两种诊断方法对术后认知功能障碍评估分析

目的：探讨更有利于术后认知功能障碍早期诊断的评估方法。方法：选择青年患者（18-45岁）60例,ASAⅠ～Ⅱ级,在全凭静脉麻醉或椎管内麻醉下行手术;青年健康志愿者30例为对照组,术前一天（T1）,术后3天（T2）行认知功能6项测定。所得结果分别采用1个标准差法（SD）和Z计分法对术后认知功能进行评定。P＆lt;0.05差异有统计学意义。结果：术后3天,依据SD法诊断认知功能受损25/90例（27.8%）,术后认知功能障碍2/90例（2.2%）,Z计分法认知受损18/90（20%）例,认知障碍3/90例（3.3%）,两种诊断方法之间差异无统计学意义（P＆gt;0.05）。经K系数检验,SD法与Z计分法诊断吻合度无统计学意义（kappa=0.000,P＆gt;0.05）。结论：两种评估方法同时进行评估,可以弥补相互不足,较大程度地避免了术后认知功能受损假阴性的诊断,更有利于术后认知功能障碍的早期发现。     

右美托咪定对腰椎全麻手术患者术后疼痛及认知功能的影响

目的:探讨右美托咪定对腰椎全麻手术患者术后疼痛及认知功能的影响。方法:选择2014年3月~2015年12月在我院行腰椎全麻手术的84例患者为研究对象,按照随机数字表法分为对照组(42例)和试验组(42例),患者均常规给予芬太尼及顺式阿曲库铵麻醉诱导,试验组患者在麻醉诱导过程中给予右美托咪定静脉注射,对照组患者仅给予氯化钠注射液静脉注射。分别于术前(T0)、手术开始2 h(T2)、术后24 h(T24)检测血清肾上腺糖皮质激素,采用疼痛视觉模拟评分法(VAS)进行疼痛评定;采用简易智能精神状态量表(MMSE)于术后1d和2d进行认知状态评定,并计算术后认知功能障碍(POCD)发生率;同时观察患者不良反应发生情况。结果:试验组患者T2和T24时肾上腺糖皮质激素水平明显低于T0,T2时试验组患者肾上腺糖皮质激素水平明显低于对照组,差异有统计学意义(P0.05)。试验组患者T2时VAS评分明显低于对照组,差异有统计学意义(P0.05)。术后1d和2d时试验组患者的MMSE评分高于对照组,POCD发生率明显低于对照组;两组患者术后2d时MMSE评分高于术后1d,POCD发生率明显低于术后1d,差异均有统计学意义(P0.05)。两组患者均未见除POCD以外的不良反应。结论:右美托咪定有较强的抗氧化能力,可有效减轻腰椎全麻手术患者的疼痛程度,提高患者的认知功能。     

术前抑郁和焦虑对腹部择期手术患者术后认知功能的影响

目的:探讨紧张和焦虑对手术患者术后认知功能的影响。方法:100例腹部择期手术病人术前1天用汉密顿焦虑量表(HAMA)、汉密顿抑郁量表(HAMD)、简易智能测试量表(MMSE)、数字广度对病人进行测试。术后7天分别用MMSE、数字广度进行神经心理学测试,术后MMSE结果低于术前一个标准差则视为术后认知障碍(POCD)。结果:术前焦虑、抑郁以及同时发生焦虑和抑郁的阳性率分别为30%、50%和10%。女性患者术后7天POCD的发生率为30%,男性患者术后7天POCD的发生率为20%;女性患者焦虑得分为7.2±4.0,高于男性患者4.5±3.3,P=0.05女性患者的抑郁得分为6.5±3.6,明显高于男性患者4.2±3.4(P=0.1),术前焦虑与POCD的相关性不显著,术前焦虑与MMSE、数字广度的Pearson’s相关系数分别为-0.50(P=0.2)和-0.20(P=0.1)。术前抑郁与POCD存在显著的相关性,其中术前抑郁与MMSE的Pearson’s相关系数为-0.61(P=0.01),术前抑郁与数字广度的Pearson’s相关系数为-0.72(P=0.03)。结论:术前抑郁的患者术后容易发生POCD;相对于男性患者,女性更容易出现POCD;而术前焦虑对POCD没有重要的影响。     

POCD 发病机制的研究进展

术后认知功能障碍(Postoperative Cognitive Dysfunction,POCD)的特征性表现是麻醉和手术后认知功能的持续性下降。这种多认知领域的功能需要感觉和广泛的神经学检测来评估,由于不同的检测仪器、不同的时间点和应用不同的统计学方法,因而对POCD一直没有统一的定义,各POCD间的研究也缺乏比较性。因此,进一步阐述POCD的影响因素及发病机制,有利于对POCD的研究建立标准的检测、诊断和防治方法。     

