Dahyot-Fizelier C, Frasca D, Debaene B
Inserm U1070, service d'anesthésie-réanimation chirurgicale, CHU de Poitiers, BP 577, 86021 Poitiers cedex, France.
Ann Fr Anesth Reanim. 2012 Oct;31(10):e229-34. doi: 10.1016/j.annfar.2012.08.003. Epub 2012 Sep 18.
Isoflurane, desflurane and sevoflurane all preserve cerebrovascular carbone dioxide (CO(2)) reactivity. They are all concentration-dependant cerebral vasodilatators and decrease cerebral metabolism. Sevoflurane induces the smallest cerebral vasodilatation and preserve cerebral autoregulation up to 1.5CAM, compared to isoflurane and desflurane which impair it upon 1CAM. Propofol has been compared to inhaled agents. Propofol preserve cerebrovascular CO(2) reactivity, blood flow-metabolism coupling, cerebral autoregulation and has no vasodilatation effect. None of the three inhaled agents induce any clinical relevant increase of intracranial pressure (ICP), but studies were conducted in patients without any intracranial hypertension (ICHT). However, compared to propofol, ICP and brain swelling were higher with inhaled agents, more with isoflurane compared to sevoflurane. Finally, neuroprotective properties have been described in experimental model for all the inhaled agents but clinical proofs are still lacking. In conclusion, for intracranial surgery without any ICHT inhaled agents can be used as a maintenance anesthetic with a preference for sevoflurane. In case of ICHT or a risk of ICHT during the surgery, propofol is preferred for it slightest effect on ICP and cerebral hemodynamic.
异氟烷、地氟烷和七氟烷均能维持脑血管对二氧化碳（CO₂）的反应性。它们都是浓度依赖性的脑血管扩张剂，并能降低脑代谢。与异氟烷和地氟烷在1个脑灌注压（CAM）时就会损害脑自动调节功能相比，七氟烷引起的脑血管扩张最小，并且在高达1.5个脑灌注压时仍能维持脑自动调节功能。丙泊酚已与吸入性麻醉剂进行了比较。丙泊酚能维持脑血管对CO₂的反应性、血流-代谢偶联、脑自动调节功能，且无血管扩张作用。这三种吸入性麻醉剂均未引起任何具有临床意义的颅内压（ICP）升高，但相关研究是在没有任何颅内高压（ICHT）的患者中进行的。然而，与丙泊酚相比，吸入性麻醉剂会使ICP和脑肿胀程度更高，异氟烷比七氟烷更明显。最后，在实验模型中已描述了所有吸入性麻醉剂的神经保护特性，但仍缺乏临床证据。总之，对于没有ICHT的颅内手术，吸入性麻醉剂可作为维持麻醉剂使用，首选七氟烷。在手术期间发生ICHT或有ICHT风险的情况下，由于丙泊酚对ICP和脑血流动力学的影响最小，因此更受青睐。
