机械通气对室间隔缺损患儿脑氧合和脑血流速度的影响
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摘要
目的探讨麻醉诱导期间机械通气变化对室间隔缺损(ventricular septal defect, VSD)修补术患儿区域脑组织氧饱和度(regional cerebral oxygen saturation, rScO_2)和大脑中动脉血流速度(cerebral blood flow velocity, CBFV)的影响。方法选择VSD修补术患儿67例,男34例,女33例,年龄<1岁,体重3.4～11.0 kg,ASAⅡ或Ⅲ级。入室麻醉诱导后气管插管,调整通气参数使P_(ET)CO_2初始值为30 mmHg(T_(30))。持续使用Fore-Sight实时监测右侧额部rScO_2,TCD间断测量CBFV_(收缩期)、CBFV_(舒张期)、CBFV_(平均值)。通过调整通气参数使P_(ET)CO_2逐渐上升至35 mmHg(T_(35))、40 mmHg(T_(40))、45 mmHg(T_(45)),记录对应的CBFV值以及rScO_2,计算每分钟通气量(MV)和T_(30)—T_(35)、T_(35)—T_(40)、T_(40)—T_(45)三个时段的脑血管CO_2反应性(CO_2R)。结果 T_(30)—T_(45)时rScO_2、CBFV_(收缩期)、CBFV_(舒张期)、CBFV_(平均值)均明显增大(P<0.01),PI、RI均明显减小(P<0.01)。T_(35)—T_(40)时CO_2R在最高值。结论室间隔缺损患儿在麻醉诱导阶段,机械通气对脑氧合和大脑中动脉脑血流速度有明显影响,正常低通气能明显增加脑氧合和脑血流速度。
Objective To monitor the regional cerebral oxygen saturation(rScO_2) and middle cerebral artery blood flow velocity(CBFV) by using near infrared spectroscopy(NIRS), and analyze the effect of mechanical ventilation on rScO_2 and CBFV in infants who undergoing ventricular septal defect(VSD) repair during anesthesia induction. Methods Sixty-seven patients undergoing VSD repair, 34 males and 33 females, aged < 1 years, weighing 3.4-11.0 kg, falling into ASA physical status Ⅱ or Ⅲ, were enrolled. After admission, anesthesia induction and intubation. By means of adjusting tidal volume(V_T, ml/kg) and respiratory rate(RR), P_(ET)CO_(2 ) was maintained at initial value of 30 mmHg(T_(30)). The right side of rScO_2 was monitored by real-time Fore-Sight, CBFV was measured intermittently by TCD(including systolic, diastolic phasemean and mean CBFV, pulsation index, resistance index). By adjusting V_T and RR, P_(ET)CO_2 was gradually increased to 35 mmHg(T_(35)), 40 mmHg(T_(40)), and 45 mmHg(T_(45)). rScO2, CBFV were recorded and ventilation(MV, ml/min/kg) was calculated at T_(30), T_(35), T_(40) and T_(45). The CO_2 reactivity(CO_2R) of T_(30)-T_(35), T_(35)-T_(40) and T_(40)-T_(45) was calculated. Results The rScO_2, CBFV_(systolic), CBFV_(diastole) and CBFV_(mean) increased significantly(P < 0.01), PI and RI were significantly decreased(P < 0.01) at T_(30)-T_(45). The CO_2R at T_(35)-T_(40) was at the highest value. Conclusion Mechanical ventilation has obvious influence on rScO_2 and CBFV in infants who underwent VSD repair during induction of anesthesia. Normal hypoventilation can significantly increase cerebral oxygenation and cerebral blood flow velocity.
Objective To monitor the regional cerebral oxygen saturation(rScO_2) and middle cerebral artery blood flow velocity(CBFV) by using near infrared spectroscopy(NIRS), and analyze the effect of mechanical ventilation on rScO_2 and CBFV in infants who undergoing ventricular septal defect(VSD) repair during anesthesia induction. Methods Sixty-seven patients undergoing VSD repair, 34 males and 33 females, aged < 1 years, weighing 3.4-11.0 kg, falling into ASA physical status Ⅱ or Ⅲ, were enrolled. After admission, anesthesia induction and intubation. By means of adjusting tidal volume(V_T, ml/kg) and respiratory rate(RR), P_(ET)CO_(2 ) was maintained at initial value of 30 mmHg(T_(30)). The right side of rScO_2 was monitored by real-time Fore-Sight, CBFV was measured intermittently by TCD(including systolic, diastolic phasemean and mean CBFV, pulsation index, resistance index). By adjusting V_T and RR, P_(ET)CO_2 was gradually increased to 35 mmHg(T_(35)), 40 mmHg(T_(40)), and 45 mmHg(T_(45)). rScO2, CBFV were recorded and ventilation(MV, ml/min/kg) was calculated at T_(30), T_(35), T_(40) and T_(45). The CO_2 reactivity(CO_2R) of T_(30)-T_(35), T_(35)-T_(40) and T_(40)-T_(45) was calculated. Results The rScO_2, CBFV_(systolic), CBFV_(diastole) and CBFV_(mean) increased significantly(P < 0.01), PI and RI were significantly decreased(P < 0.01) at T_(30)-T_(45). The CO_2R at T_(35)-T_(40) was at the highest value. Conclusion Mechanical ventilation has obvious influence on rScO_2 and CBFV in infants who underwent VSD repair during induction of anesthesia. Normal hypoventilation can significantly increase cerebral oxygenation and cerebral blood flow velocity.
