右美托咪定对心脏瓣膜置换术者围术期的神经保护作用及认知水平的影响

Effects of dexmedetomidine on perioperative neuroprotection and cognitive level in patients undergoing cardiac valve replacement

目的探究右美托咪定在心脏瓣膜置换术麻醉中的神经保护作用及对患者术后认知水平的影响。方法选取2015年8月至2018年3月实施心脏瓣膜置换术患者88例,分为研究组和对照组,各44例。研究组麻醉诱导前加用右美托咪定并使用维持量至手术完毕,对照组为等量生理盐水代替,对比患者术前麻醉诱导(T0)、手术停止后(T1)、术后第3天(T2)、术后第7天(T3)中心静脉血中白细胞介素(IL)-6、肿瘤坏死因子(TNF)-α、颈内静脉氧饱和度(SjvO2)、动脉-颈内静脉血氧含量差(Da-jvO2)、脑氧摄入率(CE-RO2),利用简易精神状态量表(MMSE)、认知情况判定量表(MoCA)对术前1天及T2、T3时的精神及认知水平进行评定。结果重复测量数据方差分析结果显示,两组IL-6、TNF-α、SjvO2、Da-jvO2水平、MMSE评分、MoCA评分的时间效应、交互效应及组间效应均有统计学意义(P均<0.01)。两组CE-RO2时间效应及组间效应均有统计学意义(P均<0.01),交互效应无统计学意义(P>0.05)。(1)IL-6、TNF-α水平:两组于T1时均增高,T0、T2、T3时比T1显著减少,且研究组T0、T1、T2、T3时均比对照组明显降低(P均<0.01)。(2)SjvO2水平:两组T1时显著增高,随后呈进行性减少,且对照组T1、T2、T3时比研究组明显减少(P均<0.05)。(3)Da-jvO2、CE-RO2水平:两组T1时显著减少,随后呈进行性增高,且对照组T1、T2、T3时比研究组明显增加(P均<0.05)。(4)MMSE及MoCA评分:T2、T3时对照组比研究组明显下降(P均<0.01)。结论右美托咪定于心脏瓣膜置换术中可起到保护神经作用,有利于改善患者脑缺氧再灌注状态,发挥保护脑组织效果,降低患者术后认知水平障碍发生率,对提高心脏瓣膜置换患者术后生活质量具有重要意义。

Objective To investigate the effects of dexmedetomidine on neuroprotection in anesthesia of patients undergoing cardiac valve replacement and on post-operative cognitive function.Methods Eighty-eight patients undergoing cardiac valve replacement from August 2015 to March 2018 were selected and divided into study group and control group(n=44,each).Dexmedetomidine was used before anesthesia induction and maintained until the end of operation in study group,while the same amount of normal saline was given in control group.At anesthesia induction before operation(T0),after cessation of operation(T1),the third day(T2)and the seventh day after operation(T3),the levels of IL-6 and TNF-α,jugular venous oxygen saturation(SjvO2),arterio-jugular venous oxygen content difference(Da-jvO2)and cerebral oxygen extraction rate(CE-RO2)were compared between two groups.At 1 day before operation,T2 and T3,the mental and cognitive levels were evaluated by mini mental state examination(MMSE)and Montreal cognitive assessment scale(MoCA).Results Repeated measurement analysis of variance showed that there were statistical differences in time-,interaction-and inter-group-effect of levels of IL-6,TNF-α,SjvO2,Da-jvO2 and MMSE score,MoCA score(all P<0.01);there were statistical differences in time effect and inter-group effect of CE-RO2(all P<0.05),but not in its interaction effect in two groups(all P>0.05).At T0,T1,T2 and T3,the levels of IL-6,TNF-αsignificantly decreased in study group compared with those in control group(all P<0.01).In both groups,the levels of IL-6 and TNF-αincreased at T1 and decreased significantly at T0,T2 and T3 compared with T1(all P<0.05);SjvO2 level increased significantly at T1,and then decreased progressively and were significantly lower in control group than that in study group at T1,T2 and T3(all P<0.05);Da-jvO2 and CE-RO2 decreased significantly at T1,and then increased progressively and were significantly higher in control group than those in study group at T1,T2 and T3(all P<0.05).At T2 and T3,the scores of MMSE and MoCA in control group were significantly lower than those in study group(all P<0.01).Conclusion Dexmedetomidine can protect the nerves,improve the state of cerebral hypoxia reperfusion,play the role of protecting brain tissue in anesthesia of patients undergoing cardiac valve replacement,reduce the incidence of post-operative cognitive disorders and improve the quality of life of patients.