OPCABG患者术中局部脑氧饱和度的变化对术后认知功能及预后的影响

发布时间：2018-04-10 15:07

  本文选题：冠脉搭桥术 + 局部脑氧饱和度　； 参考：《河北医科大学》2017年硕士论文

【摘要】：目的:通过研究非体外循环下冠状动脉旁路移植术(off-pump coronary artery bypass,OPCABG)患者术中局部脑氧饱和度(regional cerebral oxygen saturation,rSO_2)的变化,评价rSO_2的变化对术后认知功能及预后的影响,为临床正确合理应用rSO_2提供临床依据。方法:选择2016年1月至2016年12月择期行OPCABG的患者50例,ASAⅢ或Ⅳ级,男性44例,女性6例。术前合并糖尿病的13例,合并高血压的31例,心功能分级2级的30例、3级的20例。入组患者术前血红蛋白均在正常范围,肝肾功能未见明显异常。设定术中r SO_2绝对值低于50%或降低幅度大于术前20%为脑缺氧。若rSO_2绝对值低于50%或降低幅度大于术前30%为处理标准,通过提高血压来提高rSO_2。根据有无发生脑缺氧将患者分为两组,发生脑缺氧组设为H组,未发生脑缺氧组设为N组。术前用蒙特利尔认知功能(MoCA)量表评估患者认知功能。如果患者受教育年限≤12年则MoCA评分加1分,如测试评分26分或与术前相比降低2分则认为存在认知功能障碍。入室后常规监测血压(BP)、心率(HR)、脉搏氧饱和度(SpO2)、脑电双频指数(BIS)、呼吸末二氧化碳(PETCO2)、体温(Temp)、中心静脉压(CVP)、rSO_2。术中若出现严重低血压或心律失常经积极纠正后仍不能满足全身灌注改行体外循环下冠状动脉旁路移植术(on-pump coronary artery bypass,ONCABG)。术中应用自体血液回收技术,将患者血红蛋白维持在10g/L,体温维持在36.0-37.5℃。手术结束后有效镇静镇痛,控制呼吸送回心脏外科ICU。分别记录术前、插管后即刻、离断左乳内动脉前、搭桥操作结束即刻(前降支、右冠、回旋支/第一分支、侧壁钳)、关胸、术毕即刻的BP、HR、SpO2、rSO_2、BIS、PETCO2、Temp、CVP;记录患者术后1周、术后1月的MoCA评分及预后—选择严重神经系统并发症、拔管时间、ICU停留时间及术后住院时间作为预后指标。严重神经系统并发症包括:脑梗塞、脑出血、昏迷、新发癫痫。若术中发生脑缺氧,记录其当时的情况及持续时间。若术中发生特殊情况(如:室颤)亦记录当时情况及持续时间结果:入组(n=50)患者均在非体外循环下完成冠脉搭桥手术,术后均恢复顺利。其中9例患者术中rso2下降幅度基础值20%,发生了脑缺氧(h组,n=9);41例患者术中rso2下降幅度≤基础值20%且绝对值50%,无脑缺氧发生(n组,n=41)。所有患者术中未发现rso2绝对值低于50%或降低幅度大于术前30%。两组患者均完成了术后1周moca的测试,术后1月有45例病人完成moca测试(n组4例失访,h组1例失访)。两组患者术后1周及1月moca评分未发现26分者或与术前相比降低2分者。对两组患者术前一般情况可能影响术中脑缺氧发生与否的因素进行logistics回归分析,未发现年龄、性别、bmi、高血压、糖尿病、心功能、冠脉病变支数对术中脑缺氧的发生与否有影响。对map与rso2进行分析发现rso2值与map呈正相关,相关系数为0.601,p0.05。对h组患者术中发生脑缺氧时的情况进行分析发现,脑缺氧发生在吻合右冠(4例)、后室间支(4例)及出现室颤(3例)时(2例为吻合第一分支时,1例为吻合后室间支时),平均持续时间为7.64±0.81min,其中2例患者在吻合右冠及后室间支时均出现脑缺氧,持续时间为15.50±0.71min。术中发生室颤的3例患者,行胸腔内心脏按压时rso2最小值的分别是58、60、60,与术前相比下降百分比分别是21%、22%、22%,均在1min内将室颤纠正,但rso2恢复延迟,缺氧时间为7.67±0.58min。两组患者均无pocd发生,无严重神经系统并发症的发生。术中rso2下降幅度基础值20%,持续时间7-8min内对术后认知功能及严重神经系统并发症的发生无明显影响。对两组患者预后进行统计学分析发现,发现h组患者拔管时间和icu停留时间延长于n组,差异有统计学意义(p0.05);术后住院时间差异无统计学意义(p0.05)。结论:1 OPCABG术中rSO_2不能有效预测术后认知功能障碍及严重神经系统并发症的发生。2 OPCABG术中rSO_2降低幅度基础值20%,拔管时间和ICU停留时间延长。3 OPCABG术中rSO_2下降幅度维持在基线的20%以内,可缩短拔管时间及ICU停留时间。
[Abstract]:Objective: To study the off-pump coronary artery bypass grafting (off-pump coronary artery bypass, OPCABG) in patients with regional cerebral oxygen saturation (regional cerebral oxygen saturation, rSO_2) changes, changes in evaluation of rSO_2 effect on cognitive function and prognosis after surgery, to provide clinical basis for the clinical reasonable application of rSO_2. Methods: 50 cases from January 2016 to December 2016 in patients undergoing OPCABG, ASA class III or IV, 44 cases were male, 6 were female. 