Department of Anesthesiology and Critical Care, Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of Paris, Paris, France.
UMR-S 942 "MASCOT", Inserm, Paris, France.
Acta Anaesthesiol Scand. 2020 May;64(5):592-601. doi: 10.1111/aas.13537. Epub 2020 Jan 19.
During anesthesia, decreases in mean arterial pressure (MAP) are common but the impact on possible cerebral hypoperfusion remains a matter of debate. We evaluated cerebral perfusion in patients with or without cardiovascular comorbidities (Hi-risk vs Lo-risk) during induction of general anesthesia and during hypotensive episodes.
Patients scheduled for neuroradiology procedure using standardized target-controlled Propofol-Remifentanil infusion were prospectively included. Monitoring included Transcranial Doppler (TCD) measuring mean blood velocity of the middle cerebral artery (Vm), Bispectral Index with burst suppression ratio (SR) and cerebral Near-Infrared Spectroscopy (NIRS). Hypotensive episodes were treated with a 10 µg bolus of Norepinephrine.
Eighty-one patients were included, 37 Hi-risk and 44 Lo-risk. During induction of anesthesia, MAP and Vm decreased in all patients, with greater changes observed in Hi-risk patients compared to Lo-risk patients (-34 [38-29]% vs -17 [25-8]%, P < .001 and -39 [45-29]% vs -28 [34-19]%, P < .01 respectively). In Hi-risk patients, the MAP-decrease correlated with the Vm-decrease (r = .48, P < .01), and was associated with more frequent occurrences of SR (21 vs 5 patients, P < .01 for Hi-risk vs Lo-risk). For the MAP-increase induced by norepinephrine, the Vm-increase was greater in Hi-risk than in Lo-risk patients (+15 [8-21]% vs +4 [1-11]%, P < .01). During induction and norepinephrine boluses, NIRS values did not follow acute changes of Vm.
Our results showed that Hi-risk patients had a higher decrease in MAP and Vm, and a higher occurrence of SR during induction of anesthesia than Lo-risk patients. Correction of MAP with norepinephrine increased Vm mainly in Hi-rik patients.
在麻醉过程中，平均动脉压（MAP）下降很常见，但这是否会导致脑灌注不足仍存在争议。我们评估了有心血管合并症（高风险 vs 低风险）和无心血管合并症的患者在全身麻醉诱导期间和低血压发作期间的脑灌注情况。
前瞻性纳入计划行神经放射学检查的患者，采用标准化靶控输注丙泊酚-瑞芬太尼。监测包括经颅多普勒（TCD）测量大脑中动脉平均血流速度（Vm）、脑电双频指数（BIS）伴爆发抑制比（SR）和近红外光谱（NIRS）。低血压发作时给予去甲肾上腺素 10μg 推注。
共纳入 81 例患者，其中 37 例为高风险患者，44 例为低风险患者。在麻醉诱导期间，所有患者的 MAP 和 Vm 均下降，高风险患者的变化较明显（MAP 分别下降-34%[38%-29%]和-17%[25%-8%]，P<.001；Vm 分别下降-39%[45%-29%]和-28%[34%-19%]，P<.01）。在高风险患者中，MAP 下降与 Vm 下降相关（r=0.48，P<.01），且与更频繁出现 SR 相关（21 例 vs 5 例，高风险 vs 低风险，P<.01）。对于去甲肾上腺素引起的 MAP 升高，高风险患者的 Vm 升高更明显（+15%[8%-21%] vs +4%[1%-11%]，P<.01）。在诱导和去甲肾上腺素推注期间，NIRS 值没有跟随 Vm 的急性变化。
我们的结果表明，与低风险患者相比，高风险患者在麻醉诱导期间 MAP 和 Vm 下降更明显，SR 发生率更高。去甲肾上腺素纠正 MAP 主要增加了高风险患者的 Vm。
