术前联合术后PICA追加右美托咪定对老年全麻腰椎手术患者术后谵妄的影响

Effect of preoperative combined with postoperative PICA plus dexmedetomidine on postoperative delirium in elderly patients undergoing lumbar surgery under general anesthesia

关键词:  右美托咪定  术后谵妄  全身麻醉  腰椎手术  氧化应激  脑损伤  老年  病人静脉自控镇痛

Key words:  dexmedetomidine  postoperative delirium  general anesthesia  lumbar surgery  oxidative stress  brain injury  old age  patient-controlled intravenous analgesia

摘要:

目的 探讨术前联合术后静脉自控镇痛（patient-controlled intravenous analgesia，PICA）追加右美托咪定（Dex）对老年全麻腰椎手术患者术后谵妄（postoperative delirium，POD）的影响。方法 210例老年择期腰椎手术患者随机分为对照组（C组）、诱导前使用Dex组（D1组）、诱导前和术后使用Dex组（D2组），每组70例。C组麻醉诱导前10 min微量泵注入生理盐水0.15 μg/kg，静注咪达唑仑3 mg＋丙泊酚1.5 mg/kg+瑞芬太尼3μg/kg＋顺阿曲库铵0.2 mg/kg行麻醉诱导，静注丙泊酚0.2 mg/（kg·min）维持麻醉。D1组、D2组患者麻醉诱导前10 min微量泵注入Dex 0.15 μg/kg （输注时间10 min），麻醉诱导和维持药物同C组。三组术后用PICA进行镇痛，C组、D1组PICA药物为布托啡诺0.2 mg/kg，D2组为布托啡诺0.15 mg/kg+Dex 100 μg，用生理盐水配置成100 mL入镇痛泵。首剂量2 mL/h，单次给药1 mL，锁定时间30 min，持续48 h。观察三组入室时（T0）、Dex诱导前注入时或生理盐水泵注后（T1）、气管插管时（T2）、开始手术时（T3）、术毕（T4）、出室时（T5）患者的收缩压（SBP）、舒张压（DBP）及心率（HR）。于麻醉诱导前（t0）和术后1天（t1）、术后3天（t2）和术后7天（t2）采用简易认知状态检查（MMSE）量表评价患者的认知功能，采用谵妄评定法（CAM）评估术后POD的发生情况。于术前1天、术后1天、术后3天时检测皮质醇（Cor）、血糖（Glu）、C-反应蛋白（CRP）、丙二醛（MDA）、神经元特异性烯醇酶（NSE）水平。结果 （1）与同组T0时比较，D2组、D1组T1~T5时SBP、DBP、HR降低（P<0.05），但两组T1~T5时SBP、DBP、HR无明显差异（P>0.05）。与同组T0时比较，C组T1、T3、T4时HR及T1~T3时SBP、DBP降低（P<0.05）。与C组同时点比较，D2组、D1组T2、T4、T5时心率、T2时SBP及T4~T5时DBP降低（P<0.05）。（2）与同组t0时比较，C组、D1组t1~t3时MMSE评分降低（P<0.05），而D2组各时点无明显变化（P<0.05）。t1~t3时，D2组MMSE评分高于C组和D1组、POD发生率低于C组和D1组（P<0.05）。D1组与C组间t1~t3时MMSE评分及POCD发生率比较无明显差异（P<0.05）。（3）与术前1天比较，三组术后1天的Cor、Glu、CRP、MDA、NSE水平升高（P<0.05），D1组、D2组的升高程度小于C组（P<0.05），D2组的升高程度小于D1组（P<0.05）。术后3天，D2组Cor、Glu、CRP、MDA、NSE水平与术前1天相比进一步下降（P<0.05），D1组和C组无明显变化（P>0.05）。（4）三组心动过缓、低血压发生率及苏醒时间无明显差异（P>0.05）。结论 术前联合术后PICA追加Dex可更有效地抑制老年全麻腰椎手术患者氧化应激损伤和炎症反应，降低POD的发生率，且不增加不良反应，值得临床推广应用。

