不同麻醉方法对老年患者人工髋关节置换手术后认知功能的影响

目的]比较不同麻醉方式对于老年患者人工髋关节置换术后认知功能障碍（POCD ）发生的影响。方法]选拟择期行髋关节置换术的老年患者90例，性别不限，年龄65～90岁，体质量44～78 kg ，ASA分级Ⅰ～Ⅲ级。随机将其均分为三组各30例：静吸复合全麻组（GA组），腰硬联合麻醉组（CSEA组），神经阻滞麻醉组（NB组）。GA组静脉注射咪达唑仑0．03 mg/kg，利多卡因0．5mg/kg，芬太尼3μg/kg，丙泊酚1．5～2mg/kg，维库溴铵0．1mg/kg麻醉诱导，术中吸入七氟烷0．8～1．0 M AC ，根据需要间断给予芬太尼和维库溴铵；CSEA组L2～3穿刺，蛛网膜下腔给予0．5％布比卡因8～10 mg后置入硬膜外导管，麻醉平面上界调节在患侧T8以下，术中根据手术需要硬膜外追加0．5％罗哌卡因3～5 mL ；NB组在神经刺激仪定位下行患侧腰丛＋坐骨神经阻滞。分别于手术前24h，手术后6h，24h，3d，7d采用简易认知状态检查（MMSE）量表进行认知功能评分，并比较各组差异。结果]与术前比较，GA组在术后6 h ，24 h MMSE评分明显降低（ P＜0．05），CSEA组与NB组在术后6 h MMSE评分明显降低（ P ＜0．05），与GA组比较，CSEA组与NB组在术后6 h ，24 h MMSE评分明显高于GA组（ P ＜0．05）。术后6 h ，24 h时CSEA组与NB组POCD发生率明显低于GA组（ P ＜0．05）。结论]老年患者在人工髋关节置换术全麻比腰硬联合麻醉、下肢神经阻滞麻醉在术后6h，24h的 POCD 发生率更高，各种麻醉方式在手术后3d，7d的POCD发生率无明显差别。

Effect of Different Anesthesia Methods on Cognitive Function of Elderly Patients After Artificial Hip Replace-ment

Objective] To compare the effect of different anesthesia methods on postoperative cognitive dysfunction （POCD） in elderly patients after artificial hip replacement .Methods] A total of 90 ASA Ⅰ ~ Ⅲ patients（aged 65~90 years old and weighted 44~78kg） scheduled for elective HR surgery were chosen and randomly divided into venous inhalation com-bined general anesthesia group（group GA） ,combined spinal-epidural anesthesia group（group CSEA） and nerve blocking anes-thesia group（group NB） .In GA group ,patients were injected with intravenous midazolam 0 .03mg/kg ,fentanyl 3 μg/kg , propofol 1 .5~2mg/kg and vecuronium bromide 0 .1mg/kg for anesthesia induction ,and then inhaled with sevoflurane 0 .8~1 . 0 M AC during the operation ,and intermittently given fentanyl and vecuronium bromide for the anesthesia demand .In CSEA group ,patients underwent L2~3 puncture ,and were given intrathecal bupivacaine（0 .5% ） 8~10mg ,and then placed with epi-dural catheter ,and the upper bound of anesthesia level was regulated under Ts of the diseased side ,and epidural ropivacaine（0 . 5% ） 3~5mL was additionally given for anesthesia demand .In NB group ,patients received ipsilateral lumbar plexus-sciatic nerve block by using nerve stimulator .Mini-mental state exminination（MMSE） scale at 24h before operation and 6h ,24h ,3d and 7d after operation was used to assess the cognitive function .The difference among groups was compared .Results] Com-pared with before operation ,MMSE scores in group GA at 6h and 24h after operation decreased obviously （P〈 0 .05） ,and MMSE scores in group CSEA and group NB at 6h after operation decreased obviously（ P〈0 .05） .Compared with group GA , MMSE scores in group CSEA and group NB group at 6h and 24h after operation were obviously higher than those in group GA （ P 〈0 .05） .The incidence of POCD in group CSEA group and group NB at 6h and 24h after operation was obviously lower than that in group GA （ P 〈0 .05） .Conclusion] The incidence of POCD in elderly patients undergoing artificial hip replace-ment at 6h and 24h after operation under general anesthesia is higher than that under combined spinal-epidural anesthesia and lower limb nerve blocking anesthesia .There is obvious difference in the incidence of POCD at 3d and 7d after operation among different ways of anesthesia .