控制性降压对老年微创脊柱手术术后认知功能障碍的影响

Effects of controlled hypotension on postoperative cognitive dysfunction after spinal operation in elderly patients

目的观察控制性降压的实施与引起术后认知功能障碍（POCD）的联系。方法将60例ASAⅠ-Ⅱ级、年龄大于60岁、中学及以上文化程度的行择期脊柱手术的患者。随机分为3组,控制性降压Ⅰ、Ⅱ组及非降压组,每组20例,控制性降压Ⅰ组平均动脉压（MAP）70-80 mm Hg,Ⅱ组MAP80-85 mm Hg。麻醉前均不用术前药,静脉注射异丙酚、芬太尼、维库溴铵快速诱导气管插管,机械通气,维持呼气末二氧化碳分压在正常范围,麻醉用异丙酚和瑞芬太尼维持,术中定时追加维库溴铵。术中连续监测心率（HR）、MAP,脉搏血氧饱和度（SpO2）。应用简易智力状态检查（MMSE）测试方法调查患者术前和术后1 h、24h、4 d的认知功能变化。结果术后共有25例发生POCD。非降压组与降压Ⅰ、Ⅱ组术后1 h MMSE评分比较,差异有统计学意义（P〈0.01）。降压Ⅰ、Ⅱ组术后24 h MMSE评分两两比较,差异有统计学意义（P〈0.05）。MMSE计算力、近期记忆力评分在术后24 h、术后4 d,非降压组与降压Ⅰ组和Ⅱ组差异有统计学意义（P〈0.05）。结论控制性降压影响老年人POCD,以近期记忆力、计算力影响为甚,且降压程度越大发生POCD的概率越大。

Objective To investigate the relationship between controlled hypotension and postoperative cognitive dycfunction.Methods Sixty ASAⅠ-Ⅱ patients（age 〉60 years） undergoing spinal operation,assigned to three groups,according to their educational background.Each group was further randomly divided into controlled hypotension（groupⅠand groupⅡ） and non-controlled hypotension subgroups（n=20 in each subgroup）.All patients received no pre-medication.Anesthesia was induced with propofol,fentanyl and vecuronium and maintained with remifentanil and propofol.Neuropsychological tests（mini-mental state examination,MMSE） for detecting POCD were performed preoperatively and 1 h,24 h,4d after the operation.Results 25 patients had POCD.There were significant differences in MMSE test between controlled hypotension group and non-controlled hypotension group 1 h after the operation.There were significant differences in MMSE test between controlled hypotension group Ⅰand groupⅡ 24 h after the operation.In computing power and recent memory test,there were significant differences between controlled hypotension group and non-controlled hypotension group.Conclusion Controlled hypotension impairs cognitive function in elderly patients after spinal operation,especially the computing power and recent memory.The greater the decline of MAP,the more seriously the impairment of cognitive function.