神经外科手术麻醉相关问题 (2).pdf

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1、神经外科麻醉有关问题天津医科大学总医院王国林2010－8－7内容TBI(脑外伤）AwakeCraniotomy手术室外麻醉TBI的处理脑外伤•欧洲1~3.5hospitaladmissionper1000inhabitantsperyear•年轻人死亡的主要原因•6.2millionpeopleliveinEuropewithTBI-relateddisability•严重脑外伤(10%ofallpatientswithTBI),>40%vegetativeordeath•医疗费用:£4.5亿欧元/年(德国)分类与预后injuryGCSonarrivaldeathMinor15<1%

2、mild13/14<5%Moderate9~12<10%severe3~8>35%TeasdaleGMetal:JNeurolNeurosurgicalPsych1995,58:526血管扩张的恶性循环创伤性低血压CPPICP血管扩张CSF低氧血症CBV高二氧化碳血症Rosneretal.JNeurosurg1995;83:949神经损伤的时间治疗窗兴奋性毒性梗死周围去极化炎症细胞凋亡minhrsdaysmonths监测•GSC≤8或CT检查异常者，应给以ICP监测•治疗目标：–ICP<20~25mmHg–CPP>60mmHgBrainTraumaFoundation处理•目标:•措施:–

3、Normoxemia–Oxygendelivery–Normocapnia–Anageosedation/intub–Normotension/normovaton/ventilationelomia–Volumereplacement–Normoglycemia–Insulintherapy–Headuppositioning300循环处理•低血压–Doublemortality–Mustbetreatedaggressively–Lookforcause:hypovolemia,shock,bleedingsites•高血压–Common–IncreasedCAandcardiacou

4、tput–Control?(MAP100mmHg)液体治疗•Adequateresuscitation:MAP,CVP,UO•CrystalloidVScolloids:–Notallcolloidsareequal•避免:–Hypotonicfluids–Glucosecontainingsolutions关于急性脑损伤与低温的研究•mildhypothermia（33~35℃）•Moderatehypothermia（30~33℃）•Hypothermianotbenefitial•Outcomeinhypothermiagroupworse–GSC3~4(mortality47%vs

5、35%)–HighdosevasopressorsLaparotomyorcraniotomy•InsevereTBI+blunttrauma–Mostbraininjurydeathresultfromdelaysincraniotomy–50%ofpreventabletraumadeathresultfromfailuretoidentifyorstopongoingbleeding•CPPshouldbemaintainedatlest60mmHgJNeurotrauma2001,17:507ICP监测适应症InitialGCSCCTAdditionalcriteria≤8+>8+

6、Neurologicalexaminationimpossible>6h≤80Neurologicalexaminationimpossible>6hStockeretal:Anaesthesist2000,49:913ICPMonitoring•Intra-ventriclarcatheter•Subdural–subarachnoidscrew•Fibro-opticmicrosensorSjvOmonitoring2•Determinationofischemia•MonitoreffectsoftherapyforraisedICPInsertion•RetrogradeIJlin

7、eplacement-usuallyright•CheckonX-raySjvOmonitoring2SjvO2monitoringSjvO2monitoringUsefulAssessingriskofischaemiaifICPnotavailableICPiscontra-indicatedinemergencysettingAdjuncttoICPmonitorLimitationsInvasiveP