Ostapkovich N D, Baker K Z, Fogarty-Mack P, Sisti M B, Young W L
Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
Anesthesiology. 1998 Aug;89(2):358-63. doi: 10.1097/00000542-199808000-00011.
Remifentanil, a rapidly metabolized mu-opioid agonist, may offer advantages for neurosurgical procedures in which prolonged anesthetic effects can delay assessment of the patient. This study compared the effects of remifentanilnitrous oxide on cerebral blood flow (CBF) and carbon dioxide reactivity with those of fentanyl-nitrous oxide anesthesia during craniotomy.
After institutional approval and informed patient consent were obtained, 23 patients scheduled to undergo supratentorial tumor surgery were randomly assigned to remifentanil or fentanyl infusion groups in a double-blinded manner. Midazolam, thiopental, and pancuronium induction was followed by equipotent narcotic loading infusions of remifentanil (1 microg x kg(-1) x min(-1)) or fentanyl (2 microg x kg(-1) x min(-1)) for 5-10 min. Patients were ventilated with 2:1 nitrous oxideoxygen, and opioid rates were reduced and then titrated to a stable hemodynamic effect. After dural exposure, CBF was measured by the intravenous 133xenon technique at normocapnia and hypocapnia. Reactivity of CBF to carbon dioxide was calculated as the absolute increase in CBF per millimeters of mercury increase in the partial pressure of carbon dioxide (PaCO2). Data were analyzed by repeated-measures analysis of variance, unpaired Student's t-tests, or contingency analysis.
In the remifentanil group (n = 10), CBF decreased from 36+/-11 to 27+/-8 ml x 100 g(-1) x min(-1) as PaCO2 decreased from 33+/-5 to 25+/-2 mmHg. In the fentanyl group (n = 8), CBF decreased from 37+/-11 to 25+/-6 ml x 100 g(-1) x min(-1) as PaCO2 decreased from 34+/-3 to 25+/-3 mmHg. Absolute carbon dioxide reactivity was preserved with both agents: 1+/-1.2 ml x 100 g(-1) x min(-1) x mmHg(-1) for remifentanil and 1.5+/-0.5 ml x 100 g(-1) x min(-1) x mmHg(-1) for fentanyl (P = 0.318).
Remifentanil and fentanyl have similar effects on absolute CBF, and cerebrovascular carbon dioxide reactivity is maintained.
瑞芬太尼是一种代谢迅速的μ阿片受体激动剂，对于可能因长时间麻醉效应而延迟患者评估的神经外科手术或许具有优势。本研究比较了瑞芬太尼 - 氧化亚氮与芬太尼 - 氧化亚氮麻醉在开颅手术期间对脑血流量（CBF）和二氧化碳反应性的影响。
在获得机构批准和患者知情同意后，23例计划接受幕上肿瘤手术的患者以双盲方式随机分配至瑞芬太尼或芬太尼输注组。咪达唑仑、硫喷妥钠和泮库溴铵诱导后，分别给予等效的瑞芬太尼（1微克·千克⁻¹·分钟⁻¹）或芬太尼（2微克·千克⁻¹·分钟⁻¹）负荷输注5 - 10分钟。患者采用2:1氧化亚氮 - 氧气通气，阿片类药物输注速率降低后滴定至稳定的血流动力学效应。硬脑膜暴露后，通过静脉注射¹³³氙技术在正常碳酸血症和低碳酸血症状态下测量CBF。CBF对二氧化碳的反应性计算为二氧化碳分压（PaCO₂）每升高1毫米汞柱时CBF的绝对增加量。数据采用重复测量方差分析、非配对t检验或列联分析进行分析。
在瑞芬太尼组（n = 10）中，随着PaCO₂从33±5毫米汞柱降至25±2毫米汞柱，CBF从36±11降至27±8毫升·100克⁻¹·分钟⁻¹。在芬太尼组（n = 8）中，随着PaCO₂从34±3毫米汞柱降至25±3毫米汞柱，CBF从37±11降至25±6毫升·100克⁻¹·分钟⁻¹。两种药物均保持了绝对二氧化碳反应性：瑞芬太尼为1±1.2毫升·100克⁻¹·分钟⁻¹·毫米汞柱⁻¹，芬太尼为1.5±0.5毫升·100克⁻¹·分钟⁻¹·毫米汞柱⁻¹（P = 0.318）。
瑞芬太尼和芬太尼对绝对CBF的影响相似，且脑血管二氧化碳反应性得以维持。
