文献精读｜神经外科麻醉进展更新2021--新冠肺炎与神经系统

推荐语

JeffreyJ博士每年4月份都会在J Neurosurg Anesthesiol 更新去年一年神经外科麻醉的相关进展。

2021年神经外科麻醉进展隆重推出，本栏目将分期来解析这篇文章。

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

新冠肺炎与神经系统

Coronavirus and the Nervous System

严重急性呼吸系统综合征相关冠状病毒2号是一种单链阳性核糖核酸病毒，从中国武汉开始发现，导致2019冠状病毒病大流行。全球医疗系统受到本次大流行的根本影响，不仅与受感染患者的直接护理有关，而且还因非2019冠状病毒感染的医疗需求而改变了医疗护理、流程和患者获得救助的途径。麻醉和危重症神经科学学会(SNACC)针对COVID-19大流行期间神经外科患者和需要电休克治疗(ECT)患者的护理提出了具体建议。

Severe acute respiratory syndrome associated coronavirus 2  is a single strand positive-sense ribonucleic acid virus that emerged from Wuhan, China and has resulted in the coronavirus disease 2019 (COVID-19) pandemic. Global medical systems have been radically impacted by this pandemic, not only related to the direct care of infected patients, but also by changing the care, processes, and access to care by patients for non–COVID-19 related medical needs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) developed recommendations that are specific to the care of neurosurgical patients and those requiring electroconvulsive therapy (ECT) during the

COVID-19 pandemic. 

这些建议强调一般考虑，包括案例优先级，使用和保存个人防护用品，呼吸道管理和病人运送。他们还提供对具体程序的建议。对于那些有经鼻手术步骤时，由于手术过程中鼻腔分泌物雾化的风险很高。所有人员应穿戴齐全手术过程中的个人防护装备。

These recommendations address general considerations, including case prioritization, use and conservation of personal protective equipment, airway management, and patient transport. They also provide recommendations for specific procedures. For those having transnasal procedures, all personnel should be wearing full personal protective equipment throughout the surgical procedure due to the high risk for aerosolization of nasal  secretions during surgery.

除非患者COVID-19检测呈阳性，优化患者预后仍考虑清醒开颅手术。建议中讨论了对于选择清醒开颅手术患者，在手术过程中尽量减少或避免不必要的气道操作。对于急性感染COVID-19的患者，建议在考虑ECT前进行其他抑郁症治疗，避免使用ECT治疗。在ECT治疗期间，房内人员应最少，口罩通风、咳嗽和分泌物的产生应尽量减少。这些建议的作者还提供了在大流行期间支持卫生保健工作者健康的建议。

Awake craniotomy should still be considered if it may optimize patient outcome, unless the patient has tested positive for COVID-19. The recommendations discuss specific options for awake craniotomy management in the context of minimizing or avoiding unnecessary airway manipulations during the procedure. For those who may be a candidate for ECT, optimization of other treatments for depression before considering ECT and avoiding this treatment in those acutely infected with COVID-19 is recommended. During ECT treatments, personnel in the room should be the minimum required, and mask ventilation, coughing, and generation of secretions should be minimized. The authors of the recommendations also provide suggestions to support health care worker-wellness during the pandemic.

Although respiratory symptoms generally predominate,COVID-19 can also result in systemic aberrations that can affect multiple organ systems, including the nervous system. Mao et al characterized neurological manifestations among 214 patients who were hospitalized with COVID-19 in Wu-han, China. Among these patients, 41% had severe respiratory manifestations of COVID-19  and 36% developed neurological manifestations that included dizziness (17%), headache (13%), impaired consciousness (8%), acute cere-brovascular disease (3%), seizures (<1%), impairment of taste (6%) or smell (5%), nerve pain (2%), and evidence of skeletal muscle injury (11%). Skeletal muscle injury was diagnosed in those complaining of muscle pain and who also

had elevated serum creatine kinase. Nervous system mani-

festations were more common among those with severe (46%) versus nonsevere (30%) COVID-19 respiratory manifestations (P=0.02).

Matschke et al report on neuropathologic findings from 43 patients who died after COVID-19 infection.Median age of this cohort was 76 years old (interquartile range [IQR] 70 to 86y). Acute territorial ischemic lesions were identified in 6 (14%) patients and astrogliosis was identified in all brain regions assessed in 37 (86%) patients.Microglial activation and infiltration by T lymphocytes was most prominent in the brainstem and cerebellum. T-lymphocyte infiltration was also commonly noted in meninges, frontal cortex, and basal ganglia. COVID-19 virus could be detected in 53% of brains, especially in the brainstem and cranial nerves. The authors conclude that direct injury to the brain by COVID-19 virus is possible, but adverse effects may be more likely mediated by the immune response in the brain generated in response to the virus.

Radmanesh et al report on brain imaging findings

among 242 patients within 2 weeks of testing positive for 

COVID-19. The 3 most common indications for brain

imaging (either computerized tomography [CT] or magnetic resonance imaging [MRI]) were altered mental status(42%), syncope (33%), and new focal neurological deficits(12%). The most common abnormal findings were non-specific white matter angiopathy (55%), chronic infarcts(19%), new infarcts (5%), and acute hemorrhage (5%). No patient imaged for altered mental status had evidence of new ischemic or hemorrhagic stroke. Yoon et al report on CT or MRI brain imaging findings from 150 patients with COVID-19 infection. Among this cohort, 26 (17%) had abnormal imaging findings, most commonly hemorrhage (11/26, 42%), infarction (13/26, 50%), and leukoence-phalopathy (7/26, 27%).

In addition to gross neurological signs and symptoms, disorders of cognitive function have also been reported to be associated with COVID-19 infection. Helms et al reported delirium in 118 of 140 (84%) patients with COVID-19 admitted to the intensive care unit (ICU). In those with delirium, 87% exhibited hyperactive delirium

and 9% inappropriately self-extubated. Zhou et al performed neurocognitive testing on 29 patients who had recovered from COVID-19 (as demonstrated by 2 negative polymerase chain reaction tests) and compared their performance to matched persons who were never infected by COVID-19. Compared with those without prior infection,patients with prior COVID-19 infection had lower scores in tests of selective attention and impulse; greater impairment correlated with increased serum C-reactive protein concentrations. Unfortunately, the authors did not report the time interval between infection and cognitive assessment in those with prior COVID-19 infection, or assess if the severity of COVID-19 manifestations impacted cognitive performance.

Multiple review articles in 2020 addressed neurological manifestations of COVID-19. Two thorough reviews were published by Zubair et al and Nepal et al  and address not only stroke, but other neurological disorders in those with COVID-19 infection, including encephalitis, transverse myelitis, Guillan-Barre Syndrome,Bell palsy, and skeletal muscle manifestations.

打赏