心肺转流期间平均动脉压对瓣膜置换术患者脑功能的影响

Effect of mean arterial pressure during cardiopulmonary bypass on brain function of patients undergoing valve replacement

目的探讨瓣膜置换术心肺转流(CPB)期间两种不同MAP对局部脑氧饱和度(rScO_(2))、特异性神经元烯醇酶(NSE)浓度及简易精神状态量表(MMSE)评分的影响。方法选择CPB下行瓣膜置换术患者50例,男23例,女27例,年龄35~74岁,BMI 18.5~24.9 kg/m_(2),ASAⅡ或Ⅲ级,NYHAⅡ或Ⅲ级。根据CPB期间血压不同分为两组:MAP 70~85 mmHg组(H组)和MAP 55~69 mmHg组(M组),每组25例。记录麻醉诱导前(T_(0))、CPB期间(T_(1))、停机后(T_(2))的rScO_(2)。记录T_(0)、入ICU前(T_(3))、术后24 h(T_(4))血浆NSE浓度。记录CPB期间rScO_(2)下降幅度超过20%的发生率。记录术前、术后1 d和术后7 d MMSE评分。结果与T_(0)时比较,T_(1)时两组rScO_(2)明显降低,T_(3)时两组NSE浓度明显升高(P<0.05)。与T_(1)时比较,T_(2)时两组rScO_(2)明显升高(P<0.05)。与T_(3)时比较,T_(4)时两组NSE浓度明显降低(P<0.05)。H组CPB期间rScO_(2)下降幅度超过20%的发生率明显高于M组(P<0.05)。与术前比较,术后1 d两组MMSE评分明显降低(P<0.05)。与术后1 d比较,术后7 d两组MMSE评分明显升高(P<0.05)。结论在瓣膜置换术CPB期间,不同MAP对术中rScO_(2)、NSE浓度及术后认知功能的影响无明显差异,但MAP 55~69 mmHg时rScO_(2)稳定性更高,可能与去氧肾上腺素使用剂量及间断推注给药的方式有关。

Objective To investigate the effects of two different mean arterial pressures(MAP)on regional cerebral oxygen saturation(rScO_(2)),concentration of specific neuron enolase(NSE)and MMSE scores during cardiopulmonary bypass patients.Methods Fifty patients undergoing CPB valve replacement surgery,23 males and 27 females,aged 35-74 years,BMI 18.5-24.9 kg/m 2,ASA physical statusⅡorⅢ,NYHAⅡorⅢ,were divided into two groups according to the intraoperative blood pressure level:group M(MAP 55-69 mmHg)and group H(MAP 70-85 mmHg),25 patients in each group.The values of rScO_(2) and hemodynamic indicators were recorded before induction of anesthesia(T_(0)),during CPB(T_(1)),and after shutdown(T_(2)),and calculate the average;induction of anesthesia plasma NSE was measured before(T_(0)),before entering ICU(T_(3)),and 24 hours after operation(T_(4)).The number of cases where rScO_(2) during CPB has dropped by more than 20%were recored.Patients were scored with MMSE at 1 day before operation,1 day after operation and 7 days after operation.Results Compared with T_(0),rScO_(2) in the two groups was significantly reduced at T_(1)(P<0.05).Compared with T_(1),rScO_(2) was significantly increased at T_(2) in the two groups(P<0.05).Compared with T_(0),the NSE concentration of the two groups increased significantly at T_(3)(P<0.05).Compared with T_(3),the NSE concentration of the two groups was significantly reduced at T_(4)(P<0.05).Compared with group M,the number of cases where the rScO_(2) value decreased by more than 20%during CPB in group H was significantly increased(P<0.05).Compared with preoperatively,the MMSE scores of the two groups were significantly reduced 1 day after operation(P<0.05).Compared with 1 day after operation,the MMSE scores of the two groups were significantly increased 7 days after operation(P<0.05).Conclusion Different level of MAP have similar effects on intraoperative rScO_(2),postoperative cognitive function and NSE concentration during CPB of valve replacement.However,rScO_(2) in group M is more stable in group H,which may be related to the use of norepinephrine.