右美托咪定对老年患者全身麻醉术后认知功能障碍及炎症反应的影响

目的 观察右美托咪定(dexmedetomidine,Dex)对全身麻醉术后炎症反应及术后认知功能障碍(postoperative cognitive dysfunction,POCD)的影响. 方法 选择行择期腹部手术全身麻醉患者60例,年龄60～75岁,采用随机数字表法分为Dex组(D组)和对照组(C组),每组30例,两组患者均采用咪达唑仑0.03～0.05 mg/kg、芬太尼2～3 μg/kg、丙泊酚0.5～1.5 mg/kg、顺式阿曲库铵0.15 mg/kg静脉注射进行麻醉诱导.D组在诱导前10 min内静脉泵入1μg/kg Dex,随后以0.2～0.7 μg·kg-1·h-1维持泵注,根据患者HR、BP等变化及时调整输注速率;C组则与D组相同时间和途径注入相同容积的生理盐水.分别于麻醉后手术前(T1)、手术结束后即刻(T2)、手术结束后24 h(T3)抽取静脉血测定血浆IL-6含量及外周血中性粒细胞NF-κB表达水平.术前1d或2d及术后第1、3、7天用简易智能量表(mini-mental state examination,MMSE)测定认知功能,使用简易精神测定表(abbreviated mental test,AMT)评定术后谵妄情况. 结果 13例患者出现POCD(21.67％),其中D组3例,C组10例,两组间差异有统计学意义(P＜0.05).两组T2、T3时点外周血中性粒细胞NF-κB表达均较T1时增加(P＜0.05),但D组表达水平低于C组(P＜0.05).两组T2时点血浆IL-6水平均较T1时点明显升高(P＜0.01),且C组显著高于D组(P＜0.01);两组T3时点血浆IL-6水平较T2时点明显下降,但仍高于T1时点(P＜0.05),T3时点两组间差异无统计学意义(P＞0.05).D组外周血中性粒细胞NF-κB表达水平与血浆IL-6有良好的相关性(r=0.65,P＜0.01). 结论 POCD的发生可能与氧化应激反应有关,抑制NF-κB的激活可减少术后炎症反应及POCD的发生.

Effects of dexmedetomidine on postoperative cognitive dysfunction and inflammatory response in aged patients with general anesthesia

Objective To investigate the effect of dexmedetomidine (Dex) on inflammatory response and postoperative cognitive dysfunction (POCD) after general anesthesia.Methods Sixty patients with ASA Ⅰ-Ⅱ and aged 60-75 y,undergoing the selective abdomen surgery with general anesthesia,were randomly assigned into 2 groups (n=30):Dex group (group D) and control group(group C).All patients in Both groups received 0.03-0.05 mg/kg of midazolam,2-3 μg/kg of fentanyl,0.5-1.5 mg/kg of propofol and 0.15 mg/kg of cisatracurium during anesthesia induction.The patients in group D were intravenously given Dex (1 μg/kg) for 10 min before induction,followed by 0.2-0.7 μg·kg-1·h-1 maintenance,while patients in group C were administrated the same volume of 0.9％ NS and the infusion rate could be adjusted according to patients'vital signs.Blood samples were collected from the central venous to determine the plasma IL-6 level and activation of NF-κB in neutrophils before induction of anesthesia (T1),at the end of operation (T2),24 h after operation (T3).Neurocongnitive outcome was evaluated by mini-mental state examination (MMSE) and abbreviated mental test (AMT) at 1,2 d before operation and at 1,3,7 d after operation.Results 13 of 60 patients (21.67％) performed with POCD,including 3 patients in group D and 10 patients in group C (P＜0.05).Compared with T1,the activation of NF-κB in neutrophils in both groups increased significantly at T2 and T3 (P＜0.05),and was lower in group D than it in group C (P＜ 0.05).The level of IL-6 at T2 was significantly higher than that at T1 and T3 in both groups (P＜0.01),and was lower in group D than it in group C at T2 (P＜0.01).In group D,NF-κB activation in neutrophils was positively correlated with plasma IL-6 level (r=0.65,P＜0.01).Conclusions The incidence of POCD was correlated with oxidative stress.Inhibition of NF-κB activation may be helpful to attenuate inflammatory cytokines in aged patients undergoing abdomen surgery with general anesthesia and reduce the incidence of POCD.