不同麻醉方法对老年患者髋关节置换术术后认知功能障碍的影响

目的:比较全身麻醉和硬膜外麻醉两种麻醉方法对老年患者髋关节置换术术后发生认知功能障碍的影响并探讨其可能机制。方法:选择ASAⅡ-Ⅲ级行髋关节置换术的老年患者80例,随机分为全身麻醉组(GA)和硬膜外麻醉组(EA)。采用简易精神状态检查量表法(MMSE)评估两组患者术前1天、术后1天、术后5天的神经精神功能状态。采用酶联免疫吸附试验(ELISA)法检测和比较患者术前1天、术后1天、术后5天血清Aβ和tau蛋白水平。结果:GA组术后1天MMSE评分、血清Aβ蛋白和tau蛋白表达均较术前1天、术后5天明显降低(P0.05);EA组三个时间点相互比较无统计学差异。EA组T2时间点MMSE评分、血清Aβ蛋白和tau蛋白表达显著高于GA组(P0.05)。发生POCD的患者Aβ蛋白和tau蛋白表达水平均较非POCD患者明显升高(P0.05)。结论:硬膜外麻醉能明显降低行髋关节置换术老年患者术后POCD的发生,可能与减少Aβ蛋白和Tau蛋白的表达有关。     

不同麻醉维持方法对老年患者早期术后认知功能障碍的影响

目的:观察全凭静脉麻醉和静吸复合麻醉两种不同麻醉维持方法对老年患者早期术后认知功能障碍(POCD)的影响。方法:选择全麻行腰椎手术的老年患者100例,随机分A组(50例)和B组(50例),A组采用全凭静脉麻醉,B组采用静吸复合麻醉。记录患者于入室后(TI)、麻醉诱导后(T2)、插管后(T3)、切皮开始(T4)、手术结束(T5)、拔管后(T6)的SBP/DBP、HR和SctO_2;检测患者于麻醉诱导前(X1)、拔管后(X2)、术后第1d(X3)、术后第3d(X4)、术后第7d(X5)静脉血中IL-1β、IL-6、HMGB1、S100P和TNF-α的浓度。记录患者术前及术后早期的神经心理学测试结果。结果:T6时,B组SBP较A组高(P0.05);T4时,B组SctO_2较A组高(P0.05)。X1~5时,B组IL-1β均较A组低(P0.05);X2~4时,B组IL-6较A组低(P0.05);X2~5时,B组HMGB1较A组低(P0.05)。与X1时比较,A组X2~4时HMGB1均升高,B组X2~4时HMGB1均降低(P0.05);与X1时比较,A组X3时IL-6升高,B组X3时IL-6下降(P0.05)。A组术后第3 d发生POCD10例,B组3例(P0.05);A组术后第7 d发生POCD8例,B组5例(P0.05)。结论:静吸复合麻醉和全凭静脉麻醉均可引起老年患者发生早期POCD,在术后第3天时,静吸复合麻醉较全凭静脉麻醉能较少POCD的发生,而在术后第7天时,二者间无明显差异。     

小手术青年患者围术期认知功能的变化

目的:以青年健康志愿者为对照,探明青年患者小手术围术期认知功能的变化.方法:以择期行脐部以下部位小手术(手术时间＜2h)、ASA分级Ⅰ～Ⅱ级的青年患者(18-39岁)60人为病例组,青年健康志愿者30人为对照组.分别于术前一天、术后3天行6项认知功能测定.结果:术后各项测验值普遍高于术前测验值(P＜0.05).病例组在术前有2项分测验低于对照组,术后4项分测验低于对照组(P＜0.05).按Z计分诊断术后认知功能障碍,术后第3天发生5例POCD,其中时照组1例,病例组4例.组间差异无统计学意义(x2=0.539,P=0.463).结论:小手术青年患者认知功能下降在术前已经存在,应激反应有可能是导致围术期认知功能下降的主要原因之一.     

