2018 年第 4 期 第 13 卷

室间隔缺损修补手术中脑氧饱和度及脑血流速度和血流动力学变化及其相互关系

Relations among cerebral oxygen saturation, cerebral blood flow velocity and hemodynamics during surgical repair of ventricular septal defect

作者：刘亚光韩丁欧阳川

英文作者：

单位：100029首都医科大学附属安贞医院麻醉中心

英文单位：

关键词：室间隔缺损；脑氧饱和度；脑血流速度；近红外光谱仪；血流动力学

英文关键词：

• 摘要：

• 目的    探讨室间隔缺损修补手术中脑氧饱和度(rScO2)、脑血流速度、血流动力学的变化及其相互关系。方法    纳入2017年5—9月在首都医科大学附属安贞医院行室间隔缺损修补手术患儿18例，年龄（0.59±0.19）岁，体质量（6.4±1.6）kg。术中采用静脉复合麻醉，持续应用舒芬太尼2～4 μg/(kg·h)、咪达唑仑0.2～0.4 mg/(kg·h)、哌库溴铵80～160 μg/(kg·h)。采用Fore-Sight近红外光谱仪监测额部rScO2，经颅多普勒探测颞窗大脑中动脉血流速度，Mostcare(压力记录分析法)监测血流动力学。分别记录切皮前(T1)、切心包时(T2)、停体外循环时(T3)、改良超滤后10 min(T4)、术毕(T5)的rScO2、收缩期峰值脑血流速度(Vs)、舒张期峰值脑血流速度(Vd)、平均脑血流速度(Vm)、脑搏动指数(PI)、脑阻抗指数（RI）、收缩压、舒张压、重脉压、外周血管阻力指数(SVRI)、心率、每搏量指数(SVI)、心指数、动脉压力升支最大斜率(dp/dtmax)、脉压变异度(PPV)、潮气末二氧化碳分压(PETCO2)。结果    T2时Vm、收缩压、SVRI、dp/dtmax明显高于T1时；T3时rScO2、Vd、舒张压、重脉压、SVI、心指数、PETCO2明显低于，PI和RI明显高于T1、T2、T4、T5时；T5时Vs、Vm、SVRI、心率、PPV明显低于T4时，差异均有统计学意义(均P＜0.05)。相关性分析结论如下：T1时，Vs与年龄，Vm与重脉压呈明显正相关（r＝0.485、0.493，均P＜0.05）。T2时，Vs、Vm与年龄，Vs与rScO2呈明显正相关（r＝0.464、0.467、0.550，均P＜0.05）。T3时，Vs、Vm与rScO2呈明显正相关（r＝0.695、0.526，均P＜0.05）。T4时，Vm、Vd与年龄呈明显正相关（r＝0.566、0.577，均P＜0.01）；Vs、Vd、Vm与PPV呈明显负相关（r＝－0.661、－0.488、－0.659，均P＜0.05）。T5时，Vm、Vd与年龄，rScO2与dp/dtmax呈明显正相关（r＝0.453、0.625、0.592、0.489，均P＜0.05）。结论    在室间隔修补手术中，脑血流速度与年龄、血流动力学关系密切。建立体外循环阶段和体外循环结束时脑血流速度对rScO2有明显影响。改良超滤能明显增加脑血流速度，降低脑血管阻力，同时rScO2明显升高。

• Objective    To observe changes of cerebral oxygen saturation(rScO2), cerebral blood flow velocity and hemodynamics during surgical repair of ventricular septal defect. Methods    Eighteen children scheduled for ventricular septal defect repair from May to September 2017 in Beijing Anzhen Hospital, Capital Medical University were enrolled; the mean age was （0.59±0.19）years; the mean weight was （6.4±1.6）kg. After anesthesia induction and intubation, anesthesia was maintained with intravenous sufentanil 2-4 μg/(kg·h), midazolam 0.2-0.4 mg/(kg·h) and pipecuronium 80-160 μg/(kg·h). rScO2 was monitored by Fore-Sight near-infrared spectroscopy; middle cerebral artery blood flow velocity was monitored by transcranial Doppler; hemodynamic measurements were monitored by MostCare(pressure recording analytical method). rScO2, systolic peak cerebral blood flow velocity(Vs), diastolic peak cerebral blood flow velocity(Vd), mean cerebral blood flow velocity(Vm), pulsitility index(PI), resistance index(RI), systolic pressure(SysP), diastolic pressure(DiaP), dicrotic pressure(DicP), systemic vascular resistance index(SVRI), heart rate(HR), stroke volume index(SVI), cardiac index(CI), the maximal slope of systolic upstroke(dp/dtmax), pulse pressure variation(PPV) and end-tidal carbon dioxide partial pressure (PETCO2) were recorded before skin incision(T1), during pericardium incision(T2), after withdrawing from cardiopulmonary bypass(T3), after modified ultrafiltration(T4) and at the end of surgery(T5). Results   Vm, SysP, SVRI and dp/dtmax at T2 were significantly higher than those at T1; rScO2, Vd, DiaP, DicP, SVI, CI, PETCO2 at T3 were significantly lower and PI, RI were significantly higher than those at T1, T2, T4, T5; Vs, Vm, SVRI, HR and PPV at T5 were significantly lower than those at T4(all P＜0.05). At T1: Vs was positively correlated with age, Vm was positively correlated with DicP (r＝0.485, 0.493, both P＜0.05). At T2: Vs and Vm were positively correlated with age. At T3: Vs and Vm were positively correlated with rScO2 (r＝0.695, 0.526, both P＜0.05). At T4: Vm and Vd were positively correlated with age (r＝0.566, 0.577, both P＜0.01); Vs, Vd and Vm were negatively correlated with PPV (r＝-0.661, -0.488, -0.659, all P＜0.05). At T5: Vm and Vd were positively correlated with age, rScO2 was positively correlated with dp/dtmax (r＝0.453, 0.625, 0.489, all P＜0.05). Conclusion    sIn surgical repair of ventricular septal defect in children, cerebral blood flow velocity is closely related to age and hemodynamics. Cerebral blood flow velocity has influence on rScO2 during cardiopulmonary bypass. Ultrafiltration can significantly increase cerebral blood flow velocity, reduce cerebral vascular resistance and increase rScO2.