七氟烷后处理对高风险心脏瓣膜置换术患者认知功能障碍和临床结局的影响

Effects of sevoflurane postconditioning on postoperative cognitive dysfunction and clinical outcomes in patients undergoing high risk cardiac valve replacement

目的观察在心脏瓣膜置换术中,七氟烷后处理对此类高风险手术患者术后认知功能障碍(POCD)和临床结局的影响。方法选择符合纳入标准的择期行心脏瓣膜置换术患者96例,随机分对照组和七氟烷组,每组48例。七氟烷组于主动脉开放前2 min经体外心肺转流机吹入2%七氟烷,持续时间20 min,其余麻醉方式同对照组,麻醉维持采用丙泊酚联合舒芬太尼静脉全麻。记录患者入ICU后的苏醒、拔管时间, ICU停留时间,术后住院时间,检测患者术前和术后6 h血清S-100β蛋白及神经元特异性烯醇化酶(NSE)浓度,观察术后第7日POCD及不良反应发生情况。结果对照组完成45例,七氟烷组完成46例。与对照组相比,七氟烷组拔管时间、 ICU停留时间和术后住院时间均显著缩短(P <0.05或P <0.01)。术后第7日七氟烷组POCD发生率为21%,低于对照组(33%),但组间比较差异无显著意义(P> 0.05)。POCD的发生与拔管时间(OR=0.532, 95%CI:0.316~0.894, P=0.017)、 ICU停留时间(OR=0.544, 95%CI:0.320~0.925, P=0.025)显著相关。术后6 h, 2组血清S-100β蛋白和NSE水平均升高,但七氟烷组显著低于对照组(P <0.05)。2组术中循环失代偿和恶性心率失常发生率比较无显著差异(P> 0.05)。结论七氟烷后处理能够缩短高风险心脏瓣膜置换患者ICU内拔管和停留时间,进而影响术后第7日POCD的发生,可能与S-100β蛋白和NSE浓度降低有关。

AIM To observe the effects of sevoflurane postconditioning on postoperative cognitive dysfunction(POCD)and clinical outcomes in patients undergoing high risk cardiac valve replacement.METHODS Ninety-six patients,who met the inclusion criteria and scheduled for cardiac valve replacement with cardiopulmonary bypass,were selected and divided into 2 groups randomly,48 in each.In the sevoflurane group(group S),2%sevoflurane was blown into the extracorporeal circulation machine 2 minutes before the opening of the aorta for not less than 20 minutes.The remaining anesthesia was the same as the control group(group C),and the anesthesia was maintained by using propofol combined with sufentanil intravenous anesthesia.The recovery and extubation time after ICU admission,ICU stay time and the length of hospitalization were recorded.The serum S-100βand neuron-specific enolase(NSE)levels were measured before and 6 hours after operation respectively.The postoperative cognitive function of patients at 7 th days after operation and adverse reactions were observed too.RESULTS There were 45 and 46 patients completed the trial in group C and group S respectively.Compared with the group C,the extubation time,ICU stay time and the length of hospitalization were shortened significantly in the group S(P<0.05 or P<0.01).Compared with the33%incidence of POCD in the group C,there was no statistical difference in the group S in spite of a 21%incidence occurred at 7 th days after operation(P>0.05).Correlation analysis showed that extubation time(OR=0.532,95%CI:0.316-0.894,P=0.017)and ICU stay time(OR=0.544,95%CI:0.320-0.925,P=0.025)were significantly correlated with POCD at 7 th days after operation.The serum levels of S-100βand NSE in both groups increased dramatically,especially in group C when compared to group S at 6 hours after operation(P<0.05).There was no significant difference in incidence of intraoperative circulatory decompensation and malignant arrhythmia between the two groups(P>0.05).CONCLUSION Sevoflurane can reduce the extubation time and ICU stay time after heart valve replacement for high risk patients,furthermore,should decrease the incidence of POCD at 7 th days after operation.The mechanism may be related to the decrease of S-100βand NSE levels.