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1、神经外科麻醉有关问题神经外科麻醉有关问题天津医科大学总医院王国林天津医科大学总医院王国林201087内容内容TBI (脑外伤）Awake Craniotomy手术室外麻醉TBI的处理脑外伤 欧洲13.5 hospital admission per 1000 inhabitants per year 年轻人死亡的主要原因 6.2 million people live in Europe with TBI- related disability 严重脑外伤 (10% of all patients with TBI),40% vegetative or death 医疗费用: 4.5亿欧元/年
2、 (德国)分类与预后分类与预后injuryGCS on arrival deathMinor 1535%Teasdale GM et al: J Neurol Neurosurgical Psych 1995,58:526CPPICP血管扩张CBVCSF低氧血症高二氧化碳血症低氧血症高二氧化碳血症血管扩张的恶性循环Rosner et al.J Neurosurg 1995;83:949创伤性低血压创伤性低血压神经损伤的时间治疗窗minhrsdaysmonths兴奋性毒性梗死周围去极化炎症细胞凋亡监测 GSC8或CT检查异常者，应给以ICP监测 治疗目标： ICP60mmHgBrain Trau
3、ma Foundation处理 目标目标: Normoxemia Normocapnia Normotension/normov elomia Normoglycemia 措施措施: Oxygen delivery Anageosedation/intub aton/ventilation Volume replacement Insulin therapy Head up positioning 300循环处理 低血压 Double mortality Must be treated aggressively Look for cause: hypovolemia, shock, bleed
4、ing sites 高血压 Common Increased CA and cardiac output Control?(MAP 100mmHg)液体治疗 Adequate resuscitation: MAP, CVP, UO Crystalloid VS colloids: Not all colloids are equal 避免: Hypotonic fluids Glucose containing solutions关于急性脑损伤与低温的研究关于急性脑损伤与低温的研究 mild hypothermia （3335） Moderate hypothermia （3033） Hypo
5、thermia not benefitial Outcome in hypothermia group worse GSC 34(mortality 47% vs 35%) High dose vasopressorsLaparotomy or craniotomy In severe TBI+ blunt trauma Most brain injury death result from delays in craniotomy 50% of preventable trauma death result from failure to identify or stop ongoing b
6、leeding CPP should be maintained at lest 60 mmHgJ Neurotrauma 2001,17:507ICP监测适应症Initial GCSCCTAdditional criteria8+8+Neurological examination impossible6h80Neurological examination impossible6hStocker et al: Anaesthesist 2000,49:913ICP Monitoring Intra-ventriclar catheter Subdural subarachnoid scre
7、w Fibro-optic microsensorSjvO2 monitoring Determination of ischemia Monitor effects of therapy for raised ICPInsertion Retrograde IJ line placement - usually right Check on X-raySjvO2 monitoringSjvO2 monitoringUseful Assessing risk of ischaemia if ICP not available ICP is contra-indicated in emergen
8、cy setting Adjunct to ICP monitorLimitationsInvasive Problems with samplingSjvO2 monitoringCPPICP血管扩张CBVCSF脑水中CMRO2/Metabolism Viscosity O2 delivery Hypercapnia pharmacologicCPP处理SABPBleeding Dehydration Pharmacologic Mechanical metabolismRosner et al:J Neurosurgery 1995,83:949甘露醇 vs 高渗盐水Mannitol 20
9、0ml 20%Hypertonic saline/dextran 100ml 7.5%/6% N=9N=9pICP change -7.5(-5.8- 11.8)-13.0(11.5- 17.3)0.014CRITICAL CARE MEDICINE 2005,33:196过渡通气对照组过渡通气组PaCO2 (mmHg)352252Good/mederate disable4818#Severe/vagetati ve4377death106Neurological outcome after 6 month, p80mmHg,lower only if 130mmHgnormocapniaP
10、aCO2 35(40)mmHg normoxemiaPaO2 80mmHg analgosedationposition300 head up if absence of severe hypotension麻醉药的影响Critical care of TBI General care Anxiolysis Hemodynamic support Lung protection ventilation Tight glucose control Renal protection Temperature control Infection prevention ICP/CPP target th
11、erapy Positioning CSF drainage Sedative Osmotherapy Vasopressor Hyperventilation Hypothermia Crarioctomy理想的镇静药理想的镇静药 Neurospecfic protective 降低降低CMRO2 Preservation of metabolism coupling and CO2 response Preservation of pressure autoreguration 不增加不增加CBV , ICP Reduced seized activity 代谢排泄快，以利于评估代谢排泄快
12、，以利于评估 剂量可以快速调节、滴淀剂量可以快速调节、滴淀 具有神经保护作用具有神经保护作用Neuroproteciton:reduction of CMRO2耐受性增加缺血时间细胞死亡麻醉状态清醒状态Neuprotective receptor mediated effects Glutamate antagonist at MNDA and AMPA receptors Glutamate release and uptake in synaptic cleft Potentiation of GABA receptor activities Blocking Ca+ influx Ade
13、nosine A1 receptor activation Scavelling of free radicalsCerebral flow-metabolism coupling-100+10-20-30-40% change from baselinerCBF CMRO2rCBF CMRO2SEVOFLURAN 1.50.3%(BIS=40)PROPOFOL 3.7g/ml(BIS=40)Kaisti,ANESTHESIOLOGY,2003Comparative effects of anesthetics on CBV血管收缩血管收缩血管扩张血管扩张丙泊酚硫喷妥钠丙泊酚硫喷妥钠丙泊酚丙泊
14、酚N2 O基础状态七氟烷地氟烷异氟烷七氟烷地氟烷异氟烷七氟烷七氟烷N2 O异氟烷异氟烷N2 O地氟烷地氟烷N2 O Barbiturates: 610mg/kg bolus, 35mg/kg/h for maintain, EEG to burst suppression There is no evidence that barbiturate improve the outcome High dose barbiturate are reserved for the patients with severe head injury and intracranial hypertension
15、 refractory to maximal medical and surgical treatment巴比妥类药巴比妥类药Lancet 2004,364:1321麻醉药与NICU并发症的报告大剂量麻醉药大剂量麻醉药增加肺炎发生率增加肺炎发生率 减慢胃排空骨髓抑制骨髓抑制免疫抑制免疫抑制药物耐受戒断综合症电介质紊乱心肌抑制和低血压心肌抑制和低血压Delayed neurological assessment体温调节受损Suppressed neurogenesisDecreased cortisol levelsPropofol infusion syndromehypertriglyceremia/pancreatitisAwake CraniotomyIndications: Cortical mapping: avoiding any interference from the anesthesia agents on the electrophysiological recordings. Resection of lesions located close to, or in, functionally essential motor, cognitiv
