肺癌患者围术期医院感染危险因素及常用麻醉药物对预后的影响

Risk factors of nosocomiai infection during perioperative period in patients with lung cancer and influence of common used anesthetic drugs on the prognosis

目的分析肺癌围术期医院感染危险因素，分析不同麻醉药物对可溶性白细胞介素2受体（SIL-2R）、白细胞介素6（IL-6）、肿瘤坏死因子α（TNF-α）表达水平以及术后认知功能和镇痛效果的影响。方法选取2014年1月1日至2016年9月1日广东省普宁市中医医院肺癌围术期患者272例为研究对象。将性别、年龄等基本情况、手术情况、住院情况等13类因素纳入肺癌围术期医院感染相关因素分析，通过多因素Logistic回归分析得出肺癌围术期医院感染的独立危险因素。分析异氟醚、七氟烷、丙泊酚联合瑞芬太尼3种麻醉方法对发生医院感染患者不同时间SIL-2R、IL-6、TNF—α水平以及简易精神状态评价量表（MMSE）和疼痛数字评价量表（NRS）评分的影响。结果272例患者发生医院感染80例，感染率为29．4％。年龄〉60岁、手术持续时间〉4h、术中失血量〉400ml、住院时间〉15d是肺癌围术期医院感染的独立危险因素[比值比=2．974，95％置信区间：1．159～6．376，P=0．042；比值比：3．654，95％置信区间：1．432～3．865，P=0．002；比值比=3．712，95％置信区间：2．513～7．456，P〈0．001；比值比=2．324，95％置信区间：1．314～9．735，P=0．015]。80例医院感染患者中，采用异氟醚麻醉24例（A组），七氟烷麻醉28例（B组），丙泊酚联合瑞芬太尼麻醉28例（C组）。缝合时，C组SLR-2R明显高于A和B组[（634±120）kU／L比（550±128）、（559±126）kU／L]；差异均有统计学意义（均P〈0．05）。缝合时和术后12h，A和C组IL-6、TNF-α均明显高于B组[IL-6：（160±37）、（163±30）ng／L比（104±11）ng／L，（101±13）、（111±14）ng/L比（73±9）ng／L；TNF—α（74±12）、（83±6）ng／L比（50±11）ng／L，（78±7）、（70±9）ng／L比（48±10）ng／L]；差异均有统计学意义（均P〈0．05）。C组术后1hMMSE评分明显低于A和B组[（19．5±1．2）分比（27．3±2．1）、（28．1±1．9）分]，术后30min、1hNRS评分明显高于A和B组[（4．7±1．6）分比（2．9±2．0）、（2．1±1．2）分，（4．9±1．1）分比（3．2±1．0）、（3．5±1．4）分]，差异均有统计学意义（均P〈0．05）。结论年龄〉60岁、术中失血量〉400ml、手术持续时间〉4h、住院时间〉15d是肺癌围术期医院感染的独立危险因素。七氟烷能够较好地控制SIL-2R、IL-6、TNF-α表达；异氟醚和七氟烷麻醉的术后MMSE评分和镇痛效果较为理想。

Objective To analyze risk factors of nosocomial infection during perioperative period in patients with lung cancer; to analyze effects of different anesthetic drugs on expressions of soluble interleukin-2 receptor（ SIL-2R）, interleukin-6 （ IL-6 ）, tumor necrosis factor-α （ TNF-α）, postoperative cognitive function and analgesic effects. Methods Totally 272 patients with lung cancer undergoing surgical resection were enrolled from January 1, 2014 to September 1,2016 in Puning Traditional Chinese Medicine Hospital. Risk factors of nosocomial infection during perioperative period were analyzed through multivariate logistic regression method. Effects of different anesthetic drugs（ isoflurane, sevoflurane, propofol plus remifentanil） on levels of SIL-2R, IL-6, TNF-α and scores of the Mini-Mental State Examination（MMSE） and Pain Numerical Rating Scale（NRS） were analyzed. Results Nosocomial infection occurred in 80 cases, the infection rate was 29.4%. Age 〉 60 years, duration of operation 〉 4 h, intraoperative blood loss 〉 400 ml and length of hospital stay 〉 15 d were independent risk factors of nosocomial infection [ odds ratio = 2. 974, 95% confidence interval： 1. 159-6. 376, P = 0. 042 ; odds ratio = 3.654, 95% confidence interval： 1. 432-3. 865, P = 0. 002; odds ratio = 3. 712, 95% confidence interval： 2. 513-7. 456, P 〈0.001 ; odds ratio =2. 324, 95% confidence interval： 1. 314-9. 735, P =0.015 ] （P 〈0. 05）. In 80 cases of nosoeomial infection, 24 patients had isoflurane anesthesia（ group A）, 28 patients had sevoflurane anesthesia（ group B） and 28 patients had propofol plus remifentanil（ group C）. The level of SLR-2R when stitching incision in group C was significantly higher than that in group A and B[ （634 ± 120）kU/L vs （550 ± 128）, （559 ± 126）kU/L] （P 〈0. 05）. Levels of IL-6 and TNF-α when stitching incision and at 12 h after operation in group C were significantly higher than those in group A and B [ IL-6 ： （ 160 ± 37 ）, （ 163 ± 30 ） ng/L vs （ 104 ± 11 ） ng/L ; （101 ±13）,（111 ± 14）ng/L vs （73 ±9）ng/L; TNF-α （74 ± 12）,（83 ±6）ng/L vs （50 ± ll）ng/L; （78 ±7）, （70 ±9）ng/L vs （48 ± 10）ng/L] （P 〈0. 05）. The score of MMSE 1 h after operation in group C was significantly lower than that in group A and B [ （ 19.5 ± 1.2） points vs （27.3 ± 2.1 ）, （ 28.1 ± 1.9） points ] （ P 〈 0. 05 ） ; scores of NRS 30 min, 1 h after operation in group C were significantly lower than those in group A and B [（4.7±1.6）points vs （2.9 ±2.0）,（2. 1 ± 1.2）points; （4.9 ± 1. 1）points vs （3.2 ±1.0）,（3.5 ± 1.4 ） points ] （ P 〈 0. 05 ）. Conclusions Age 〉 60 years, intraoperative blood loss 〉 400 ml, duration of operation 〉 4 h, length of hospital stay 〉 15 d are independent risk factors of nosocomial infection during perioperative period of lung cancer resection. Sevoflurane has a better effect on inhibiting expressions of SIL-2R, IL-6 and TNF-α; isoflu- rane and sevoflurane have better postoperative analgesic effects and patients generally have higher MMSE scores.