腦血管疾病頸動(dòng)脈內(nèi)膜切除術(shù)的麻醉管理雙語

1、Anesthetic Management of Cerebrovascular Disease Carotid Endarterectomy,Daniel J.Cole,M.D.Phoenix, Arizona 翻譯：福建醫(yī)科大學(xué)附屬協(xié)和醫(yī)院麻醉科規(guī)培住院醫(yī)師：曾燕,腦血管疾病頸動(dòng)脈內(nèi)膜切除術(shù)的麻醉管理,Introduction,Stroke （中風(fēng)）is the third leading cause of death.

2、 carotid artery disease（勁動(dòng)脈疾?。?is a significant anesthetic issue （麻醉問題）for patients over 50 years of age. A stroke occurs due to occlusive or hemorrhagic conditions. Occlusive cerebrovascular disease ca

3、n be thrombotic, embolic, or stenotic(血栓，栓塞或狹窄)in origin.(閉塞性或出血性中風(fēng)的發(fā)生是由于閉塞性腦血管疾病，血栓，栓塞或起源于狹窄) Patients with a history of prior stroke （既往中風(fēng)史）or transient ischemic attack（短暫性腦缺血發(fā)作） have an increased risk o

4、f recurrent perioperative stroke （圍術(shù)期再次中風(fēng)的危險(xiǎn)）.,簡介,Major symptoms of carotid artery disease include changes in vision, headache, changes in speech, or facial(發(fā)熱) and extremity(四肢) weakness. Signs(體征) suggestive of caroti

5、d artery disease include a high-pitched bruit (高亢的雜音)at the origin(起源) of the internal carotid artery, increase in size and pulsation（強(qiáng)度） of the ipsilateral (同側(cè))superficial temporal artery（顳淺動(dòng)脈）, and changes in the retin

6、al examination（眼底檢查）. Confirmation（確診） of carotid artery disease is achieved by vascular imaging which may include ultrasound, MR angiography, or catheter angiography.（頸動(dòng)脈疾病的確認(rèn)是通過血管成像，其中可能包括超聲，磁共振血管造影或?qū)Ч茉煊埃?Introduction,

7、Presently, there is insufficient （不足的）information to regarding the timing of surgery （手術(shù)時(shí)機(jī)） following an ischemic episode（缺血性發(fā)作）. Data（數(shù)據(jù)） suggests there is a small but real increase in morbidity（發(fā)病

8、率） if surgery is performed shortly after the onset of symptoms（癥狀）.（數(shù)據(jù)表明，如果進(jìn)行手術(shù)后不久出現(xiàn)癥狀，有一個(gè)小，但真正的發(fā)病率增加） Risk may be associated with the presence（存在） of a low density（低密度） lesion （病變）on CT scan,

9、vascular territory（血管壁內(nèi)） of the infarct（梗塞）, brain shift（腦組織移位）, and level of consciousness（意識(shí)）.,,,Carotid Artery Revascularization（頸動(dòng)脈再灌注）,Carotid endarterectomy (CEA) （頸動(dòng)脈內(nèi)膜切除術(shù)）was introduced in 1954 as treatment for

10、 occlusive（閉塞性） carotid artery disease. Efficacy（療效） data on CEA was limited until the 1990s. Analysis of three trials has demonstrated that CEA has a marginal（微?。?benefit in symptomatic patients with 50%-69% stenosis

11、 of the carotid artery, and was of greatest benefit in patients with >70% stenosis.（三項(xiàng)試驗(yàn)分析表明，CEA在狹窄面積為50％-69％的頸動(dòng)脈狹窄癥狀的患者身上收效甚微，在狹窄> 70％的患者收益最大。）,Carotid Artery Revascularization（頸動(dòng)脈再灌注）,Stenting(支架植入術(shù)) and angiopla

12、sty（血管成形術(shù)） of the carotid artery (CAS) has been performed for almost two decades. Potential （潛在） advantages of CAS include avoiding cranial nerve（顱神經(jīng)） damage, wound hematoma（傷口血腫）, and general anesthesia（全身麻醉）.

