摘要
目的观察不同麻醉方式对老年患者膝关节置换手术早期认知功能障碍的影响。方法择期行单侧膝关节置换术的老年患者120例,随机数字法分为:腰—坐骨神经阻滞联合喉罩全麻组(LL)、腰硬联合麻醉组(SE)和气管插管全身麻醉组(GA)三组,各组40例。LL组:使用0.5%罗哌卡因行腰丛和坐骨神经阻滞,静注丙泊酚1~2 mg/kg后,置入喉罩,术中持续静脉泵注丙泊酚,保留自主呼吸;SE组:使用罗哌卡因和利多卡因,实施常规腰硬联合麻醉;GA组:采用咪达唑仑、芬太尼、瑞芬太尼、丙泊酚、顺式阿曲库铵诱导与维持。釆用简易精神状态检查量表(MMSE)分别于术前1d(T 0)、术后1d(T 1)、3d(T 2)、7d(T 3),对患者进行认知功能评分及检测血浆皮质醇的水平。记录患者术前一般情况、手术时间、液体出入量、术中麻醉药的用量、术中、术后24小时内不良反应发生情况。结果与T 0时相比,GA组T 1-3时、SE组与LL组T 1-2时MMSE评分降低(P<0.05);三组患者T 1-3时,POCD的发生率无差异(P>0.05),与T 1时相比,SE组和GA组T 2-3时POCD的发生率降低(P<0.05);三组患者T 0-3时,CORT浓度无差异(P>0.05),与T 0时相比,三组T 1-3时的CORT浓度升高(P<0.05);与T 0时相比,POCD组与非POCD组T 1-3时血浆CORT水平升高(P<0.05),POCD组T 1-3时血浆CORT水平比非POCD组高(P<0.05);GA组的唤醒睁眼时间和拔管时间比LL组长(P<0.05),GA组丙泊酚用量比LL组多(P<0.05);三组患者的一般情况、手术时间、液体出入量、术后并发症无差异(P>0.05)。结论三种麻醉方式均可能导致老年患者膝关节置换术后早期认知功能障碍,但无差异;相比于腰硬联合麻醉和腰丛—坐骨神经阻滞联合喉罩麻醉,气管插管全身麻醉对手术患者认知功能的影响更为持久,临床上应给予足够重视;POCD组术后血浆CORT水平比非POCD组高,提示应激反应可能是早期POCD的发生机制之一。
Objective To observe the impact of three types of anesthetic on the postoperative cognitive dysfunction(POCD)occurring to elderly patients having knee arthroplasty.Methods 120 cases of elderly patients having unilateral knee arthroplasty at a selected time,were randomly divided into lumbar plexus-sciatic nerve block combined with LMA general anesthesia group(LL,n=40),combined spinal epidural anesthetic group(SE,n=40),and intravenous general anesthetic with trachea cannula(GA,n=40)using a random number table method.LL group:the lumbar plexus-sciatic nerve block with 0.5%ropivacaine,insert a laryngeal mask,after Intravenous administration of propofol 1~2 mg/kg,intraoperative continuous pump injection of propofol,pontaneous breathing being kept.SE group:the implementation of conventional spinal epidural anesthetic with ropivacaine and lidocaine.GA group:being induced and maintained with midazolam,fentanyl,remifentanil,propofol,and cisatracurium.Respectively,before surgery 1d(T 0),after surgery 1d(T 1),3d(T 2)and 7 d(T 5),the MMSE scores were evaluated,the serum levels of Cortisol were detected.Record groups of patients with preoperative general situation operation duration,fluid infusion and urine volume,dosage of intraoperative anesthetic,intraoperative and postoperative adverse effects.Results Compared with T 0,MMSE scores in GA group at T 1-3,SE group and LL group at T 1-2 decreased(P<0.05).There was no significant difference in the incidence of POCD between the three groups at T 1-3(P>0.05).Compared with T 1,the incidence of POCD in SE group and GA group at T 2-3 was lower(P<0.05).There was no significant difference in CORT concentration between the three groups of patients at T 0-3(P>0.05).Compared with T 0,the CORT concentration in the three groups at T 1-3 was higher(P<0.05).Compared with T 0,the plasma CORT level in POCD group and non-POCD group at T 1-3 was increased(P<0.05).The plasma CORT level in POCD group at T 1-3 was higher than that in non-POCD group(P<0.05).The time of wake up blink and extubation i
作者
列锦弟
许立新
郑彬
李恒昌
LIE Jindi;XU Lixin;ZHENG Bin;LI Hengchang(Guangzhou First People's Hospital,The Second Affiliated Hospital of South China University of Technology,Guangzhou 510180,China)
出处
《广州医药》
2019年第6期1-6,28,共7页
Guangzhou Medical Journal
关键词
术后认知功能障碍
全身麻醉
椎管内麻醉
腰丛阻滞
坐骨神经阻滞
老年人
Postoperative Cognitive Dysfunction(POCD)
General anesthesia with intubation
Combined spinal-epidural
Lumbar plexus-sciatic nerve blocks
Total knee arthroplasty
Elderly patients
