kg、羅庫溴銨0.6mg/kg和舒芬太尼0.5μg/kg,滿足插管條件后置入氣管導管,連接麻醉機進行機械通氣。設(shè)定潮氣量為8~10ml/kg,維持呼氣末二氧化碳分壓(PETCO2)在30~40mmHg之間。在右股靜脈處穿刺置管;在右頸內(nèi)靜脈處逆行穿刺置管至頸內(nèi)靜脈球部。以3~6mg/(kg·h)速率輸注丙泊酚和0.1~0.3μg/(kg·h)速率輸注瑞芬太尼維持麻醉。G組當每搏量變異度(stroke volume variation,SVV)高于13%超出5分鐘時,指示患者體內(nèi)有效循環(huán)血容量不足,需要補液以使其低于13%;當SVV降低至13%以下時,以1~2ml/(kg·h)的速度補充維持所需液體。n組在麻醉誘導后開始靜脈輸注小劑量去甲腎上腺素,速度為0.01~0.03μg/(kg·min),維持平均動脈壓(map)≥65mmhg,其他同g組。兩組術(shù)中均維持hb8g/dl。在兩組中分別于麻醉誘導后(t1)、打開硬腦膜時(t2)、開硬腦膜1h(t3)、術(shù)畢(t4),抽取橈動脈血和頸內(nèi)靜脈球部血進行血氣分析,計算ca-jvo2、cero2、腦血流/腦氧代謝率比值(cbf/cmro2比值)和lacpr。取頸內(nèi)靜脈球部靜脈血2ml至試管靜置后離心,采用酶聯(lián)免疫吸附法(elisa)測定血清中s-100b蛋白的含量。記錄并統(tǒng)計術(shù)中總液體量、晶體液入量、膠體液入量、出血量和尿量。結(jié)果:1兩組患者的性別構(gòu)成比、年齡、asa分級構(gòu)成比、體質(zhì)指數(shù)(bmi)和麻醉時長(min)等相比差異無統(tǒng)計學意義(p0.05)。2兩組各時點心率(hr)相比差異無統(tǒng)計學意義(p0.05)。n組的map在t4時點與g組相比顯著升高(p0.05)。g組的map在不同時點差異無統(tǒng)計學意義(p0.05);n組的map在t4較t1~t3時點明顯升高(p0.05);其余時點間差異無統(tǒng)計學意義。3n組的總液體量和晶體液入量低于g組,差異有統(tǒng)計學意義(p0.05)。兩組尿量相比差異無統(tǒng)計學意義(p0.05)。4兩組在各時點的ca-jvo2值組間比較差異無統(tǒng)計學意義(p0.05)。g組在t3、t4較t1時點明顯下降;n組的ca-jvo2值在t2較t1時點明顯下降(p0.05);其余時點差異無統(tǒng)計學意義。5在t3、t4時點g組的cero2與n組相比顯著降低(p0.05)。g組在t4較t1、t2時點明顯下降(p0.05);n組的cero2在t3較t2時點明顯升高(p0.05);其余時點差異無統(tǒng)計學意義。6兩組各時點lacpr相比差異無統(tǒng)計學意義(p0.05)。7g組的cbf/cmro2在t3較t1時點明顯升高(p0.05);n組在t2較t1時點明顯升高(p0.05);其余時點差異無統(tǒng)計學意義。8兩組各時點血清s100b蛋白含量相比差異均無統(tǒng)計學意義(p0.05)。n組在t4時點較t1明顯下降,差異有統(tǒng)計學意義(p0.05)。結(jié)論:對接受目標導向液體治療的顱內(nèi)腫瘤切除術(shù)患者,在麻醉期間輸注小劑量去甲腎上腺素,可減少術(shù)中輸液量,維持內(nèi)環(huán)境穩(wěn)定,增加腎臟的灌注和尿量;可維持血流動力學穩(wěn)定,改善腦灌注和腦氧供需關(guān)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鍚，

本文編號：1590137