七氟醚和丙泊酚麻醉对颅脑外伤患者术后早期神经功能恢复的影响：一项回顾性队列研究

doi:10.24920/004188

摘要/Abstract

摘要：

目的本研究旨在探讨丙泊酚和七氟醚对创伤性颅脑外伤（traumatic brain injury，TBI）患者术后早期神经功能恢复的影响。

方法我们回顾性分析了244例行去骨瓣或非去骨瓣减压手术的TBI患者的临床资料。应用广义相加混合模型比较丙泊酚和七氟醚对患者术后第1、3、7天格拉斯哥昏迷（Glasgow Coma Scale，GCS）评分影响的差异。采用多元回归分析比较两种麻醉药对患者出院时格拉斯哥结局量表（GOS）评分影响的差异。

结果丙泊酚组与七氟醚组患者入院时GCS评分的差异无统计学意义（β = 0.75，95%CI：-0.55~2.05，P = 0.260）。在接受非去骨瓣减压手术的患者中，七氟醚组术后GCS评分较基线水平升高的值显著低于丙泊酚组：在术后第1天低1.73（95%CI：-2.81~-0.66，P = 0.002），在术后第3天低2.03（95%CI：-3.14~-0.91，P < 0.001），在术后第7天低1.31（95%CI：-2.43~-0.19，P = 0.022）；在出院时，七氟醚组患者发生不良GOS评分（评分为1、2、3分）的风险较高（OR = 4.93，95%CI：1.05~23.03，P = 0.043）。在接受去骨瓣减压手术的患者中，两组GCS与GOS评分的差异无统计学意义。

结论在接受非去骨瓣减压手术的TBI患者中，与丙泊酚相比，七氟醚可能与患者住院期间神经功能恢复较差相关；而在接受去骨瓣减压手术的TBI患者中，两者对患者神经功能恢复影响的差异不明显。

关键词: 格拉斯哥评分, 格拉斯哥预后评分, 丙泊酚, 七氟醚, 颅脑外伤

Abstract:

Objective To investigate the effects of propofol and sevoflurane on neurological recovery of traumatic brain injury (TBI) patients in the early postoperative stage.

Methods We retrospectively analyzed the clinical data of TBI patients who underwent craniotomy or decompressive craniectomy. Generalized additive mixed model (GAMM) was used to analyze effects of propofol and sevoflurane on Glasgow Coma Scale (GCS) on postoperative days 1, 3, and 7. Multivariate regression analysis was used to analyze effects of the two anesthetics on Glasgow Outcome Scale (GOS) at discharge.

Results A total of 340 TBI patients were enrolled in this study. There were 110 TBI patients who underwent craniotomy including 75 in the propofol group and 35 in the sevoflurane group, and 134 patients who underwent decompressive craniectomy including 63 in the propofol group and 71 in the sevoflurane group. It showed no significant difference in GCS at admission between the propofol and the sevoflurane groups among craniotomy patients (β = 0.75, 95%CI: -0.55 to 2.05, P = 0.260). However, elevation in GCS from baseline was 1.73 points (95%CI: -2.81 to -0.66, P = 0.002) less in the sevoflurane group than that in the propofol group on postoperative day 1, 2.03 points (95%CI: -3.14 to -0.91, P < 0.001) less on day 3, and 1.31 points (95%CI: -2.43 to -0.19, P = 0.022) less on day 7. The risk of unfavorable GOS (GOS 1, 2, and 3) at discharge was higher in the sevoflurane group (OR = 4.93, 95%CI: 1.05 to 23.03, P = 0.043). No significant difference was observed among two-group decompressive craniectomy patients in GCS and GOS.

Conclusions Compared to propofol, sevoflurane was associated with worse neurological recovery during the hospital stay in TBI patients undergoing craniotomy. This difference was not detected in TBI patients undergoing decompressive craniectomy.

Key words: Glasgow Coma Scale, Glasgow Outcome Scale, propofol, sevoflurane, traumatic brain injury

Bei Wu, Wan-Qing Song, Jin-Qian Dong, Hong-Li Yue, Yu Lu, Yun Yu, Shu-Yu Hao, Bai-Yun Liu, Wei-Hua Cui. Effects of Sevoflurane and Propofol on Neurological Recovery of Traumatic Brain Injury Patients in the Early Postoperative Stage: A Retrospective Cohort Study[J].Chinese Medical Sciences Journal, 2023, 38(2): 97-108.

