改良抬胸Trendelenburg位对老年腹腔镜手术患者脑功能的影响
发布时间：2018-08-21 07:43
【摘要】：本课题以择期全麻腹腔镜手术老年患者为研究对象,探讨改良抬胸Trendelenburg位对患者脑功能的影响,主要研究内容分为以下两部分:第一部分:改良抬胸Trendelenburg位对妇科腹腔镜手术老年患者颅内压和脑循环的影响【研究目的】应用超声观察改良抬胸位时妇科腹腔镜手术老年患者的颅内压(ICP)和脑血流动力学的变化。【研究方法】纳入2014年1月至2015年10月在第二军医大学附属长海医院和南京医科大学附属无锡人民医院择期拟行妇科腹腔镜手术患者40例,年龄60岁以上,BMI指数19~24,ASAⅠ~Ⅱ级,随机分为2组(n=20):研究组(M组)加用定制体位垫使患者呈改良抬胸Trendelenburg体位(简称T位),对照组(T组)采用T位手术。于常规全麻插管后平卧位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15min(T6)时分别测量视神经鞘直径(ONSD)、大脑中动脉时间平均峰值(TAP)流速、搏动指数(PI)和阻力指数(RI)。采用SPSS 19.0统计学软件进行分析,计量资料以均数±标准差(x±s)表示,组间比较和组内气腹前后比较采用方差分析,P㩳0.05为差异有统计学意义,P㩳0.01为差异有高度统计学意义。【结果】与T1时比较,两组患者T2~5时TAP和PI升高,M组T4,5时ONSD和RI升高;T组T3~6时ONSD和RI升高,T6时PI升高(P㩳0.05)。与T组比较,M组T3和T6时ONSD和RI减小,T2时TAP和PI降低(P㩳0.05)。【结论】改良抬胸T位可延缓颅内压和脑血流量(CBF)升高的发生,且气腹结束后较早恢复正常,可能有利于较长时间腹腔镜手术老年患者的安全。第二部分:改良抬胸Trendelenburg位对腹腔镜结直肠癌根治术老年患者脑氧代谢和术后早期认知功能的影响【研究目的】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术后早期认知功能的影响。【研究方法】纳入2014年1月至2015年10月在第二军医大学附属长海医院和南京医科大学附属无锡人民医院择期拟行腹腔镜结直肠癌根治术患者80例,年龄60岁以上,BMI指数19~25,ASAⅠ~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位手术。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)时分别采集桡动脉和颈静脉球血样,记录血气分析、血糖、乳酸以及MAP等,计算脑动静脉氧含量差(Ca-jvD02)及脑葡萄糖摄取(Da-jvglu)等;并于麻醉前,麻醉结束后2、6、24、48 h和72 h时,采用简易智能量表(MMSE)进行认知功能评分。应用SPSS 19.0软件进行统计学处理,计量资料以均数±标准差(x±s)表示,组间比较和组内气腹前后比较采用方差分析,P㩳0.05认为差异有统计学意义,P㩳0.01为差异有高度统计学意义。【结果】与Tl时比较,两组患者动脉血二氧化碳分压(Pa CO2)T3~6均显著升高,MAP在T2时显著降低,T3~5时颈静脉球血氧分压(PjvO2)显著升高,T4~5时颈静脉球血氧饱合度(Sjv02)显著升高;M组MAP在T4~6时显著升高,T组在T3~6时显著升高;T组在T6时Sjv02显著升高,T5时Ca-jvD02显著下降而颈静脉球血乳酸(Lacjv)显著上升(P㩳0.05)。与T组比较,M组MAP在T4~6时上升较慢;Ca-jvD02在T5时无明显下降,Da-jvglu气腹前后差异无统计学意义,Sjv02和Lacjv无显著上升而Pa CO2在T6时显著降低(P㩳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㩳0.01)。【结论】改良抬胸T位可缓解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,可能有利于较长时间腹腔镜手术老年患者的安全。
[Abstract]:In this study, elderly patients undergoing elective laparoscopic surgery under general anesthesia were studied to investigate the effect of modified Trendelenburg position on brain function. The main contents were divided into the following two parts: Part I: The effect of modified Trendelenburg position on intracranial pressure and cerebral circulation in elderly patients undergoing gynecological laparoscopic surgery. The changes of intracranial pressure (ICP) and cerebral hemodynamics in elderly patients undergoing gynecological laparoscopic surgery were observed by ultrasonography. [Methods] From January 2014 to October 2015, 40 patients who were scheduled to undergo gynecological laparoscopic surgery in Changhai Hospital Affiliated to Second Military Medical University and Wuxi People's Hospital Affiliated to Nanjing Medical University were enrolled. BMI index 19-24 and ASA I-II were randomly divided into two groups (n=20). Patients in study group (M) were treated with modified Trendelenburg position (T position) and patients in control group (T position). Patients in control group (T position) were treated with T position surgery. After general anesthesia intubation, patients in the horizontal position were treated with 5 min (T1) and in the pneumoperitoneal modified T/T position (T2), 30 min (T3), 60 min (T4) and 90 min (T position). (T5) Optic sheath diameter (ONSD), mean time peak velocity (TAP), pulsatility index (PI) and resistance index (RI) were measured in pneumoperitoneum degassing supine position for 15 minutes (T6). SPSS 19.0 software was used to analyze the data. The measurement data were expressed by mean (+) standard deviation (x (+) s). Variance scores were used for inter-group comparison and intra-group