全麻联合硬膜外麻醉及硬膜外自控镇痛降低老年患者术后认知功能障碍的发生率

目的：探讨全麻联合硬膜外麻醉及硬膜外自控镇痛对老年患者术后认知功能障碍(post-operative cognitive dysfunction，POCD)发生率的影响。方法：选取2012年3月至2015年3月于延安市人民医院行胃癌根治术的老年患者共100例，采用随机数字表法将其分为3组：全麻+静脉自控镇痛(patient-controlled intravenous analgesia，PCIA)组(I组，n=35) 、全麻联合硬膜外麻醉+PCIA组(II组，n=30)和全麻联合硬膜外麻醉+硬膜外自控镇痛(patient-controlled epidural analgesia，PCEA)组(III组，n=35)。3组患者年龄、性别、BMI和手术时长及美国麻醉师协会(American Society of Anesthesiologists，ASA)分级和术前简易精神状态量表(Mini-Mental State Examination，MMSE)评分等各项指标相比较，差异均无统计学意义(均P>0.05)。于术前1 d以及术后6 h，12 h，2 d和6 d对患者进行MMSE认知功能评价，比较3组POCD发生率。同时考察患者手术过程中各时间点平均动脉压(mean arterial pressure，MAP)、血糖、皮质醇及TNF-α含量变化，记录术中七氟醚(sevoflurane， SEVO)用量，随访患者术后6，12和24 h的疼痛评分。结果：对患者术POCD的发生率进行比较，I组术后6 h发生率为45.71%，II组为34.28%，均高于III组(10.00%)；I组12 h发生率为34.29%，II组为28.57%，均高于III组(3.33%)；I组2 d发生率为28.57%，II组为17.14%，均高于III组(0)；I组6 d发生率为17.14%，II组为2.85%，均高于III组(0)。血糖值、皮质醇以及TNF-α含量与POCD发生率各组趋势一致，差异均具有统计学意义(均P<0.05)。II组、III组术中MAP波动幅度显著小于I组，III组的术后镇痛效果明显优于其他两组(均P<0.05)。结论：全麻联合硬膜外麻醉与硬膜外镇痛相结合的方式可有效稳定患者的血流状态，对患者认知功能的影响较小，可作为一种值得推荐的麻醉及手术方式。

Incidence of the post-operative cognitive dysfunction in elderly patients with general anesthesia combined with epidural anesthesia and patient-controlled epidural analgesia

Objective: To explore the effect of general anesthesia combined with epidural anesthesia and patient-controlled epidural analgesia on the incidence of the post-operative cognitive dysfunction (POCD) in elderly patients.Methods: A total of 100 elderly patients with gastric cancer, who underwent radical gastrectomy in Yan’an People’s Hospital from March 2012 to March 2015, were randomly divided into 3 groups: a general anesthesia and patient-controlled intravenous analgesia (PCIA) (Group I, n=35), a general anesthesia combined with epidural anesthesia and PCIA (Group II, n=30), and a general anesthesia combined with epidural anesthesia and patient-controlled epidural analgesia (PCEA) (Group III, n=35). There was no significant difference in age, gender, body mass index (BMI), length of operation, American Society of Anesthesiologists (ASA) grade and Mini-Mental State Examination (MMSE) score (all P>0.05). The cognitive function was assessed at the 1st day before operation and at the 6 h, 12 h, 2 d and 6 d after operation by the Mini-Mental State Examination test (MMSE), and the incidence of POCD was compared among the 3 groups. The mean arterial pressure (MAP), blood glucose, cortisol and tumor necrosis factor α (TNF-α) content during the operation were considered. The dosage of sevoflurane (SEVO) in the operation process and the pain score at the 6, 12 and 24 h after operation were recorded.Results: The incidence of POCD at 6 h was 45.71% in the Group I and 34.28% in the Group II, which were higher than that in the Group III (10.00%). The incidence of POCD at 12 h was 34.29% in the Group I and 28.57% in the Group II, which were higher than that in the Group III (3.33%). The incidence of POCD at the 2 d was 28.57% in the Group I and 17.14% in the Group II, which were higher than that in the Group III (0). The incidence of POCD at 6 d was 17.14% in the Group I and 2.85% in the Group II, which were higher than that in the Group III (0). The blood glucose, cortisol and TNF-α content were consistent with the incidence of POCD, with significant difference (all P<0.05). The amplitude of MAP in the Group II and the Group III was significantly less than that in the Group I, and the postoperative analgesia effect in the Group III was obviously better than that in the other two groups (both P<0.05).Conclusion: The general anesthesia combined with epidural anesthesia and patient-controlled epidural analgesia can effectively maintain the stable hemodynamic status in the patients and display inhibitory effect on postoperative cognitive dysfunction.