颈静脉球部压力对CPB下瓣膜置换术-冠状动脉旁路移植术老年患者术后认知功能的影响

Effects of jugular vein bulb pressure on postoperative cognitive function in elderly patients undergoing valve replacement-coronary artery bypass grafting under cardiopulmonary bypass

目的评价颈静脉球部压力(JVBP)对体外循环(CPB)下瓣膜置换术-冠状动脉旁路移植术老年患者术后认知功能的影响。方法择期CPB下行瓣膜置换术-冠状动脉旁路移植术患者92例,性别不限,年龄65~75岁,体重指数18~25 kg/m2,ASA分级Ⅱ或Ⅲ级,NYHA分级Ⅱ或Ⅲ级。右侧颈内静脉穿刺置管监测CVP并行逆行置管测定JVBP,于麻醉诱导后即刻(T11)、CPB结束10 min(T12)和手术结束(T13)时记录JVBP,并依据JVBP将患者分为2组:JVBP<12 mmHg组(L组)和JVBP≥12 mmHg组(H组)。于T11-13、术后第1天(T14)和术后第2天(T15)时记录HR、MAP和CVP,采集颈内静脉球部血2 ml测定血浆S100β蛋白、基质金属蛋白酶9(MMP-9)浓度和血清神经元特异性烯醇化酶(NSE)浓度;分别于术前1 d(T21)、术后3、7 d(T22,23)和术后3个月(T24)时采用简易精神状态量表(MMSE)法评价认知功能。结果纳入80例患者,L组46例,H组34例。与T11时比较,H组T12时、2组T13-15时CVP、T12,13时JVBP、T12-15时血浆S100β蛋白、MMP-9浓度和血清NSE浓度升高(P<0.05);与T21时比较,2组T22,23时MMSE评分降低(P<0.05);与L组比较,H组T12,13时JVBP、T12-14时CVP、T13时血浆S100β蛋白、MMP-9浓度和血清NSE浓度升高,T12时血浆S100β蛋白浓度升高,T22-24时MMSE评分降低,POCD发生率升高(P<0.05)。JVBP与CVP、血浆S100β蛋白、MMP-9浓度及血清NSE浓度呈正相关,r分别为0.95、0.56、0.70和0.58(P<0.05)。结论JVBP升高可降低CPB下瓣膜置换术-冠状动脉旁路移植术老年患者术后认知功能,其机制与血脑屏障损伤有关。

Objective To evaluate the effect of jugular vein bulb pressure(JVBP)on postoperative cognitive function in elderly patients undergoing valve replacement-coronary artery bypass grafting under cardiopulmonary bypass(CPB).Methods Ninety-two patients of both sexes,aged 65-75 yr,with body mass index of 18-25 kg/m2,of American Society of Anesthesiologists physical statusⅡorⅢ,with New York Heart Association classⅡorⅢ,were selected.All the patients underwent right internal jugular vein catheterization to monitor central venous pressure(CVP)and retrograde catheterization to measure JVBP.JVBP was recorded immediately after anesthesia induction(T11),10 min after CPB(T12)and at the end of operation(T13).The patients were divided into 2 groups according to JVBP:JVBP<12 mmHg group(group L)and JVBP≥12 mmHg group(group H).At T11-13 and on 1st and 2nd days after operation(T14,15),heart rate,mean arterial pressure(MAP)and central venous pressure(CVP)were recorded,and blood samples from the jugular vein bulb were collected to determine the concentrations of S100βprotein and matrix metalloproteinase-9(MMP-9)in plasma and nerve specific enolase(NSE)in serum.Cognitive function was evaluated by Mini-Mental State Examination(MMSE)at 1 day before operation(T21),3 and 7 days after operation(T22,23)and 3 months after operation(T24).Results A total of 80 patients were included in this study,including 46 patients in group L and 34 patients in group H.Compared with those at T11,CVP,JVBP,and concentrations of S100βprotein and MMP-9 in plasma and NSE in serum were significantly increased at T12 in group H,and CVP at T13-15 and JVBP at T12,13 and concentrations of S100βprotein and MMP-9 in plasma and NSE in serum at T12-15 were significantly increased in two groups(P<0.05).MMSE scores were significantly lower at T22,23 than at T21 in the two groups(P<0.05).Compared with group L,JVBP at T12,13,CVP at T12-14 and concentrations of S100βprotein and MMP-9 in plasma and NSE in serum at T13 were significantly increased,concentrations of S100βprote in plasma were increased at T12,MMSE scores were decreased at T22-24,and the incidence of POCD was increased in group H(P<0.05).JVBP was positively correlated with CVP,plasma S100βprotein,MMP-9 concentration and serum NSE concentration,and the r values were 0.95,0.56,0.70 and 0.58,respectively(P<0.05).Conclusion Increased JVBP can decrease the postoperative cognitive function of elderly patients undergoing valve replacement-coronary artery bypass grafting under CPB,and the mechanism is related to blood-brain barrier damage.