图/表 5

Items	Craniotomy (n=110)	Decompressive craniectomy (n=134)	Statistics	P value
Age (yrs, mean ± SD)	46.99 ± 16.73	47.78 ± 15.48	t = -0.38	0.704
Sex [n (%)]			χ²= 0.24	0.625
Male	85 (77.27)	107 (79.85)
Female	25 (22.73)	27 (20.15)
GCS on admission (score, mean ± SD)	11.46 ± 3.60	6.52 ± 3.54	t = 10.76	<0.001
Pupil reactivity on admission [n (%)]			χ²= 71.76	<0.001
Both reactive	90 (83.33)	55 (41.67)
One reactive	18 (16.67)	15 (11.36)
None reactive	0	62 (46.97)
Diagnosis [n (%)]			χ²= 61.43	<0.001
EDH	65 (59.09)	27 (20.30)
SDH	6 (5.45)	42 (31.58)
Cerebral contusion	28 (25.45)	51 (38.35)
Diffuse cerebral swelling	1 (0.91)	11 (8.27)
Skull fracture	10 (9.09)	2 (1.50)
Hemoglobin on admission（g·L^-1）	135.34 (20.61)	137.58 (20.55)	t = -0.85	0.397
CT findings on admission [n (%)]			χ²= 36.74	<0.001
Normal basal cistern	54 (49.54)	18 (13.64)
Abnormal basal cistern	55 (50.46)	114 (86.36)
Midline shift^# (mm)	3.11 [0.00-5.61(0.00-22.59)]	6.24 [4.19-11.75(0.00-23.44)]	t = -6.08	<0.001
Systolic blood pressure (mmHg, mean ± SD)	134.77 ± 18.78	140.11 ± 27.56	t = -1.70	0.090
Diastolic blood pressure (mmHg, mean ± SD)	79.62 ± 10.42	78.99 ± 15.55	t = 0.35	0.723
Anesthesia maintenance [n (%)]			χ²= 11.02	<0.001
Propofol	75 (68.18)	63 (47.01)
Sevoflurane	35 (31.82)	71 (52.99)
Operation duration^# (h)	3.00 [2.50-4.00 (1.00-8.00)]	3.50 [2.50-4.00 (1.00-8.50)]	t = 0.87	0.864
Intraoperative fluid^#
Mannitol (ml·kg^-1)	0.00 [0.00-0.00[0.00-5.68)]	0.00 [0.00-0.00(0.00-6.67)])	t = -2.16	0.032
Crystalloid (ml·kg^-1)	25.00 [17.46-33.67(5.26-61.54)]	31.25 [23.08-40.00(7.14-102.35)]	t = -3.93	<0.001
Colloid (ml·kg^-1)	8.33 [6.85-12.50(0.00-26.67)]	11.76 [7.69-14.93(0.00-31.25)]	t = -3.90	<0.001
Autologous blood (ml·kg^-1)	0.00 [0.00-0.00(0.00-33.16)]	3.12 [0.00-7.62(0.00-30.77)]	t = -4.01	<0.001
PRBC (ml·kg^-1)	0.00 [0.00-0.00(0.00-7.43)]	0.00 [0.00-3.25(0.00-18.35)]	t = -3.03	0.004
Plasma (ml·kg^-1)	0.00 [0.00-0.00(0.00-10.81)]	0.00 [0.00-5.73(0.00-23.33)]	t = -4.57	<0.001
Blood loss^# (ml·kg^-1)	4.62 [2.50-8.62(0.00-68.42)]	9.16 [4.56-19.80(0.81-69.23)]	t = -3.65	<0.001
Urine volume^# (ml·kg^-1)	10.00 [6.12-15.04(0.00-36.00)]	11.76 [7.14-17.97(2.00-101.18)]	t = -2.51	0.058
Vasoactive drugs^#
Atropine (mg)	0.00 [0.00-0.00(0.00-1.50)])	0.00 [0.00-0.00(0.00-3.00)]	t = -0.06	0.951
Dopamine (mg)	0.00 [0.00-0.00(0.00-51.70) )]	0.00 [0.00-0.00(0.00-139.00)]	t = -2.07	0.057
Esmolol (mg)	0.00 [0.00-0.00(0.00-100.00)]	0.00 [0.00-0.00(0.00-400.00)]	t = -0.96	0.377
Epinephrine (mg)	0.00 [0.00-0.00(0.00-0.00)]	0.00 [0.00-0.00(0.00-17.00)]	t = -1.30	0.195
Norepinephrine (mg)	0.00 [0.00-0.00(0.00-18.00)]	0.00 [0.00-0.24(0.00-13.00)]	t = 0.79	0.385
Phenylephrine (mg)	0.00 [0.00-0.00(0.00-28.00)]	0.00 [0.00-0.00(0.00-48.00)]	t = -1.02	0.324
Length of hospitalization^# (d)	13.00 [9.00-17.00[1.00-124.00)]	14.50 [6.00-22.75[0.00-69.00)]	t = -0.36	0.719
GCS on postoperative day 1[score, mean ± SD]	11.34 ± 3.98	6.40 ± 3.96	t = 9.35	<0.001
GCS on postoperative day 3[score, mean ± SD]	11.40 ± 4.19	7.52 ± 4.25	t = 6.47	<0.001
GCS on postoperative day 7[score, mean ± SD]	12.39 ± 3.90	7.92 ± 4.44	t = 7.35	<0.001
GOS at discharge [n (%)]			t = 54.74	<0.001
Unfavorable	30 (27.52)	100 (75.19)
Favorable	79 (72.48)	33 (24.81)

