文献精读｜神经外科麻醉进展更新2021--减少神经外科患者不良结局

目 录

神经外科麻醉进展更新

JeffreyJ. Pasternak, MD

摘要：本文综述了2020年发表的与神经外科患者、神经系统疾病患者及神经系统疾病危重患者围手术期护理相关的文献。广泛的主题包括一般围手术期神经科学注意事项，中风，创伤性脑损伤，监测，麻醉神经毒性，和围手术期认知功能障碍。

Abstract: This review summarizes the literature published in 2020 that is relevant to the perioperative care of neurosurgical patients and patients with neurological diseases as well as critically ill patients with neurological diseases. Broad topics include general perioperative neuroscientific considerations, stroke, traumatic brain injury, monitoring, anesthetic neurotoxicity, and perioperative disorders of cognitive function.

关键词：围手术期神经科学、神经麻醉学、中风、创伤性脑损伤、脑监测、脊柱外科、谵妄、术后认知功能障碍、麻醉神经毒性

Key Words: perioperative neuroscience, neuroanesthesiology, stroke, traumatic brain injury, brain monitoring, spine surgery, delirium, postoperative cognitive dysfunction, anesthetic neurotoxicity

围手术期神经科学方面的顾虑

PERIOPERATIVE NEUROSCIENTIFIC

CONSIDERATIONS

减少神经外科患者不良结局

Coronavirus and the Nervous System

脑室外引流(EVDs)用于测量颅内压(ICP)，治疗脑积水，给药，并获得脑脊液(CSF)样本进行分析。对EVDS的处理不当可能导致潜在的危及生命的并发症。对于那些对EVD管理不熟悉或有疑问的人，神经麻醉与重症监护学会（SNACC）为EVD患者的护理制定了指导方针和管理原则。

External ventricular drains (EVDs) are used to measure intracranial pressure (ICP), treat hydrocephalus, administer therapeutic drugs, and obtain cerebrospinal fluid (CSF) samples for analysis. Mismanagement of EVDs can result in

potentially life-threatening complications. For those unfamiliar with, or with questions about, EVD management,SNACC developed guidelines and management principles for the care of patients with an EVD.

为了评估麻醉医师对EVD的熟悉程度，Lele等开展了EVD的认识研究，对北美、欧洲和亚洲27家机构的麻醉医师进行了调查。共有599名受访者(33%应答率)，其中143名是神经专科麻醉医师。

To assess the degree of familiarity with EVDs among anesthesiologists, Lele et al conducted the EVD Aware Study, administering a survey among anesthesiologists at 27 institutions in North America,Europe, and Asia. There were 599 respondents (33% response rate) of whom 143 were neuroanesthesiologists.

虽然调查受访者很少亲自参与运送EVDs患者，但51%的人确实保证EVD在运输过程中被夹住，尽管只有13%的人在运输过程中通过EVD监测ICP。神经专科麻醉医师比非神经麻醉医生更有可能去确定EVD患者术前的脑脊液输出量、脑脊液颜色、ICP趋势和EVD钳试验结果。总的来说，EVD并发症包括脑脊液过度引流、脑脊液渗漏、EVD系统受到污染以及不小心将药物注入EVD系统。

Although survey respondents were rarely personally involved in transporting patients with EVDs, 51% did assure that the EVD was clamped during transport although only 13% monitored ICP via the EVD during transport. Neuroanesthesiologists were more likely than non-neuroanesthesiologists to ascertain CSF output, CSF color, ICP trends, and findings of EVD clamp trials preoperatively in patients with an EVD in place.Collectively, EVD complications included CSF over draining, CSF leakage, contamination of the EVD system, and inadvertent injection of medications into the EVD system.

一天中进行手术的时间可能会潜在地影响结局，因为当手术在晚上进行时，资源可能较少，团队疲劳可能更严重。

The time of day that a surgical procedure is performed can potentially impact outcome as resources may be less available and team fatigue may be greater when procedures are performed at night.

Qadri等回顾性比较了304例18岁及以上患者的急诊神经外科手术后的结局。在这些手术中，199项在上午7时至晚上7时(即日间)开始，105项在晚上7时至晚上7时(即夜间)开始。两组间的人口统计数据相似，尽管动脉瘤夹闭和钻孔血肿清除术在白天更常见，而开颅血肿清除术在夜间更常见。

Qadri et al  retrospectively compared outcome following 304 emergent neurosurgical procedures in patients 18 years old and above stratified by time of day. Of these procedures, 199 started during the hours of 7 AM to 7 PM (ie, daytime) and 105 started between 7 PM to 7 AM (ie, nighttime). Demographics were similar between groups, although aneurysm clipping and burr holes for hematoma evacuation were more common during the day, whereas craniotomy for hematoma evacuation was more commonly performed during the night hours.

两组患者的内科或外科并发症发生率以及出院时不良结局发生率(定义为格拉斯哥预后评分(GOS)为3至5，其中GOS为1为良好结局)均无差异。Logistic回归分析发现，年龄增长、术前格拉斯哥昏迷评分(GCS)较低、手术方式类型、手术病例的敏感度和术中并发症是与不良预后几率增加相关的独立因素，但不是手术时机。

The groups did not differ in rates of medical or surgical complications or rates of poor outcome at discharge (defined as a Glasgow Outcome Score [GOS] of 3 to 5 where a GOS of 1 is a good outcome). Logistic regression identified increasing age, lower preoperative Glasgow Coma Score (GCS), surgical procedure type, surgical case acuity, and intraoperative complications, but not timing of surgery, as independent factors associated with increased odds for poor outcome.

肢端肥大症或库欣病患者的阻塞性睡眠呼吸暂停发生率增加。持续气道正压通气(CPAP)可以减少阻塞性睡眠呼吸暂停患者的气道阻塞，但如果在经蝶窦手术后使用，可能增加颅内积气或颅内感染的风险。

The prevalence of obstructive sleep apnea is increased in those with acromegaly or Cushing disease. Continuous positive airway pressure (CPAP) can decrease airway obstruction in those with obstructive sleep apnea but may increase risk for pneumocephalus or intracranial infection if used following transsphenoidal surgery.

Rieley等回顾性分析了在11年的时间里接受垂体瘤经蝶窦切除术的427例患者。在这个队列中，有64人(15%)患有阻塞性睡眠呼吸暂停。肢端肥大症(而非库欣病)在阻塞性睡眠呼吸暂停患者中更为常见。阻塞性睡眠呼吸暂停患者中，29例(45%)术前使用CPAP。

Rieley et al  retrospectively identified 427 patients who underwent transsphenoidal resection of a pituitary tumor during an 11-year period. In this cohort, 64 (15%) had obstructive sleep apnea. Acromegaly, but not Cushing disease, was more common in those with obstructive sleep apnea. Of those with obstructive sleep apnea, 29 (45%) used CPAP preoperatively.

8例患者需要在麻醉后恢复室内进行CPAP，并继续送往ICU。随后分析未发现有症状性脑积气或脑脊液泄漏的病例。读者应该谨慎解读这些发现，因为这些数据是回顾性获得的，只有8例患者术后采用了CPAP，而且没有正式的前后颅内气体容量评估。

Eight patients required CPAP to be instituted while in the postanesthesia recovery room and continued into the ICU. No cases of symptomatic pneumocephalus or CSF leak were subsequently identified. The reader should interpret these findings with caution as data were retrospectively obtained, only 8 patients had CPAP employed postoperatively, and there was no formal before-and-after assessment of intracranial air volume.