不同体温及PaCO2对老年患者腹腔镜术后早期精神改变的影响

Effects of body temperature and PaCO2 levels on early mental change after laparoscopy in elderly patients

关键词:  体温  允许性高碳酸血症  腹腔镜手术  术后谵妄  术后认知功能障碍

Key words:  permissive hypercapnia  laparoscopy surgery  postoperative delirium  postoperative cognitive dysfunction

摘要:

目的　探讨不同水平的体温及PaCO₂对老年患者腹腔镜术后早期精神改变的影响。方法　纳入在择期、全麻下行腹腔镜胃癌根治术的患者120例，随机分为4组,每组30例。对照组（N组）（35 ℃＜T＜36℃+ PaCO₂35～45 mmHg）、加温组(T组)（T≥36℃+PaCO₂ 35～45 mmHg）、允许性高碳酸血症组（C组）（35 ℃＜T＜36 ℃+PaCO₂45～50 mmHg）和加温联合允许性高碳酸血症组（TC组）（T≥36 ℃+PaCO₂45～50 mmHg）。分别于气腹前（T₀）、气腹后30 min（T₁）、开腹后30 min（T₂）及手术结束时（T₃）监测PetCO₂及PaCO₂，术中依据PetCO₂调控呼吸参数，各组患者PaCO₂维持在设定范围内。加温组，术中维持T≥36 ℃，于麻醉诱导后（T₄）、气腹后1 h（T₅）、开腹后1 h（T₆）及手术结束时（T₇）测量鼻咽温（T），并在术前1天及术后7天采用蒙特利尔智能量表（MoCA）进行术后认知功能障碍（POCD）评估，术后1、2、3天采用谵妄评定方法（CAM）进行术后谵妄（POD）评估。结果　与N组和T组相比，C组、TC组患者的PetCO2和PaCO2在T1、T2、T3显著升高，差异有统计学意义（P<0.05）。与N组和C组相比，T组和TC组于T₆和T₇时T升高，差异有统计学意义(P<0.05)；与N组相比，C组和TC组患者POD发生率降低，差异有统计学意义（P<0.05），与T组相比，TC组POD发生率降低，差异也具有统计学意义（P<0.05）；与术前相比，4组患者术后7天MoCA评分均降低，差值均有统计学意义（P<0.05）。而术后7天，C组和TC组较N组和T组评分高，差异有统计学意义（P<0.05）；与N组相比，C组和TC组患者POCD发生率降低，差异有统计学意义（P<0.05），TC组与T组相比差异也具有统计学意义（P<0.05）。结论　在老年患者腹腔镜手术中35°＜T＜36°及T≥36°，应用允许性高碳酸血症可明显减少POD和POCD的发生；当机体维持在正常碳酸水平时35°＜T＜36°及T≥36°，对患者POD和POCD的发生率无明显影响。

Abstract:

Objective To investigate the effects of different levels of body temperature and PaCO₂ on early postoperative mental change in elderly patients, who underwent elective laparoscopic surgery. Methods Totally 120 patients over 60 years of age, who were diagnosed with gastric carcinoma and scheduled for laparoscopic radical surgery, were randomly divided into four groups (n=30 in each group): control group with 35 ℃＜T＜36℃ and PaCO₂ 35-45 mmHg (group N), normothermia group with T≥36°and PaCO₂ 35-45 mmHg (group T), hypercapnia group with 35 ℃＜T＜36 ℃ and PaCO₂ 45-50 mmHg (group C), and normothermia-hypercapnia group with T≥36 ℃ and PaCO₂45-50 mmHg (group TC). We monitored PetCO₂ and PaCO₂ levels at the time points of before pneumoperitoneum (T₀), 10 min (T₁) and 30 min (T₂) after pneumoperitoneum, and at the end of the operation (T₃). Respiratory parameters were controlled based on the PetCO₂ level to ensure the PaCO₂ in the setting range. Patient’s postoperative cognitive function was assessed on the day before operation and on the postoperative 7th day using MoCA score, as well as on the postoperative 1-3 days using CAM score. Results Compared with group N and group T, the levels of PetCO₂ and PaCO₂ in the group C and TC were significantly higher at the points of T₁, T₂, and T₃. Compared with group T and group TC, the nasopharyngeal temperature of the patients in the group N and C were significantly lower at the points of T₆ and T₇. Compared with group N, the occurrence of postoperative delirium in the group C and TC patients decreased significantly. Compared with group T, the occurrence of postoperative delirium in group TC patients decreased significantly. Compared with the preoperative MoCA scores, the patients in all groups had reduced scores and the difference was statistically significant. The study on the postoperative 7th day showed that the scores in the group C and TC were higher than those in the group N and T, and the difference was statistically significant. Compared with group N, the incidence of POCD in group C and TC decreased significantly. The difference of incidence of POCD in group T and TC was also statistically significant. Conclusions Permissive hypercapnia can significantly reduce the incidence of POD and POCD in elderly patients who suffer from the operation of laparoscopy no matter the temperature is normothermia or hypothermia. There is no difference in the incidence of POD and POCD in the elderly patients with laparoscopic surgery when the PaCO₂ is normal, no matter the temperature is normothermia or hypothermia.