本文選題：血壓 + 頸動脈內(nèi)膜剝脫術(shù)�。� 參考：《河北醫(yī)科大學》2017年碩士論文

【摘要】：目的:擬探討局部腦氧飽和度聯(lián)合神經(jīng)電生理監(jiān)測對頸動脈內(nèi)膜剝脫術(shù)(Carotid Endarterectomy,CEA)中患側(cè)頸動脈阻斷期間血壓管理的效果,為臨床提供參考。方法:擇期行CEA患者40例,年齡50~80歲,性別不限,美國麻醉醫(yī)師協(xié)會(ASA)分級II或III級,采用隨機數(shù)字表法將其分為2組(n=20):對照組(C組)和聯(lián)合監(jiān)測組(M組)。C組患者在頸動脈阻斷期間依照傳統(tǒng)方法升高收縮壓,升高幅度為術(shù)前基礎(chǔ)血壓的20%~30%;M組根據(jù)局部腦氧飽和度(rSO_2)監(jiān)測和神經(jīng)電生理監(jiān)測調(diào)節(jié)收縮壓,使監(jiān)測指標維持在臨床許可變化范圍�；颊呷胧液蟊O(jiān)測無創(chuàng)血壓(NIBP)、心率(HR)、心電圖(ECG)、脈搏血氧飽和度(SpO_2)、rSO_2及腦電雙頻譜指數(shù)(BIS),局麻下橈動脈穿刺置管,連接Flo Trac/Vigileo監(jiān)護儀連續(xù)監(jiān)測并記錄有創(chuàng)動脈壓(IBP)、心輸出量(CO)和每搏量變異度(SVV)。麻醉誘導:依次靜脈注射咪達唑侖0.01~0.05 mg/kg、依托咪酯0.1~0.3mg/kg、順式阿曲庫銨0.1~0.2 mg/kg、枸櫞酸舒芬太尼0.4~0.6μg/kg和利多卡因60~100 mg。麻醉維持:微量泵持續(xù)泵入丙泊酚2~6 mg·kg-1·h-1、瑞芬太尼0.1~0.3μg·kg-1·min-1,BIS值維持在40~60。誘導后由神經(jīng)電生理醫(yī)生連接神經(jīng)電生理監(jiān)護儀,監(jiān)測腦電圖和體感誘發(fā)電位。兩組患者均在術(shù)前1 d用簡易智能狀態(tài)檢查量表(MMSE)評估認知功能,記錄年齡,性別,教育程度,術(shù)前合并癥等。以入院后護士每日清晨(T0)測得的病房平均血壓記為基礎(chǔ)血壓,術(shù)中分別記錄兩組患者入室(T0)rSO_2,插管即刻(T1)血壓,麻醉誘導平穩(wěn)后5 min(T2)血壓,阻斷頸動脈后5 min(T3)血壓穩(wěn)定值,開放頸動脈后5 min(T4)血壓穩(wěn)定值,拔管即刻(T5)血壓和同時刻的rSO_2。記錄全麻藥物用量,血管活性藥物用量及次數(shù),阻斷頸動脈時間,蘇醒時間,拔管時間,術(shù)后并發(fā)癥等。術(shù)后第1天,第3天,第7天采用MMSE評估患者認知功能。結(jié)果:1兩組患者年齡、性別比例、教育程度、術(shù)前合并癥等一般情況比較,差異無統(tǒng)計學意義(P0.05)。2兩組組間比較T0-2、T4-5時刻血壓差異無統(tǒng)計學意義(P0.05),T3有統(tǒng)計學意義(P0.05)。與C組T3血壓高于基礎(chǔ)血壓20%~30%比較,M組有4例患者血壓升高10%~20%,11例患者血壓升高0%~10%,5例患者血壓低于基礎(chǔ)血壓0%~10%。與T0時刻比較,T2,4-5時血壓降低,T1,3時血壓升高,差異有統(tǒng)計學意義(P0.05)。3兩組組間比較各時刻rSO_2差異無統(tǒng)計學意義(P0.05),與T0時比較,T1時rSO_2值最高,T3時rSO_2值最低,與其余時刻比較差異有統(tǒng)計學意義(P0.05)。T3時C組rSO_2平均下降9.7%,M組rSO_2平均下降10.0%,差異無統(tǒng)計學意義(P0.05)。開放后rSO_2恢復至阻斷前水平,稍高于T2并直至T5。4兩組術(shù)前MMSE評分統(tǒng)計值差異無統(tǒng)計學意義(P0.05),兩組術(shù)后1和3 d MMSE評分下降,術(shù)后7 d基本恢復至術(shù)前水平。兩組術(shù)后認知功能障礙的發(fā)生率術(shù)后1 d分別為C組20%,M組15%;術(shù)后3 d C組10%,M組15%;術(shù)后7 d C組5%,M組0%。5與C組比較,M組血管活性藥物使用次數(shù)和用量減少,阻斷期間心肌耗氧量降低(P0.05)。兩組全麻藥物用量,阻斷時間,蘇醒時間,拔管時間,術(shù)后并發(fā)癥差異無統(tǒng)計學意義(P0.05)。結(jié)論:腦氧飽和度聯(lián)合神經(jīng)電生理監(jiān)測對頸動脈阻斷期間的血壓管理有指導作用,比傳統(tǒng)方法更精確、安全,減少心臟做功,并且不會降低術(shù)后認知功能。
[Abstract]:Objective: To explore the effect of local cerebral oxygen saturation combined with neuroelectrophysiological monitoring on the management of blood pressure during the occlusion of carotid artery endarterectomy (Carotid Endarterectomy, CEA), and to provide reference for clinical practice. Methods: 40 cases of CEA patients, age 50~80, sex unlimited, II or III grade of American anesthesiologist Association (ASA) were selected. The random digital table was used to divide it into 2 groups (n=20): the control group (group C) and the joint monitoring group (group M).C patients increased the systolic pressure according to the traditional methods during the occlusion of the carotid artery, the increase was 20%~30% of the pre operation basic blood pressure, and the M group adjusted the systolic pressure according to the local cerebral oxygen saturation (rSO_2) monitoring and the neurophysiological monitoring. The patients were maintained in the range of clinical licensing changes. After the admission, the patients were monitored without invasive blood pressure (NIBP), heart rate (HR), electrocardiogram (ECG), pulse oxygen saturation (SpO_2), rSO_2 and electroencephalogram double spectrum index (BIS), radial artery puncture tube under local anesthesia, continuous monitoring and recording of invasive arterial pressure (IBP), cardiac output (CO) and pacing quantitative change with Flo Trac/Vigileo monitoring instrument. SVV. Induction of anesthesia: intravenous injection