Abstract:

Objective To explore the effect of preoperative combined with postoperative PICA plus dexmedetomidine (Dex) on postoperative delirium in elderly patients, who received lumbar surgery under general anesthesia. Methods 210 elderly patients with elective lumbar surgery were randomly divided into group C, group D1 and group D2, with 70 patients in each group. In group C, normal saline (0.15 μg/kg) was injected with micropump 10 min before anesthesia induction; midazolam (3 mg) + propofol (1.5 mg/kg) + remifentanil (3 μg/kg)+cisatracurium (0.2 mg/kg) were intravenously injected to induce anesthesia and propofol was intravenously injected to maintain anesthesia. The patients in D1 group and D2 group were injected with 0.15 μg/kg DEX by micropump 10 min before anesthesia induction (infusion time 10 min); the anesthesia induction and maintenance drugs were the same as group C. All patients were treated with PICA for pain control. The C group and D1 group were treated with butoranol 0.2 mg/kg for PICA, and the D2 group was treated with butoranol 0.15 mg/kg+ DEX 100 μg , the latter was prepared in 100 mL normal saline and administered using analgesia pump. The first dose was 2 mL/h, the single dose was 1 mL, the locking time was 30 min, and the duration time was 48 h. SBP, DBP and HR of 3 groups were observed at entry (T0), injection before DEX induction or physiological salt pump injection (T1), endotracheal intubation (T2), start of operation (T3), end of operation (T4) and exit (T5). Before anesthesia induction (T0), postoperative 1 d (T1), postoperative 3 d (T2) and postoperative 7 d (T2), patients' cognitive function was evaluated by MMSE scale, and postoperative POD incidence was evaluated by delirium assessment (CAM). Cortisol (Cor), blood glucose (Glu), C-reactive protein (CRP), malondialdehyde (MDA) and neuron-specific enolase (NSE) levels were measured 1 day before surgery, 1 day after surgery, and 3 days after surgery. Results (1) Compared with the same group at T0, SBP, DBP and HR in group D2 and group D1 were decreased from T1~T5 (P<0.05), but SBP, DBP and HR in the two groups were not significantly changed from T1~T5 (P>0.05). HR at T1, T3 and T4 and SBP and DBP at T1~T3 in group C were lower than those at T0 (P<0.05). HR at T2, T4 and T5, SBP at T2 and DBP at T4~T5 in group D2 and group D1 were lower than those in group C at the same time points (P<0.05). (2) Compared with the same group at T0, the MMSE scores of group C and group D1 were decreased from T1~T3 (P<0.05), but there was no significant change at each time point in group D2 (P<0.05). During T1~T3, MMSE score in group D2 was higher than that in group C and group D1, and POD incidence was lower than that in group C and group D1 (P<0.05). There were no significant differences in MMSE score and POCD incidence between group D1 and group C at T1~T3 (P<0.05). (3) Compared with 1 day before surgery, the levels of Cor, Glu, CRP, MDA and NSE in the 3 groups on 1 day after surgery were increased (P<0.05), the degree of increase in group D1 and group D2 was less than that in group C (P<0.05), and the degree of increase in group D2 was less than that in group D1 (P<0.05). The levels of Cor, Glu, CRP, MDA and NSE in group D2 were further decreased at 3 days after surgery compared with 1 day before surgery (P<0.05), but there were no significant changes in group D1 and group C (P>0.05).(4) There were no significant differences in the incidence of bradycardia, hypotension and recovery time among the three groups (P>0.05). Conclusion Preoperative combined with postoperative PICA plus Dex can more effectively inhibit oxidative stress injury and inflammatory response in elderly patients undergoing lumbar surgery under general anesthesia, reduce the incidence of POD without increasing adverse reactions, which is worthy of clinical promotion and application.