Tijero Teresa, Ingelmo Ildefonso, García-Trapero Jorge, Puig Alberto
Servicio de Neuroanestesiología, Reanimación y Cuidados Críticos, Hospital Universitario Ramón y Cajal, Madrid, Spain.
J Neurosurg Anesthesiol. 2002 Apr;14(2):149-52. doi: 10.1097/00008506-200204000-00011.
Awake craniotomy is indicated for surgical resection of tumors located near eloquent areas of the brain. The anesthetic technique is based on a combination of local anesthesia, sedation, and analgesia. Usually only clinical parameters are assessed and no other cerebral oxygenation monitoring techniques are applied. The authors report the use of brain tissue oxygen pressure monitoring during awake craniotomy. A 48-year-old right-handed man with a left temporoparietal mass was scheduled for awake craniotomy, cortical stimulation, and selective tumor removal. Monitoring included electrocardiography, pulse oximetry, end-tidal CO2, bladder temperature, invasive and noninvasive arterial pressure, and brain tissue oxygen pressure (PtiO2). The anesthetic technique consisted of continuous perfusions of 0.02 to 0.05 microg/kg/min remifentanil, propofol (target concentration, 0.5 to 1.2 microg/mL), and 25 to 50 microg/kg/min esmolol, and local anesthetic blockade of the head pin insertion sites and surgical incision area (a mixture of 0.2% ropivacaine, 1% lidocaine, and epinephrine, 1:200 000). Intraoperative cortical stimulation was performed to guide the resection according to the patient's verbal response. A change in PtiO2 was observed, gradually falling from 28 mm Hg at the beginning of the intervention down to 3 mm Hg. At this stage, surgical resection was concluded. On arrival at the intensive care unit, mixed dysphasia and slight weakness of the right arm were noted. Three weeks after surgery, the patient's speech is improving and the motor deficit has disappeared. This case suggests a possible role of PtiO2 in awake craniotomy as an aid in detecting intraoperative adverse events, but further experience with PtiO2 in this setting is needed.
清醒开颅手术适用于手术切除位于脑功能区附近的肿瘤。麻醉技术基于局部麻醉、镇静和镇痛的联合应用。通常仅评估临床参数，不应用其他脑氧合监测技术。作者报告了在清醒开颅手术中使用脑组织氧分压监测的情况。一名48岁右利手男性，患有左颞顶叶肿块，计划行清醒开颅手术、皮质刺激和选择性肿瘤切除。监测包括心电图、脉搏血氧饱和度、呼气末二氧化碳、膀胱温度、有创和无创动脉压以及脑组织氧分压（PtiO2）。麻醉技术包括持续输注瑞芬太尼0.02至0.05微克/千克/分钟、丙泊酚（目标浓度0.5至1.2微克/毫升）和艾司洛尔25至50微克/千克/分钟，并对头钉插入部位和手术切口区域进行局部麻醉阻滞（0.2%罗哌卡因、1%利多卡因和肾上腺素的混合物，1:200 000）。术中进行皮质刺激以根据患者的语言反应指导切除。观察到PtiO2发生变化，从干预开始时的28毫米汞柱逐渐降至3毫米汞柱。此时，手术切除结束。到达重症监护病房时，发现患者有混合性言语困难和右臂轻度无力。术后三周，患者的言语功能正在改善，运动功能障碍已消失。该病例表明PtiO2在清醒开颅手术中可能有助于检测术中不良事件，但在这种情况下还需要对PtiO2进行更多的经验积累。