不同麻醉方式对老年肺肿瘤患者术后早期认知功能的影响

目的:探讨不同麻醉选择对老年肺肿瘤术后患者早期认知功能的影响。方法:分析我院2011年3月至2013年3月老年肺肿瘤患者,分别有62例用全凭静脉麻醉和61例用静吸复合麻醉的麻醉方法,记录手术时间和麻醉时间,用MMSE量表进行认知功能评分,分别评定手术前1天和手术后出麻醉室时及1、3、5天患者的认知功能,并判断患者的POCD。结果:两组患者在手术时间和麻醉时间方面无统计学差异。与术前1天比较,全凭静脉麻醉组、静吸复合麻醉组出麻醉恢复室时、术后1 d时MMSE评分降低(P0.05);与术前1 d比较,两组在术后3天和7天时MMSE评分恢复正常(P0.05),两组患者之间的MMSE认知功能评分在术前、术后均无统计学差异(P0.05),出麻醉恢复室时,全凭静脉麻醉组发生POCD24例(39.34%),全凭静脉麻醉组发生25例(40.32%),两组发生率比较无统计学差异(P0.05);术后1天、3天、7天两组分别POCD的发生率比较均无统计学意义(P0.05)。结论:老年患者用全凭静脉麻醉、静吸复合麻醉不同麻醉方法对老年患者术后早期发生认知功能障碍的影响无统计学差异。     

乌司他丁对心肺转流下心脏手术患者炎症因子及认知功能的影响

目的:探索乌司他丁(UTI)对心肺转流(CPB)下心脏手术患者炎症因子及认知功能的影响。方法:选择自2010年5月至2014年9月我院收治的CPB瓣膜置换手术患者60例,按照随机数表法将患者分成对照组和观察组,每组30例。观察组患者在麻醉诱导后静脉泵入1.2×10~4U/kg UTI,在CPB结束前5 min从体外管道内给予0.6×10~4U/kg UTI,对照组患者给予等量的生理盐水。对比两组CPB前(T0)、CPB开始后1 h(T1)、CPB结束后1 h(T2)、术后4 h(T3)及术后24 h(T4)的血浆肿瘤坏死因子-α(TNF-α)、白细胞介素-6/10(IL-6/10)、中性粒细胞弹性蛋白酶(NE)、星形胶质细胞S100蛋白的β亚型(S100β)、超氧化物歧化酶(SOD)和丙二醛(MDA),在术前1 d和术后7 d时,采用简易精神状态检查表(MMSE)对患者进行神经精神功能测试,并评价患者的术后认知功能障碍(POCD)的发生率。结果:与T0相比,两组患者T1-T4的TNF-α、IL-6、NE、S100β、MDA水平明显升高,且观察组显著低于对照组,而两组IL-10、SOD水平显著下降,观察组显著高于对照组(P0.05)。术后7d,两组患者MMSE评分均明显高于术前1 d,且观察组显著高于对照组(P0.05);观察组POCD的发生率明显低于对照组(P0.05)。结论:UTI可以有效降低CPB下行瓣膜置换术患者的炎症因子水平,并改善患者的POCD,对于临床用药具有指导意义。     

不同麻醉方式对骨科手术患者血流动力学、术后精神状态及认知功能的影响

目的:探讨不同麻醉方式对骨科手术患者血流动力学、术后精神状态及认知功能的影响。方法:选取2016年1月～2018年12月期间我院收治的89例骨科手术患者,根据数字表法将患者随机分为对照组(n=44)和研究组(n=45),对照组给予全身麻醉,研究组给予硬膜外麻醉,比较两组患者围术期指标情况,比较两组患者不同时间点血流动力学、术后精神状态及术后认知功能障碍(POCD)发生率。结果:两组患者术中麻醉时间、术中出血量比较,差异无统计学意义(P0.05);研究组麻醉药物使用量少于对照组,苏醒时间、语言恢复时间短于对照组(P0.05)。两组患者麻醉后术前(T2)时间点平均动脉压(MAP)、心率(HR)均较麻醉前(T1)时间点降低,两组患者手术30 min(T3)、手术结束时(T4)时间点MAP、HR均较T2时间点升高(P0.05),但两组患者T1～T4时间点MAP、HR比较,差异无统计学意义(P0.05)。对照组术后6 h(T5)～术后72 h(T8)时间点、研究组T5～术后24 h(T7)时间点MMSE评分低于T1时间点(P0.05),而研究组T8时间点MMSE评分与T1时间点比较,差异无统计学意义(P0.05);研究组T7、T8时间点MMSE评分高于对照组(P0.05)。研究组T5、术后12 h(T6)时间点POCD发生率均低于对照组(P0.05),两组T7、T8时间点POCD发生率比较,差异无统计学意义(P0.05)。结论:两种麻醉方式均可对骨科手术患者血流动力学、术后精神状态造成一定影响,但硬膜外麻醉对术后精神状态的影响程度相对更轻,同时还可降低POCD发生率,改善围术期部分指标。     

Low Pre-Existing Gray Matter Volume in the Medial Temporal Lobe and White Matter Lesions Are Associated with Postoperative Cognitive Dysfunction after Cardiac Surgery

Objectives

Postoperative cognitive dysfunction (POCD) is recognized as a complication in the elderly after cardiac surgery. Imaging of the brain provides evidence of neurodegeneration in elderly patients; however, abnormalities in brain structure and their relation to POCD are uncertain. This pilot study investigated whether loss of gray matter in the bilateral medial temporal lobe (MTL), seen in preoperative MRI, was associated with POCD.

