经颅多普勒超声在主动脉弓手术中脑灌注监测应用的探讨

摘要

目的:应用经颅多普勒超声(transcranial Doppler,TCD)监测主动脉弓手术中脑血流变化,探讨其在主动脉弓手术中监测脑灌注流量的可行性,并为改进脑灌注方法提供临床依据.方法:40例行主动脉弓部手术患者随机分为TCD组(术中TCD监测组,20例)及对照组(非TCD监测组,20例),TCD组术中全程监测患者双侧大脑中动脉(middle cerebra artery,MCA)脑血流动力学的变化并指导脑灌注,分别记录麻醉诱导后(T1)、心脏停跳10min(T2)、顺行性选择性脑灌注(antegrade selective cerebral perfusion,ASCP)3min(T3)、恢复全身循环3min(T4)、停CPB后10min(T5)5个时点Vm,检测两组患者麻醉诱导后(T1)、复跳后20min(T6)、停CPB后30min(T7)、2h(T8)、6h(T9)、12h(T10)共6个时间点血浆S-100β蛋白浓度,比较两组患者术后清醒、拔除气管插管、ICU停留时间及术后并发症、院内病死率.结果:TCD组ASCP流量及S-100β蛋白浓度在T6、T7、T8明显低于对照组,两组有显著差异.两组患者术后清醒、拔除气管插管、ICU停留时间及术后并发症、院内病死率均无明显差异.结论:主动脉弓手术中可应用TCD实时监测脑血流并指导CPB期间的脑灌注流量,对降低主动脉弓外科手术后中枢神经系统并发症的发生有重要的意义.%Objective: Using transcranial Doppler (TCD) monitor cerebral blood flow during aortic arch procedure with antegrade selective cerebral perfusion (ASCP). Methods : Forty patients who underwent surgical reconstruction of aortic arch with ASCP through the right axillary artery were randomly divided into the TCD group of (TCD monitoring group, 20 cases) and control group (non-TCD monitoring group, 20 cases). In the TCD group, we monitored mean blood flow velocities of bilateral middle cerebral arteries using TCD, recorded at five different time periods; after induction of anesthesia(T1) , 10min after aortic-cross clamping( T2) ,3min after ASCP(T3) , 3min after resume systemic circulation (T4) and 10min after termination of cardiopulmonary bypass(T5). Detected two groups of plasma S-100β protein concentration; after induction of anesthesia(T1) , 20min after the release of aortic clamping(T6) ,30min(T7) ,2h(T8) ,6h(T9) , 12h(T10) after termination of cardiopulmonary bypass. Time of postoperative awake, extubation, ICU stay and postoperative complications, in-hospital mortality had been compared between two groups. Results; ASCP perfusion flow and S-100β protein concentration of TCD group in T6, T7, T8 were obviously lower than the control group (P < 0.05). Time of postoperative awake,extubation, ICU stay and postoperative complications, in-hospital mortality did not show significant difference in both groups. Conclusion :TCD can monitor cerebral blood flow in real-time. The perfusion method can be improved using TCD monitoring during aortic arch procedure.