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摘要：
目的 观察改良抬胸位对腹腔镜结直肠癌根治术老年患者的脑氧代谢和早期术后认知功能的影响。 方法 择期拟行腹腔镜结直肠癌根治术患者80例，年龄60~82岁，体重44~69 kg，ASA分级 Ⅰ、Ⅱ级，性别不限，按随机数字表法分为2组（每组40例）：M组加用定制体位垫使患者呈改良抬胸Trendelenburg体位（简称T位），T组采用T位。于常规全身麻醉插管后平卧位5 min（T1），气腹改良抬胸T位/T位即刻（T2）、30 min（T3）、60 min（T4）和90 min（T5），气腹放气平卧位15 min（T6），分别采集桡动脉和颈静脉球血样，记录血气分析、血糖、乳酸值及MAP等，计算脑动静脉氧含量差（arteriovenous O2 content difference, Ca-jvDO2）及脑葡萄糖摄取（arteriovenous O2 glucose difference, Da-jvglu）等；并于麻醉前，麻醉结束后2、6、24、48、72 h时，采用简易智能量表（mini-mental state exam, MMSE）进行认知功能评分。 结果 与T１时比较，两组患者动脉血二氧化碳分压(arterial partial pressure carbon dioxide, PaCO2）在T3~6时均显著升高，MAP在T2时显著降低，两组患者在T3~5时颈静脉球血氧分压（jugular venous partial pressure oxygen, PjvO2）显著升高，T4~5时颈静脉球血氧饱合度(jugular venous oxygen saturation, SjvO2）显著升高（P<0.05）；M组MAP在T4~6时显著升高，T组在T3~6时显著升高（P<0.05）；T组在T6时SjvO2［（75±9）%］显著升高，T5时Ca-jvDO2［（5.2±1.5） %］显著下降，而颈静脉球血乳酸（jugular venous lactate, Lacjv）［（2.0±0.5） mmol/L］显著上升（P<0.05）。与T组比较，M组MAP在T4~6时上升较慢，Ca-jvDO2［（5.9±1.6） %］在T5时无明显下降，Da-jvglu气腹前后差异无统计学意义（P＞0.05），SjvO2［（75±9）%］和Lacjv［（1.5±0.5） mmol/L］无显著上升，而PaCO2［（34±3） mmHg（1 mmHg=0.133 kPa）］在T6时显著降低（P<0.05）。与T组比较，M组麻醉结束后6、24 h时MMSE评分明显较高；与麻醉前比较，麻醉结束后2 h两组MMSE评分显著降低（P<0．05）。 结论 改良抬胸T位缓解了气腹后期脑氧供需失衡, 麻醉结束后24 h内认知功能下降的发生率明显降低，有利于较长时间手术的安全。
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Abstract: Ｏｂｊｅｃｔｉｖｅ To study the effects of modified chest-up Trendelenburg position on cerebral oxygen metabolism and early postoperative cognitive function in elderly patients undergoing laparoscopic radical resection of colorectal carcinoma. Methods Eighty ASA Ⅰ orⅡpatients, 60-82 years old, weighing 44-69 kg, scheduled for elective laparoscopic radical resection of colorectal carcinoma, were randomly divided into 2 groups(n=40)：group M, patients in chest-up position using custom-made posture cushions, group T, patients in conventional Trendelenburg position. Blood samples were simultaneously taken from radial artery and jugular bulb at 5 min after regular general anesthesia induction in supine position(T1)， immediately after pneumoperitoneum in modified Trendelenburg position or Trendelenburg position(T2), at 30 min (T3), 60 min(T4), 90 min(T5) after pneumoperitoneum，and at 15 min after deflation in horizon position(T6)． The values of blood gas， blood glucose, lactate, and MAP were recorded. he differences of arteriovenous O2 content (Ca-jvDO2) and glucose content (Da-jvglu) were calculated. Cognitive function was assessed by mini-mental state examination at 24 h before anesthesia and at 6, 24, 48 h and 72 h after anesthesia． Results Compared with T1, arterial partial pressure carbon dioxide(PaCO2) at T3-6, jugular venous partial pressure oxygen(PjvO2) at T3-5 and jugular venous oxygen saturation(SjvO2) at T4-5 were significantly increased in both groups, MAP at T2 were significantly decreased in both groups, MAP at T4-6 were significantly increased in group M, MAP at T3-6, SjvO2 [(75±9)%] at T6 and jugular venous lactate（Lacjv）[(2.0±0.5) mmol/L] at T5 were significantly increased and Ca-jvDO2[(5.2±1.5)%] at T5 were significantly decreased in group T(P<0.05). Compared with group T, Ca-jvDO2[(5.9±1.6)%] at T5 was not significantly decreased, MAP at T4－6, SjvO2[(75±9)%] and Lacjv[(1.5±0.5) mmol/L] at T5 were not significantly increased, Da-jvglu before and after pneumoperitoneum were not significantly different and PaCO2 at T6 was significantly decreased in group M (P<0.05). Compared with T group, MMSE scores at 6, 24 h after anesthesia were significantly higher in group M. Compared with pre-anesthesia, MMSE scores decreased significantly 2 h after anesthesia in both groups (P<0.05). Conclusions Modified chest-up Trendelenburg position can alleviate the cerebral oxygen supply and demand imbalance in the late stage of pneumoperitoneum, and decreases the incidence of cognitive decline within 24 h after anesthesia．
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