在選擇性鐮幕上腦腫瘤切除手術中使用Isoflurane之麻醉方法：比較有無合併Fentonyl持續輸注之術後恢復情形

Comparison of the Recovery from Isoflurane Anesthesia with or without Fentanyl Infusion in Patients Undergoing Elective Supratentorial Craniotomy

背景：在進行鐮幕上腦腫瘤切除手術之麻醉中，已知有許多藥物可成功地使用在麻醉維持上。為避免在開刀房之早期恢復較容易造成術後顱內出血，本院外科醫師希望採用病患晚期恢復的作法。根據此種情形設計本次實驗，將病患分成兩組──isoflurane合併或不合併fentanyl持續輸注，並比較兩組開顱手術之病患其術後血液動力學變化及神經學評估(GCS score)、拔管時間，以及病患預後之情形。方法：42名病人隨機分為兩組，一組以isoflurane為主來維持麻醉深度，另一組合併以持續fentanyl輸注來進行。當傷口縫合後，所有麻醉藥物均停止給予。根據病患術後血液動力學變化及術後48小時內其各階段意識恢復的情形，比較兩組之間有無明顯的差別。結果：使用isoflurane之一組病患和使用fentanyl之一組相較之下，術後恢復早期有較高之GCS score，且拔管所需時間較短。但，加護照顧所需時間，兩組之間無明顯差別。關於病患術後 血壓、心跳之平均變化，兩組亦無明顯之不同。結論：在鐮幕上腦腫瘤切除手術之麻醉中，若採用晚期恢復的作法，相較於以fentanyl為主之麻醉維持，我們認為於術中單獨使用isoflurane或許可提供病患較快的恢復，而且不會導致併發症的增加，不失為另一種替代之麻醉方法。

Background: Several anesthetic agents have been used successfully to provide optimal anesthetic maintenance in neurosurgery for supratentorial tumors. Due to longer surgical time that these procedures demand and thoughtout avoidance of intracranial bleeding from a hastened emergence of anesthesia in the operating room, the neurosurgeons in our hospital favor a placid late emergence from anesthesia in the neurosurgical intensive care unit (NCU). Accordingly, we designed this clinical trial to compare the effects of volatile general anesthesia with or without fentanyl infusion on postoperative hemodynamics, Glasgow coma scale (GCS) score, extubation time, as well as neurological outcome in patients after craniotomy. Methods: Forty-two patients undergoing elective surgery for supratentorial lesions were randomly divided into two anesthetic groups. In isoflurane group, after induction, anesthesia was maintained with isoflurane up to 1.2% end-tidal concentration. In fentanyl-isoflurane group, an infusion of fentanyl was started at a rate of 3 μg/kg/h after induction, and anesthesia was maintained with isoflurane up to 0.6% end-tidal concentration. All the anesthetics were discontinued once the surgical wound was dressed. We studied the postoperative hemodynamics and several recovery variables for 48 h after completion of anesthesia. Results: The time from completion of surgery to extubation was shorter in isoflurane group (9.3 ± 6.6 h) as compared with fentanyl-isoflurane group (14 ± 3.5 h, P< 0.05). Better GCS score was seen in isoflurane group in the early recovery period. However, both groups did not differ in both average postoperative blood pressure and heart rate and there was no significant difference between 2 groups in total duration of the postoperative NCU stay. Conclusions: In pursuance of the policy of late emergence, we are of the opinion that isoflurane anesthesia offers an earlier recovery than fentanyl-isoflurane anesthesia in patients undergoing supratentorial craniotomy.