13、 The anesthetic technique for this procedure involves（ 涉及）minimal sedation(鎮(zhèn)靜）. This procedure can cause severe （嚴(yán)重）bradycardia（心動(dòng)過緩） and hypotension, and can result in cerebral hyperperfusion（高灌注）.,Anatomic/Physiol

14、ogic（解剖/生理學(xué)） Considerations（注意事項(xiàng)）,Carotid artery disease is typically（通常是） the result of ather-osclerosis（動(dòng)脈粥樣硬化）at the bifurcation（分支） of the common carotid artery（頸總動(dòng)脈）or the origin（主支） of the internal carot

15、id artery（頸內(nèi)動(dòng)脈）. （頸動(dòng)脈疾病通常是頸內(nèi)動(dòng)脈主支和頸總動(dòng)脈分支粥樣硬化的結(jié)果） Ischemia is most often embolic in origin but may also have a hemodynamic basis.（ 缺血最常見的起源于栓塞，但可能也有血液動(dòng)力學(xué)基礎(chǔ)） There are three phases（階段） of the response of vario

16、us cerebral variables（腦變量） to progressive（進(jìn)展的） carotid artery disease.（頸動(dòng)脈疾病的進(jìn)展在腦變量的反應(yīng)上分三階段） During ischemia（缺血）, collateral flow（側(cè)支循環(huán)） is a cornerstone（基礎(chǔ)） of cerebral blood flow (CBF) compensation（補(bǔ)償）.,Anatomic/

17、Physiologic（解剖/生理學(xué)） Considerations,The principal pathways of collateral flow are the Circle of Willis（側(cè)支循環(huán)的主要途徑是Willis環(huán)）, extracranial anastomotic channels（顱外吻合通道）, and leptomeningeal （腦膜）communications that bridge “wate

18、rshed”（分水嶺） areas between major arteries. During CEA, the risk of ischemia is related to the dependency of the circulation on the ipsilateral（同側(cè)） internal carotid（頸內(nèi)） artery, and the cerebrovascular（腦血管） reserve（儲(chǔ)備） of t

19、he contralateral（對(duì)側(cè)） hemisphere（半球）.,Preoperative Concerns（術(shù)前關(guān)注點(diǎn)）,CEA has an inherent（固有） risk of perioperative（圍手術(shù)期） stroke and cardiovascular（心血管） events.（CEA存在著圍術(shù)期中風(fēng)和心血管事件的固有風(fēng)險(xiǎn)） In symptomatic patients, there is a

20、 6.5% rate of stroke and death associated with CEA; while the reported stroke and death rate for patients with asymptomatic disease is 2.3%. The risk for stroke following CEA is most strongly associated with an active n

21、eurologic（神經(jīng)） process（活動(dòng)） prior to surgical intervention（手術(shù)干預(yù)）.,Other factors which have been reported to increase neurological risk include:（其他有報(bào)道的增加神經(jīng)系統(tǒng)風(fēng)險(xiǎn)的因素包括）,? hemispheric versus retinal transient ischemic attack（

22、半球與視網(wǎng)膜短暫性腦缺血發(fā)作）? an urgent procedure（緊急手術(shù)）? a left sided procedure（左側(cè)手術(shù)）? ipsilateral ischemic lesion on computerized tomography（電腦斷層掃描同側(cè)缺血性病變）? contralateral carotid occlusion or poor collaterals（對(duì)側(cè)的頸動(dòng)脈閉塞或者側(cè)支循環(huán)差）?

