全麻联合硬膜外麻醉及PCEA对老年患者术后早期认知功能的影响

发布时间：2018-05-18 12:57

本文选题：硬膜外阻滞 + 硬膜外镇痛　；参考：《福建医科大学》2014年硕士论文

【摘要】：【目的】以接受开放性胃癌根治术（ORG）的老年患者为研究对象，比较全身麻醉联合硬膜外麻醉+术后硬膜外自控镇痛（PCEA）与全身麻醉+术后静脉自控镇痛（PCIA）、全身麻醉联合硬膜外麻醉+术后静脉自控镇痛（PCIA）对术后早期认知功能的影响，为选择更适合于老年患者中上腹部手术的麻醉方式提供理论依据。【方法】 1.选取2013年3月至2014年1月行择期ORG的老年患者90例，年龄＞65岁，ASA分级I级~III级，所有受试者对实验及治疗方案均知情同意，且得到医院伦理道德委员会批准。 2.采用随机数字表法，将其分为三组（n＝30）：全身麻醉+PCIA组（A组）、全身麻醉联合硬膜外麻醉+PCIA组（B组）、全身麻醉联合硬膜外麻醉+PCEA组（C组）。B、C两组术中硬膜外阻滞选用0.375%罗哌卡因。 3.分别于术前1d及术后6h、12h、2d、3d、5d采用MMSE对患者进行认知功能评价；于麻醉诱导前10min（T0）、切皮后1h（T1）、关腹后1min（T2）、拔除气管导管即刻（T3）各时间点记录其HR、MAP；于麻醉诱导前、气管拔管后30min采集中心静脉血样（肝素抗凝）测定血糖及皮质醇含量；于麻醉诱导前、术后24h采集中心静脉血样（肝素抗凝），采用酶联免疫吸附双抗体夹心法测定S-100β、NSE、TNF-α浓度；记录术中SEVO及血管活性药物的用量；随访并记录患者术后6h、12h、24h的VAS疼痛评分。【结果】 1.一般情况：三组患者年龄、性别、ASA分级、BMI、手术时长及术前认知功能水平各项指标比较，差异无统计学意义。 2. POCD发生率：术后6h、12h，C组较A组、B组显著降低（P0.05），A组、B组间差异无统计学意义；术后2d，C组显著低于A组（P0.05），B组与A、C两组差异无统计学意义；术后3d、5d，B、C两组显著低于A组（P0.05），B组与C组差异无统计学意义。 3.血流动力学变化情况：术毕及拔管期，A组患者较B、C两组MAP、HR变化较大（P0.05）；组内比较，A组血流动力学变化较大，以术毕和拔管期明显。 4. SEVO用量：A组大于B、C两组，差异有统计学意义（P0.05）。 5. NE用量：B、C两组大于A组，差异有统计学意义（P0.05）。 6.血糖值及皮质醇含量：与术前水平相比，三组患者拔管后均显著增加（P0.05），其中A组增幅明显大于B、C两组（P0.05）。 7. TNF-α变化情况：与术前水平相比，三组术后24h均显著增加（P0.05），其中，A组增幅明显大于B、C两组（P0.05）。 8. S-100β蛋白、NSE变化情况：与术前水平相比，三组术后24h均显著增加（P0.05），其中，A组S-100β蛋白增幅明显大于B、C两组（P0.05）；三组间术后24h NSE指标无显著差异。 9. VAS疼痛评分：术后6h， C组显著低于A、B两组（P0.05）；术后12h，B、C两组显著低于A组（P0.05）；术后24h，三组间无显著差异。 10. Spearman相关分析显示：POCD的发生与术中SEVO用量，，术后VAS评分，拔管后血糖值、皮质醇浓度及术后1d S-100β蛋白、TNF-α浓度呈正相关；与术中血流动力学的稳定性及术中NE用量呈负相关。【结论】 1.麻醉及ORG，对老年患者认知功能均有一定程度的损害。全身麻醉联合硬膜外麻醉+PCEA较全身麻醉+PCIA及全身麻醉联合硬膜外麻醉+PCIA对行ORG的老年患者术后早期认知功能损害最小。 2.全身麻醉联合硬膜外麻醉+PCEA对术后早期认知功能的正面影响可能与其术中硬膜外阻滞和PCEA从脊髓水平抑制伤害性刺激反射弧的上行传导，同时，全身麻醉使患者在整个手术过程中意识丧失，消除了患者术中的心理应激，有效阻断了手术操作等伤害性刺激传入引起的应激反应，从而更好地抑制神经炎症反应，稳定神经系统功能，降低脑损伤有关。
[Abstract]:Purpose of the project

To study the effects of general anesthesia combined with epidural anesthesia + postoperative epidural anesthesia ( PCIA ) , general anesthesia combined with epidural anesthesia + postoperative intravenous analgesia ( PCIA ) on early cognitive function in elderly patients receiving open gastric cancer radical operation ( ORG ) .