引文
[1] 李稼.体外循环术对先天性心脏病患儿手术前后神经系统发育障碍的影响.中华实用儿科临床杂志,2014,9(18):1368-1371.
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[8] 王俊芳,王得新,高凤玲,等.经颅多普勒血管搏动指数与脑血管反应性的关系.临床神经病学杂志,2008,21(1):12-14.
[9] Quarti A,Nardone S,Manfrini F,et al.Effect of the adjunct of carbon dioxide during cardiopulmonary bypass on cerebral oxygenation.Perfusion,2013,28(2):152-155.
[10] Van Beek AH,Lagro J,Olde-Rikkert MG,et al.Oscillations in cerebral blood flow and cortical oxygenation in Alzheimer's disease.Neurobiol Aging,2012,33(2):428.e21-31.
[11] Lindahl SG,Yates AP,Hatch DJ.Relationship between invasive and noninvasive measurements of gas exchange in anesthetized infants and children.Anesthesiology,1987,66(2):168-175.
[12] 刘晨,罗毅,欧阳川,等.室间隔缺损修补术患儿不同呼气末二氧化碳状态脑氧饱和度与血流动力学的关系.中华实用儿科临床杂志,2018,33(7):519-522.
[13] Ricci Z,Garisto C,Favia I,et al.Cerebral NIRS as a marker of superior vena cava oxygen saturation in neonates with congenital heart disease.Paediatr Anaesth,2010,20(11):1040 -1045.
[14] Redlin M,Koster A,Huebler M,et al.Regional differences in tissue oxygenation during cardiopulmonary bypass for correction of congenital heart diseasein neonates and small infants:relevance of near-infrared spectroscopy.J Thorac Cardiovasc Surg,2008,136(4):962-967.
[2] Ferry PC.Neurologic sequelae of open-heart surgery in children.An 'irritating question.Am J Dis Child,1990,144:369-373.
[3] Sanchez-De-Toledo J,Chrysostomou C,Munoz R,et al.Cerebral regional oxygen saturation and serum neuromarkers for the prediction of adverse neurologic outcome in pediatric cardiac surgery.Neurocrit Care,2014,21(1):133-139.
[4] 张淑静,朱德明,王伟.经颅多普勒在小儿体外循环中应用初探.中国体外循环杂志,2009,7(3):132-134.
[5] Cheng HH,Wypij D,Laussen PC,et al.Cerebral blood flow velocity and neurodevelopm outcome in infants undergoing surgery for congenital heart disease.Ann Thorac Surg,2014,98:125-132.
[6] Kampf S,Schramm P,Klein KU.Transcranial doppler and near infrared spectroscopy in the perioperative period.Current Opinion Anesthesiology,2013,26:543-548.
[7] Abu-Sultaneh S,Hehir DA,Murkowski K,et al.Changes in cerebral oxygen saturation correlate with S100B in infants undergoing cardiac surgery with cardiopulmonary bypass.Pediatr Crit Care Med,2014,15(3):219-228.
[8] 王俊芳,王得新,高凤玲,等.经颅多普勒血管搏动指数与脑血管反应性的关系.临床神经病学杂志,2008,21(1):12-14.
[9] Quarti A,Nardone S,Manfrini F,et al.Effect of the adjunct of carbon dioxide during cardiopulmonary bypass on cerebral oxygenation.Perfusion,2013,28(2):152-155.
[10] Van Beek AH,Lagro J,Olde-Rikkert MG,et al.Oscillations in cerebral blood flow and cortical oxygenation in Alzheimer's disease.Neurobiol Aging,2012,33(2):428.e21-31.
[11] Lindahl SG,Yates AP,Hatch DJ.Relationship between invasive and noninvasive measurements of gas exchange in anesthetized infants and children.Anesthesiology,1987,66(2):168-175.
[12] 刘晨,罗毅,欧阳川,等.室间隔缺损修补术患儿不同呼气末二氧化碳状态脑氧饱和度与血流动力学的关系.中华实用儿科临床杂志,2018,33(7):519-522.
[13] Ricci Z,Garisto C,Favia I,et al.Cerebral NIRS as a marker of superior vena cava oxygen saturation in neonates with congenital heart disease.Paediatr Anaesth,2010,20(11):1040 -1045.
[14] Redlin M,Koster A,Huebler M,et al.Regional differences in tissue oxygenation during cardiopulmonary bypass for correction of congenital heart diseasein neonates and small infants:relevance of near-infrared spectroscopy.J Thorac Cardiovasc Surg,2008,136(4):962-967.