Fábregas N, Valero R, Carrero E, González M, Soley R, Nalda M A
Servicio de Anestesiología y Reanimación, Hospital Clínic i Provincial, Barcelona.
Rev Esp Anestesiol Reanim. 1995 May;42(5):163-8.
To compare the hemodynamic stability and time to recovery of consciousness after long-duration (> 3 h) neurosurgery with 2 anesthetic protocols: total intravenous anesthesia with propofol as the single hypnotic agent and inhalational anesthesia with isoflurane.
We studied 58 middle-aged patients (range 40-50 years) scheduled for intracranial surgery. The patients, who all scored over 13 on the Glasgow coma scale before surgery, were randomly divided into two groups: 27 in group I received isoflurane and 31 in group II received propofol. Anesthetic induction was with sodium thiopental 4 mg/kg i.v. in group I and with propofol 2.5 mg/kg i.v. in group II. Both groups then received fentanyl 2 micrograms/kg i.v., lidocaine 1.5 mg/kg i.v. and vecuronium 0.2 mg/kg i.v. Before placement of the Mayfield head grip, with clamps, or before start of surgery in those cases in which the head grip was not used, all patients were given a 3 micrograms/kg i.v. dose of fentanyl. Hypnosis was maintained in group I with concentrations of isoflurane that were adequate for keeping minimum alveolar concentration (MAC) between 0.6 and 1. In group II maintenance was by continuous i.v. perfusion of propofol 10 mg/kg/h for 30 min., followed by 8 mg/kg/h for 30 min. and 6 mg/kg/h until the end of surgery. N2O was never used.
After induction systolic and mean arterial pressures (SAP and MAP) decreased significantly in both groups in comparison with baseline values (SAP: 113.1 +/- 30.0 vs. 140.9 +/- 27.08 mmHg in group I and 109.6 +/- 22.1 vs. 135.0 +/- 19.7 mmHg in group II; MAP: 76.8 +/- 18.7 vs. 95.6 +/- 17.0 mmHg in group I and 74.9 +/- 13.2 vs. 93.4 +/- 13.7 mmHg in group II). The patients in group II showed less tendency to develop arterial hypertension in response to orotracheal intubation (SAP and MAP at the moment of intubation: 156.4 +/- 33.7 and 104.6 +/- 18.1 mmHg, respectively, in group I as compared to 135.1 +/- 31.2 and 93.5 +/- 22.4 mmHg in group II; p < 0.05 between the 2 groups and p < 0.05 for the baseline and intubation pressures in group I). Time to recovery of effective, spontaneous breathing was shorter in group I (5.9 +/- 4.9 and 8.9 +/- 5.7 min.) than in group II (10.9 +/- 9.6 and 13.0 +/- 7.4 min.) and tubes could be extracted earlier from patients in the isoflurane group (10.4 +/- 6.1 min. vs. 17.6 +/- 12.8 min.; p < 0.01). We found no differences between the 2 groups for time until eye opening, response to verbal orders or time until start of spontaneous movement.
Propofol can be considered an alternative to the traditional thiopental-isoflurane sequence in neurosurgery lasting more than 3 h. In our study the hypertensive response to the stimulus of orotracheal intubation was lower in the propofol group than in the thiopental-isoflurane group.
比较两种麻醉方案用于时长超过3小时的神经外科手术时的血流动力学稳定性及意识恢复时间，这两种方案分别是：以丙泊酚作为单一催眠剂的全静脉麻醉和异氟烷吸入麻醉。
我们研究了58例计划接受颅内手术的中年患者（年龄范围40 - 50岁）。这些患者术前格拉斯哥昏迷量表评分均超过13分，被随机分为两组：第一组27例接受异氟烷麻醉，第二组31例接受丙泊酚麻醉。第一组静脉注射硫喷妥钠4mg/kg进行麻醉诱导，第二组静脉注射丙泊酚2.5mg/kg进行麻醉诱导。两组随后均静脉注射芬太尼2μg/kg、利多卡因1.5mg/kg和维库溴铵0.2mg/kg。在放置梅菲尔德头架（用夹子固定）之前，或在未使用头架的病例中手术开始前，所有患者均静脉注射3μg/kg剂量的芬太尼。第一组通过维持异氟烷浓度使最低肺泡浓度（MAC）保持在0.6至1之间来维持麻醉。第二组通过持续静脉输注丙泊酚维持麻醉，开始30分钟以10mg/kg/h的速度输注，随后30分钟以8mg/kg/h的速度输注，直至手术结束前一直以6mg/kg/h的速度输注。从未使用氧化亚氮。
诱导后两组的收缩压和平均动脉压（SAP和MAP）与基线值相比均显著降低（第一组：SAP：113.1±30.0 vs. 140.9±27.08mmHg，MAP：76.8±18.7 vs. 95.6±17.0mmHg；第二组：SAP：109.6±22.1 vs. 135.0±19.7mmHg，MAP：74.9±13.2 vs. 93.4±13.7mmHg）。第二组患者在经口气管插管时发生动脉高血压的倾向较小（插管时第一组的SAP和MAP分别为156.4±33.7和104.6±18.1mmHg，第二组分别为135.1±31.2和93.5±22.4mmHg；两组间p<0.05，第一组基线与插管时压力比较p<0.05）。第一组有效自主呼吸恢复时间（5.9±4.9和8.9±5.7分钟）短于第二组（10.9±9.6和13.0±7.4分钟），异氟烷组患者气管导管拔除时间更早（10.4±6.1分钟对1).6±12.8分钟；p<0.01）。我们发现两组在睁眼时间、对言语指令的反应或自主运动开始时间方面没有差异。
在持续超过3小时的神经外科手术中，丙泊酚可被视为传统硫喷妥钠 - 异氟烷麻醉方案的替代方案。在我们的研究中，丙泊酚组对经口气管插管刺激的高血压反应低于硫喷妥钠 - 异氟烷组。
