Евалуација на ефект на хипертоничен натриум хлорид врз мозочна оксигенација и врз мозочна релаксација при краниотомии

Abstract

Introduction: In patients scheduled for elective craniotomy osmotherapy is regularly administered for obtaining cerebral relaxation. Osmotherapeutic agens with the longest history is mannitol, but for this clinical indication, hypertonic saline arouses increased interest, having in mind his potentials for other clinical benefit beside brain relaxation. Aim of the study: Our intention is to compare the effect on cerebral relaxation and regional cerebral oxygenation between hypertonic saline and mannitol, to determine the correlation with BIS value and to evaluate the effect on hemodynamic parameters, diuresis, osmolarity and electrolytes values during neurosurgical procedures. Study design: Study was performed as prospective, randomized interventional clinical study, one side blinded. Methods: We investigate 87 patients with diagnosed supratentorial pathologic lesion. They were divided in two groups related to type of agents administered: isoosmolar doses of 3ml/kg 3% hypertonic saline (HTN group) and 3ml/kg 20% mannitol (M group). Serum values of lactate, urea, C-reactive protein (CRP), glucose, electrolytes were investigated preoperatively and on the day of surgery. Several parameters with noninvasive methods were followed intraoperatively: regional cerebral oxygenation with Near Infra-red Spectroscopy (NIRS), anesthesia depth with Bispectral Index (BIS) и Mean Arterial Pressure (MAP). Parameters were followed in several time intervals: TB - before anesthesia induction, T0 - 5min before administering osmotic active substance (OAS), T1 – 30 min. after, T2 – 60 min. after and T2 – 120 min. after administering osmotic active substance (OAS). Results: The study shows homogenous sex and age distribution. Statistic analysis shows non significant difference in quality of brain relaxation (p=0.61). After 30 min. of administering OAS, MAP in Mannitol group, on an average amounts 68.2±5.9, and in HTN group it was higher and amounts 72.79±5.2. The difference of 4.59 between two groups statistically was confirmed as significant (p=0.0002). The difference in average values of serum sodium and osmolarity in patients between Mannitol and HTN group were statistically non significant. Higher diuresis was measured in patients in Mannitol group comparing to HTN group and difference was statistically significant after 30min, 60 min. and 120 min. after administering OAS (p=0.014, p=0.000086, p<0.0001). Higher values of CRP in serum were measured in Mannitol group. On last time interval, 120 min. after OAS (T2), these higher values were statistically confirmed as significant (p=0.000022). Results of regional cerebral oxygenation (rSO2) 30 min. after OAS showed that two groups of patients had significantly different cerebral oxygenation in left hemisphere (p=0.037), with much higher significant values in HTN group comparing to Mannitol group. Conclusion: During the elective supratentorial craniotomies, 3% hypertonic saline comparing to mannitol demonstrates better regional cerebral oxygenation and cortical perfusion, more stable hemodynamics without effect upon diuresis and without hypovolemia and at the same time achieved equally adequate brain relaxation as mannitol.