国际麻醉学与复苏杂志   2014, Issue (9): 2-2
    
老年患者全凭静脉麻醉中应用磷酸肌酸钠术后 认知功能变化与脑氧饱和度监测的相关性
贾宝森, 刘合年, 米卫东, 张宏, 汪东昱1()
1.解放军总医院
The relationship of cerebral oximeter and postoperative cognition function of geriatric patients under intravenous anesthesia using creatine phosphate disodium salt
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摘要:

目的 探讨围术期脑氧饱和度(regional cerebral saturation of oxygenation, rSO2)与全凭静脉应用磷酸肌酸钠麻醉下老年患者术后认知功能变化的关系,为临床麻醉提供指导。 方法 60例美国麻醉医师协会(ASA)分级Ⅰ~Ⅱ级,年龄>60岁的患者,行择期腹部及下肢手术。以患者就诊顺序进行编号,按完全随机分组法分为3组:磷酸肌酸钠组1(C1组)、磷酸肌酸钠组2(C2组)和空白对照组(C 组),每组20例。麻醉前均不用术前药,入室后给予阿托品0.5 mg,缓慢静脉注射异丙酚、芬太尼、顺式阿曲库铵快速诱导气管插管,机械通气,维持呼气末二氧化碳分压(expiration carbon dioxide pressure, PETCO2)在正常范围,监测术中的rSO2变化。术中采用靶控输注模式(target controlled infusion, TCI)泵入异丙酚(3 μg)及静脉泵注瑞芬太尼(0.2 μg·kg-1·min-1~0.4 μg·kg-1·min-1)维持麻醉,间断静脉注射顺式阿曲库铵(0.07 mg/kg~0.10 mg/kg)维持肌松。应用简易智力状态检查(mini-mental scale examination, MMSE)、连线测试及凹槽拼板测试来评定3组患者术前24 h及术后4、8、12、24 h的认知功能变化。 结果 ① 3组患者的一般情况比较差异无统计学意义(P>0.05)。② 3组患者术前MMSE、连线测试及凹槽拼板测试评分差异无统计学意义(P>0.05);与患者入室时MMSE比较,所有患者术后4、8、12 h的MMSE均明显降低(P<0.05)。3组患者连线测试与凹槽拼板测试实验的测试时间比较发现:术前测试时间与术后测试时间相比较,差异无统计学意义(P>0.05),其中C1组和C2组患者任务完成的时间明显缩短(其中C2组要比C1组完成任务的时间更短些),C组患者完成任务的时间延长。术后认知功能变化比较,术后4 h,发生认知功能变化的C组中患者有3例(15%),C2组中患者有1例(5%),C1组患者有2例(10%);术后8 h,C组中患者有2例(10%),C1组中患者有1例(5%),C2组患者认知功能基本恢复;术后12 h,仅C组患者中有1例(5%),C1组和C2组患者认知功能基本恢复;术后24 h,所有组患者的认知功能均恢复,所有进入研究的患者均未发生谵妄。③ C2组和C1组患者术后认知测试评分均明显高于C组(P<0.01), 术中3组患者的rSO2水平差异无统计学意义(P>0.05)。 结论 磷酸肌酸钠在麻醉中的应用,能降低老年患者术后认知功能障碍的发生率,可能与其独特的神经保护、提供外源性能量、提高中枢对于缺血/缺氧的耐受力有关。

关键词: 老年患者; 术后认知功能; 脑氧饱和度; 磷酸肌酸钠
Abstract:

Objective To discuss the relationship of perioperative regional cerebral saturation of oxygenation(rSO2) and postoperative cognition function alteration of geriatric patients under intravenous anesthesia using creatine phosphate disodium salt, and to establish the clinical practical guides. Methods Sixty ASA Ⅰ-Ⅱpatients, aged>60 y scheduled for selective abdominal surgeries or surgeries on lower limb were enrolled in this study. We used a completely randomized grouping design for this study and the 20 patients were divided into 3 groups: creatine phosphate disodium salt group 1 (C1), creatine phosphate disodium salt group 2 (C2), Control group(C). All patients were not premeditated with atropine 0.5 mg until entering the operation room. Anesthesia was induced with intravenous infusion of propofol, fentanyl and cisatracurium slowly, The anesthesia was maintained by intravenous propofol infusion in target controlled infusion target controlled infusion(TCI) (3 μg) and remifentanyl (0.2 μg·kg-1·min-1-0.4 μg·kg-1·min-1) infusion,intravenous bolus cisatracurium(0.07 mg/kg-0.10 mg/kg). After tracheal intubation, all patients were mechanically ventilated with expiration carbon dioxide pressure(PETCO2) at normal scale. The rSO2 was continuously monitored and recorded in operations. The mini-mental state examination (MMSE), trail-making test and grooved pegboard test were adopted to access cognitive function 24 h before surgery and 4,8,12,24 h after surgery. Results ① There were no significantly difference of general status among the three groups(P>0.05). ② The scales of MMSE, trail-making test and grooved pegboard test were not different 24 h before operations among three groups(P>0.05). Compared with scales of MMSE before operation, 4, 8, 12 h after operation in all patients were significantly lower(P<0.05). Three groups of patients trail-making test and the grooved pegboard test time comparison experiment found: there were no difference between preoperative and postoperative testing time (P>0.05), which time of patients in group C2 completed the task significantly shorter than group C1, the control group of patients needed more time to complete the task. Comparison of postoperative cognitive function changes after 4 h, cognitive function changes occurred in the control group of patients with 3 patients (15%), creatine phosphate (C2) of patients in group 1 patient (5%), creatine phosphate sodium (C1) patients, 2 patients(10%). After 8 h, patients in the control group 2 patients(10%), creatine phosphate (C1) patients in group 1 patients (5%), phosphoric acid muscle sodium (C2) cognitive function in patients recovered. Postoperative 12 h, patients in the control group only one case (5%), creatine phosphate groups (group C1 and C2) cognitive function in patients recovered, after 24 h, cognitive function of all patients recovered , the delirium did not occur in all patients entered the study. ③ The scales of cognitive tests were higher in group C2 and group C1 than C(P<0.01). The numbers of rSO2 in the three groups were identical(P>0.05). Conclusions Creatine phosphate disodium salt can reduce the occurrence of postoperative cognitive dysfunction in geriatric patients combined the intravenous and inhalational anesthesia. The results may relate to its neural protection effects, unique natural energy supply and increasing central neural system tolerance of ischemia and hypoxia.

Key words: Geriatric patients; Postoperative cognition function; Regional cerebral saturation of oxygenation; Creatine phosphate disodium salt