Shiau J M, Chen T Y, Tseng C C, Chang P J, Tsai Y C, Chang C L, Lee C G
Department of Anesthesiology, 806 General Hospital, Taiwan, R.O.C.
Acta Anaesthesiol Sin. 1998 Dec;36(4):215-20.
Sudden and overwhelming increases in blood pressure (BP) and heart rate (HR) during incision of the scalp may give rise to morbidity or mortality in patients with intracranial pathology undergoing neurosurgery. A modification of the method proposed by Labat to abate this circumstantiality was applied in a group of patients receiving craniotomy. The modified method was to combine scalp circuit infiltration of local anesthetic with general anesthesia to control the hemodynamic response to craniotomy.
Twenty-six patients scheduled to undergo craniotomy were randomly divided into two groups. Patients whose conditions or their current medication that might affect the stability of hemodynamics were excluded. In group A patients (N = 16) 25-30 ml of 0.25% bupivacaine was used for scalp circuit infiltration on the operation side, while in those of group B (N = 10) the same volume of 0.9% normal saline was used. After induction, anesthesia was maintained with 0.6% to 1.2% end-tidal isoflurane (ET-Iso) and 50% N2O in oxygen (N2O:O2 = 2 l/min:2 l/min). The end-tidal CO2 was kept within the range of 25-30 mmHg. BP and HR were recorded every five min before incision and then every two min after incision until one hour after induction. ET-Iso was also recorded every two min throughout a period of sixty min. If the BP and HR increased above 20% of the baseline (10 min before incision), thiopental 2.5 mg/kg and fentanyl 2 micrograms/kg were administered. If hypertension became sustained, the isoflurane concentration was adjusted until an acceptable level was obtained.
The mean BP during the surgery was 92 +/- 1 mmHg in group A and 92 +/- 7 mmHg in group B. The difference in BP between incision to 6 min after incision was statistically significant (P < 0.05). The mean HR during surgery was 101 +/- 5 beats/min in group B and 91 +/- 2 beats/min in group A, the difference of which was not statistically significant. All of the patients in group B required a deepened anesthesia to keep the BP and HR within the normal range, but no patient in group A had such need. The average concentration of ET-Iso during the 60 min period was 0.95 +/- 0.12% in group B and 0.41 +/- 0.01% in group A, respectively. The difference was statistically significant (P < 0.05).
Our results showed that scalp circuit infiltration with 0.25% bupivacaine significantly improved the cardiovascular stability and reduced the requirement of isoflurane during craniotomy. The routine use of bupivacaine scalp circuit infiltration in patients undergoing craniotomy should be considered.
在为患有颅内病变的患者进行神经外科手术时，头皮切开过程中血压（BP）和心率（HR）突然急剧升高可能会导致患者发病或死亡。在一组接受开颅手术的患者中应用了对拉巴特提出的方法进行改良后的方法来减轻这种情况。改良后的方法是将局部麻醉药头皮环形浸润与全身麻醉相结合，以控制开颅手术时的血流动力学反应。
将26例计划接受开颅手术的患者随机分为两组。排除那些病情或当前用药可能影响血流动力学稳定性的患者。A组患者（N = 16）在手术侧使用25 - 30 ml 0.25%布比卡因进行头皮环形浸润，而B组患者（N = 10）使用相同体积的0.9%生理盐水。诱导后，用0.6%至1.2%的呼气末异氟烷（ET - Iso）和50%的氧化亚氮与氧气混合（N₂O:O₂ = 2 l/min:2 l/min）维持麻醉。呼气末二氧化碳保持在25 - 30 mmHg范围内。在切开前每五分钟记录一次BP和HR，切开后每两分钟记录一次，直至诱导后一小时。在整个60分钟期间，每两分钟也记录一次ET - Iso。如果BP和HR升高超过基线（切开前10分钟）的20%，则给予硫喷妥钠2.5 mg/kg和芬太尼2微克/kg。如果高血压持续存在，则调整异氟烷浓度直至达到可接受水平。
A组手术期间平均BP为92 ± 1 mmHg，B组为92 ± 7 mmHg。切开至切开后6分钟之间的BP差异具有统计学意义（P < 0.05）。手术期间B组平均HR为101 ± 5次/分钟，A组为91 ± 2次/分钟，两者差异无统计学意义。B组所有患者都需要加深麻醉以将BP和HR维持在正常范围内，但A组没有患者有此需要。60分钟期间ET - Iso的平均浓度在B组为0.95 ± 0.12%，在A组为0.41 ± 0.01%。差异具有统计学意义（P < 0.05）。
我们的结果表明，0.25%布比卡因头皮环形浸润可显著改善开颅手术期间的心血管稳定性，并降低异氟烷的需求量。应考虑在接受开颅手术的患者中常规使用布比卡因头皮环形浸润。
