Zabolotskikh Igor, Trembach Nikita
Kuban State Medical University, Sedin st.,4, Krasnodar, 350063, Russian Federation.
BMC Anesthesiol. 2015 May 15;15:76. doi: 10.1186/s12871-015-0056-2.
The increased intracranial pressure can significantly complicate the perioperative period in major abdominal surgery, increasing the risk of complications, the length of recovery from the surgery, worsening the outcome. Epidural anesthesia has become a routine component of abdominal surgery, but its use in patients with increased intracranial pressure remains controversial. The goal of the study was to evaluate the safety and efficacy of epidural anesthesia, according to monitoring of intracranial pressure in patients with increased intracranial pressure.
The study includes 65 surgical patients who were routinely undergone the major abdominal surgery under combined epidural/general anesthesia. Depending on the initial ICP all patients were divided into 2 groups: 1 (N group) - patients with the normal intracranial pressure (≤12 mm Hg, n = 35) and 2 (E group) - patients with the elevated intracranial pressure (ICP > 12 mm Hg, n = 30). During the surgery we evaluated ICP, blood pressure, cerebral perfusion pressure (CPP). The parameters of recovery from anesthesia and the effectiveness of postoperative analgesia were also assessed.
In N group ICP remained stable. In E group ICP decreased during anesthesia, the overall decline was 40% at the end of the operation (from 15 to 9 mm Hg (P <0.05)). The correction of MAP with vasopressors to maintain normal CPP was required mainly in patients with increased ICP (70% vs. 45%, p <0.05). CPP declined by 19% in N group. In E group the CPP reduction was 23%, and then it remained stable at 60 mm Hg. No significant differences in time of the recovery of consciousness, effectiveness of postoperative analgesia and complications between patients with initially normal levels of ICP and patients with ICH were noted.
The combination of general and epidural anesthesia is safe and effective in patients with increased intracranial pressure undergoing elective abdominal surgery under the condition of maintaining the arterial pressure. Its use is not associated with the increase in intracranial pressure during the anesthesia, but it needs an intraoperative monitoring of ICP in order to prevent CPP reduction.
颅内压升高会使大型腹部手术的围手术期显著复杂化，增加并发症风险、延长手术恢复时间并恶化手术结果。硬膜外麻醉已成为腹部手术的常规组成部分，但其在颅内压升高患者中的应用仍存在争议。本研究的目的是根据对颅内压升高患者颅内压的监测来评估硬膜外麻醉的安全性和有效性。
本研究纳入65例接受硬膜外/全身联合麻醉下常规大型腹部手术的患者。根据初始颅内压，所有患者分为两组：1组（N组）——颅内压正常（≤12 mmHg，n = 35）的患者和2组（E组）——颅内压升高（颅内压>12 mmHg，n = 30）的患者。手术期间，我们评估了颅内压、血压、脑灌注压（CPP）。还评估了麻醉恢复参数和术后镇痛效果。
N组颅内压保持稳定。E组在麻醉期间颅内压下降，手术结束时总体下降40%（从15 mmHg降至9 mmHg（P<0.05））。主要在颅内压升高的患者中需要使用血管升压药纠正平均动脉压以维持正常脑灌注压（70%对45%，p<0.05）。N组脑灌注压下降19%。E组脑灌注压下降23%，然后在60 mmHg保持稳定。在初始颅内压水平正常的患者和颅内出血患者之间，在意识恢复时间、术后镇痛效果和并发症方面未发现显著差异。
在维持动脉压的情况下，全身麻醉与硬膜外麻醉联合应用于颅内压升高并接受择期腹部手术的患者是安全有效的。其使用与麻醉期间颅内压升高无关，但需要术中监测颅内压以防止脑灌注压降低。