Methods

Data were collected prospectively on 28 elderly patients scheduled for elective cardiac surgery. MRI of the brains of all patients were assessed for prior cerebral infarctions, and carotid and intracranial arterial stenosis. Patients also completed six neuropsychological tests of memory, attention and executive function before and after surgery. POCD was defined as an individual decrease in more than two tests of at least 1 standard deviation from the group baseline mean for that test. The degree of gray matter loss in the MTL of each patient was calculated using voxel-based morphometry with three-dimensional, T1-weighted MRI. This represented the degree of gray matter change as a Z score.

Results

Postoperative cognitive dysfunction was identified in 8 of the 28 patients (29%). Patients with POCD had significantly more white matter lesions on MRI, and greater loss of gray matter in the bilateral MTL (average Z score 2.0±0.9) than patients without POCD. An analysis by stepwise logistic regression identified gray matter loss in the MTL and cerebral infarctions on MRI as independent predictors of POCD.

Conclusions

These preliminary findings suggested that reduced gray matter in the bilateral MTL and white matter lesions existed in brains of elderly cardiac surgery patients who experienced POCD. Additional studies with larger sample sizes are needed to confirm these findings.     

Postoperative Cognitive Dysfunction is Correlated with Urine Formaldehyde in Elderly Noncardiac Surgical Patients

Post-operative cognitive dysfunction (POCD), especially in elderly patients, has been reported in many studies. Although increasing age, duration of anesthesia, postoperative infections, and respiratory complications were regarded as the risk factors for POCD, no extracerebral diagnostic biomarkers have been identified as indicators of POCD. Ninety-five patients, ages 65-80?years, scheduled for major orthopedic or abdominal surgery were enrolled. Twenty-two patients aged between 20 and 40?years undergoing the same procedures served as controls. Subjects received neuropsychological tests one-day prior and one week post procedure.?To determine the presence of POCD, the criteria were used as described in most previous studies. Morning urine samples were obtained one day before surgery and on day 1, day 2 and day 7 post operatively. Urine formaldehyde was determined with high-performance liquid chromatography. The urine formaldehyde level of all patients with and without POCD increased on the first 2?days after surgery. But the formaldehyde concentration (on day 7) in patients with POCD was significantly higher than that in patients without POCD (p?相似文献   

Assessment of risk factors for postoperative cognitive dysfunction after coronary artery bypass surgery: a single-center retrospective cohort study

Aim: To find out risk factors for postoperative cognitive dysfunction (POCD) after coronary artery bypass grafting (CABG), and to provide basis for clinical prevention of POCD. A total of 88 patients who underwent CABG were surveyed with Telephone Questionnaire (TICS-M) for their cognitive impairment after 3, 7, 21, 90, 180 days post-surgery. The occurrence of POCD was diagnosed by Neuropsychological Battery which included Vocabular Learning Test (VLT), Wisconsin Card Sorting Test (WCST), Trail Making Test (TMT) and Symbol Digit Modalities Test (SDMT). The preoperative, intraoperative and postoperative risk factors were assessed by the χ² or t test. Multivariate analysis was used to study the correlation between the risk factors and the occurrence of POCD. Age, aortic plaque, carotid artery stenosis, cerebrovascular disease, anesthesia time, the rate of decline in intraoperative hemoglobin concentration (ΔHb) and systemic inflammatory response syndrome (SIRS) score on postoperative day 2 had statistically significant (P<0.05) influence on the occurrence of POCD. Aortic plaque, carotid artery stenosis, anesthesia time and SIRS score (odds ratio (OR) value > 1, P<0.05) are the risk factors for POCD. The incidence of day-21 and -180 POCD was approximately 26.1 and 22.7%, respectively.     

