Ditz Claudia, Baars Henning, Schacht Hannes, Leppert Jan, Smith Emma, Tronnier Volker M, Küchler Jan
Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
World Neurosurg. 2023 May;173:e194-e206. doi: 10.1016/j.wneu.2023.02.032. Epub 2023 Feb 11.
Volatile sedation after aneurysmal subarachnoid hemorrhage (aSAH) promises several advantages, but there are still concerns regarding intracranial hypertension due to vasodilatory effects. We prospectively analyzed cerebral parameters during the switch from intravenous to volatile sedation with isoflurane in patients with poor-grade (World Federation of Neurosurgical Societies grade 4-5) aSAH.
Eleven patients were included in this prospective observational study. Between day 3 and 5 after admission, intravenous sedation was switched to isoflurane using the Sedaconda Anesthetic Conserving Device (Sedana Medical, Danderyd, Sweden). Intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain tissue oxygenation (PBrO), cerebral mean flow velocities (MFVs; transcranial Doppler ultrasound) and regional cerebral oxygen saturation (rSO, near-infrared spectroscopy monitoring), as well as cardiopulmonary parameters were assessed before and after the sedation switch (-12 to +12 hours). Additionally, perfusion computed tomography data during intravenous and volatile sedation were analyzed retrospectively for changes in cerebral blood flow.
There were no significant changes in mean ICP, CPP, and PBrO after the sedation switch to isoflurane. Mean rSO showed a non-significant trend towards higher values, and mean MFV in the middle cerebral arteries increased significantly after the initiation of volatile sedation. Isoflurane sedation resulted in a significantly increased norepinephrine administration. Despite an increase in mean inspiratory pressure, we observed a significant increase in mean partial arterial pressure of carbon dioxide.
Isoflurane sedation does not compromise ICP or cerebral oxygenation in poor-grade aSAH patients, but the significant depression of CPP could limit the use of volatiles in case of hemodynamic instability or high vasopressor demand.
动脉瘤性蛛网膜下腔出血（aSAH）后采用挥发性药物镇静有诸多优势，但仍有人担心其血管舒张作用会导致颅内高压。我们对低级别（世界神经外科协会联盟4 - 5级）aSAH患者从静脉镇静转换为异氟烷挥发性镇静期间的脑参数进行了前瞻性分析。
本前瞻性观察性研究纳入了11例患者。入院后第3天至第5天，使用Sedaconda麻醉节省装置（瑞典丹德吕德市Sedana Medical公司）将静脉镇静转换为异氟烷。在镇静转换前后（-12至+12小时）评估颅内压（ICP）、脑灌注压（CPP）、脑组织氧合（PBrO）、脑平均血流速度（MFVs；经颅多普勒超声）和局部脑氧饱和度（rSO，近红外光谱监测）以及心肺参数。此外，回顾性分析静脉镇静和挥发性镇静期间的灌注计算机断层扫描数据，以观察脑血流量的变化。
转换为异氟烷镇静后，平均ICP、CPP和PBrO无显著变化。平均rSO呈非显著的升高趋势，挥发性镇静开始后大脑中动脉的平均MFV显著增加。异氟烷镇静导致去甲肾上腺素给药量显著增加。尽管平均吸气压力升高，但我们观察到动脉血二氧化碳分压平均值显著升高。
异氟烷镇静不会损害低级别aSAH患者的ICP或脑氧合，但在血流动力学不稳定或血管升压药需求较高的情况下，CPP的显著降低可能会限制挥发性药物的使用。