13 cases with diabetes, 31 patients with hypertension, heart function classification of 30 cases of grade 2, grade 3 in 20 cases. The patients of preoperative hemoglobin were in the normal range, liver and kidney function had no obvious abnormalities. Set the intraoperative R SO_2 absolute value less than 50% or greater than 20% to reduce preoperative cerebral hypoxia. If the absolute value of rSO_2 is less than 50% or greater than 30% to reduce the preoperative treatment standards by improving The blood pressure to improve rSO_2. according to whether the occurrence of cerebral ischemia patients were divided into two groups, the occurrence of cerebral hypoxia group as group H, without the occurrence of cerebral hypoxia group as N group. With Montreal cognitive function before operation (MoCA) scale to assess cognitive function in patients. If the patient is less than or equal to 12 years of schooling years MoCA scores add 1 points, such as test scores of 26 or lower compared with the preoperative 2 points that have cognitive dysfunction. After entering the routine monitoring of blood pressure (BP), heart rate (HR), pulse oxygen saturation (SpO2), bispectral index (BIS), end tidal carbon dioxide (PETCO2), temperature (Temp), center venous pressure (CVP), rSO_2. operation in case of serious hypotension or cardiac arrhythmia after active correction still can not meet the whole body perfusion diverted to coronary artery bypass grafting (on-pump coronary artery bypass, ONCABG). The application of intraoperative autotransfusion system, patients with hemoglobin maintained at 10g /L, the temperature maintained at 36.0-37.5 degrees. After the end of surgery is effective for sedation and analgesia, respiratory control back to cardiac surgery ICU. were recorded before surgery, immediately after intubation, transection of left internal mammary artery bypass operation before, immediately after (the anterior descending branch of right coronary artery, circumflex branch / first, side wall clamp), closed chest. At the end of operation of the BP, HR, SpO2, rSO_2, BIS, PETCO2, Temp, CVP; recorded 1 weeks after surgery, the MoCA score and the outcome of the January selection of serious neurological complications after surgery, extubation time, ICU stay time and postoperative hospital stay as a prognostic indicator of serious neurological complications included.: cerebral infarction, cerebral hemorrhage, coma, new onset epilepsy. If brain hypoxia occurred during operation, record the situation at that time and duration. If special circumstances occur during operation (such as ventricular fibrillation) also recorded at the time and duration of the results: in the group (n=50) were performed in the off-pump coronary artery bypass surgery circulation, postoperative 鍧囨仮澶嶉『鍒，

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