瑞芬太尼对急性高容量血液稀释后颅内动脉瘤夹闭术患者脑氧代谢以及术后认知功能的影响

目的:探究瑞芬太尼对急性高容量血液稀释(AHH)后颅内动脉瘤夹闭术患者脑氧代谢以及术后认知功能的影响。方法:选择2015年5月至2016年12月期间在我院进行颅内动脉瘤夹闭术的92例患者作为研究对象,并将其随机均衡分为研究组和对照组,每组46例,研究组给予瑞芬太尼治疗,对照组给予硝酸甘油治疗。对两组患者AHH前(T0)、AHH后(T1)、降压前(T2)、降压后30 min(T3)、动脉瘤夹闭术后5 min(T4)等时间点的平均动脉压(MAP)、心率(HR)进行记录,在T2-T4时间点对颈内静脉球部血、桡动脉血两处位置的动、静脉血氧饱和度(SAO_2、SjvO_2)、动脉血氧分压(PAO_2)、静脉血氧分压(PjvO_2)进行统计,计算动脉氧含量(CAO_2)、颈内静脉氧含量(CjvO_2)、动脉颈内静脉球部血氧差(Da-jvO_2)、颈内静脉球部动脉乳酸差(VADL)和脑氧摄取率(CERO_2)。在术前、术后3 d、术后7 d采用简易智力状态量表(MMSE)对两组患者的认知功能进行评估。结果:相对于T2时间点,在T3、T4时间点,两组患者MAP均出现显著降低(P0.05);对照组患者HR显著升高,研究组患者HR显著降低(P0.05)。两组患者SaO_2均为100.00%,在T3、T4时间点研究组SjvO_2、CjvO_2显著高于T2时间点,且较对照组患者升高,差异均有统计学意义(P0.05),Da-jvO_2、CERO_2显著低于T2时间点,且较对照组患者降低,差异均有统计学意义(P0.05)。PaO_2、CaO_2、PjvO_2、VADL组间比较差异均无统计学意义(P0.05)。术前、术后3 d、术后7 d两组患者的MMSE评分比较均无统计学差异(P0.05),术前、术后7 d两组患者的MMSE评分均高于术后3 d的MMSE评分(P0.05)。结论:瑞芬太尼对急性高容量血液稀释进行颅内动脉瘤夹闭术,能够有效维持患者机体血流动力学稳定,同时还可以对脑氧代谢率进行有效控制,相对于硝酸甘油进行急性高容量血液稀释,瑞芬太尼优势较为明显,但对于认知功能无明显的改善作用。

Effect of Remifentanil on Cognitive Function and Cerebral Oxygen Metabolism in Patients with Intracranial Aneurysm Clipping after Acute Hypervolemic Hemodilution

ABSTRACT Objective: To investigate the effect of remifentanil on the cognitive function and cerebral oxygen metabolism in pa- tients with intracranial aneurysms after acute hypervolemic hemodilution (AHH). Methods: A total of 92 patients, who underwent in- tracranial aneurysm clipping in Suining Central Hospital from May 2015 to December 2016, were selected and were randomly divided into study group(n=46) and control group(n=46). The study group was treated with remifentanil, and the control group was treated with nitroglycerin. Mean arterial pressure (MAP) and heart rate (HR) of the patients in the two groups before AHH (T0), after AHH (T1), be- fore lowering blood pressure (T2), 30min after lowering blood pressure (T3), 5 min after aneurysm clipping (T4) were recorded. The arte- rial and venous blood oxygen saturation (SAO₂, SjvO₂), arterial oxygen partial pressure (PAO₂), and arterial oxygen partial pressure (PjvO₂) were counted at T2-T4 time points. The arterial oxygen content (CAO₂), internal jugular vein oxygen content (CjvO₂), arterial internal jugular bulb oxygen deficit (Da-jvO₂), arterial bulb lactate difference (VADL) and brain oxygen uptake rate (CERO₂) were calculated. The cognitive functions of two groups were evaluated by the Mini Mental State Scale (MMSE) before operation, 3 d and 7 d after opera- tion. Results: Compared with the T2 time point, the MAP was decreased significantly in the two groups at T3 and T4 time points (P<0.05). The HR in the control group was increased significantly, but the HR in the study group was decreased significantly (P<0.05). The SaO₂ of the two groups was 100%. At T3 and T4 time points, SjvO₂ and CjvO₂ in the study group were significantly higher than those at T2 time point,which was higher than those in the control group, and the differences were statistically significant (P<0.05); the Da-jvO₂ and CERO₂ were significantly lower than at T2 time point, which were lower than those in the control group,and the differences were sta- tistically significant (P<0.05). There were no significant differences in the PaO₂, CaO₂, PjvO₂, VADL between the two groups (P>0.05). There were no significant differences in MMSE scores between the two groups before operation, 3d and 7d after operation (P>0.05); the MMSE scores of the two groups before operation and 7d after operation were higher than those of the two groups 3d after operation (P<0.05). Conclusion: Remifentanil in the acute hypervolemic hemodilution with intracranial aneurysm clipping can effectively maintain the stability of hemodynamics of patients, at the same time,the rate of cerebral oxygen metabolism can be effectively controlled. Compared with nitroglycerin, remifentanil is superior in acute hypervolemic hemodilution, but there is no obvious improvement in cognitive func- tion.