冠状动脉搭桥术后中枢神经系统并发症病人围术期神经内分泌和术后神经心理的变化

Changes in perioperative plasma melatonin, cortisol and neuron-specific enolase and neuropsychological function in patients who develop CNS complication after coronary artery bypass

目的观察冠状动脉搭桥术后中枢神经系统并发症病人围术期血浆褪黑激素、皮质醇和神经元特异性烯醇化酶(NSE)和术后神经心理的变化。方法择期在体外循环下行冠脉搭桥术病人3例,在术后分别出现脑梗塞、运动性失语、运动性和感觉性失语的中枢神经系统并发症。3例病人均在麻醉诱导前、气管插管后10min、肝素化后10min、转机后30min、中和肝素前、关胸缝皮后、回到ICU即刻、术后3、6、9、12、15、18、21、24 h抽血,分别用酶联免疫和放射免疫法测定血浆褪黑激素、皮质醇和NSE的浓度。在术前1 d、术后10-20 d及术后3个月,应用抑郁自评量表、焦虑状态/特性询问表和神经心理量表评估抑郁和焦虑程度以及认知功能。结果三例病人术后NSE浓度在不同时点升高。术后24 h内病例1和病例2褪黑激素和皮质醇昼夜分泌节律紊乱;病例3的褪黑激素和皮质醇则表现昼夜分泌节律。病例1和病例3术后连线测验A型、符号数字模式测验和斯特鲁字色干扰测验减退;术后抑郁程度增高,但焦虑程度减轻。结论冠状动脉搭桥术后神经系统并发症病人认知功能减退,情绪紊乱;这些改变可能与病人围术期NSE浓度升高,褪黑激素和皮质醇昼夜分泌节律紊乱有关。

Objective To determine the changes in perioperative plasma melatonin, cortisol and neuronspecific enolase （NSE） and neuropsychological function in patients who developed CNS complications after coronary artery bypass grafting （CABG）.Methods Three patients developed CNS complications （cerebral infarction, motor aphasia, motor and sensory aphasia） after CABG performed under hypothermic cardiopulmonary bypass （CPB）were studied. Blood samples were taken before induction of anesthesia （T1 ）, 10 min after tracheal intubation （T2 ）, 10 min after heparinization （T3）, at 30 min of CPB （T4）, immediately after discontinuation of CPB （T5 ）,at closure of chest （T6 ）, immediately after returning to ICU（T7 ） and every 3 h in ICU for 24 h （T8.15） for determination of plasma concentrations of NSE, cortisol and melatonin using enzyme-linked immunosorbent assay and radioimmunoassay. Cognitive function was measured before and 10 to 20 days after operation using a battery of tests, while depression and anxiety were assessed by self-rating depression scale and state-trait anxiety inventory respectively. Results The plasma NSE concentration was increased after operation in all 3 patients. The circadian rhythms of melatonin and cortisol were disturbed in patient 1 and 2 during the 24h after operation but were retained in patient 3. In patient 1 and 3 the performance of the trailing making test, the digit symbol subtest of WAIS-R and the stroop color word interference test were poor, meanwhile they became more depressed and less anxious, Conclusion In patients who develop CNS complication after CABG, there are cognitive decline,sentimental disorders and disrupted circadian rhythm of melatonin and cortisol secretion.