23、impaired consciousness（意識(shí)障礙）? an irregular or ulcerated ipsilateral plaque（不規(guī)則或者破潰的同側(cè)斑塊）,,Medical complications occur about 10% of the time after CEA and are associated with the following:（CEA后并發(fā)癥的發(fā)生還與下列有關(guān)）,? Hypertens

24、ion (HTN) （高血壓?。?the incidence（發(fā)病率） of a neurologic deficit（神經(jīng)功能缺損） is greater in patients with uncontrolled（ 未控制的）HTN preoperatively （術(shù)前）and postoperative HTN（術(shù)后高血壓）.（術(shù)前未控制的高血壓和術(shù)后高血壓的神經(jīng)功能缺損的發(fā)病率更高）? Cardiac（心臟?。?a ca

25、rdiac assessment（心臟評(píng)估） is indicated in patients who present for CEA.? Diabetes（糖尿病）： data indicate（表明） that CEA can be performed safely in patients with diabetes（糖尿病人可以安全的進(jìn)行CEA）? Renal insufficiency（腎功能不全）： patients

26、 with renal insufficiency have an overall（整體）increased（增加） risk for stroke, death, and cardiac morbidity（發(fā)病率）, associated with CEA,Monitoring （監(jiān)控）,Basic Monitoring ：this should include basic ASA monitoring and i

27、ntra-arterial blood pressure monitoring. （基本監(jiān)控應(yīng)包括基礎(chǔ)麻醉的監(jiān)測和動(dòng)脈內(nèi)血壓監(jiān)測）CNS Monitoring：no special cerebral monitor is required in awake patients with regional anesthesia.special cerebral monitor（腦監(jiān)測） is employed（用于） when gen

28、eral anesthesia（全麻）.,Monitoring （監(jiān)控）,Electrophysiological（電生理） Monitoring: The 16-channel EEG（腦電圖） remains a sensitive indicator（指標(biāo)） of inadequate（不足） cerebral perfusion（腦灌注）. Ipsilateral（單） or bilateral（雙） atten

29、uation（降低） of high frequency amplitude（高頻壓力） or development（增長） of low frequency activity seen during carotid cross-clamping is indicative of inadequate cerebral perfusion.Intraoperative neurologic complications have bee

30、n shown to correlate well with EEG changes indicative of ischemia. （同側(cè)或雙側(cè)高頻衰減幅度或開發(fā)低頻活動(dòng)期間看到頸動(dòng)脈交叉夾緊是反映腦灌注不足，術(shù)中已顯示出良好的相關(guān)性腦電圖改變，預(yù)示缺血的神經(jīng)系統(tǒng)并發(fā)癥）,,Most studies suggest that SSEPs are useful for monitoring cerebral perfusion

31、 during cross-clamping and have similar or superior sensitivity and specificity to conventional EEG.(SSEPs在監(jiān)測夾閉動(dòng)脈的腦灌注上有類似或優(yōu)于常規(guī)腦電圖的敏感性和特異性） Stable anesthesia must be maintained to minimize the influence of anestheti

32、cs on the SSEP amplitude. In general, >50% reduction of amplitude of the cortical component is considered to be a significant indicator of inadequate cerebral perfusion. In contrast to conventional EEG, SSEP monitors

33、the cortex as well as the subcortical pathways in the internal capsule, an area not reflected in the cortical EEG.（必須維持麻醉平穩(wěn)麻醉藥對(duì)體感誘發(fā)電位的振幅的影響減到最小。在一般情況下，減少>50％的振幅皮質(zhì)成分被認(rèn)為是腦灌注不足一個(gè)重要的指標(biāo)。與常規(guī)腦電圖相反，體感誘發(fā)電位監(jiān)測皮層和皮層下通路， 而沒有反映在皮層腦

34、電圖,Monitoring （監(jiān)控）,Measurement of Stump（殘端）Pressure: Since one important determinant of CBF is perfusion pressure, it seems reasonable to assume that the distal（遠(yuǎn)端） arterial pressure in the ipsilateral（同側(cè)） hemisphe

35、re（半球） during carotid occlusion（頸動(dòng)脈閉塞） would provide some indication（跡象） of collateral（側(cè)枝的） CBF. Stump pressure involves direct measurement of the retrograde internal carotid artery pressure following occlusion of the mo

