Oltre al monitoraggio dei principali parametri vitali ed emogasanalitici, in letteratura si trovano consigliati anche altri metodi di monitoraggio, particolarmente indicati nei pazienti più delicati o in alcuni tipi di chirurgia.
In uno studio del 1979 si trova citata la misurazione della eccitabilità elettrica corticale, durante craniotomia su 10 pazienti operati
per la rottura di aneurismi cranici. Viene misurata la risposta corticale diretta ad uno stimolo, evocata e registrata sulla superficie del cervello. La risposta è direttamente proporzionale ai valori della pressione arteriosa e al flusso cerebrale corticale. Per questo motivo è stato considerato un metodo per stimare la tollerabilità all’ipotensione controllata [40].
La saturazione regionale di O2 misurata con la spettroscopia nel
vicino infrarosso (NIRS), è un’altra metodica disponibile, anche se il suo uso non è ancora così diffuso. In aria ha un valore di circa 67%±3, e aumenta di circa 5,6%±0,8 se la FiO2 è del 100% [139]. Sono da considerare segni di allarme valori assoluti al di sotto del 50%, oppure una caduta del 20% rispetto ai valori basali. Valori assoluti sotto il 40%, oppure un decremento maggiore del 25% rispetto ai valori basali, si associano a disfunzione neurologica.
La riduzione della disponibilità di ossigeno a livello cerebrale può essere causata da diversi fattori, anche combinati tra loro: anemia, ipovolemia, ipotensione, desaturazione arteriosa, ipertermia, vasocostrizione cerebrale. Questo monitoraggio è dunque utile in ipotensione controllata nei pazienti a rischio, come i cardiopatici e i cerebrovasculopatici, sia per regolare la FiO2 e la pressione arteriosa, che per decidere se sia necessario trasfondere o meno il malato [137,181]. Anche nelle anestesie condotte in posizione seduta, può essere un valido aiuto per avere una stima della disponibilità di ossigeno a livello cerebrale [137,138].
I potenziali evocati somatosensoriali sono citati nella chirurgia
della colonna per la correzione della scoliosi. Una riduzione della PAM del 20% rispetto ai valori basali, associata allo stiramento e alla manipolazione della colonna vertebrale, può portare a ischemia midollare e paraplegia; queste complicanze possono essere evitate riportando i valori pressori un 20% sopra ai valori preoperatori, non appena i potenziali presentino alterazioni significative indicanti un danno spinale. Il ritorno dei potenziali evocati alla normalità costituisce una conferma che il problema è stato risolto [126].
Per quanto riguarda il normale monitoraggio della pressione arteriosa, è meglio che sia invasivo, non solo perché più accurato, ma anche
perché consente prelievi ripetuti per l’emogasanalisi ed altri esami di laboratorio. Per fare il confronto con la PA invasiva, il bracciale della pressione dovrebbe essere posizionato dallo stesso lato dell’arteria incannulata; fare un confronto può essere utile nel caso che la PA invasiva diventi per vari motivi indisponibile. Comunque è possibile ricorrere anche al solo monitoraggio non invasivo della PA, specialmente se il paziente è ASA I-II e se la procedura richiedente l’ipotensione controllata è breve
[170].
Negli interventi lunghi è fondamentale il monitoraggio della temperatura corporea, sia perché i vasodilatatori causano una dispersione del calore, sia perché l’ipotermia, inducendo vasocostrizione, aumenta le richieste dei vasodilatatori stessi, e quindi aumenta la probabilità di comparsa dei loro effetti collaterali [170].
In genere è utile monitorizzare la diuresi se l’intervento dura più di cinque ore, sia perché in ipotensione controllata viene prodotta meno urina, sia perché il monitoraggio dell’equilibrio idroelettrolitico è fondamentale: durante anestesia ipotensiva infatti, la fisiologica risposta all’ipovolemia può essere mascherata o ridotta. L’uso della PVC è citata solo per i pazienti più complessi [170].
Figura 1: l’ipertensione arteriosa tende a spostare la
curva dell’autoregolazione cerebrale verso destra.
Per questo motivo la soglia di danno ischemico si sposta verso PAM più elevate. Valore normale del FEC: 70-50 ml/100g/min.
Figura 2: la figura mostra che l’emivita contesto sensibile del
remifentanil non cambia qualunque sia la durata dell’infusione continua.
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