本文選題：食道咽腔導(dǎo)管 + 食道鼻咽腔導(dǎo)管�。� 參考：《南方醫(yī)科大學(xué)》2014年博士論文

【摘要】：癲癇是最常見的慢性神經(jīng)系統(tǒng)障礙性疾病之一,為一非特異性以腦功能異常為主的慢性腦疾病。影響到世界上近1%的人口,我國約有癲癇患者上千萬,其中包括活動性癲癇約600萬�，F(xiàn)代醫(yī)學(xué)的變化已使癲癇成為一種可治性疾病。由于新抗癲癇藥物的不斷問世,約80%的癲癇患者,通過正規(guī)的藥物治療,可以獲得滿意的控制,但約有120～180萬的患者藥物治療效果不佳為難治性癲癇。外科治療難治性癲癇主要通過精確定位致癇灶并切除,去除致癇因素,達(dá)到治愈的目的。 癲癇的外科治療主要為致癇灶和癲癇病理灶的切除或傳導(dǎo)通路切斷的方法,以達(dá)到控制癲癇發(fā)作為目標(biāo)。故術(shù)前對致癇灶的準(zhǔn)確定位非常重要�，F(xiàn)代神經(jīng)影像學(xué)技術(shù)的發(fā)展為癲癇的病因、診斷定位起著重要的作用。致癇灶和功能區(qū)定位方法應(yīng)根據(jù)發(fā)作癥狀、電生理監(jiān)測和影像學(xué)綜合判定。神經(jīng)電生理監(jiān)測技術(shù)已成為神經(jīng)外科術(shù)中監(jiān)測神經(jīng)功能狀態(tài)、減少神經(jīng)損傷、提高手術(shù)療效的重要手段。癲癇手術(shù)術(shù)中電生理監(jiān)測的目的是準(zhǔn)確尋找致癇灶,切除致癇灶是控制癲癇發(fā)作的有效措施,而精確定位則是手術(shù)成功的關(guān)鍵。 雖然定位方法多樣,但由于腦組織在病變后的解剖移位以及個體差異,對于運(yùn)動、感覺和語言區(qū)的術(shù)中定位仍以喚醒和電刺激條件下患者與醫(yī)生進(jìn)行交流為“金標(biāo)準(zhǔn)”。擺在麻醉醫(yī)生面前的難題是如何既能保證患者的通氣安全,又能在適當(dāng)時候?qū)⑵鋸穆樽頎顟B(tài)喚醒來配合外科醫(yī)生完成功能區(qū)的定位。國內(nèi)外很多學(xué)者圍繞通氣裝置、麻醉方法和麻醉藥物進(jìn)行了研究,但目前并沒有很好的解決這些問題。針對以上問題,我們進(jìn)行了如下的研究： 第一部分關(guān)于癲癇手術(shù)麻醉的研究 腦功能區(qū)手術(shù)是神經(jīng)外科臨床醫(yī)師面臨的難題之一,也是21世紀(jì)全球神經(jīng)外科界要解決的重點(diǎn)之一。最大限度地切除病變控制癲癇發(fā)作,盡可能地保護(hù)病變周圍的正常腦組織是現(xiàn)代神經(jīng)外科發(fā)展的方向,也是腦功能區(qū)手術(shù)的新策略。為此,術(shù)中喚醒精確定位致癇灶成為手術(shù)成功的關(guān)鍵。 癲癇手術(shù)麻醉有一定的特殊性,特別是當(dāng)需要術(shù)中喚醒進(jìn)行語言功能區(qū)精確定位時,涉及到一定的特殊藥物和技巧,需要高年資且有經(jīng)驗(yàn)的麻醉醫(yī)生來實(shí)施。只有這樣才能做到與外科醫(yī)生和患者的良好配合,共同完成手術(shù),保護(hù)患者的功能區(qū)不受損害。 癲癇手術(shù)麻醉雖有其特殊性,但顱腦外科手術(shù)麻醉的基本原則是相同的,必須遵守的。基本原則：完善的術(shù)前準(zhǔn)備；平穩(wěn)的麻醉誘導(dǎo)與維持；維持心血管系統(tǒng)穩(wěn)定和良好的腦灌注；維持呼吸道通暢和良好的呼吸功能；維持內(nèi)環(huán)境平衡；控制顱內(nèi)壓；術(shù)后盡快平穩(wěn)地清醒。 第二部分腦功能區(qū)手術(shù)術(shù)中喚醒麻醉的研究 隨著影像學(xué)、微創(chuàng)手術(shù)技術(shù)的發(fā)展,神經(jīng)外科手術(shù)也越來越細(xì)致,尤其是累及腦功能區(qū)的腫瘤、癲癇灶、血管畸形等手術(shù),既要盡可能的切除病灶,又要最大限度的保留正常腦組織和避免神經(jīng)功能的損傷,因此,精確定位腦功能區(qū)是關(guān)鍵。