Items	Craniotomy				Decompressive craniectomy
Items	Propofol (n=75)	Sevoflurane (n=35)	Statistics	P value	Propofol (n=63)	Sevoflurane (n=71)	Statistics	P value
Age (yrs, mean ± SD)	46.36 ± 15.50	48.34 ± 19.28	t = -0.58	0.565	47.21 ± 16.84	48.28 ± 14.27	t = -0.40	0.690
Sex [n (%)]			χ²= 0.91	0.340			χ²=0.02	0.895
Male	56 (74.67)	29 (82.86)			50 (79.37)	57 (80.28)
Female	19 (25.33)	6 (17.14)			13 (20.63)	14 (19.72)
GCS on admission (score, mean ± SD)	11.31 ± 3.88	11.80 ± 2.94	t = -0.67	0.506	6.76 ± 3.28	6.31 ± 3.77	t = 0.74	0.463
Pupil reactivity on admission [n (%)]			χ²= 2.27	0.118			χ²= 2.12	0.347
Both reactive	58 (79.45)	32 (91.43)			29 (47.54)	26 (36.62)
One reactive	15 (20.55)	3 (8.57)			5 (8.20)	10 (14.08)
None reactive	0 (0.00)	0 (0.00)			27 (44.26)	35 (49.30)
Diagnosis [n (%)]			χ²= 3.35	0.501			χ²= 3.47	0.483
EDH	45 (60.00)	20 (57.14)			14 (22.22)	13 (18.57)
SDH	5 (6.67)	1 (2.86)			17 (26.98)	25 (35.71)
Cerebral contusion [n (%)]	16 (21.33)	12 (34.29)			24 (38.10)	27 (38.57)
Diffuse cerebral swelling [n (%)]	1 (1.33)	0			6 (9.52)	5 (7.14)
Skull fracture [n (%)]	8 (10.67)	2 (5.71)			2 (3.17)	0
Hemoglobin on admission (g·L^-1, mean ± SD)	134.87 ± 20.62	136.34 ± 20.86	t = -0.35	0.728	138.05 ± 22.44	137.17 ± 18.87	t = 0.25	0.806
CT findings on admission [n (%)]			χ²= 0.02	0.889			χ²= 0.08	0.782
Normal basal cistern	37 (50.00)	17 (48.57)			9 (14.52)	9 (12.86)
Abnormal basal cistern	37 (50.00)	18 (51.43)			53 (85.48)	61 (87.14)
Midline shift^# (mm)	3.58 [0.00-5.78 (0.00-22.59)]	2.73 [0.85-4.57 (0.00-12.98)]	t = 1.14	0.307	6.24 [4.25-11.09 (0.00-21.39)]	6.24 [4.14-12.36 (0.00-23.44)]	t = -0.42	0.674
Systolic blood pressure (mmHg, mean ± SD)	133.93 ± 15.17	136.53 ± 24.88	t = -0.66	0.510	135.16 ± 25.18	144.51 ± 28.97	t = -1.98	0.053
Diastolic blood pressure (mmHg, mean ± SD)	79.89 ± 10.02	79.06 ± 11.37	t = 0.38	0.705	77.40 ± 13.42	80.41 ± 17.20	t = -1.12	0.265
Operation duration^# (h)	3.00 [2.25-3.50 (1.00-4.50)]	3.50 [2.85-4.00 (1.00-8.00)]	t = 0.11	0.937	3.50 [2.50-4.22 (1.00-8.50)]	3.00 [2.50-4.00 (1.50-3.50)]	t = -0.97	0.360
Intraoperative fluids
Mannitol^# (ml·kg^-1)	0.00 [0.00-0.00 (0.00-5.68)]	0.00 [0.00-0.00 (0.00-3.68)]	t = -0.63	0.524	0.00 [0.00-0.00 (0.00-6.67)]	0.00 [0.00-0.00 (0.00-5.56)]	t = -0.07	0.941
