多重监测下的全凭静脉麻醉对老年患者术后认知功能的影响

Effects of multiple monitoring of total intravenous anesthesia on postoperative cognitive dysfunction in elderly patients

目的观察多重监测下的全凭静脉麻醉对老年患者术后认知功能的影响。方法选择择期行全麻下腹部手术患者100例,男56例,女44例,年龄65~80岁,ASAⅡ或Ⅲ级。采用随机数字表法分为多重监测组(M组)和常规监测组(R组),每组50例。M组通过调节麻醉药物使麻醉深度指数(NTI)维持在37~56,rSO2>50%或不低于基础值的20%,根据TOF值输注肌松药物;R组术中由麻醉医师根据监护仪指标调整丙泊酚、瑞芬太尼及肌松药物的输注速率。于术前1d、术后1、3、7d、1个月和3个月采用MMSE量表评估认知功能,记录术后7d、1个月和3个月的术后认知功能障碍(postoperative cognitive dysfunction,POCD)的发生情况。记录术毕至呼唤睁眼时间、术毕至拔管时间和术毕至定向力恢复时间;记录单位时间丙泊酚、瑞芬太尼和顺式阿曲库铵用量。于麻醉前(T0)、手术开始1h(T1)、术毕(T2)、术后24h(T3)采集静脉血标本,采用ELISA法测定血清S100β和Aβ1-42蛋白含量。结果 M组术后1d认知功能下降发生率明显低于R组(8%vs.22%,P<0.05)、术后3d认知功能下降发生率明显低于R组(2%vs.16%,P<0.05)。术后7d和1个月、3个月两组POCD的发生差异无统计学意义。M组丙泊酚用量明显小于R组[(3.3±0.8)mg·kg^(-1)·h^(-1) vs.(3.7±0.7)mg·kg^(-1)·h^(-1),P<0.05],顺式阿曲库铵用量明显小于R组[(104±47)μg·kg^(-1)·h^(-1) vs.(124±68)μg·kg^(-1)·h^(-1),P<0.05],术毕至呼唤睁眼时间[(10±3)min vs.(16±6)min,P<0.01]、拔管时间[(13±3)min vs.(22±7)min,P<0.01]和定向力恢复时间[(17±4)min vs.(27±9)min,P<0.01]均明显短于R组。与T0时比较,T1、T2时M组和T1~T3时R组血清S100β蛋白含量明显升高(P<0.05),T_1~T_3时M组血清S100β蛋白含量明显低于R组(P<0.05)。与T_0时比较,T_1、T_2时两组Aβ1-42蛋白含量明显降低(P<0.05)。结论多重监测下的全凭静脉麻醉可减轻腹部手术老年患者神经损伤,降低术后早期认知功能下降发生率,但对术后认知功能障碍的发生无明显影响。

Objective To observe the effect of multiple monitoring of total intravenous anesthesia on postoperative cognitive function in elderly patients.Methods Elective 100 patients undergoing general anesthesia for abdominal operation,56 males,44females,aged 65-80 years,ASA physical statusⅡ orⅢ.All patients were divided into multiple monitoring group（group M）and routine monitoring group（group R）by random digital table method,n=50each.In group M,the anesthesiologists modulated anesthetic drugs to make NTI of 37-56 and rSO2 higher than 50% or not lower than the baseline value by 20%,while in group R the infusion rate of propofol,remifentanil and cisatracurium was adjusted by anesthesiologists according to anesthesiologist＇s experiences by the patients＇ monitoring index.Cognitive function of patients in the two groups were evaluated using MMSE 1dbefore surgery and 1d,3d,7d,1month and 3months after surgery.The occurrence of cognitive dysfunction 7d,1 month and 3 months after surgery,the postoperative recovery and the dosage of propofol,remifentanil and cisatracurium were recorded.Blood was randomly selected from each group to determine the serum content of S100β and Aβ1-42 by ELISA method at the time point of before surgery（T0）,one hour after starting surgery（T1）,the end of surgery（T2）and postoperative 24 hours（T3）.Results The incidence of postoperative cognitive decline in group M on 1d（8% vs.22%）,3d（2% vs.16%）after surgery were significantly lower than that in group R（P〈0.05）.Postoperative cognitive dysfunction between the two groups 7dand 1month,3months after surgery has no statistical significance.The dose of propofol[（3.3±0.8）mg·kg-1·h-1 vs.（3.7±0.7）mg·kg-1·h-1,P〈0.05]and cisatracurium [（104±47）μg·kg-1·h-1 vs.（124±68）μg·kg-1·h-1,P〈0.05]in group M was less than that in group R.The time of eye-opening[（10±3）min vs.（16±6）min,P〈0.01],extubation[（13±3）min vs.（22±7）min,P〈0.01]and location[（17±4）min vs.（27±9）min,P〈0.01]was shorter in group M.Compared with T0,the serum level of S100βprotein was significantly increased in group M at T1,T2 and group R at T1-T3（P〈0.05）;The level of serum S100βprotein in group M was significantly lower than that in group R（P〈0.05）.Compared with T0,Aβ1-42 protein level was significantly reduced in two groups at T1 and T2（P〈0.05）,but there was no significant difference between the two groups.Conclusion Total intravenous anesthesia with multiple monitoring can reduce neural injury and reduce the incidence of early postoperative cognitive decline in elderly patients with abdominal surgery,but has no significant effect on the incidence of POCD.