右美托咪定联合远端缺血预处理对胸腔镜手术老年患者局部脑氧饱和度及术后谵妄的影响

Effect of Dexmedetomidine combined with remote ischemic preconditioning on rSO_(2) and postoperative delirium in elderly patients undergoing video-assisted thoracoscopic surgery

目的探讨右美托咪定(Dex)联合远端缺血预处理(RIPC)对单肺通气(OLV)老年患者局部脑氧饱和度(rSO_(2))及术后谵妄(POD)的影响。方法选取择期行胸腔镜下OLV的老年患者80例,按随机数表法分为4组(每组20例):对照组(C组)、单纯Dex组(Dex组)、单纯RIPC组(RIPC组)和Dex联合RIPC组(Dex+RIPC组)。观察各组患者麻醉诱导前(T_(0))、OLV前(T_(1))、OLV后10 min(T_(2))、OLV后30 min(T_(3))、OLV结束时(T_(4))以及手术结束时(T_(5))的rSO_(2),并记录T_(0)、T_(2)、T_(4)、术后6 h(T_(6))和术后24 h(T_(7))静脉血中血清白细胞介素-10(IL-10)、白细胞介素-6(IL-6)及肿瘤坏死因子-α(TNF-α)的含量及术后并发症发生情况;于术后1 d评估各组患者POD。结果在T_(2)时点,Dex+RIPC组rSO_(2)明显高于其他3组(P<0.05);在T_(3)和T_(4)时点,C组、Dex组、RIPC组和Dex+RIPC组rSO_(2)依次升高,组间相互比较,差异均有统计学意义(P<0.05);在T_(5)时点,RIPC组rSO_(2)明显高于C组和Dex组(P<0.05),Dex+RIPC组明显高于RIPC组(P<0.05),但C组与Dex组比较差异无统计学意义。与C组比较,Dex组和RIPC组术后1 d谵妄评定方法中文修订版(CAM-CR)评分差值明显降低(P<0.05),且Dex+RIPC组明显低于Dex组和RIPC组(P<0.05)。Dex+RIPC组POD发生率明显低于C组(P<0.05)。Dex组、RIPC组和Dex+RIPC组IL-6和TNF-α在T_(4)、T6和T7时点均较C组低,而IL-10较C组高。Dex+RIPC组术后恶心呕吐和苏醒期躁动发生率较C组明显降低(P<0.05),而与Dex组和RIPC组比较,差异无统计学意义。结论Dex联合RIPC能够稳定老年患者单肺通气后rSO_(2)水平,并可有效抑制炎性细胞因子释放,降低POD发生率。

Objective To evaluate the effect of Dexmedetomidine(Dex)combined with remote ischemic preconditioning(RIPC)on regional cerebral oxygen saturation(rSO_(2))and postoperative delirium(POD)in elderly patients with one-lung ventilation(OLV).Methods 80 elderly patients with elective thoracoscopic OLV were selected,and they were divided into 4 groups(20 cases in each group)according to the random number table:the control group(C group),the pure Dex group(Dex group),simple RIPC group(RIPC group)and Dex combined with RIPC group(Dex+RIPC group).Record the rSO_(2) of each group before induction of anesthesia(T_(0)),before OLV(T_(1)),10 min after OLV(T_(2)),30 min after OLV(T_(3)),end of OLV(T_(4))and at the end of surgery(T_(5)),serum interleukin 10(IL-10),interleukin-6(IL-6)and tumor necrosis factor-α(TNF-α)level at T_(0),T_(2),T_(4),6 h after surgery(T_(6))and 24 h after surgery(T_(7)),and the occurrence of adverse postoperative complications in each group.POD was evaluated 1 day after operation.Results At T_(2),rSO_(2) in the Dex+RIPC group was significantly higher than that in the other 3 groups(P<0.05);At T_(3) and T_(4),rSO_(2) in C,Dex,RIPC and Dex+RIPC group increased in sequence,and the differences were statistically significant(all P<0.05);At T_(5),rSO_(2) in the RIPC group was significantly higher than that in group C and Dex group(P<0.05),the Dex+RIPC group was significantly higher than the RIPC group(P<0.05),but there was no statistical difference between the C and Dex groups.Compared with C group,the difference in CAM-CR scores of Dex group and RIPC group was significantly reduced at 1 day after surgery(P<0.05),and the Dex+RIPC group was significantly lower than that of Dex group and RIPC group(P<0.05).The incidence of POD in Dex+RIPC group was significantly lower than that in group C(P<0.05).Compared with C group,IL-6 and TNF-αin Dex group,RIPC group and Dex+RIPC group decreased at T_(4),T6 and T7,while IL-10 increased.The incidence of postoperative nausea and vomiting and agitation in Dex+RIPC group was significantly reduced(P<0.05).Conclusion Dex combined with RIPC can stabilize the rSO_(2) level after OLV in elderly patients,and can effectively inhibit the release of inflammatory cytokines and reduce the incidence of postoperative delirium.