Methodology

1 . From March 2013 to January 2014 , 90 elderly patients with ORG were selected , age > 65 years , ASA grade I ~ III , all subjects informed consent to the experimental and treatment regimens , and approved by the Ethics Committee of the Hospital .

2 . It was divided into three groups ( n = 30 ) : general anesthesia + PCIA group ( group A ) , general anesthesia combined with epidural anesthesia + PCIA group ( group B ) , general anesthesia combined with epidural anesthesia + PCEA group ( group C ) .

3 . MMSE was used to evaluate the cognitive function in 1d and 6h , 12h , 2d , 3d and 5d after operation respectively .
HR and MAP were recorded at each time point of the tracheal catheter ( T3 ) before induction of anesthesia for 10 minutes ( T0 ) , 1 hour ( T1 ) after skin incision , 1 min ( T2 ) in the abdomen , and immediately ( T3 ) of the tracheal catheter .
Blood samples of central venous blood ( heparin anticoagulant ) were collected for 30 min before induction of anesthesia , and blood glucose and cortisol were measured .
The central venous blood sample ( heparin anticoagulant ) was collected 24 hours after induction of anesthesia , and the concentration of S - 100尾 , NSE and TNF - 伪 was determined by enzyme - linked immunosorbent assay .
The amount of SEVO and active agents in the procedure was recorded .
VAS pain scores at 6 , 12 h , 24 h post - operation were recorded and recorded .

The result is not valid .

1 . General situation : The age , sex , ASA grade , BMI , duration of operation and the level of preoperative cognitive function in three groups showed no statistical significance .

2 . The incidence of POCD : 6h , 12h , group C were significantly lower than that in group A and group B ( P0.05 ) , there was no significant difference between group A and group B .
There was no significant difference between group B and group A and C in group B and group A ( P0.05 ) .
The postoperative 3d , 5d , B and C were significantly lower than that in group A ( P0.05 ) . There was no significant difference between group B and group C .

3 . Changes of hemodynamics : The MAP and HR in group A were significantly higher than those in group B and C ( P0.05 ) .
The hemodynamic changes in group A were larger in group A than in group A .

4 . The dosage of SEVO : group A was more than group B and C , the difference was statistically significant ( P0.05 ) .

5.NE dosage : group B and group C were more than that in group A , the difference was statistically significant ( P0.05 ) .

6 . Blood glucose and cortisol levels : Compared with the preoperative level , the three groups increased significantly ( P0.05 ) , in which group A was significantly larger than that in group B and C ( P0.05 ) .

7 . Changes of TNF - 伪 : Compared with preoperative level , the group A was significantly higher than that in group B and group C ( P0.05 ) .

8 . The changes of S - 100尾protein and NSE in group A were significantly higher than those before operation ( P0.05 ) , and the increase of S - 100 尾 protein in group A was significantly higher than that in group B and C ( P0.05 ) .
There was no significant difference in NSE between the three groups .

9 . VAS pain score : 6 hours after operation , group C was significantly lower than that in group A and group B ( P0.05 ) ;
At 12 h , group B and C were significantly lower than those in group A ( P0.05 ) .
24 hours after operation , there was no significant difference among the three groups .

10 . The correlation analysis showed that the incidence of POCD was positively correlated with the amount of SEVO used in the operation , VAS score after operation , blood glucose level after extraction , cortisol concentration and the concentration of 1d S - 100尾protein and TNF - 伪 after operation .
There was a negative correlation between the stability of hemodynamics and the amount of NE in operation .

Conclusion

1 . Anesthesia and ORG had a certain degree of damage to the cognitive function of elderly patients . General anesthesia combined with epidural anesthesia + PCEA combined with epidural anesthesia + PCIA combined with epidural anesthesia + PCIA had minimal impairment of cognitive function in elderly patients undergoing ORG .

2 . The positive effects of general anesthesia combined with epidural anesthesia + PCEA on early postoperative cognitive function may be related to the effect of epidural block and PCEA on the ascending conduction of the reflex arc from the spinal level . At the same time , general anesthesia makes the patient lose consciousness during the whole operation , eliminates the psychological stress in the operation of the patient , effectively blocks the stress response caused by the harmful stimulation of the operation of the operation and the like , thereby better inhibiting the neuroinflammatory reaction , stabilizing the nervous system function and reducing the brain injury .
【学位授予单位】：福建医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R614

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