Crystalloid^# (ml·kg^-1)	25.00 [16.67-33.33(5.75-50.00)]	28.57 [21.43-36.04 (5.26-61.54)]	t = -1.74	0.070	33.33 [23.95-42.00 (8.06-102.35)]	29.41 [22.62-36.04 (7.14-60.34)]	t = 1.83	0.065
Colloid^# (ml·kg^-1)	8.33 [6.41-12.66 (0.00-26.67)]	8.33 [7.14-11.81 (0.00-21.05)]	t = -0.38	0.730	11.76 [7.69-15.24 (5.00-31.25)]	11.90 [7.30-14.29 (0.00-27.27)]	t = 0.10	0.924
Autologous blood^# (ml·kg^-1)	0.00 [0.00-0.00 (0.00-23.33)]	0.00 [0.00-3.62 (0.00-33.16)]	t = -1.23	0.153	0.00 [0.00-7.92 (0.00-30.77)]	3.79 [0.00-7.41 (0.00-20.00)]	t = -0.42	0.673
PRBC^# (ml·kg^-1)	0.00 [0.00-0.00 (0.00-7.43)]	0.00 [0.00-0.00 (0.00-5.47)]	t = -0.03	0.977	0.00 [0.00-0.00 (0.00-18.35)]	0.00 [0.00-3.25 (0.00-9.45)]	t = 0.96	0.327
Plasma^# (ml·kg^-1)	0.00 [0.00-0.00 (0.00-10.81)]	0.00 [0.00-0.00 (0.00-8.42)]	t = -0.58	0.535	0.00 [0.00-6.13 (0.00-18.82)]	0.00 [0.00-5.62 (0.00-23.33)]	t = 0.47	0.639
Blood loss^# (ml·kg^-1)	4.00 [2.35-8.33 (0.00-60.00)]	5.45 [4.00-8.79 (0.61-68.42)]	t = -0.82	0.371	7.27 [4.00-18.75 (0.81-69.23)]	10.91 [5.88-20.00 (1.25-53.85)]	t = -0.38	0.703
Urine volume^# (ml·kg^-1)	9.20 [5.71-13.16 (0.00-30.00)]	12.24 [6.82-15.87 (3.16-36.00)]	t = -1.39	0.157	12.31 [8.00-20.00(3.08-101.18)]	10.67 [6.25-15.38 (2.00-45.45)]	t = 2.01	0.056
Intraoperative vasoactive drugs
Atropine^# (mg)	0.00 [0.00-0.00 (0.00-1.50)]	0.00 [0.00-0.00 (0.00-0.00)]	t = 1.72	0.247	0.00 [0.00-0.00 (0.00-3.00)]	0.00 [0.00-0.00 (0.00-1.00)]	t = 0.54	0.572
Dopamine^# (mg)	0.00 [0.00-0.00 (0.00-39.60)]	0.00 [0.00-0.00 (0.00-51.70)]	t = -0.50	0.547	0.00 [0.00-0.00 (0.00-122.00)]	0.00 [0.00-0.00 (0.00-139.00)]	t = -0.18	0.855
Esmolol^# (mg)	0.00 [0.00-0.00 (0.00-100.00)]	0.00 [0.00-0.00 (0.00-60.00)]	t = -0.21	0.847	0.00 [0.00-0.00 (0.00-230.00)]	0.00 [0.00-0.00 (0.00-400.00)]	t = -0.52	0.614
Epinephrine^# (mg)	0.00 [0.00-0.00 (0.00-0.00)]	0.00 [0.00-0.00 (0.00-0.00)]	-	-	0.00 [0.00-0.00 (0.00-17.00)]	0.00 [0.00-0.00 (0.00-5.79)]	t = 0.65	0.495
Norepinephrine^# (mg)	0.00 [0.00-0.00 (0.00-18.00)]	0.00 [0.00-0.00 (0.00-3.42)]	t = 1.00	0.497	0.00 [0.00-0.00 (0.00-13.00)]	0.00 [(0.00-0.50 (0.00-2.77)]	t = 0.70	0.460
Phenylephrine^# (mg)	0.00 [0.00-0.00 (0.00-28.00)]	0.00 [0.00-0.00 (0.00-3.50)]	t = 1.02	0.480	0.00 [0.00-0.00 (0.00-7.00)]	0.00 [0.00-0.00 (0.00-48.00)]	t = -1.58	0.139

