Influence Of Hypertonic Saline,Mannitol And Albumin On Cerebral Perfusion And Cerebral Hemodynamics In Patients Of Intracranial Hypertension

BackgroundThere are mang small short procedurals in ICU.Most of these procedurals are invasive,inducing pain commonly.Usually we underestimate the physical and mental pressure that induced by the procedural associated pains.But the physical and mental pressure can cause harmful effect on the prognosis of our patient.Until now,local infiltration anesthesia is still the major way to control procedural associated pains.We find that our patients still feel pain during the procedurals despite prophylactic local infiltration anesthesia.Some researches tell us that the analgesic effect of intravenous anesthesia together with local infiltration anesthesia is better to control the pains during small short procedurals than local infiltration anesthesia alone.Remifentanil is a potent,ultra-short-acting?-receptor agonist with a context-sensitive half-time of 3-6min,which makes it a proming opoid for ICU patients.But there is little research on the effect of remifentanil during small short procedurals in ICU in our country.Objectives1.We aimed to observe the analgesic effect of remifentanil together with lidocaine during small short procedurals in ICU;2.We aimed to realize the side effects of remifentanil during small short procedurals in ICU.Methods1.67multipal injured ICU patients were included in this research and randomly divided into lidocaine?L?group and remifentanil+lidocaine?RL?group.L group patients were treated with intravenous bolus of normal saline 0.025-0.05ml/kg in 1min,then 0.25ml/kg·h continuously,followed by lidocaine 0.1g for local infiltration anesthesia.RL group patients were treated with intravenous bolus of remifentanil 0.5¹.0?g/kg in 1min,then 5? g/kg/h continuously,followed by lidocaine 0.1g for local infiltration anesthesia.Heart rate?HR?,blood pressure?BP?,respiratory rate?RR?,Critical care Pain Observation Tool?CPOT?and Visual Analogue Scale?VAS?were continuly monitored before treatment and at the time of the whole procedure.Record the potential side effect of remifentanil like respiratory depression,tachycardia,bradycardia,hypotension,myotonia,nauseaand vomiting.Compare the statistical difference of these observed indicator.2.99 patients who were going to do percutaneous dilational tracheostomy were included in this research and randomly divided into lidocaine?L?group and remifentanil+lidocaine?RL?group.One patient in each group was switched to the surgical way of tracheostomy because of uncontrolled bleeding.L group patients were treated with intravenous bolus of propofol 1.5 mg/kg in 1 minute,then 1.8mg/kg/h continuously,followed by intravenous bolus of normal saline 0.035ml/kg in 1min,then 0.3ml/kg/h continuously,followed by lidocaine 0.1g for local infiltration anesthesia.RL group patients were treated with the same doses of propofol,followed by intravenous bolus of remifentanil 0.7?g/kg in 1min,then 6?g/kg/h continuously,followed by lidocaine 0.1g for local infiltration anesthesia.Heart rate?HR?,blood pressure?BP?,respiratory rate?RR?,Critical care Pain Observation Tool?CPOT?and Visual Analogue Scale?VAS?were continuly monitored before treatment and at the time of the whole procedure.Record the potential side effect of remifentanil like respiratory depression,tachycardia,bradycardia,hypotension,myotonia,nausea and vomiting.Compare the statistical difference of these observed indicator.Results1.For patients undergoing central venous catheter,HR changes in group L and group RL had no statistical differences.RR had no statistical differences in the two groups before the procedure?P=0.672?,but there were obvious statistical differences from the stage of after anesthesia to the stage of fixation,there were no statistical differences after the procedure.There was an obvious descending of SpO₂ after the anesthesia in group RL,which had statistical differences comparing with group L?P<0.05?.SpO₂ changes in group L and group RL had no statistical differences during the whole procedure.There was a fluctuant of SBP in group L before and after the procedure,the SBP increased obviously during the stage of dilatation,there was statistical differences comparing with the baseline?<0.05?.There was a decline of SBP after analgesia in group RL,and had statistical differences comparing with the baseline?<0.05?.SBP changes in group L and group RL had no statistical differences.DBP changes in group L and group RL had no statistical differences.There were significant differences about CPOT during the whole procedure.CPOT in group RL was lower than in group L during the procedure.CPOT tended to become the same in the two group 30min after the procedure.CPOT changes in group L and group RL had statistical differences from stage“after analgesia”to stage“10min after the procedure”?P<0.05?.There were significant differences about VAS during the whole procedure?P<0.05?.VAS in group RL was lower than in group L during the procedure.VAS tended to become the same in the two group 30min after the procedure.Patients in group L didn't show any side effects like fever,hypotension,apnea,rash,pruritus,myotonia,etc.Two patients in group RL showed respiratory depression during bolus remifentanil,claimed chest distress.SpO₂ was persisted>92%by increasing the rate of oxygen flow.During the decrease use of remifentanil,the RR increased,and the procedural was finished smoothly.Three patients showed hypotension during bolus remifentanil.The BP increased by increasing the fluid speed.The BP showed steadily during persistent stage of remifentanil.Two patients showed myotonia during the bolus stage of remifentanil.Introvenous ingection of pipecurium 0.06mg/kg could stop the myotonia in 1minute?There were no nausea or vomiting happened in group RL.2.For patients undergoing percutaneous dilation tracheostomy,there were no statistical differences in HR,MAP and CPOT during the whole procedure;There were statistical differences about time to wakeness and the dosage of propofol between the two groups.Time to wakeness in group RL?7.68±3.12min?was significantly shorter than in group L?10.26±2.47min??P=0.021*?.The dosage of propofol in group RL?90±15mg?was significantly smaller than group L?120 ±27mg??P=0.017*?.The rate of hypertension was higher in group L than in group RL?P=0.026?.The rate of myotonia in group RL was 4.1%comparing 0%in group L.There were no statistical differences about hypotension,tachycardia,bradycardia,bleeding,nausea and vomiting between the two groups.VAS in group RL was significantly lower than in group L during the whole procedure.Conclusions1.Remifentanil together with lidocaine can make a better analgesic effect during the central venous catheter procedure.Remifentanil can increase the rike of respiratory depression and hypotension.2.Based on the use of propofol,remifenntanil together with lidocaine can make the time to wakeness significantly shorter and the tolerance of pain increasing during the percutaneous dilation tracheostomy procedure.Vigilant the increasing risk of myotonia during bolus stage of remifentanil.