右美托咪定联合脉搏压变异度监测在缺血型烟雾病血管搭桥术中的应用

【摘要】目的探讨缺血型烟雾病(MMD)搭桥术中，右美托咪定联合脉搏压变异度（PPV）监测的应用效果。方法纳入择期全麻下行颅内-颅外血管搭桥术的缺血型MMD患者90例，按照随机数字表法分为3组（n=30）：对照组（C组）、右美托咪定处理组（S组）、右美托咪定联合PPV监测组（P组）。S组患者麻醉诱导前及术中泵注右美托咪定，P组患者麻醉诱导前及术中泵注右美托咪定联合术中PPV监测，C组患者麻醉诱导前及术中泵注同等剂量的生理盐水。记录患者入室时（T0）、气管导管插管后5 min（T1）、手术开始切皮即刻（T2）、硬脑膜切开即刻（T3）、硬脑膜切开后1 h（T4）、硬脑膜关闭即刻（T5）、手术结束即刻（T6）两组SpO2、HR、SBP、MAP及颈内静脉球血氧饱和度（SjvO2），并计算动脉收缩压变异度（SPV）。记录患者术中液体输入总量、尿量、出血量、术后意识恢复时间和气管导管拔管时间，记录患者围术期补救血管活性药物去甲肾上腺素使用比例及总量、新发脑梗、脑高灌注综合征等不良反应发生情况。结果与T0时比较，T2-T6时3组SBP、MAP均明显升高，SPV降低（P<0.05）。与C组比较，S组、P组患者术中输液总量、术后麻醉苏醒时间、气管导管拔管时间、去甲肾上腺素使用比例及总量、再发脑梗及脑高灌注综合征发生率明显降低，其中P组明显低于S组（P<0.05）。与C组同时间点比较，S组、P组T2-T6时SPV降低，T4-T6时SjvO2升高（P<0.05），与S组比较，P组T2-T6时SPV降低，T4-T6时SjvO2无显著差异（P>0.05）。结论右美托咪定联合PPV监测用于缺血型MMD血管搭桥术，能缩短麻醉苏醒及气管导管拔管时间，血流动力学、脑氧代谢更趋平稳，术后再发脑梗、脑高灌注综合征发生率降低。

Abstract: ObjectiveTo investigate the effect of dexmedetomidine combined with intraoperative monitoring of pulse pressure variation in patients with moyamoya disease(MMD) undergo vascular bypass. Methods90 patients undergoing MMD for vascular bypass operation were randomly divided into three groups(n=30). Patients in group S received dexmedetomidine alone, patients in group P received dexmedetomidine combined with pulse pressure variation, and patients in group C received the same dose of normal saline. SpO2, HR, SBP, MAP and SjvO2 were recorded at these time points: baseline(T0), 5 min after tracheal intubation(T1), skin incision(T2), opening the dura mater(T3), 1 h after dura mater(T4), occluding the dura mater(T5), operation fininshed(T6), and calculate the systolic blood pressure variability(SPV). The total amount of intraoperative fluid input, urine volume, bleeding volume, consciousness recovery time and tracheal tube extubation time, the proportion and total amount of noradrenaline, new cerebral infarction and cerebral hyperperfusion syndrome were recorded. ResultsSBP and MAP at T2-T6 in three groups were higher and PPV at T2-T6 in both groups were lower than that at T0(P<0.05). Compared with group C, the total amount of intraoperative infusion, the recovery time of anesthesia, extubation time of tracheal tube, the proportion and total amount of noradrenaline, the incidence of recurrent cerebral infarction and cerebral hyperper fusion syndrome in group S and group P(P<0.05), group P was significantly lower than group S(P<0.05). The hemodynamic SPV was lower at T2-T6 and SjvO2 was higher at T4-T6 in group S and group P(P<0.05). Compared with group S, the hemodynamic SPV in group P was lower at T2-T6(P<0.05), while SjvO2 in group P at T4-T6 has no statistical difference. ConclusionsDexmedetomidine combined with intraoperative monitoring of pulse pressure variation is safe and effective in elderly patients with MMD for vascular bypass. The time of recovery from anesthesia and extubation of tracheal tube were shorter, the hemodynamic and cerebral oxygen metabolism were more stable, and the incidence of postoperative recurrent cerebral infarction and cerebral hyperperfusion syndrome were lower.