Thongrong Cattleya, Kasemsiri Pornthep, Duangthongphon Pichayen, Kitkhuandee Amnat
Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
Khon Kaen Head and Neck Oncology Research, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
Anesthesiol Res Pract. 2020 Apr 1;2020:6539456. doi: 10.1155/2020/6539456. eCollection 2020.
Delayed ischemic neurologic deficit (DNID) is a problem after cerebral aneurysm clipping. Intraoperative hypotension seems to be indicated as a risk factor, but it remains a controversial issue with varying low-blood pressure levels accepted.
A retrospective, hospital-based, case-control study was performed with patients who received general anesthesia for cerebral aneurysm clipping. 42 medical record charts were randomly selected and matched 1 : 2 (1 case with DNID : 2 controls without DNID) based on the type of general anesthetic techniques and severity of subarachnoid hemorrhage. The optimal cutoff points of hemodynamic response were calculated by the area under the curve.
Data suggested that the optimal cutoff points for lowest blood pressure for prevention of DNID should be systolic blood pressure (SBP) of 95 mmHg (sensitivity of 78.6%; specificity of 53.6%), diastolic blood pressure (DBP) of 50 mmHg (sensitivity of 71.4%; specificity of 67.9%), and mean arterial pressure (MAP) of 61.7 mmHg (sensitivity of 85.7%; specificity of 35.7%). Furthermore, the optimal cutoff point mean difference baseline blood pressure was recommended as Δ SBP of 36 mmHg (sensitivity of 85.7%; specificity of 60.7%), Δ DBP of 27 mmHg (sensitivity of 92.9%; specificity of 71.4%), and Δ MAP of 32 mmHg (sensitivity of 92.9%; specificity of 85.7%). No significant difference between DNID and non-DNID groups was found for end-tidal carbon dioxide (ETCO) and has poor diagnostic value for predicting DNID.
To prevent DNID, we recommend that optimal blood pressure should not be lower than 95 for SBP, 50 for DBP, and 61.7 mmHg for MAP. Additionally, we suggest that Δ SBP, Δ DBP, and Δ MAP should be less than 36, 27, and 32 mmHg, respectively.
迟发性缺血性神经功能缺损（DNID）是脑动脉瘤夹闭术后的一个问题。术中低血压似乎被认为是一个危险因素，但对于不同的低血压水平是否可接受，这仍然是一个有争议的问题。
对接受脑动脉瘤夹闭术全身麻醉的患者进行了一项基于医院的回顾性病例对照研究。随机选择42份病历，并根据全身麻醉技术类型和蛛网膜下腔出血的严重程度按1：2进行匹配（1例DNID患者：2例无DNID的对照）。通过曲线下面积计算血流动力学反应的最佳截断点。
数据表明，预防DNID的最低血压最佳截断点应为收缩压（SBP）95mmHg（敏感性78.6%；特异性53.6%），舒张压（DBP）50mmHg（敏感性71.4%；特异性67.9%），平均动脉压（MAP）61.7mmHg（敏感性85.7%；特异性35.7%）。此外，最佳截断点平均差异基线血压建议为收缩压差值（ΔSBP）36mmHg（敏感性85.7%；特异性60.7%），舒张压差值（ΔDBP）27mmHg（敏感性92.9%；特异性71.4%），平均动脉压差值（ΔMAP）32mmHg（敏感性92.9%；特异性85.7%）。呼气末二氧化碳（ETCO）在DNID组和非DNID组之间未发现显著差异，对预测DNID的诊断价值较差。
为预防DNID，我们建议收缩压最佳血压不应低于95mmHg，舒张压不应低于50mmHg，平均动脉压不应低于61.7mmHg。此外，我们建议收缩压差值、舒张压差值和平均动脉压差值应分别小于36mmHg、27mmHg和32mmHg。