雖然定位方法多樣,但由于腦組織在病變后的解剖移位以及個體差異,對于運(yùn)動、感覺和語言區(qū)的術(shù)中定位仍以喚醒和電刺激條件下患者與醫(yī)生進(jìn)行交流為“金標(biāo)準(zhǔn)”。若全麻下氣管內(nèi)插管或置入喉罩通氣在喚醒時均需將氣管導(dǎo)管或喉罩拔除,待監(jiān)測定位完畢后在將其重新置入,不僅有風(fēng)險不安全,而且操作也十分不便,遇到如癲癇發(fā)作等緊急情況處理起來十分困難和棘手。 為提高麻醉的安全性和操作方便快捷,解決既能維持良好的通氣實(shí)施全麻,又能在患者被喚醒后能發(fā)音講話配合腦功能區(qū)定位這一難題,我們進(jìn)行了系列研究,研制出食道咽腔導(dǎo)管(Ⅰ型)、食道鼻咽腔導(dǎo)管(Ⅱ型)和帶吸引導(dǎo)管的食道鼻咽腔導(dǎo)管(Ⅲ型)。以上三種型號的聲門上通氣設(shè)備的研制成功和應(yīng)用,解決了：①良好的通氣效果保證了全麻的安全實(shí)施,也就是說在腦功能區(qū)手術(shù)開始和定位結(jié)束后的兩個階段能安全的使用全麻,以保證患者有足夠的鎮(zhèn)靜鎮(zhèn)痛和肌肉松弛,有條件實(shí)行手術(shù)開顱,切除腫瘤、致癇灶或血管畸形等腦內(nèi)病變；②氣道和發(fā)音器官未被占用,在患者清醒狀態(tài)下即可發(fā)音講話,并與醫(yī)生交流,從而實(shí)現(xiàn)對腦功能區(qū)的精確定位,即解決了通氣與講話的矛盾；③食道被封閉避免了胃內(nèi)容物的反流與誤吸,并有吸引導(dǎo)管可防止導(dǎo)管側(cè)孔被分泌物堵塞,保證導(dǎo)管的通暢；④操作方便簡單,置管后氣囊充氣即可行機(jī)械通氣,喚醒時排除咽部氣囊中的氣體,患者即可講話,無需反復(fù)拔管插管,降低了氣道控制上的風(fēng)險；⑤病情發(fā)生變化時便于緊急處理,如癲癇發(fā)作時,可立即給予鎮(zhèn)靜藥或肌松劑,并將氣囊充氣行機(jī)械通氣實(shí)施全麻或其他緊急處理,極大地提高了麻醉的安全性。 右美托咪定(DEX)是強(qiáng)效的α2腎上腺素受體激動劑。α2腎上腺素受體主要分布在交感神經(jīng)末梢和中樞神經(jīng)系統(tǒng)的腎上腺素神經(jīng)元,被刺激后可抑制去甲腎上腺素的釋放。右美托咪定作為新型高選擇性α2腎上腺素受體激動劑具有鎮(zhèn)靜、鎮(zhèn)痛和抗焦慮等作用。起效快,作用時間短,兼具鎮(zhèn)靜、鎮(zhèn)痛作用且無呼吸抑制作用是其相對于其他傳統(tǒng)鎮(zhèn)靜藥物最大的優(yōu)勢,右美托咪定主要作用于皮層下,不涉及γ-氨基丁酸(GABA)系統(tǒng),故不損害認(rèn)知功能,不干擾皮質(zhì)腦電圖檢查結(jié)果,不影響皮質(zhì)定位及功能測試,其獨(dú)特的“清醒鎮(zhèn)靜”,類似于自然睡眠的非快速動眼相,患者在無外界刺激的情況下處于睡眠狀態(tài),但易被言語刺激喚醒,并與醫(yī)護(hù)人員進(jìn)行合作與交流,刺激消失后很快又進(jìn)入睡眠狀態(tài),而且對呼吸幾乎無抑制作用。目前認(rèn)為DEX的鎮(zhèn)靜作用不影響功能神經(jīng)外科手術(shù)中的電生理學(xué)監(jiān)測。DEX還具有穩(wěn)定血流動力學(xué)、抑制應(yīng)激反應(yīng)、減少麻醉劑及阿片類藥物的用量和抗寒顫等作用。以上特點(diǎn)正適合于腦功能區(qū)術(shù)中喚醒。這些特性讓其喚醒時間明顯長于丙泊酚,不良反應(yīng)明顯減少,且喚醒期間血流動力學(xué)更穩(wěn)定。DEX減少了嗆咳和體動的發(fā)生次數(shù),讓患者在喚醒期間更舒適,同時也可減少顱內(nèi)壓升高和提高手術(shù)操作的安全。近年來在臨床上特別是神經(jīng)外科腦功能區(qū)手術(shù)麻醉中的應(yīng)用越來越多。 