comparison before and after pneumoperitoneum. Analysis, P? 0.05 was statistically significant, P? 0.01 was highly statistically significant. [Results] Compared with T1, TAP and PI increased at T2-5 in both groups, while ONSD and RI increased at T4 and 5 in M group; ONSD and RI increased at T3-6 in T group, and PI increased at T6 (P? 0.05). Compared with T group, ONSD and RI decreased at T3 and T6 in M group, and TAP and PI decreased at T2 (P? 0.05). [Conclusion] Modified chest lifting T-position can delay the occurrence of intracranial pressure and cerebral blood flow (CBF) elevation, and restore to normal early after pneumoperitoneum, which may be conducive to the safety of elderly patients undergoing long-term laparoscopic surgery. Part II: Modified chest lifting Trendelenburg position in elderly patients undergoing laparoscopic colorectal cancer radical surgery for cerebral oxygen metabolism and early postoperative cognitive function [Objective] To observe the effect of modified thoracic elevation on cerebral oxygen metabolism and early postoperative cognitive function in elderly patients undergoing laparoscopic radical resection of colorectal cancer. Eighty patients with colorectal cancer undergoing radical resection were divided into two groups according to the random number table. The patients in group M were treated with modified Trendelenburg position (T position) and in group T were treated with T position operation. Blood samples of radial artery and jugular bulb were collected immediately (T2), 30 min (T3), 60 min (T4) and 90 min (T5) at T / T position, 15 min (T6) at pneumoperitoneal degassing and lying position, respectively. Blood gas analysis, blood glucose, lactic acid and MAP were recorded. Cerebral arteriovenous oxygen content difference (Ca-jvD02) and cerebral glucose uptake (Da-jvglu) were calculated. Simple Intelligence Scale (MMSE) was used to assess cognitive function at 48 h and 72 h. SPSS 19.0 software was used for statistical analysis. The measurement data were expressed as mean (+) standard deviation (x (+) s). The analysis of variance was used for comparison between groups and before and after pneumoperitoneum. P? 0.05 showed that there was significant difference, P? 0.01 was highly significant difference. [Conclusion] Results: Compared with Tl, the arterial partial pressure of carbon dioxide (Pa CO2) T3~6 was significantly increased, the MAP was significantly decreased at T2, the jugular bulb partial pressure of oxygen (PjvO2) was significantly increased at T3~5, the jugular bulb oxygen saturation (Sjv02) was significantly increased at T4~5, the MAP in M group was significantly increased at T4~6, and the MAP in T group was significantly increased at T6. Compared with T group, MAP in M group increased slowly at T4-6, Ca-jvD02 did not decrease significantly at T5, and there was no significant difference between Da-jvglu pneumoperitoneum and Da-jvglu pneumoperitoneum. Sjv02 and Lacjv did not increase significantly but Pa CO2 decreased significantly at T6 (P?0.05). The MMSE score was significantly higher at 6 and 24 hours after anesthesia, and significantly lower at 2 hours after anesthesia than that before anesthesia (P? 0.01). [Conclusion] Modified chest lifting T-position can relieve the imbalance of cerebral oxygen supply and demand in the late pneumoperitoneum, and the incidence of cognitive decline within 24 hours after anesthesia is significantly lower, which may be beneficial to the elderly patients undergoing long-term laparoscopic surgery. It's safe.
