体外循环下Stanford A型主动脉夹层手术中深低温停循环时不同流量选择性脑灌注对术后认知功能的影响

Effect of selective cerebral perfusion with different flow during deep hypothermic circulatory arrest on postoperative cognitive function in Stanford A aortic dissection under cardiopulmonary bypass

目的观察体外循环深低温停循环(DHCA)下Stanford A型主动脉夹层手术中不同流量顺行选择性脑灌注(ASCP)对术后认知功能障碍的影响。方法选取新乡医学院第一附属医院2019年9月至2020年12月Stanford A型主动脉夹层并实施手术的患者60例,所有患者均在CPB DHCA+ASCP下行主动脉置换术。按ASCP流量不同分为三组,低流量组(L组,3 ml·kg^(-1)·min^(-1)),中流量组(M组,5 ml·kg^(-1)·min^(-1)),高流量组(H组,7 ml·kg^(-1)·min^(-1))。分别于术前(T0)、停循环5 min(T1)、复温至36℃时(T2)、术后24 h(T3)、术后48 h(T4)、术后72 h(T5),采集静脉血测定血清中神经特异性烯醇化酶(neuro-specific enolase,NSE)与S-100?蛋白浓度,记录苏醒和拔管时间。拔管后3天(T6)、7天(T7)及出院后1月(T8)以简易智能精神状态量表(MMSE)和蒙特利尔评估表(MoCA)评估其认知功能。术中用NIRS监测脑氧饱和度(rSO2)值,间断监测血气分析记录乳酸水平和术后认知功能障碍(postoperative cognitive dysfunction,POCD)发生率。结果三组患者在一般情况和转机前血红蛋白水平以及转机时间、升主动脉阻断时间、脑灌注时间均无明显差异(P>0.05);rSO2水平:T1、T2、T3时刻M组和H组均高于L组,P<0.05;T4和T5时刻三组rSO2水平无差别,P>0.05;血乳酸水平:T1、、T2时刻L组乳酸水平明显高于M组和H组P<0.05;T0,T3,T4,T5时刻组内比较无明显差异,P>0.05;S100β蛋白水平:T1、T2、T3、T4时刻M组S100β蛋白水平明显低于L和H组,P<0.05,H组S100β蛋白水平明显低于L组,P<0.05;NSE水平:T1、T2、T3、T4时刻M组NSE水平明显低于L组和H组,P<0.05;M组的POCD发生率在T6、T7、T8时刻均明显低于L组和H组,P<0.05。结论选择性脑灌注采用5 ml·kg^(-1)·min^(-1)有较好的神经系统保护作用,可满足深低温停循环下脑灌注,减少术后认知功能障碍的发生率和神经系统并发症。

Objective To explore the effect of antegrade selective cerebral perfusion of(ASCP)with different flow rates during deep hypothermic circulatory arrest((DHCA))on cognitive impairment in patients undergoing cardiovascular surgery.Methods 60 patients with aortic aneurysm in The First Affiliated Hospital of Xinxiang Medical College from September 2018 to December 2020 were selected.All patients underwent DHCA+ASCP operation.According to the difference of ASCP flow,they were divided into three groups:low flow group(L group 3 ml·kg^(-1)·min^(-1)),medium flow group(M group 5 ml·kg^(-1)·min^(-1))and high flow group(H group 7 ml·kg^(-1)·min^(-1)).Before operation(T0),circulatory arrest 5 min(T1),rewarming to 36℃(T2),postoperative 24 h(T3),postoperative 48 h(T4),postoperative72 h(T5)S100 protein and neuron specific enolase(NSE)were measured by ELISA method.The cognitive function was evaluated with Mini Mental State scale((MMSE))and Montreal assessment form at 3 days after extubation(T6)and 7 days after extubation(T7),and 1 month after discharge(T8).Cerebral oxygen saturation(rSO2)was monitored by NIRS during operation.The level of lactate and the incidence of postoperative cognitive dysfunction(POCD)were recorded.Record the time of awakening and extubation.Results There was no significant difference in hemoglobin level,transit time,ascending aorta occlusion time and cerebral perfusion time among the three groups(P>0.05).rSO2 level in group M and group H was higher than that in group L at T1,T2 and T3(P<0.05);there was no significant difference in rSO2 level between the three groups at T4 and T5(P>0.05).At T1,T2,the lactate level of group L was significantly higher than that of group M and group H(P<0.05)and there was no significant difference at T0,T3,T4 and T5(P>0.05).S100βProtein level in group M at T1,T2,T3 and T4 were significantly lower than that in group L and H(P<0.05)and that in group H was significantly lower than that in group L(P<0.05).At T1,T2,T3 and T4,NSE level of group M were significantly lower than that of group L and group H(P<0.05).The incidence of POCD in group M was significantly lower than that in group L and group H at T6,T7 and T8(P<0.05).Conclusion Selective cerebral perfusion with 5 ml·kg^(-1)·min^(-1)can satisfy cerebral perfusion under deep hypothermic circulatory arrest and with brain protective effect and reduce the incidence of postoperative cognitive dysfunction.