36、re proximal common and external carotid arteries.（由于CBF的一個(gè)重要的決定因素是灌注壓，這似乎是合理的假設(shè)，在同側(cè)半球在頸動(dòng)脈閉塞遠(yuǎn)端動(dòng)脈壓會(huì)提供一些補(bǔ)償，CBF樹樁壓力涉及直接測量閉塞的逆行頸內(nèi)動(dòng)脈的近端壓力和頸外動(dòng)脈壓力）Transcranial Doppler （經(jīng)顱多普勒超聲）(TCD): TCD has been utilized（利用） as a monitoring（

37、監(jiān)控） tool by measuring blood flow velocity（速度） in the middle cerebral artery（中腦動(dòng)脈） during CEA. （TCD被用來作為監(jiān)測工具，通過測量CEA過程中大腦中動(dòng)脈血流速度）,,Anesthetic Management,General anesthesia is preferred in patients with anatomy/

38、pathology that may make the surgical conditions difficult.（全麻是那些在解剖/病理學(xué)上有手術(shù)困難的患者的首選）One caveat that is often not appreciated regards nitrous oxide. It is very difficult to place a shunt in the carotid artery, or to re

39、lease the carotid artery cross-clamp, without exposing the distal cerebral circulation to air bubbles.（需要注意的一點(diǎn)是氧化亞氮是不被推薦的。放置頸動(dòng)脈分流器或釋放頸動(dòng)脈交叉鉗時(shí)不暴露前端而使氣泡進(jìn)入到腦循環(huán)，這是非常困難的）,Anesthetic Management,Sevoflurane and desflurane have b

40、een shown to result in quicker extubation times and recovery profiles after CEA, compared to isoflurane, with no significant perioperative difference in cardiac morbidity.（與異氟烷相比，七氟烷和地氟烷被證明CEA術(shù)后更快的拔管時(shí)間、更好的蘇醒質(zhì)量，

41、而無圍術(shù)期心臟事件發(fā)生率的不同。） Propofol and narcotics may be associated with better hemodynamic stability than isoflurane, and remifentanil/propofol may have less evidence of myocardial ischemia than isoflurane/fentanyl.（與異氟烷相比，丙泊

42、酚和阿片類可能有更好的血流動(dòng)力學(xué)穩(wěn)定性，瑞芬太尼/丙泊酚與異氟烷/芬太尼相比可能更少的心肌缺血發(fā)生）,Anesthetic Management,A regional technique for CEA requires anesthesia of cervical nerves 2-4. （CEA的區(qū)域麻醉需要麻醉頸神經(jīng)2-4） Superficial cervical plexus block, deep cervical plex

43、us block, epidural anesthesia, straight local, and combinations of these techniques have all been used successfully.（頸淺神經(jīng)叢阻滯、頸深神經(jīng)叢阻滯、硬膜外麻醉、單純局麻或以上技術(shù)的結(jié)合都被成功的使用過）Until recently, non-randomized studies suggested that th

44、e use of a regional technique may be associated with reductions (approximately 50%) in the odds of stroke, death, myocardial infarction and pulmonary complications.（直到最近，非隨機(jī)研究提示區(qū)域性技術(shù)可能與術(shù)后中風(fēng)、死亡、心肌梗死、肺部并發(fā)癥的減少（近50%）相關(guān)。）,,

45、Modalities of Cerebral Protection腦保護(hù)的方式,Surgical（外科）： a shunt is placed to maintain CBF during cross-clamping（分流在頸動(dòng)脈夾閉時(shí)用于維持腦血流）. Most often, placement of the shunt is dependent on the data of a cerebral monitor.（

46、大多數(shù)情況下，是否放置分流取決于腦功能監(jiān)測的數(shù)據(jù)） A shunt entails the risks of embolization and carotid intimal dissection， and limits surgical exposure. （分流意味著栓塞和頸動(dòng)脈內(nèi)膜剝脫的風(fēng)險(xiǎn)，并限制了外科暴露） There is insufficient evidence from randomized controlled t

