| Purpose:To investigate the effect of epidural anesthesia combined general anesthesia versus general anesthesia on reducing central venous pressure in hepatectomy patients,and to study the effects of Controlled low central venous pressure on cerebral oxygen metabolism and brain energy metabolism,and the effect of thoracic epidural anesthesia on brain microcirculation in normal adult patients was further explored.Method:1.General informationA total of 40 patients who underwent elective hepatectomy in our hospital from January 2019 to December 2019 were selected.The patients were divided into two groups using a random number table before surgery:the epidural combined general anesthesia group(group C)General anesthesia control group(S group),20 cases in each group.Inclusion criteria:(1)aged 18-65 years;(2)body mass index(BMI)18-28;(3)ASA grade ?-?,no contraindications to conventional anesthesia,and good cardiopulmonary function.Exclusion criteria:(1)abnormal liver function before surgery;(2)previous history of acute or chronic cardio-cerebral vascular disease;(3)unwilling participants Anesthesia method2.Anesthesia methodAll patients were routinely monitored for ECG,heart rate,and blood oxygen saturation without inhaling oxygen.ABP,PPV were monitored under radial anesthesia with local anesthesia,and CVP was monitored with retrograde puncture with right internal jugular vein After the epidural puncture(T9-10)was successfully placed in group C,1.5%lidocaine test dose was given,and intravenous anesthesia induction was started when the test anesthesia level was satisfactory;group S was directly intravenously induced.Induction of general anesthesia in both groups was given intravenously with sufentanil 0.4ug/kg,etomidate 0.3 mg/kg,and rocuronium bromide 0.6mg/kg.Group C was administered intravenously with propofol(3-4 mg/kg/h)and remifentanil(0.1-0.3 ug/kg/min)during general anesthesia maintenance;the first time of epidural administration was before the incision 15min,the dosage is 10ml of 0.15%ropivacaine,and 5ml of ropivacaine is added by epidural every 1h during the operation.In group S,anesthesia was maintained by inhalation and Intravenous pump maintenance,such as sevoflurane(1-2MAC),propofol(6-8mg/kg/h),and remifentanil(0.5-0.6ug/kg/min).The depth of anesthesia was monitored in both groups,and the BIS was maintained between 40-60.According to the needs of surgery,intramuscular relaxant cis-atracurium 0.06?0.08mg/Kg can be added during the operation.In group C,PCEA was used for self-controlled analgesia,and in group S,PCIA was used for self-controlled analgesia.During the operation,the infusion was adjusted according to the PPV During the period of low central venous pressure,group C was temporarily added with epidural 0.5%ropivacaine 5ml.In group S,the purpose of low central venous pressure was mainly achieved by limiting the fluid method3.Specimen collection and inspection indicatorsBefore general anesthesia induction(T1),after hepatic hilar occlusion(T2),and before leaving the postanesthesia care unit(T3),radial blood and internal jugular vein blood were collected simultaneously for blood gas analysis at three points.The results should include the patient's oxygen saturation(SaO2/SjvO2),partial oxygen pressure(PaO2/PjvO2),hemoglobin(Hb),lactic acid(Lac),and blood glucose(Glu).Then the arterial blood oxygen content(CaO2),jugular bulb blood oxygen content(CjvO2),arteriovenous blood oxygen content difference(Ca-jvO2),and cerebral oxygen uptake rate(CERO2)were calculated according to the formula,the glucose uptake rate(GluER)),Lacjv-a,Brain Lactate Oxygen Index(LOI),etc were also calculated according to the formula.The mean arterial pressure(MAP),central venous pressure(CVP),heart rate(HR),and EEG double frequency index(BIS)of the patients were recorded simultaneously at three time points;the blood loss during the operation,the infusion volume before and after the block,and Blood transfusions were recorded,on the day after surgery we record the VAS scores and CAM-CR scores by visual analogue scoring and delirium assessment in Chinese versionResult:1.General situation of patients in two groupsThere was no significant difference in age,BMI,bleeding volume,operation time,hilar occlusion time,and total infusion between the two groups(P>0.05).The volume of infusion before blocking was significantly higher in group C than in group S(P<0.05)2.The intraoperative situation of the two groups of patients Intraoperative MAP and CVP groups had significantly lower T2 time points than T1 and T3 time points,and the changes of MAP at three different time points in group C were significantly less than those in group S,with significant differences between groups(P<0.05);There was no significant difference between the CVP groups(P>0.05).The T2 time point in the HR group of group C was lower than the T1 and T3 time points,and the T2 time point in the HR group of group S was higher than the T1 and T3 time points.There was no significant difference in intraoperative BIS values between the two groups(P>0.05).There was no significant difference in the number of patients transfused with suspended red blood cells and plasma during the two groups(P>0.05)3.Measurement parameters of cerebral oxygen metabolism in two groups of patients3.1 Arterial blood oxygen content(CaO2),Jugular bulb blood oxygen content(CjvO2)The time points T2 and T3 of the two groups CaO2 and CjvO2 were significantly lower than those of T1,and the difference was significant(P<0.05).There was no significant difference between the two groups(P>0.05)3.2 Venous blood oxygen saturation(SjvO2)The SjvO2 in the two groups was lower at T2 than at T1 and T3,and at T3 was lower than at T1,with significant differences(P<0.05).There was no significant difference between the two groups(P>0.05)3.3 Arterial and venous blood oxygen content difference(Ca-jvO2),cerebral oxygen uptake rate(CERO2)Compared with the T1 and T3 time points,the Ca-jvO2 significantly increased and the T3 and T1 time points of the two groups significantly decreased.Ca-jvO2 in group C was significantly higher than that in group S at T2,and the difference was statistically significant(P<0.05).The CERO2 in the two groups was significantly higher at T2 than at T1 and T3,and the difference at T3 was significantly higher than that at T1,with statistical significance(P<0.05).The C group was higher than the S group at T2 and lower than the S group at T3.There was a statistically significant difference between the groups(P<0.05).4.Measurement parameters of brain energy metabolism in two groups of patients Glucose uptake rate(GluER),brain lactate difference(Lacjv-a),brain lactate oxygen index(LOI)GluER at T2 was significantly higher than T1 and T3 at two groups,and the difference was statistically significant(P<0.05).GluER was significantly higher in group C than in group S at time T2,and the differences between groups were statistically significant(P<0.05).Lacjv-a in the two groups was significantly higher at T2 than at T1 and T3,and at T3 was significantly higher than at T1.The difference was statistically significant(P<0.05).The LOI of the two groups was higher at T2 than at T1 and T3,and the difference was statistically significant(P<0.05).There was no significant difference between the two groups of Lacjv-a and LOI at each time point(P>0.05).5.There was no significant difference in postoperative VAS score between groups(P>0.05).6.There was no significant difference between the postoperative CAM-CR score groups(P>0.05).Conclusion:Compared with general anesthesia,combined thoracic epidural general anesthesia can achieve the purpose of controlled low central venous pressure(CVP?5cmH2O)without restricting fluid infusion,and can ensure good postoperative analgesia.Combining changes in perioperative cerebral oxygen metabolism,cerebral energy metabolism,and postoperative CAM-CR scores,we believe that cerebral oxygen metabolism and cerebral energy metabolism in normal adult patients will increase during LCVP,although ischemic deficits in the brain tissue occur during CLCVP,but the balance between the oxygen and flow in cereblow during the perioperative period is still within a safe range,and will not cause further damage to nerve cells and brain tissue.Therefore,thoracic epidural combined general anesthesia can effectively reduce CVP during hepatectomy without causing brain dysfunction. |
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