Abstract
The objective of this review is to review the anaesthetic implications of vasoactive compounds particularly with regard to the cerebral circulation and their clinical importance for the practicing anaesthetist. Material was selected on the basis of validity and application to clinical practice and animal studies were selected only if human studies were lacking. Hypotensive drugs have been used to induce hypotension and in the treatment of intraoperative hypertension during cerebral aneurysm surgery. After subarachnoid haemorrhage, cerebral blood flow is reduced and cerebral vasoreactivity is disturbed which may lead to brain ischaemia. Also, cerebral arterial vasospasm decreases cerebral blood flow, and may lead to delayed ischaemic brain damage which is a major problem after subarachnoid haemorrhage. Recently, the use of induced hypotension has decreased although it is still useful in patients with intraoperative aneurysm rupture, giant cerebral aneurysm, fragile aneurysms and multiple cerebral aneurysms. In this review, a variety of vasodilating agents, prostaglandin E1 sodium nitroprusside, nitroglycerin,’ trimetaphan, adenosine, calcium antagonists, and inhalational anaesthetics, are discussed for their clinical usefulness. Sodium nitroprusside, nitroglycerin and isoflurane are the drugs of choice for induced hypotension. Prostaglandin E1, nicardipine and nitroglycerin have the advantage that they do not alter carbon dioxide reactivity. Local cerebral blood flow is increased with nitroglycerin, decreased with trimetaphan and unchanged with prostaglandin E1. Intraoperative hypertension is a dangerous complication occurring during cerebral aneurysm surgery, but its treatment in association with subarachnoid haemorrhage is complicated in cases of cerebral arterial vasospasm because fluctuations in cerebral blood flow may be exacerbated. Hypertension should be treated immediately to reduce the risk of rebleeding and intraoperative aneurysmal rupture and the choice of drugs is discussed. Although the use of induced hypotension has declined, the control of arterial blood pressure with vasoactive drugs to reduce the risk of intraoperative cerebral aneurysm rupture is a useful technique. Intraoperative hypertension should be treated immediately but the cerebral vascular effects of each vasodilator should be understood before their use as hypotensive agents.
Résumé
L’objectif de cet article est de revoir les implications anesthésiques des composés vasoactifs particulièrement en rapport avec la circulation cérébrale ainsi que leur importance clinique pour l’anesthésiste. Les agents ont été choisis sur la base de leur validité et de leur application à la pratique clinique et des études animales ont été choisies seulement en l’absence d’étude sur l’homme. Les agents hypotenseurs ont été utilisés pour induire de l’hypotension et pour traiter l’hypertension preopératoire pendant la chirurgie d’anévrisme cérébrale. Après une hémorragie sous-arachnoidienne, le débit sanguin cérébrale réduit et la vasomotricité cérébrale perturbée peuvent entraîner une ischémie cérébrale. Ainsi, le vasospasme artériel cérébral diminue le débit sanguin cérébral et peut conduire à des dommages cérébraux retardés d’ischémie, problème majeur après une hémorragie sous-arachnoïdienne. Récemment, l’utilisation de l’hypotension contrôlée s’est raréfiée bien qu’elle soit encore utile chez les patients avec une rupture peropératoire d’anévrisme, en cas d’anévrisme cérébral géant, d’anévrismes fragiles et d’anévrismes cérébraux multiples. Dans cet article, une variété de vasodilatateurs, le prostaglandine E1 le nitroprussiate de sodium, la nitroglycérine, le trimétaphan, l’adénosine, les antagonistes calciques et les agents d’inhalation son discutés pour leur utilité clinique. Le nitroprussiate de sodium, la nitroglycérine et l’isoflurane sont les agents de choix pour l’hypotension contrôlée. La prostaglandine E1 la nicardipine et la nitroglycérine ont l’avantage de ne pas altérer la réactivité au dioxyde de carbone. Le débit sanguin cérébral local est augmenté avec la nitroglycérine, diminué avec le trimétaphan et inchangé avec la prostaglandine E1. L’hypertension peropératoire est une complication dangereuse aux cours d’une chirurgie d’anévrisme cérébral, mais son traitement lors d’hémorragie sousarachnoïdienne se complique dans les cas de vasospasme artériel cérébral parce que les fluctuations du débit sanguin cérébral peuvent s’exacerber. L’hypertension devrait être traitée immédiatement pour réduire le risque de resaignement et de rupture peropératoire de l’anévrisme. Le choix des agents est discuté. Bien que l’utilisation de l’hypotension contrôlée est moins fréquente, le contrôle de la pression artérielle avec des agents vasoactifs dans le but de réduire le risque de rupture peropératoire d’anévrisme cérébral est une technique courante. L’hypertension peropératoire devrait être traitée immédiatement mais tes effets vasculaires cérébraux de chaque vasodilatateurs devraient être compris avant qu’ils soient utilisés comme agents hypotenseurs.
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Abe, K. Vasodilators during cerebral aneurysm surgery. Can J Anaesth 40, 775–790 (1993). https://doi.org/10.1007/BF03009775
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DOI: https://doi.org/10.1007/BF03009775