第三部分全麻喚醒中患者能講話的聲門外通氣設(shè)備的系列研制與應(yīng)用 目的：研制一種腦功能區(qū)全麻喚醒手術(shù)患者可以帶管講話的聲門外通氣裝置,使其可以應(yīng)用于臨床,滿足腦功能區(qū)手術(shù)患者術(shù)中精確定位的需要。方法：ASA Ⅰ～Ⅱ級患者,食道咽腔導(dǎo)管(Ⅰ型)臨床應(yīng)用于婦科全麻腹腔鏡手術(shù)60例,腦功能區(qū)術(shù)中喚醒麻醉10例；食道鼻咽腔導(dǎo)管(Ⅱ型)應(yīng)用于婦科全麻腹腔鏡手術(shù)60例,腦功能區(qū)術(shù)中喚醒麻醉10例；帶吸引導(dǎo)管的食道鼻咽腔導(dǎo)管(Ⅲ型)應(yīng)用于婦科全麻腹腔鏡手術(shù)60例,腦功能區(qū)術(shù)中喚醒麻醉20例。分別觀察術(shù)中通氣情況,氣道壓、設(shè)置潮氣量與實(shí)際潮氣量、PETCO2、血?dú)夥治�、術(shù)中BP、HR變化情況等。結(jié)果：研制的三種型號的聲門上通氣裝置,均能達(dá)到術(shù)中喚醒后患者帶管能講話的目的,但食道鼻咽腔導(dǎo)管(Ⅱ、Ⅲ型)的通氣效果和講話效果均明顯優(yōu)于食道咽腔導(dǎo)管(Ⅰ型)。術(shù)中患者通氣情況和血流動力學(xué)指標(biāo)穩(wěn)定。結(jié)論：食道咽腔導(dǎo)管(Ⅰ型)、食道鼻咽腔導(dǎo)管(Ⅱ型)和帶吸引導(dǎo)管的食道鼻咽腔導(dǎo)管(Ⅲ型)均可以安全的用于腦功能區(qū)全麻喚醒手術(shù)中,食道鼻咽腔導(dǎo)管(Ⅱ、Ⅲ型)相比較食道咽腔導(dǎo)管(Ⅰ型)具有更好的通氣和講話效果。 我們計劃將食道鼻咽腔導(dǎo)管進(jìn)一步進(jìn)行改進(jìn),將智能芯片植入氣囊之中,可以更加方便的監(jiān)測氣囊的容積和壓力,讓麻醉醫(yī)生更加直觀的掌握氣囊內(nèi)的壓力是否安全以及是否氣囊發(fā)生漏氣,增加安全性。 第四部分特殊的聲門外通氣裝置—食道鼻咽腔導(dǎo)管的研制和使用 目的：評價自行研制能講話的聲門外通氣裝置—食道鼻咽腔導(dǎo)管的通氣效果和講話功能。方法：將6.5號氣管導(dǎo)管的前端開口封閉,導(dǎo)管前端帶套囊,相距8～10cm處上端帶套囊,兩囊之間導(dǎo)管上開側(cè)孔6個。導(dǎo)管經(jīng)鼻出后鼻孔沿咽后壁前端進(jìn)入食道,側(cè)孔開口于喉咽腔內(nèi),上下兩端氣囊充氣后可同時封閉食道、鼻咽腔和口咽腔,導(dǎo)管外口與麻醉機(jī)相接。氣體經(jīng)導(dǎo)管側(cè)孔進(jìn)入喉咽腔,只能經(jīng)聲門進(jìn)入呼吸道形成密閉的呼吸回路而實(shí)現(xiàn)聲門外通氣。臨床用于宮腹腔鏡探查手術(shù)全麻20例,腦功能區(qū)手術(shù)6例,觀察通氣和講話效果。結(jié)果：26例置管均順利,一次到位,漏氣量0～56m1平均26±10ml,氣道壓12～25cmH20平均16±4cmH20,血?dú)庵笜?biāo)正常；講話清晰、流利,可按指令回答各種問題。結(jié)論：食道鼻咽腔導(dǎo)管為一種新型帶管能講話的聲門外通氣裝置。置管后能嚴(yán)密封閉食道,鼻咽腔和口咽腔,頭頸活動基本不受影響,具有良好的通氣效果。上端氣囊放氣后帶管講話吐詞清晰、流利,能滿足腦功能區(qū)術(shù)中喚醒,按指令發(fā)音講話配合監(jiān)測定位的需要。 第五部分右美托咪定在腦功能區(qū)癲癇病灶切除術(shù)中的應(yīng)用 目的：探討右美托咪定在腦功能區(qū)手術(shù)患者麻醉中應(yīng)用的可行性,并比較在不影響腦電圖及腦功能區(qū)電生理監(jiān)測的情況下的適宜劑量。方法：ASA Ⅰ-Ⅱ級擇期行腦功能區(qū)手術(shù)患者60例,男性34例,女性26例,年齡18～45歲,體重40～74kg,采用隨機(jī)數(shù)字表法,將其隨機(jī)分為4組(n=15)。