超前镇痛对腹部手术全麻患者术后认知功能障碍的影响

目的 分析超前镇痛干预对腹部手术全麻患者术后认知功能的影响。方法 择期开腹胃肠部手术、麻醉时间超过3小时的患者40例，分为四组，全凭静脉麻醉组（TIVA组）10例与全凭静脉麻醉+超前镇痛干预组（TIVA干预组）10例；静吸复合麻醉组（CIIA组）10例与静吸复合麻醉+超前镇痛干预组（CIIA干预组）10例。术前1天、术后1天、术后7天对所有患者采用简易精神状态检查量表（MMSE）、连线测验量表（TMT）、简易视觉记忆量表（BVMT）、霍普金斯词语学习量表（HVLT）进行认知功能的评分，并检测血清C-反应蛋白（CRP）、白介素-6（IL-6）含量，对所有患者术后24小时均用视觉模拟评分法（VAS）进行疼痛评分，比较四组患者认知功能、CRP与IL-6含量、VAS评分的差异。结果 TIVA、CIIA、CIIA干预三组患者术后1天MMSE、BVMT、HVLT评分下降明显（P<0.05）：MMSE、BVMT评分下降最多的是CIIA组；HVLT-T评分下降最多的是CIIA与CIIA干预组；术后7天TIVA组患者HVLT-R评分恢复到术前1天水平，CIIA组患者HVLT-R评分虽较术后1天有所改善但仍低于术前1天水平（P<0.05）；术后7天CIIA、CIIA干预两组患者HVLT-T评仍低于术前1天水平（P<0.05）。TIVA干预与CIIA干预两组术后24小时VAS评分明显低于TIVA与CIIA组（P<0.05）。TIVA干预、CIIA干预两组术后1天CRP、IL-6含量的总体均数明显低于TIVA、CIIA两组（P<0.05）。结论 七氟醚在术后短时间POCD发生中占主导地位；而NASIDs类药物帕瑞昔布钠和局部神经阻滞超前镇痛对于POCD的影响有局限性，在全凭静脉麻醉患者应用则有积极作用，对于持续吸入3小时以上七氟醚的静吸复合麻醉患者作用不明显。

Effect of preemptive analgesia on postoperative cognitive dysfunction in general anesthesia patients undergoing abdominal surgery

Objective To investigate the effects of preemptive analgesia on postoperative cognitive function in patients undergoing general anesthesia. Methods Forty patients who underwent abdominal surgery with the anesthetic duration longer than 3 hours were included in this study. The patients were attibuted to four groups:the total intravenous anesthesia group（TIVA group, n=10）, TIVA + preemptive analgesia group（TIVAPA group, n=10）, Combined intravenous and inhalative anesthesia （CIIA group, n=10）and CIIA + preemptive analgesia group（CIIAPA group, n = 10）. Cognitive function was assessed at three time points:1 d preoperation, 7 d and 30 d post-operation by several scoring systems including MMSE, TMT, BVMT, HVLT. The levels of serum C-reactive protein（CRP）and interleukin-6 （IL-6）were measured. The pain assessment in all patients were assessed by visual analogue scale（VAS） in 24 hours post-operation. The scores of cognitive function, CRP and IL-6 and VAS were compared between the four groups. Results MMSE, BVMT and HVLT scores decreased significantly in the three groups of patients treated with TIVA group, CIIA group and CIIAPA group （P<0.05）. The most significant decrease in MMSE and BVMT scores was CIIA group. The most significant decrease in HVLT-T score was CIIA group And CIIA PA group. At 7 days post-operation, the HVLT-R score of TIVA group was restored to the level of 1 day before operation. The HVLT-R score of CIIA group was improved by 1 day after operation but still lower than that before operation（P<0.05）. After 7 days of CIIA group and CIIAPA group, HVLT-T was still lower than that of preoperative day（P<0.05）. The VAS scores of TIVAPA group and CIIAPA group were significantly lower than those of TIVA group and CIIA group （P<0.05）. The levels of serum CRP and IL-6 in CIIA + PA group and TIVAPA group was significantly lower than that in TIVA and CIIA groups（P<0.05）. Conclusion The sevoflurane plays a leading role in the occurrence of POCD in the short time after operation. The effect of preemptive analgesia that used NSAIDs drugs Parecoxib sodium and local nerve block on the POCD is very limited.