不同麻醉诱导方法对老年腰椎手术患者早期术后认知功能障碍发生率的影响

Effects of different anesthetic induction methods on early postoperative cognitive dysfunction in elderly patients

目的观察清醒健忘慢诱导麻醉和快诱导麻醉对老年腰椎手术患者早期术后认知功能障碍(post operative cognitive dysfunction,POCD)的影响。方法选择行全身麻醉的腰椎手术患者100例,将其随机分为清醒健忘慢诱导组(M组,n=50)和快诱导组(K组,n=50),术中全凭静脉麻醉维持。于麻醉诱导前(A1)、拔管后(A2)、术后第1天(A3)、术后第3天(A4)、术后第7天(A5)5个时间点采集2组患者静脉血,用ELISA法测定血浆中炎性细胞因子白细胞介素1β(IL-1β)、白细胞介素6(IL-6)、肿瘤坏死因子(TNF-α)、高迁移率族蛋白1(high mobility group box-1 protein,HMGB1)和S100蛋白(S100P)的浓度。于术前第1天、术后第3天、术后第7天进行神经心理学测试,评估患者术后是否发生早期POCD;于入室后静卧5 min(T1)、麻醉诱导后即刻(T2)、插管后即刻(T3)、手术开始(T4)、手术结束(T5)、拔管后即刻(T6)6个时间点记录2组患者的血压(SBP/DBP)、心率(heart rate,HR)和脑氧饱和度(Sct O2);并记录2组患者术前及术中一般情况。结果T1时,M组HR较K组快(P<0.05);T2时,M组SBP较K组高(P<0.05);T4时,M组Sct O2较K组高(P<0.05)。A3、A4时,K组IL-6较M组高(P<0.05);A2、A3、A4时,K组HMGB1较M组高(P<0.05)。与A1时比较,A3、A5时2组IL-6均明显升高(P<0.05),与A2时比较,A3时2组IL-6均明显升高(P<0.05)。与A1时比较,A2、A3和A4时K组HMGB1明显升高(P<0.05),A3时M组HMGB1明显下降(P<0.05)。K组术后第3天POCD 10例(20%),M组1例(2%)(χ~2=8.274,P<0.01);K组术后第7天POCD 8例(16%),M组0例(0),(χ~2=6.658,P<0.05)。结论清醒健忘慢诱导麻醉方式比快诱导麻醉方式引起老年患者术后早期POCD的发生率低。

Objective To find out whether there is any difference in the incidence of early POCD between awake slow induction anesthesia and fast induction anesthesia in elderly patients.Methods A total of 100 patients undergoing lumbar surgery in general anesthesia were enrolled. All the patients were randomly divided into awake slow induction group （Group M,n=50） and fast induction group （Group K,n=50）, and were maintained with total intravenous anesthesia（TIVA）. Venous blood was collected from the two groups at five time points： before anesthetic induction （A0）, after extubation （A1）, the first day after operation （A2）, the third day after operation （A3） and the seventh day after operation （A4）, to test the concentration of plasma inflammatory cytokines IL-1β, IL-6, TNF-α, HMGB1 and S100P by ELISA method. Neuropsychological tests were conducted the day before surgery, the third day and seventh day after surgery respectively to assess whether the elderly patients had early POCD after operation. The blood pressure （SBP/DBP）, heart rate （HR） and cerebral regional oxygen saturation（SctO2） were recorded at six time points as follows： before operation （T1）, immediately after induction of anesthesia （T2）, immediately after intubation （T3）, at the beginning of operation（T4）, at the end of operation（T5）, immediately after extubation （T6）. The general condition of the two groups of patients before and during operation was recorded.Results Compared with Group K, HR was quicker at T1 in Group M（P〈0.05）, SBP was higher at T2（P〈0.05）, so was SctO2 at T4（P〈0.05）.The level of IL-6 in Group K at A3 and A4 was higher than in Group M （P〈0.05）. The level of HMGB1 in Group K at A2, A3 and A4 was higher than in Group M （P〈0.05）. The level of IL-6 in both groups at A3 and A5 was significantly elevated compared with A1 or A2（P〈0.05）. The level of HMGB1 in Group K at A2, A3 and A5 was more significantly elevated than at A1（P〈0.05）, but the level of HMGB1 in Group M at A3 was significantly decreased（P〈0.05）. On the third day after operation, there were ten patients diagnosed with early POCD in Group K（20%） and one in Group M（2%） （P〈0.05）. On the seventh day after operation, there were eight patients diagnosed with POCD in Group K（16%） but none in Group M（0%） （P〈0.05）.Conclusion The incidence of early POCD in elderly patients with awake slow induced anesthesia is lower than that of fast induced anesthesia.