對照組(C組)靜脈輸注生理鹽水10ml/h,右美托咪定0.25μg·kg-1·h-1組(D1組),O.5μg·kg-1·h-1組(D2組)和1μg·kg-1·h-1組(D3組)。三組均于15min內(nèi)靜脈輸注右美托咪定負(fù)荷劑量0.5μg/kg,然后分別以0.25μg·kg-1·h-1、0.5μg·kg-1·h-1或1μg·kg-1·h-1速率靜脈輸注右美托咪定至手術(shù)結(jié)束。術(shù)中以丙泊酚+瑞芬太尼+順式阿曲庫銨全憑靜脈維持麻醉,根據(jù)BIS指數(shù)調(diào)節(jié)麻醉深度,監(jiān)測開始前將丙泊酚減量并開始輸注生理鹽水或右美托咪定,記錄術(shù)中腦電圖及電生理監(jiān)測的情況,術(shù)中血壓、心率變化以及不良反應(yīng)發(fā)生情況。結(jié)果：與C組比較,D1組、D2組和D3組的BIS值有明顯降低(P0.05)；C組腦電圖波幅較高,夾雜的干擾波比較多,偶爾可見丙泊酚引起的爆發(fā)抑制；D3組腦電圖較前三組波幅明顯低平；D1和D2組的腦電圖波幅適中。結(jié)論：作者認(rèn)為腦功能區(qū)癲癇病灶切除術(shù)患者麻醉中適宜皮層腦電圖(ECoG)及電生理監(jiān)測的右美托咪定劑量范圍是O.25μg·kg-1·h-1和0.5μg·kg-1·h-1之間,對術(shù)中腦電圖及電生理監(jiān)測的影響較小,比較適合于腦功能區(qū)病灶性癲癇手術(shù)術(shù)中監(jiān)測時的麻醉。 第六部分右美托咪定在腦語言區(qū)全麻喚醒中的應(yīng)用 目的：觀察a2腎上腺素受體激動劑右美托咪定(DEX)用于腦功能語言區(qū)手術(shù)全麻術(shù)中喚醒的效果。方法：ASA Ⅰ～Ⅱ累及腦功能語言區(qū)手術(shù)患者20例,于全麻下行開顱手術(shù),術(shù)中適時停用全麻用藥,并以右美托咪定和瑞芬太尼維持,喚醒前減量至右美托咪定0.1～0.5μg/kg·h和瑞芬太尼O.05μg/kg·min維持,保持患者清醒。觀察并記錄清醒時間、清醒期間BP、HR、顱內(nèi)壓以及患者清醒講話的清晰程度、完成指令和不良反應(yīng)情況。結(jié)果：20例患者術(shù)中通氣功能和血流動力學(xué)情況穩(wěn)定,血?dú)庵笜?biāo)其中有2例PC0255-56mmHg,其余均正常,無不良反應(yīng)。術(shù)后無不良記憶。發(fā)音、吐詞清楚,講話流利,均準(zhǔn)確定位語言、視覺皮層功能區(qū),順利切除病灶或致癇灶,術(shù)后恢復(fù)良好,無并發(fā)癥和后遺癥。結(jié)論：右美托咪定不損害認(rèn)知功能,不干擾皮質(zhì)腦電圖檢查結(jié)果,不影響皮質(zhì)定位及功能測試,其獨(dú)特的“清醒鎮(zhèn)靜”,類似于自然睡眠的非快速動眼相,患者在無外界刺激的情況下處于睡眠狀態(tài),但易被言語刺激喚醒,并與醫(yī)護(hù)人員進(jìn)行合作與交流,刺激消失后很快又進(jìn)入睡眠狀態(tài),而且對呼吸幾乎無抑制作用。用于腦功能語言區(qū)手術(shù)全麻術(shù)中喚醒具有易調(diào)控、易喚醒,患者易配合而循環(huán)、呼吸干擾輕微的優(yōu)勢。
[Abstract]:Epilepsy is one of the most common diseases of chronic nervous system disturbance . It is a kind of chronic brain disease characterized by abnormal brain function . It affects nearly 1 % of the population in the world , including active epilepsy about 6 million . The change of modern medicine has made epilepsy a kind of curable disease .