47、rials to support or refute the use of routine or selective shunting during CEA.（沒有足夠隨機(jī)對(duì)照實(shí)驗(yàn)證據(jù)支持或拒絕在CEA中常規(guī)或選擇性分流）,Physiologic:（生理）1. Hypothermia（低溫）-much has been studied about the beneficial（有益） effect of mild h

48、ypothermia（低溫） on cerebral ischemia（腦缺血）. Accordingly, is the concern that if hypothermia is employed as a cerebral protectant for CEA, many patients may suffer from shivering during recovery; and a consequent increase i

49、n myocardial oxygen consumption which may precipitate myocardial ischemia. Thus, routine employment of hypothermia is not recommended for patients undergoing CEA. Conversely, hyperthermia should be avoided.（很多研究已經(jīng)表明低溫對(duì)腦缺

50、血的有利，但是，如果采用低溫作為CEA術(shù)中的腦保護(hù)劑，許多患者可出現(xiàn)在恢復(fù)過程中寒戰(zhàn)發(fā)抖以及心肌耗氧量的增加可能誘發(fā)心肌缺血，因此，不建議常規(guī)對(duì)接受CEA的患者進(jìn)行低溫麻醉，相反，應(yīng)避免高溫）,2. Hyperglycemia（高血糖）-should be avoided（避免） and treated（處理） when possible.3. Hypertension（高血壓）-during ischemia, autoregul

51、ation（自動(dòng)調(diào)節(jié)） is impaired and CBF is dependent on perfusion pressure（灌注壓）. It is advisable to maintain normal to high arterial pressure in most situations.（缺血過程中，自動(dòng)調(diào)節(jié)受損，腦血流是依賴于灌注壓力以維持正常的動(dòng)脈血壓，在大多數(shù)情況下，這是可取的）4. Hemodilution（

52、血液稀釋）-using hemodilution to improve CBF is dependent upon the rationale（原理） that CBF is inversely related to（負(fù)相關(guān)的） hematocrit（血細(xì)胞比容）.（使用血液稀釋改善CBF是根據(jù)CBF負(fù)相關(guān)于血細(xì)胞比容的原理）5. Carbon Dioxide（二氧化碳）-normocarbia（正常二氧化碳分壓） shoul

53、d be the goal.（必須維持正常的二氧化碳分壓）,Modalities of Cerebral Protection,Anesthetics:（麻醉藥）1. Barbiturates（巴比妥類藥物）-as a whole, the evidence does not support the use of barbiturates as a cerebral protectant for permanent focal

54、ischemia. (總的來說，證據(jù)不支持使用巴比妥類藥物作為永久性局灶性腦缺血腦保護(hù)劑)2. Volatile Anesthetics（揮發(fā)性麻醉藥）-general anesthesia with isoflurane and sevoflurane is associated with a lower critical CBF (that at which EEG evidence of ischemia was presen

55、t) compared to halothane and enflurane（與氟烷、安氟醚相比，全身麻醉中使用異氟醚和七氟醚更少出現(xiàn)危險(xiǎn)的腦血流（腦電圖證實(shí)的腦缺血）3. Etomidate（依托咪酯）-etomidate is not recommended for use as a cerebral protectant.（依托咪酯，不建議用做腦保護(hù)劑）4. Propofol（異丙酚）-the amassed data

56、base is not as large as that for barbiturates （數(shù)據(jù)有限）5. Dexmedetomidine（右美托咪啶）-it should be pointed out that in human volunteers dexmedetomidine decreases CBF but does not increase the incidence of shunt placement dur

57、ing awake CEA（應(yīng)該指出的是，在人類志愿者，右旋美托咪啶降低腦血流，但是在清醒麻醉下的CEA中不增加分流率）,The Postoperative Period（術(shù)后）,Concernsin the immediate postoperative period include:（術(shù)后即刻應(yīng)關(guān)注的是：）1. HTN（高血壓）-HTN may worsen neurologic outcome by exacerbatin

