Abstract：Objective To explore the preventive effect of different monitoring methods on ischemic brain injury in beach chair arthroscopy. Methods A total of 60 patients underwent elective arthroscopic shoulder arthroscopy in the Second People's Hospital of Shenzhen were selected and divided into routine monitoring group, SjvO2 monitoring group, NIRS monitoring group and TCD monitoring group according to the random number table, with 15 cases in each group. The mini mental state examination(MMSE) and the repeatable battery for the assessment of neuropsychological status (RBANS) were used to evaluate the congnitive function and neuropsychological function of the patients. Results Before operation for 1 d, there were no statistically significant differences in the scores of MMSE among the four groups (P ＞ 0.05). After operation for 1 d, the scores of MMSE in the routine monitoring group, SjvO2 monitoring group and TCD monitoring group were all lower those before operation for 1 d, SjvO2 monitoring group, NIRS monitoring group and TCD monitoring group were all higher than that of routine monitoring group, with statistically significant differences (P ＜ 0.05). After operation for 3 d, the score of MMSE in the routine monitoring group was lower than that before operation for 1 d, and the scores in SjvO2 monitoring group and TCD monitoring group were all significantly higher than that of routine monitoring group, with statistically significant differences(P ＜ 0.05); After operation for 5 d, there were no statistically significant differences in the score of MMSE among the four groups and compared with 1 d before operation (P ＞ 0.05). Before operation for 1 d, there were no statistically significant differences in the scores of RBANS among the four groups (P ＞ 0.05). After operation for 1 d, the scores of RBANS in the four groups were all lower than those before operation for 1 d, and the sores in SjvO2 monitoring group, NIRS monitoring group and TCD monitoring group were all higher than that of routine monitoring group, with statistically significant differences (P ＜ 0.05). After operation for 3 d, the scores of RBANS in the routine monitoring group, SjvO2 monitoring group and NIRS monitoring group were all lower than that of 1 d before operation, with statistically significant differences (P ＜ 0.05). After operation for 5 d, there were no statistically significant differences in the score of RBANS among the four groups and compared with 1 d operation (P ＞ 0.05). Conclusion TCD monitoring is the best way to prevent ischemic brain injury in arthroscopic surgery of beach chair shoulder. If TCD monitoring can not be carried out, NIRS is recommended to instead of SjvO2.
的指标。而Baraka等[16]不同意这种观点，其认为NIRS作为一种无创可连续监测脑氧的指标，通过与基础值比较有利于发现脑缺氧。国内吴镜湘等[17]的研究得出了类似的结论。有学者[18]在一篇专门针对沙滩椅位肩关节镜手术的研究报告中指出SctO2与SjvO2之间没有良好的相关性，认为主要是由于NIRS自身的局限性，无法排除脑外血流对颅内血流的干扰所致。也有学者[19]随即针对该结论提出了质疑，认为可能是由于研究人员没有排除不同麻醉方法对结果的影响而导致结果的偏差，且随机对照研究表明，监测脑氧饱和度并及时处理脑缺氧可以改善患者的预后[20]。
但是仍然无法忽视NIRS监测技术自身存在的不足：NIRS无法辨别动静脉血流，动静脉血流比例改变会影响监测的准确性[21]，因此本研究中，NIRS监测组患者认知功能和精神状态与TCD监测组和SjvO2监测组比较，恢复速度无明显优势。特别是体位的改变本身就会引起颅内动静脉血流比例的变化。因此，当体位改变时，NIRS监测结果的变化即可能是由于脑组织氧饱和度变化所致，也可能是颅内动静脉血流比例变化的结果。解决该问题的最好方法是能够实时监测颅内血流变化。关于NIRS能否取代SjvO2作为围术期脑氧饱和度监测的标准，目前各个研究之间存在很大的争议。本研究结果显示，在沙滩椅体位肩关节镜手术中，NIRS能够取代SjvO2，可以避免因SjvO2导致的血栓、感染、血肿和气胸等并发症。
TCD是一种脑血流超声监测技术，可连续无创地对脑血流速率及颅内动脉中的微血栓进行较准确的实时监测，围术期可以根据TCD监测脑血流情况以便及时采取脑保护措施，尤其是对脑血管或颈动脉术前就存在病变的患者至关重要[22]，有助于减少术中及围术期脑卒中的发生风险[23]。本研究结果显示，TCD监测组患者的认知功能恢复最快，提示TCD监测能够较好地反映患者在术中脑部的供血情况。然而由于沙滩椅位肩关节镜手术的特殊性，在术中操作过程中，很难通过传统的监测窗口对患者脑血流进行连续监测，且受到诸如操作者经验、颅骨的厚度及皮下血肿等因素的影响，这可能是导致至今国内外未见TCD技术应用于沙滩椅位肩关节镜手术报道的原因。综合国内外研究来看，目前尚无一种方法可以完全满足沙滩椅位肩关节镜手术围术期脑血流和脑氧监测的要求，可能需要在今后临床研究中联合两种或多种监测手段，从而最大限度地保证患者的安全。
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