The surgical treatment of epilepsy is mainly to cut or cut the conduction path of epileptogenic foci and epileptic foci , so as to achieve the goal of controlling epilepsy . The development of modern neuroimaging technique is an important means to monitor the state of neurological function , reduce nerve injury and improve the curative effect of epilepsy .

Although the localization method is diverse , due to the anatomical displacement and individual difference of the brain tissue after the lesion , the patient and the doctor are still under the condition of arousal and electrical stimulation . The problem before the anesthesiologist is how to ensure the patient ' s ventilation safety , but also can wake up from the state of anesthesia to cooperate with the surgeon to complete the positioning of the functional area . Many scholars at home and abroad have studied the ventilation device , the anesthesia method and the narcotic drugs , but the problems are not solved well .

The first part of the study on the anesthesia of epilepsy surgery

Brain functional area surgery is one of the difficult problems faced by neurosurgeons , and it is one of the most important problems to be solved by the global nervous system in the 21st century . It is also a new strategy for the development of modern neurosurgery to protect the normal brain tissues around the lesion as much as possible .

There is a certain particularity in the anesthesia operation anesthesia , especially when the language functional area needs to be accurately positioned during surgery , it involves a certain special drug and skill , requires high - aged and experienced anesthesiologist to implement . Only in this way can the surgeon and the patient cooperate well , complete the operation together , protect the functional area of the patient from damage .

Although the general principle of anesthesia for craniocerebral operation is the same and must be observed , the basic principle is to prepare before the operation .
Stable anesthesia induction and maintenance ;
Maintenance of cardiovascular system stability and good cerebral perfusion ;
maintain airway patency and good breathing function ;
Maintenance of internal environmental balance ;
controlling intracranial pressure ;
The patient was awake as soon as possible after the procedure .

The study of wake - up anesthesia during the operation of the second part of the brain functional area

With the development of imaging and minimally invasive surgery technique , neurosurgery is becoming more and more detailed , especially the tumor , epileptic focus and vascular malformation of the brain functional area .

In order to improve the safety and operation of anesthesia , it is convenient and rapid to solve the problem that the general anesthesia can be maintained well while the patient is awaked and able to speak and coordinate with the brain functional area .
( 2 ) the airway and the sound - emitting organ are not occupied , can be pronouncing in the awake state of the patient and communicate with the doctor , so that the precise positioning of the brain functional area is realized , and the contradiction between ventilation and speech is solved ;
( 3 ) the esophagus is closed to avoid reflux and missuction of the gastric contents , and the suction catheter can prevent the catheter side hole from being blocked by the secretion , so that the smoothness of the catheter is ensured ;
( 4 ) the operation is convenient and simple ; after the air bag is arranged , the air bag can be mechanically ventilated , the gas in the pharyngeal air bag is eliminated when the patient is awakened , and the patient can speak without repeatedly pulling the tube and reducing the risk on the control of the airway ;
( 5 ) when the condition is changed , the emergency treatment is convenient , such as a sedative drug or a muscle relaxant can be immediately administered when the condition is changed , and the air bag inflation line is mechanically ventilated to carry out general anesthesia or other emergency treatment , thereby greatly improving the safety of anesthesia .

DEX is a potent alpha - 2 - adrenergic receptor agonist . The 偽 - 2 - adrenergic receptor is mainly distributed in the sympathetic nerve endings and the adrenergic neurons of the central nervous system .

The development and application of a series of acoustic door ventilation equipment capable of speaking to patients in the third part of general anesthesia

Objective : To develop an acoustic external ventilation device which can be used in clinical diagnosis of patients with brain functional area . Methods : ASA grade 鈪，

本文編號：2087961