58、g the hyperperfusion syndrome with resultant intracerebral hemorrhage（高血壓可能加劇高灌注綜合征，導(dǎo)致腦出血，使預(yù)后惡化）2. Hyperperfusion （高灌注）–Normotension should be maintained in patients at risk for hyperperfusion.（有高灌注危險(xiǎn)的患者應(yīng)保持患者正常灌注）3. Hy

59、potension（低血壓）-Regional anesthesia may be associated with a higher incidence of postoperative hypotension while general anesthesia is more often associated with postoperative hypertension（區(qū)域麻醉可能伴隨術(shù)后高發(fā)生率的低血壓，而全麻往往與術(shù)后高血壓

60、相關(guān)）4. Myocardial Infarction（心梗）-the most frequent cause of morbidity and mortality（心梗是發(fā)病率和死亡率的最常見的原因，）5. Stroke（中風(fēng)）-most often embolic in origin.（中風(fēng)常源于栓塞）,,6. Bleeding- airway obstruction has been attributed to neck h

61、ematoma that is worsened by hypertension.（氣道阻塞已被歸因于高血壓惡化導(dǎo)致的頸部血腫） 7. Cranial Nerve Injury -Damage to the recurrent laryngeal nerve may compromise protective reflexes as well as cause airway obstruction. Bilateralinjurie

62、s can result in upper airway obstruction.（喉返神經(jīng)的損傷除了可能引起氣道梗阻，還可能損害保護(hù)性反射。雙側(cè)損傷可能會(huì)導(dǎo)致上呼吸道阻塞。）8. Carotid Body Damage results in reduced ventilatory response to hypoxemia and hypercapnia. Patients undergoing second-side CE

63、A merit close observation.（頸動(dòng)脈體損傷導(dǎo)致對(duì)低氧血癥和高碳酸血癥的通氣反應(yīng)降低，患者接受第二側(cè)CEA應(yīng)密切觀察。）9. CNS Dysfunction（中樞神經(jīng)系統(tǒng)功能障礙）,Conclusions,Approximately one third of perioperative strokes are hemodynamic in nature. （圍術(shù)期中風(fēng)大約有三分之一源于血流動(dòng)力學(xué)的變化）

64、It is reasonable that tight physiologic management might affect this subset of patients. （嚴(yán)格的生理管理可能影響這一部分患者，這是合理的）Patients who have undergone CEA have increased risk of a perioperative myocardial event. （接受過CEA的患者圍術(shù)期心肌

65、事件的風(fēng)險(xiǎn)增加）There is no demonstrable advantage of a specific anesthetic technique for patients undergoing CEA.（沒有一種特別的麻醉技術(shù)對(duì)CEA患者有明顯的優(yōu)勢） Whichever anesthetic technique is employed, it is imperative that CBF is optimized ther

66、e is minimal cardiac stress, and that anesthetic recovery is rapid. （無論采用哪種麻醉技術(shù)，都要求合適的腦血流和更小的心臟負(fù)荷以及更快的蘇醒）Additional concerns in the immediate postoperative period are tight hemodynamic control.（在術(shù)后即刻期間應(yīng)特別關(guān)注嚴(yán)格的血流動(dòng)力學(xué)控制）,T

67、able 2-key points of anesthetic management of CEA.（CEA麻醉管理的關(guān)鍵點(diǎn)）,Indications （適應(yīng)癥）? In symptomatic patients, CEA is indicated if stenosis is >70 percent; and for selected patients if the stenosis is 50-69 percent. In

68、asymptomatic patients, the indications are controversial. （在有癥狀的患者中，狹窄>70％的患者是手術(shù)的適應(yīng)癥，狹窄在50-69％可有選擇的進(jìn)行手術(shù)。無癥狀患者的手術(shù)適應(yīng)癥是有爭議的）,Preoperative Concerns（術(shù)前關(guān)注點(diǎn)）：Hypertension（高血壓） coronary artery disease（冠狀動(dòng)脈疾?。?diabetes mell