围术期脑保护的研究进展
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围术期脑保护的研究进展
解轶 2012年3月
• 尽管近年麻醉技术及监测手段不断进步，但是术中与术后神经损伤仍是最 严重的并发症。
• 目前尚无足够的临床证据制订的官方指南，其主要原因是脑缺血机制错综 复杂。
• 对脑缺血高风险患者不仅要避免不利因素的影响，而且要积极采取措施来 保护神经系统功能稳定。
1． 1 选择性脑降温 1． 2 控制血糖 1． 3 控制血压和保证氧供 1. 4 血红蛋白浓度
• This trial was terminated prematurely due to futility. There was no difference in the rate of poor outcome (60% vs. 45% for hypothermia and normothermia, respectively; P=0.67) or death (23% vs. 14%, P=0.52).
2 麻醉药的脑保护
2． 1 吸入麻醉药
• 挥发性液体 • 惰性气体
2． 2 静脉麻醉药
• 巴比妥类药物 • 丙泊酚与氯胺酮 • 右旋美托咪啶 • 利多卡因
• The effect of sevoflurane preconditioning was abolished by the administration of dimethylthiourea and N-acetylcysteine .
• Cell-free hemoglobin-based oxygen carriers, such as polynitroxylated pegylated hemoglobin, offer promise in this setting by increasing oxygen-carrying capacity without excessively increasing blood viscosity.
• 选择性脑降温是指在离头部较近处加强热量散发，使颅内温度低于 躯体温度，可以避免全身低温所带来的不利影响，同时又能有效地 改善缺血缺氧性脑损伤。
• 脑保护机制不仅与降低脑代谢率有关，还涉及抑制缺血缺氧诱发的 “瀑布式反应”的进展，如抑制谷氨酸释放、减少自由基生成、抑 制凋亡、保护血脑屏障等，并且可为其他治疗措施延长治疗时间窗。
Very early hypothermia induction in patients with severe brain injury (the National Acute Brain Injury Study: Hypothermia II): a randomised trial. Lancet Neurol. 2011;10:131–139.
• ROS may also play a key role in remote postconditioning, whereby ischemia is produced in a limb during reperfusion of the brain after an ischemic injury.
• Patients with anemia during the first 5 days of hospitalization were 2.61 (P=0.005) times more likely to have a poor outcome at 3 months.
Cerebral oxygen transport failure?: decreasing hemoglobin and hematocrit levels after ischemic stroke predict poor outcome and mortality: Stroke: RelevAnt Impact of hemoGlobin, Hematocrit and Transfusion (STRAIGHT)–an observational study. Stroke. 2011;42: 2832–2837.
可
使颈动脉内膜剥脱术围术期脑卒中发生Baidu Nhomakorabea增高。但是严格的血糖控制
( 4． 44～ 6． 11 mmol /L) 可能会增加低血糖的风险。
维持基础的平均动脉血压和保证足够的 氧供是最基本的脑保护措施
• Keller reported that anemia on admission and at day 5 was more common in patients with a poor outcome at 3 months.
Polynitroxylated pegylated hemoglobin: a novel neuroprotective hemoglobin for acute volumelimited fluid resuscitation after combined traumatic brain injury and hemorrhagic hypotension in mice. Crit Care Med. 2011; 39:494–505.
Limb remote postconditioning alleviates cerebral reperfusion injury through reactive oxygen species-mediated inhibition of delta protein kinase C in rats. Anesth Analg. 2011;113:1180–1187.
• 大量研究证实，围术期控制血糖有助于改善患者神经功能预后。
•
在一些危重和心脏手术患者中，严格控制围术期的血糖水平可以降低脑缺 血发病率和病死率。
•
围术期持续高血糖可增加缺血性脑损伤的范围，使得临床结局更差。 McGirt 的研究发现，血糖＞ 11． 11 mmol /L ( 无论患者是否患有糖尿病)
解轶 2012年3月
• 尽管近年麻醉技术及监测手段不断进步，但是术中与术后神经损伤仍是最 严重的并发症。
• 目前尚无足够的临床证据制订的官方指南，其主要原因是脑缺血机制错综 复杂。
• 对脑缺血高风险患者不仅要避免不利因素的影响，而且要积极采取措施来 保护神经系统功能稳定。
1． 1 选择性脑降温 1． 2 控制血糖 1． 3 控制血压和保证氧供 1. 4 血红蛋白浓度
• This trial was terminated prematurely due to futility. There was no difference in the rate of poor outcome (60% vs. 45% for hypothermia and normothermia, respectively; P=0.67) or death (23% vs. 14%, P=0.52).
2 麻醉药的脑保护
2． 1 吸入麻醉药
• 挥发性液体 • 惰性气体
2． 2 静脉麻醉药
• 巴比妥类药物 • 丙泊酚与氯胺酮 • 右旋美托咪啶 • 利多卡因
• The effect of sevoflurane preconditioning was abolished by the administration of dimethylthiourea and N-acetylcysteine .
• Cell-free hemoglobin-based oxygen carriers, such as polynitroxylated pegylated hemoglobin, offer promise in this setting by increasing oxygen-carrying capacity without excessively increasing blood viscosity.
• 选择性脑降温是指在离头部较近处加强热量散发，使颅内温度低于 躯体温度，可以避免全身低温所带来的不利影响，同时又能有效地 改善缺血缺氧性脑损伤。
• 脑保护机制不仅与降低脑代谢率有关，还涉及抑制缺血缺氧诱发的 “瀑布式反应”的进展，如抑制谷氨酸释放、减少自由基生成、抑 制凋亡、保护血脑屏障等，并且可为其他治疗措施延长治疗时间窗。
Very early hypothermia induction in patients with severe brain injury (the National Acute Brain Injury Study: Hypothermia II): a randomised trial. Lancet Neurol. 2011;10:131–139.
• ROS may also play a key role in remote postconditioning, whereby ischemia is produced in a limb during reperfusion of the brain after an ischemic injury.
• Patients with anemia during the first 5 days of hospitalization were 2.61 (P=0.005) times more likely to have a poor outcome at 3 months.
Cerebral oxygen transport failure?: decreasing hemoglobin and hematocrit levels after ischemic stroke predict poor outcome and mortality: Stroke: RelevAnt Impact of hemoGlobin, Hematocrit and Transfusion (STRAIGHT)–an observational study. Stroke. 2011;42: 2832–2837.
可
使颈动脉内膜剥脱术围术期脑卒中发生Baidu Nhomakorabea增高。但是严格的血糖控制
( 4． 44～ 6． 11 mmol /L) 可能会增加低血糖的风险。
维持基础的平均动脉血压和保证足够的 氧供是最基本的脑保护措施
• Keller reported that anemia on admission and at day 5 was more common in patients with a poor outcome at 3 months.
Polynitroxylated pegylated hemoglobin: a novel neuroprotective hemoglobin for acute volumelimited fluid resuscitation after combined traumatic brain injury and hemorrhagic hypotension in mice. Crit Care Med. 2011; 39:494–505.
Limb remote postconditioning alleviates cerebral reperfusion injury through reactive oxygen species-mediated inhibition of delta protein kinase C in rats. Anesth Analg. 2011;113:1180–1187.
• 大量研究证实，围术期控制血糖有助于改善患者神经功能预后。
•
在一些危重和心脏手术患者中，严格控制围术期的血糖水平可以降低脑缺 血发病率和病死率。
•
围术期持续高血糖可增加缺血性脑损伤的范围，使得临床结局更差。 McGirt 的研究发现，血糖＞ 11． 11 mmol /L ( 无论患者是否患有糖尿病)