of midazolam 0.01~0.05 mg/kg, etomidate 0.1~0.3mg/kg, CIS atracurium 0.1~0.2 mg/kg, sufentanil citrate 0.4~0.6 mu g/kg and lidocaine 60~100 mg. anesthesia maintenance: micropump continued to pump propofol 2~6 mg. 40~60. was induced by electrophysiologists to monitor electroencephalogram and somatosensory evoked potentials. The two groups of patients were assessed the cognitive function by the simple intelligence state Checklist (MMSE) before 1 D, and recorded age, sex, education, and preoperative complication. The average day morning (T0) of nurses after admission was measured. Blood pressure was recorded as basic blood pressure, and two groups of patients (T0) rSO_2, immediate (T1) blood pressure, 5 min (T2) blood pressure after anesthesia induction, 5 min (T3) blood pressure stability after carotid artery occlusion, 5 min (T4) after opening carotid artery were opened, and the amount of drug dosage and vasoactivity of immediate (T5) blood pressure and simultaneous rSO_2. were recorded and vasoactive activity was recorded. Drug dosage and times, occlusion of carotid artery time, awakening time, extubation time, postoperative complications and so on. First days, third days and seventh days after operation were used to evaluate the cognitive function of patients with MMSE. Results: there was no significant difference in age, sex ratio, education level and preoperative complication between group 1 and two groups (P0.05), there was no significant difference between group.2 and two groups of T0-2, The blood pressure difference at T4-5 time was not statistically significant (P0.05), and T3 had statistical significance (P0.05). Compared with the C group, the blood pressure of M group was higher than that of the basic blood pressure 20%~30%, in group M, blood pressure was elevated in 4 patients, and in 11 cases, the blood pressure was higher in 0%~10%, and the blood pressure was lower in the 5 patients than that in the T0. There was no statistical significance (P0.05) between groups of.3 two groups at different times (P0.05). Compared with T0, the rSO_2 value of T1 was the highest and T3 was the lowest at the time of T3. There was a significant difference between T3 and the rest time. (P0.05).T3, the C group decreased by an average of 10%, and the difference was not statistically significant. SO_2 was restored to pre blocking level, slightly higher than T2 and until T5.4 two groups had no statistical significance (P0.05) before operation (P0.05). The 1 and 3 D MMSE scores decreased after operation, and 7 d recovered to the preoperative level after operation. The two groups after operation 1 D were 20% in C group and 15% in M group; 3 D, 10%, 15% and 7 after operation. D C group 5%, group M 0%.5 compared with the C group, the number and dosage of vasoactive drugs in group M decreased and the myocardial oxygen consumption decreased during the blocking period (P0.05). There was no significant difference between two groups of anesthetic dosage, blocking time, time of awakening, extubation time and postoperative complications (P0.05). Conclusion: cerebral oxygen saturation combined with electrophysiological monitoring of carotid artery obstruction (P0.05). The blood pressure management during the period of interruption has a guiding role, which is more accurate and safe than traditional methods, and reduces cardiac work and does not reduce postoperative cognitive function.

【學位授予單位】：河北醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R614

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