贫血患者腹腔镜手术中脑氧饱和度与神经损伤标志物的变化

Changes of cerebral oxygenation saturation and postoperative cognitive function in anemia patients undergoing laparoscopic surgery

背景脑对缺氧性损伤敏感,贫血可引起患者术中脑氧浓度下降,但目前鲜有研究探讨贫血对围术期中枢神经的影响。目的探讨不同程度贫血患者腹腔镜手术中脑氧饱和度和神经损伤标志物的变化。方法选取2018年10月-2019年10月拟择期行腹腔镜手术的132例患者,根据术前血红蛋白浓度(hemoglobin,Hb)分为3组:正常组58例(N组,Hb>120 g/L),轻度贫血组45例(A组,90~120 g/L),中度贫血组29例(B组,60~90 g/L)。记录各组患者在手术开始(T1)、改变体位(T2)、改变体位后40 min(T3)以及人工气腹结束(T4)时的平均动脉压、心率、脉搏氧饱和度(SPO2)以及呼气末二氧化碳分压(etCO2),并计算各时间段的脑氧饱和度(rSO2)平均值和术中脑氧合不良发生率。比较各组患者术前术后血清中枢神经特异性蛋白(S-100β)浓度变化及术后认知功能障碍(postoperative cognitive dysfunction,POCD)的发生率。结果三组患者性别、年龄、术前血清S-100β浓度、术前蒙特利尔认知评估(Montreal cognitive assessment,MoCA)评分无统计学差异(P>0.05)。与N组比较,A组在各时间点的rSO2、术中脑氧合不良发生率和苏醒时间无统计学差异,B组在T0(70.7%±6.3%vs 63.6%±8.5%,P<0.01)和T3-4(81.2%±7.5%vs 71.6%±17.8%,P<0.01)时的rSO2降低,术中脑氧合不良发生率(10.4%vs 34.5%,P=0.02)升高,苏醒时间(min)(14.0±4.7 vs 17.4±4.9,P=0.01)延长。与N组比较,B组术后MoCA评分[Md(IQR)][28(27,29)vs 27(24,28),P=0.03]降低,血清S-100β浓度(μg/L)(0.48±0.17 vs 1.08±0.37,P=0.00)和POCD发生率(17.2%vs 44.8%,P=0.02)升高。结论中度贫血患者在腹腔镜手术中更容易出现脑氧饱和度下降和中枢神经损伤,POCD发生率更高。

Background Brain is sensitive to hypoxic injury,and anemia can cause decreased cerebral oxygen concentration in patients during operation.However,few studies have explored the effect of anemia on central nervous system during perioperative period.Objective To explore the effect of different degree of anemia on intraoperative cerebral oxygenation saturation and postoperative cognitive function in patients undergoing laparoscopic surgery.Methods Totally 132 patients undergoing elective laparoscopic surgery from October 2018 to October 2019 were divided into normal group(group N,n=58),mild anemia group(group A,n=45)and moderate anemia group(group B,n=29)according to preoperative hemoglobin concentration.MAP,HR,SPO2 and etCO2 were recorded at the beginning of the operation(T1),body position change(T2),40 min after body position change(T3)and the end of artificial pneumoperitoneum(T4),and the average cerebral oxygen saturation(rSO2)of each period and incidence of cerebral hypoxia were calculated.Changes of serum S100βbetween before and after surgery as well as the incidence of postoperative cognitive dysfunction(POCD)were compared among groups.Results There was no significant difference in general condition,preoperative serum S-100βconcentration,preoperative MoCA score at each time point among different groups(P>0.05).No significant difference was found in rSO2,incidence of cerebral hypoxia and recovery time between the group N and the group A,while rSO2 at T0(63.6%±8.5%vs 70.7%±6.3%)and T3-4(71.6%±17.8%vs 81.2%±7.5%)in the group A were significantly lower than those in the group N,and the incidence of cerebral hypoxia(34.5%vs 10.4%),recovery time([17.4±4.9]min vs[14.0±4.7]min)were significantly higher than those in the group N(P<0.05,respectively).Compared with group N,MoCA score(28[6]vs 27[9],P=0.03)were significantly lower,and serum S-100βconcentration([0.48±0.17]μg/L vs[1.08±0.37]ug/L,P<0.01)and the incidence of POCD(17.2%vs 44.8%,P=0.02)were significantly higher after surgery in the group B(P<0.05).Conclusion Patients with moderate anemia are more prone to have cerebral oxygen desaturation and central nerve injury during laparoscopic surgery,those may lead to a higher incidence of POCD.