【学位授予单位】：第二军医大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R614
[Abstract]:In this study, elderly patients undergoing elective laparoscopic surgery under general anesthesia were studied to investigate the effect of modified Trendelenburg position on brain function. The main contents were divided into the following two parts: Part I: The effect of modified Trendelenburg position on intracranial pressure and cerebral circulation in elderly patients undergoing gynecological laparoscopic surgery. The changes of intracranial pressure (ICP) and cerebral hemodynamics in elderly patients undergoing gynecological laparoscopic surgery were observed by ultrasonography. [Methods] From January 2014 to October 2015, 40 patients who were scheduled to undergo gynecological laparoscopic surgery in Changhai Hospital Affiliated to Second Military Medical University and Wuxi People's Hospital Affiliated to Nanjing Medical University were enrolled. BMI index 19-24 and ASA I-II were randomly divided into two groups (n=20). Patients in study group (M) were treated with modified Trendelenburg position (T position) and patients in control group (T position). Patients in control group (T position) were treated with T position surgery. After general anesthesia intubation, patients in the horizontal position were treated with 5 min (T1) and in the pneumoperitoneal modified T/T position (T2), 30 min (T3), 60 min (T4) and 90 min (T position). (T5) Optic sheath diameter (ONSD), mean time peak velocity (TAP), pulsatility index (PI) and resistance index (RI) were measured in pneumoperitoneum degassing supine position for 15 minutes (T6). SPSS 19.0 software was used to analyze the data. The measurement data were expressed by mean (+) standard deviation (x (+) s). Variance scores were used for inter-group comparison and intra-group comparison before and after pneumoperitoneum. Analysis, P? 0.05 was statistically significant, P? 0.01 was highly statistically significant. [Results] Compared with T1, TAP and PI increased at T2-5 in both groups, while ONSD and RI increased at T4 and 5 in M group; ONSD and RI increased at T3-6 in T group, and PI increased at T6 (P? 0.05). Compared with T group, ONSD and RI decreased at T3 and T6 in M group, and TAP and PI decreased at T2 (P? 0.05). [Conclusion] Modified chest lifting T-position can delay the occurrence of intracranial pressure and cerebral blood flow (CBF) elevation, and restore to normal early after pneumoperitoneum, which may be conducive to the safety of elderly patients undergoing long-term laparoscopic surgery. Part II: Modified chest lifting Trendelenburg position in elderly patients undergoing laparoscopic colorectal cancer radical surgery for cerebral oxygen metabolism and early postoperative cognitive function [Objective] To observe the effect of modified thoracic elevation on cerebral oxygen metabolism and early postoperative cognitive function in elderly patients undergoing laparoscopic radical resection of colorectal cancer. Eighty patients with colorectal cancer undergoing radical resection were divided into two groups according to the random number table. The patients in group M were treated with modified Trendelenburg position (T position) and in group T were treated with T position operation. Blood samples of radial artery and jugular bulb were collected immediately (T2), 30 min (T3), 60 min (T4) and 90 min (T5) at T / T position, 15 min (T6) at pneumoperitoneal degassing and lying position, respectively. Blood gas analysis, blood glucose, lactic acid and MAP were recorded. Cerebral arteriovenous oxygen content difference (Ca-jvD02) and cerebral glucose uptake (Da-jvglu) were calculated. Simple Intelligence Scale (MMSE) was used to assess cognitive function at 48 h and 72 h. SPSS 19.0 software was used for statistical analysis. The measurement data were expressed as mean (+) standard deviation (x (+) s). The analysis of variance was used for comparison between groups and before and after pneumoperitoneum. P? 0.05 showed that there was significant difference, P? 0.01 was highly significant difference. [Conclusion] Results: Compared with Tl, the arterial partial pressure of carbon dioxide (Pa CO2) T3~6 was significantly increased, the MAP was significantly decreased at T2, the jugular bulb partial pressure of oxygen (PjvO2) was significantly increased at T3~5, the jugular bulb oxygen saturation (Sjv02) was significantly increased at T4~5, the MAP in M group was significantly increased at T4~6, and the MAP in T group was significantly increased at T6. Compared with T group, MAP in M group increased slowly at T4-6, Ca-jvD02 did not decrease significantly at T5, and there was no significant difference between Da-jvglu pneumoperitoneum and Da-jvglu pneumoperitoneum. Sjv02 and Lacjv did not increase significantly but Pa CO2 decreased significantly at T6 (P?0.05). The MMSE score was significantly higher at 6 and 24 hours after anesthesia, and significantly lower at 2 hours after anesthesia than that before anesthesia (P? 0.01). [Conclusion] Modified chest lifting T-position can relieve the imbalance of cerebral oxygen supply and demand in the late pneumoperitoneum, and the incidence of cognitive decline within 24 hours after anesthesia is significantly lower, which may be beneficial to the elderly patients undergoing long-term laparoscopic surgery. It's safe.
【学位授予单位】：第二军医大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R614
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