血清pNF-H、NSE、ESR与老年脊柱手术患者病情和术后认知功能的相关性研究

摘要 目的：研究老年脊柱手术患者血清神经丝蛋白H磷酸化亚型（pNF-H）、神经元特异性烯醇化酶（NSE）以及红细胞沉降率（ESR）水平与患者病情以及术后认知功能障碍发生的相关性。方法：选取2017年6月到2021年6月在我院进行脊柱手术的老年患者82例,根据病情严重程度分为脊髓未损伤组（n=35）、脊髓不完全损伤组（n=27）和脊髓完全损伤组（n=20）,根据术后是否发生认知功能障碍（POCD）分为认知功能障碍组（POCD组,n=30）和无认知功能障碍组（No-POCD组,n=52）。比较各组患者术前和术后1天、3天、7天血清pNF-H、NSE和ESR水平。结果：（1）脊髓未完全损伤组患者血清pNF-H、NSE和ESR均显著高于脊髓未损伤组患者,而均显著低于脊髓完全损伤组患者（P<0.05）;（2）No-POCD组和POCD组在性别、年龄、体重、BMI、手术时间以及术中失血量均具有可比性（P>0.05）;（3）POCD组患者术前和术后1天、3天、7天血清pNF-H、NSE和ESR水平均显著高于No-POCD组患者（P<0.05）。结论：老年脊柱手术患者血清pNF-H、NSE和ESR水平与患者病情以及术后认知功能障碍发生有关,术前及术后血清pNF-H、NSE和ESR水平升高可能增加老年脊柱手术患者术后认知功能障碍风险,检测血清pNF-H、NSE和ESR水平有助于评估老年手术患者病情和术后认知功能障碍发生风险。     

AMPKα1 overexpression improves postoperative cognitive dysfunction in aged rats through AMPK-Sirt1 and autophagy signaling

Postoperative cognitive dysfunction (POCD) is a common complication in elderly patients who undergo surgery involving anesthesia. Its underlying mechanisms remain unclear. Autophagy plays an important role in the damage and repair of the nervous system and is associated with the development of POCD. Using a rat model, adenosine monophosphate-activated protein kinase α1 (AMPKα1), an important autophagy regulator, was found to be significantly downregulated in rats with POCD that was induced by sevoflurane anesthesia or by appendectomy. Overexpression of AMPKα1-ameliorated POCD, as indicated by decreased escape latencies and increased target quadrant swimming times, swimming distances, and platform crossing times during Morris water maze tests. AMPKα1 overexpression activated autophagy signals by increasing the expression of light chain 3 II (LC3-II) and Beclin1 and decreasing the expression of p62 in the hippocampus of rats with POCD. Moreover, blocking autophagy by 3-methyladenine partly attenuated AMPKα1-mediated POCD improvement. Furthermore, overexpression of AMPKα1 could upregulate the expression of p-AMPK and Sirt1 in the hippocampus of rats with POCD. Intriguingly, inhibiting AMPK signals via Compound C effectively attenuated AMPKα1-mediated POCD improvement, concomitant with the downregulation of p-AMPK, Sirt1, LC3-II, and Beclin1 and the upregulation of p62. We thus concluded that overexpression of AMPKα1 can improve POCD via the AMPK-Sirt1 and autophagy signaling pathway.     

右美托咪定联合舒芬太尼对老年下肢骨折手术患者术后镇痛效果、应激反应和认知功能的影响

摘要 目的：探讨舒芬太尼联合右美托咪定在老年下肢骨折术后镇痛中的效果及对术后应激反应和认知功能的影响。方法：选取我院2017年4月~2021年12月期间收治的老年下肢骨折手术患者80例,根据随机数字表法分为对照组和研究组,各为40例。对照组术后镇痛予以舒芬太尼,研究组术后镇痛予以右美托咪定联合舒芬太尼,观察两组镇静镇痛效果,并观察镇痛方案对患者血流动力学、术后应激反应和认知功能的影响,记录两组不良反应情况。结果：研究组术后8 h（T1）~术后16 h（T2）时间点平均动脉压（MAP）、心率（HR）低于对照组（P<0.05）。研究组T1~术后24 h（T3）时间点视觉模拟评分法（VAS）评分低于对照组,Ramsay 镇静评分高于对照组（P<0.05）。研究组T3时间点去甲肾上腺素（NE）、肾上腺素（E） 、皮质醇（Cor）水平低于对照组（P<0.05）。研究组的术后认知功能障碍（POCD）发生率低于对照组（P<0.05）。研究组T1、T3时间点简易精神状态量表（MMSE）评分高于对照组（P<0.05）。两组的不良反应发生率对比无差异（P>0.05）。结论：右美托咪定联合舒芬太尼应用于老年下肢骨折术后患者,镇痛镇静效果确切,可减轻术后应激反应,降低POCD发生率。