老年腹腔镜肝部分切除术后认知功能障碍的影响因素

INFLUENCING FACTORS FOR POSTOPERATIVE COGNITIVE DYSFUNCTION IN ELDERLY PATIENTS UNDERGOING LAPAROSCOPIC PARTIAL HEPATECTOMY

目的探讨腹腔镜肝部分切除术老年病人术后认知功能障碍(POCD)的相关影响因素。方法选择全身麻醉下行腹腔镜肝部分切除术病人138例,男79例,女59例;年龄≥65岁,BMI 18~29 kg/m^(2),美国麻醉医师协会(ASA)分级Ⅱ或Ⅲ级。所有病人均于麻醉开始后实施控制性低中心静脉压(CLCVP)至肝实质切除,术中持续监测局部脑氧饱和度(rScO_(2)),采用老年病人衰弱(FRAIL)量表评估病人术前衰弱情况,采用简易智力状况检查(MMSE)量表评估病人术前1 d与术后第7天的认知功能。根据术后第7天认知功能评分将病人分为POCD组与非POCD组。记录病人一般情况、手术时间、麻醉时间、CLCVP时间、肝门阻断例数、术中舒芬太尼和瑞芬太尼用量、失血量、输液量、尿量、rScO_(2)基线值(rScO_(2)base)、术中rScO_(2)最小值(rScO_(2min))和最大值(rScO_(2max))以及下降最大百分数(rScO_(2)%max)等围术期监测指标,采用多因素logistic回归分析POCD发生的影响因素。结果138例病人POCD发生率为26.1%。与非POCD比较,POCD组病人术前衰弱比例升高、受教育程度降低,术中rScO_(2min)下降、失血量及rScO_(2)%max增大,术后住院时间延长及非神经系统并发症发生率增加,差异均有统计学意义(t/χ^(2)/z=-5.043~9.320,P<0.05)。多因素logistic回归分析结果显示,术前衰弱(OR=5.314)、rScO_(2min)(OR=1.282)以及rScO_(2)%max(OR=1.567)是POCD发生的独立危险因素。结论腹腔镜肝部分切除术老年病人术前衰弱以及术中rScO_(2)下降程度增大会增加POCD发生的风险。

Objective To investigate the influencing factors for postoperative cognitive dysfunction(POCD)in elderly patients undergoing laparoscopic partial hepatectomy.Methods A total of 138 patients who underwent laparoscopic partial hepatectomy under general anesthesia were enrolled,among whom there were 79 male patients and 59 female patients,with an age of≥65 years,a body mass index of 18-29 kg/m 2,and an ASA grade ofⅡorⅢ.All patients received controlled low central venous pressure(CLCVP)after the start of anesthesia till parenchymal hepatectomy,and regional cerebral oxygen saturation(rScO_(2))was constantly monitored during surgery.Fatigue,Resistance,Ambulation,Illnesses,and Loss of Weight(FRAIL)scale was used to evaluate the preoperative frailty of patients,and Mini-Mental State Examination(MMSE)scale was used to evaluate the cognitive function of patients on 1 day before surgery and on day 7 after surgery.The patients were divided into POCD group and non-POCD group according to cognitive function score on day 7 after surgery.Related perioperative indicators were recorded,including general conditions,time of operation,duration of anesthesia,CLCVP time,number of cases with hepatic portal occlusion,the amount of sufentanil and remifentanil used during surgery,blood loss,infusion volume,urine volume,baseline rScO_(2)(rScO_(2base)),minimum rScO_(2)(rScO_(2min))and maximum rScO_(2)(rScO_(2max))during surgery,and the maximum percentage of reduction in rScO_(2)(rScO_(2)%max),and a multivariate logistic regression analysis was used to investigate the influencing factors for POCD.Results The incidence rate of POCD was 26.1%among the 138 patients.Compared with the non-POCD group,the POCD group had a significantly higher proportion of patients with preoperative frailty,a significantly lower educational level,a significant reduction in rScO_(2min)during surgery,significant increases in blood loss and rScO_(2)%max,a significantly longer length of postoperative hospital stay,and a significantly higher incidence rate of non-neurological complications(t/χ^(2)/z=-5.043 to 9.320,P<0.05).The multivariate logistic regression analysis showed that preoperative frailty(OR=5.314),rScO_(2min)(OR=1.282),and rScO_(2)%max(O R=1.567)were independent risk factors for POCD.Conclusion For elderly patients undergoing laparoscopic partial hepatectomy,preo-perative frailty and the reduction in rScO_(2)during surgery may increase the risk of POCD.