远隔缺血预处理联合后处理对体外循环下心脏瓣膜置换术患者术后谵妄的影响

Effect of remote ischemic preconditioning combined with postconditioning on postoperative delirium in patients undergoing cardiac valve replacement under cardiopulmonary bypass

目的探讨远隔缺血预处理联合后处理(RIPC+RIPostC)对体外循环(CPB)下心脏瓣膜置换术患者术后谵妄(POD)的影响。方法招募于本院手术室接受择期CPB下心脏瓣膜置换术的患者80例,年龄44~64岁,依据随机数字表法将其分成对照组(C组)和处理组(R组),每组40例。R组患者于CPB开始前30 min实施RIPC,并于CPB结束前30 min实施RIPostC。具体处理措施:患者下肢绑好充气式袖带,充气加压直至压力为200 mmHg(1 mmHg=0.133 kPa),保持5 min,随后袖带完全放气直至压力为0;5 min后再次充气加压,如此进行3个循环;C组将袖带绑于患者下肢,但不进行充气及放气操作。分别于术前1天及术后第1、3天时抽取外周静脉血并测定血常规。术后3天内采用重症监护室(ICU)意识障碍评估法(CAM-ICU)进行POD的评估。神经认知测试在术前、出院时和术后3个月进行,术后认知功能障碍(POCD)和痴呆症(AD)的评估采用简易精神状态检查量表(MMSE),并排除术前<24分的患者。记录术中及术后任何不良事件包括窦性心动过缓或低血压/高血压、术后感染等。记录住院时间及90天病死率。3个月后,使用问卷收集与睡眠有关的数据、生活质量、焦虑和疼痛。结果两组术后第1、3天时白细胞计数、中性粒细胞计数和中性粒细胞百分比较术前1天时的均增高,但R组均显著低于C组(P<0.05)。C组共有13例患者(32.5%)在术后第3天内发生POD,27例患者(67.5%)未发生POD,组间比较差异有统计学意义(P<0.05)。R组共有5例患者(12.5%)在术后3天内发生POD,35例患者(87.5%)未发生POD。术后90天随访时,MMSE评分与基线相比差异无统计学意义(P>0.05)。术后共有4例(10%)患者出现神经认知功能障碍。两组间POCD发生率差异无统计学意义(P>0.05)。术中心动过缓或低血压/高血压、术后感染等不良事件发生率在两组间均接近,差异无统计学意义(P>0.05)。在术后90天的随访期内,两组均无患者死亡。两组在术后住院时间方面差异无统计学意义(P>0.05)。使用EQ-5D问卷对两组患者的生活质量进行评估,结果显示,两组患者差异无统计学意义(P>0.05)。术后3个月,两组间的睡眠质量差异无统计学意义(P>0.05)。结论RIPC+RIPostC可减低CPB下心脏瓣膜置换术患者炎症反应,降低POD发生率,改善术后生活质量。

Objective To investigate the effect of remote ischemic preconditioning combined with postconditioning(RIPC+RIPostC)on postoperative delirium(POD)in patients undergoing cardiac valve replacement under cardiopulmonary bypass(CPB).Methods Eighty patients aged 44-64 years old and scheduled to elective heart valve replacement under CPB in the operating room of our hospital were recruited and divided into control group(group C)and group R according to random number table method,with 40 cases in each group.Patients in group R underwent RIPC 30 minutes before the start of CPB and RIPostC 30 minutes before the end of CPB.The specific treatment measures were as follows:tie an inflatable cuff on the patient's lower limb,inflate and pressurize until the pressure to 200 mmHg,hold for 5 minutes,and then completely deflate the cuff until the pressure to 0;after 5 minutes,inflate and pressurize again,and repeat for 3 cycles.The cuff was tied to the patient's lower limb,but no inflation and deflation were performed in group C.Peripheral venous blood was drawn 1 day before operation and 1 day and 3 days after operation,and blood routine was determined.POD was assessed by the intensive care unit(ICU)consciousness disturbance assessment method(CAM-ICU)within 3 days after the operation.Neurocognitive testing was performed preoperatively,at discharge,and 3 months postoperatively,and postoperative cognitive dysfunction(POCD)and dementia(AD)were assessed using the Mini-Mental State Examination Scale(MMSE),with exclusion of preoperative patients with<24 points.Intraoperative and postoperative adverse events including sinus bradycardia or hypotension/hypertension,postoperative infection,etc.were recorded.The length of hospital stay and 90-day mortality were recorded.After 3 months,data related to sleep,quality of life,anxiety and pain were collected using questionnaires.Results The white blood cell count,neutrophil count and percentage of neutrophils in the two groups at 1 day and 3 days after operation were all higher than those at 1 day before operation,but the indexes in group R was significantly lower than those in group C(P<0.05).A total of 13 patients(32.5%)in group C developed POD within 3 days after surgery,while 27 patients(67.5%)did not develop POD,and there was a significant difference between the groups(P<0.05).A total of 5 patients(12.5%)in group R developed POD within 3 days after surgery,and 35 patients(87.5%)did not develop POD.At the 90-day follow-up,there was no difference in the MMSE score compared with the baseline(P>0.05).A total of 4 patients(10%)developed neurocognitive dysfunction after surgery.There was no difference in the incidence of POCD between the two groups(P>0.05).The incidence of adverse events such as bradykinesia,hypotension/hypertension,and postoperative infection were similar between the two groups,and there was no significant difference(P>0.05).During the 90-day follow-up period after surgery,no patient died in either group.There was no significant difference in postoperative hospital stay between the two groups(P>0.05).Using the EQ-5D questionnaire to evaluate the quality of life of the two groups of patients,the results showed that there was no statistically significant difference between the two groups(P>0.05).At 3 months after operation,there was no significant difference in sleep quality between the two groups(P>0.05).Conclusion RIPC+RIPostC can reduce the inflammatory response,reduce the incidence of POD and improve the quality of life after operation in patients with heart valve replacement under CPB.