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Items	Craniotomy group		Decompressive craniectomy group		Total
Items	β (95%CI)	P value	β (95%CI)	P value	β (95%CI)	P value
Unadjusted
Propofol on admission	Ref		Ref		Ref
Sevoflurane on admission	0.59 (-1.00, 2.18)	0.470	-0.23 (-1.64, 1.19)	0.755	0.10 (-0.95, 1.15)	0.853
Propofol postoperative day 1	0.53 (-0.10, 1.16)	0.098	0.05 (-0.62, 0.73)	0.878	0.31 (-0.16, 0.77)	0.195
Propofol postoperative day 3	0.82 (0.17, 1.46)	0.014	0.54 (-0.18, 1.27)	0.145	0.69 (0.21, 1.18)	0.005
Propofol postoperative day 7	1.52 (0.86, 2.17)	<0.001	1.16 (0.38, 1.93)	0.004	1.36 (0.86, 1.86)	<0.001
Sevoflurane-Propofol postoperative day 1	-1.73 (-2.79, -0.68)	0.001	-0.57 (-1.50, 0.36)	0.234	-1.07 (-1.76, -0.38)	0.003
Sevoflurane-Propofol postoperative day 3	-1.96 (-3.04, -0.87)	<0.001	0.08 (-0.92, 1.07)	0.876	-0.72 (-1.45, 0.00)	0.052
Sevoflurane-Propofol postoperative day 7	-1.27 (-2.36, -0.18)	0.023	-0.47 (-1.50, 0.57)	0.376	-0.83 (-1.56, -0.09)	0.029
Adjusted
Propofol on admission	Ref		Ref		Ref
Sevoflurane on admission	0.75 (-0.55, 2.05)	0.260	-0.03 (-1.11, 1.05)	0.959	0.25 (-0.59, 1.09)	0.555
Propofol postoperative day 1	0.53 (-0.11, 1.17)	0.105	0.07 (-0.61, 0.76)	0.833	0.31 (-0.15, 0.78)	0.188
Propofol postoperative day 3	0.86 (0.20, 1.52)	0.011	0.54 (-0.20, 1.28)	0.152	0.70 (0.21, 1.19)	0.005
Propofol postoperative day 7	1.55 (0.88, 2.22)	<0.001	1.17 (0.38, 1.96)	0.004	1.38 (0.87, 1.88)	<0.001
Sevoflurane-Propofol postoperative day 1	-1.73 (-2.81, -0.66)	0.002	-0.59 (-1.54, 0.36)	0.225	-1.08 (-1.78, -0.38)	0.003
Sevoflurane-Propofol postoperative day 3	-2.03 (-3.14, -0.91)	<0.001	0.06 (-0.95, 1.08)	0.905	-0.75 (-1.48, -0.02)	0.045
Sevoflurane-Propofol postoperative day 7	-1.31 (-2.43, -0.19)	0.022	-0.52 (-1.57, 0.53)	0.330	-0.88 (-1.62, -0.13)	0.021

Exposure	Craniotomy group		Decompressive craniectomy group		Total
Exposure	OR (95%CI)	P value	OR (95%CI)	P value	OR (95%CI)	P value
Unadjusted
Propofol	1.00		1.00		1.00
Sevoflurane	1.98 (0.83, 4.75)	0.125	1.53 (0.69, 3.37)	0.294	1.72 (0.95, 3.09)	0.072
Adjusted
Propofol	1.00		1.00		1.0
Sevoflurane	4.93 (1.05, 23.03)	0.043	1.01 (0.35, 2.97)	0.982	1.58 (0.72, 3.45)	0.250

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