右美托咪定对老年患者单肺通气术后认知功能改变的影响

摘要

目的 观察右美托咪定对老年患者单肺通气术后认知功能改变的影响.方法 选择2013年1月至2015年1月于河南省胸科医院择期行单肺通气术老年患者60例,根据随机数字表法分为右美托咪定组和对照组,各30例.右美托咪定组给予右美托咪定负荷量0.5 μg/kg,10 min泵注完毕,开始麻醉诱导,后以维持量0.2～0.4μg/(kg·h)持续泵注至手术结束.对照组麻醉诱导前给予等量0.9％氯化钠注射液,余同右美托咪定组.记录并比较2组麻醉时间,观察麻醉诱导前(T0)、诱导后10 min(双肺通气,T1)、1h(单肺通气,T2)及手术结束后1h(双肺通气,T3)、6 h(T4)、24 h(T5)、48 h(T6)和72 h(T7)时患者心率、平均动脉压(MAP)、颈内静脉血氧饱和度(SJvO2)和血氧分压(PJvO2),T7时点进行简明精神状态量表(MMSE)评分并记录患者术后认知功能障碍(POCD)发生率.结果 2组患者麻醉时间、心率、MAP比较,差异均无统计学意义(均P ＞0.05);T1、T2时点对照组和右美托咪定组MAP和心率均明显低于T0时点[对照组:(68±9)、(62 ±9)mmHg(1 mmHg =0.133 kPa)比(88±10) mmHg,(63±5)、(61±8)次/min比(71±4)次/min;右美托咪定组:(64±9)、(60±8)mmHg比(83±9)mmHg,(60±6)、(62 ±7)次/min比(74±9)次/min],差异均有统计学意义(均P＜0.05).对照组T1～T7时点、右美托咪定组T1、T4 ～T7时点S JvO2、PJvO2均明显低于T0时点[对照组:(60.3±4.3)％、(58.3±4.4)％、(56.0±5.6)％、(54.9±4.5)％、(54.7±5.4)％、(50.9±4.6)％、(51.5±5.1)％比(68.6±2.1)％ ,(36.5±4.8)、(35.8±2.7)、(33.7±6.0)、(32.9±5.1)、(30.9±2.0)、(26.2±3.6)、(27.7±4.0) mmHg比(41.7±4.4)mmHg;右美托咪定组:(54.1±2.9)％、(60.1±2.9)％、(56.5±3.1)％、(52.9±3.9)％、(54.3±3.5)％比(67.2±3.0)％,(32.9±2.6)、(34.1±2.8)、(33.0±2.0)、(33.7±1.7)、(32.8±2.2)mmHg比(39.4±3.1)mmHg,P＜0.05],右美托咪定组T2、T3时点SJvO2、PJ vO2均明显高于T0时点和对照组同时点[T2时点:(73.8±3.1)％比(67.2±3.0)％、(58.3±4.4)％,(46.9 ±3.0) mmHg比(39.4±3.1)、(35.8±2.7)mmHg;T3时点:(76.7±4.1)％比(67.2±3.0)％、(56.0±5.6)％,(49.6±9.3) mmHg比(39.4±3.1)、(33.7±6.0) mmHg],差异均有统计学意义(P＜0.05或P＜0.01);T2～T7时点,2组血红蛋白与血细胞比容均明显低于T0时点[对照组:(84±10)、(95±12)、(103±13)、(104±15)、(98±13)、(97±12) g/L比(137±16)g/L,(25±3)％、(28±3)％、(30±4)％、(31±4)％、(28 ±4)％、(28±5)％比(40±5)％;右美托咪定组:(85±9)、(97±16)、(104 ±8)、(119±11)、(107±21)、(104±21) g/L比(153±13) g/L, (24±1)％、(28±4)％、(30±3)％、(33±4)％、(31±7)％、(31±6)％比(42±6)％],差异均有统计学意义(均P＜0.05),但2组间比较,差异均无统计学意义(均P＞0.05).T7时点,右美托咪定组与对照组患者MMSE评分均明显低于T0时点[(26.1±1.0)分比(28.2±1.1)分,(24.4±1.3)分比(28.3±0.8)分],但右美托咪定组明显高于对照组,差异有统计学意义(P＜0.01);右美托咪定组POCD发生率为13.3％ (4/30),对照组为36.7％ (11/30),2组比较差异有统计学意义(P＜0.05).结论 老年单肺通气术患者围术期使用右美托咪定可以改善患者的认知功能,降低POCD的发生率.%Objective To observe the effect of dexmedetomidine (DEX) on cognitive function in elderly patients receiving one lung ventilation (OLV).Methods Sixty patients undergoing OLV were randomly divided into DEX group (30 cases) and control group (30 cases).In DEX group, loading dose of DEX (0.5 μg/kg) was infused via pump within 10 min before anesthesia induction, then maintain infusion of DEX with rate of 0.2-0.4 μg/(kg · h) was given after anesthesia induction;in control group, the equivalent 0.9％ saline was given.The anesthesia duation was recorded;the heart rate (HR), mean arterial pressure (MAP), jugular venous oxygen saturation (SJvO2) and jugular venous oxygen partial pressure (PJvO2) before anesthesia induction (T0), 10 min (two-lung ventilation) and 1 h (one-lung ventilation) after induction (T1, T2) , 1 h (two-lung ventilation) , 6 h,24 h, 48 h, 72 h after operation (T3 , T4 , Ts, T6, T7) were monitored;the minimum mental state examination (MMSE) scale was performed at T7 time point after surgery and the incidence of postoperative cognitive dysfunction (POCD) was calculated.Results There were no statistical differences regarding anesthesia duration, HR and MAP between groups (P ＞ 0.05).At T1, T2 time points, the MAP and HR were significantly lower than those at T0 point in c ontrol group [(68 ±9), (62 ±9) mmHg vs (88 ± 10) mmHg;(63 ±5), (61 ±8) times/min vs (71 ±4) times/min] and DEX group [(64 ±9), (60 ±8) mmHg vs (83 ±9) mmHg;(60 ±6), (62 ±7) times/min vs (74 ±9) times/min,P ＜0.05].In control group, the SJvO2, PJvO2 at T1-T7 were significantly lower than those at T0[(60.3±4.3) ％, (58.3 ±4.4)％, (56.0 ±5.6)％, (54.9 ±4.5)％, (54.7 ±5.4)％, (50.9±4.6)％, (51.5 ±5.1)％ vs (68.6±2.1)％;(36.5 ±4.8), (35.8±2.7), (33.7±6.0),(32.9±5.1), (30.9±2.0), (26.2±3.6), (27.7±4.0) mmHgvs (41.7±4.4) mmHg];in DEX group the SJvO2, PJvO2 at T1, T4-T7 were significantly lower than those at T0 [(54.1 ± 2.9)％, (60.1 ± 2.9)％,(56.5±3.1)％, (52.9±3.9)％,(54.3 ±3.5)％ vs (67.2±3.0)％;(32.9 ±2.6), (34.1 ±2.8),(33.0 ±2.0) , (33.7 ± 1.7), (32.8 ±2.2) mmHg vs (39.4 ±3.1) mmHg,P ＜0.05];the SJvO2 and PJvO2 at T2, T3 were significantly higher than those at T0 in DEX group and those in control group at the same time points [T2: (73.8±3.1)％ vs (67.2±3.0)％, (58.3 ±4.4)％;(46.9 ±3.0) mmHg vs (39.4 ±3.1),(35.8±2.7) mmHg;T3:(76.7 ±4.1)％ vs (67.2±3.0)％, (56.0 ±5.6)％;(49.6 ±9.3) mmHgvs (39.4±3.1) , (33.7 ±6.0) mmHg] (P ＜0.05 or P ＜0.01).At T2-T7 time points, the hemoglobin and hematocrit were significantly reduced compared with those at T0 time point in control group [(84 ± 10), (95 ± 12), (103 ± 13),(104±15), (98 ± 13), (97 ± 12) g/L vs (137 ± 16) g/L;(25 ±3)％, (28 ±3)％, (30 ±4)％, (31 ±4)％, (28±4)％, (28±5)％ vs (40±5)％] and DEX group [(85±9), (97±16), (104±8), (119±11), (107±21), (104±21) g/Lvs (153±13) g/L;(24±1)％, (28±4)％, (30±3)％, (33±4)％,(31 ± 7) ％, (31 ± 6) ％ vs (42 ± 6) ％] (P ＜ 0.05);meanwhile no significantly differences were found betweenthe two groups (P ＞ 0.05).The MMSE score at T7 time point was significantly lower than that at T0 point in DEX group and control group [(26.1 ± 1.0) scores vs (28.2 ± 1.1) scores, (24.4 ± 1.3) scores vs (28.3 ±0.8) scores], and was more higher in DEX group (P ＜0.01).The incidence of POCD in DEX group was 13.3％(4/30), significantly lower than that in control group [36.7％ (11/30)] (P ＜0.05).Conclusion Perioperative adninistration of dexmedetomidine can improve cognitive function and decrease the incidence of POCD in elderly patients undergoing OLV.