本文選題：硬膜外阻滯 + 硬膜外鎮(zhèn)痛��； 參考：《福建醫(yī)科大學(xué)》2014年碩士論文

【摘要】：【目的】 以接受開放性胃癌根治術(shù)（ORG）的老年患者為研究對(duì)象，比較全身麻醉聯(lián)合硬膜外麻醉+術(shù)后硬膜外自控鎮(zhèn)痛（PCEA）與全身麻醉+術(shù)后靜脈自控鎮(zhèn)痛（PCIA）、全身麻醉聯(lián)合硬膜外麻醉+術(shù)后靜脈自控鎮(zhèn)痛（PCIA）對(duì)術(shù)后早期認(rèn)知功能的影響，為選擇更適合于老年患者中上腹部手術(shù)的麻醉方式提供理論依據(jù)。 【方法】 1.選取2013年3月至2014年1月行擇期ORG的老年患者90例，年齡＞65歲，ASA分級(jí)I級(jí)~III級(jí)，所有受試者對(duì)實(shí)驗(yàn)及治療方案均知情同意，且得到醫(yī)院倫理道德委員會(huì)批準(zhǔn)。 2.采用隨機(jī)數(shù)字表法，將其分為三組（n＝30）：全身麻醉+PCIA組（A組）、全身麻醉聯(lián)合硬膜外麻醉+PCIA組（B組）、全身麻醉聯(lián)合硬膜外麻醉+PCEA組（C組）。B、C兩組術(shù)中硬膜外阻滯選用0.375%羅哌卡因。 3.分別于術(shù)前1d及術(shù)后6h、12h、2d、3d、5d采用MMSE對(duì)患者進(jìn)行認(rèn)知功能評(píng)價(jià)；于麻醉誘導(dǎo)前10min（T0）、切皮后1h（T1）、關(guān)腹后1min（T2）、拔除氣管導(dǎo)管即刻（T3）各時(shí)間點(diǎn)記錄其HR、MAP；于麻醉誘導(dǎo)前、氣管拔管后30min采集中心靜脈血樣（肝素抗凝）測(cè)定血糖及皮質(zhì)醇含量；于麻醉誘導(dǎo)前、術(shù)后24h采集中心靜脈血樣（肝素抗凝），采用酶聯(lián)免疫吸附雙抗體夾心法測(cè)定S-100β、NSE、TNF-α濃度；記錄術(shù)中SEVO及血管活性藥物的用量；隨訪并記錄患者術(shù)后6h、12h、24h的VAS疼痛評(píng)分。 【結(jié)果】 1.一般情況：三組患者年齡、性別、ASA分級(jí)、BMI、手術(shù)時(shí)長(zhǎng)及術(shù)前認(rèn)知功能水平各項(xiàng)指標(biāo)比較，差異無統(tǒng)計(jì)學(xué)意義。 2. POCD發(fā)生率：術(shù)后6h、12h，C組較A組、B組顯著降低（P0.05），A組、B組間差異無統(tǒng)計(jì)學(xué)意義；術(shù)后2d，C組顯著低于A組（P0.05），B組與A、C兩組差異無統(tǒng)計(jì)學(xué)意義；術(shù)后3d、5d，B、C兩組顯著低于A組（P0.05），B組與C組差異無統(tǒng)計(jì)學(xué)意義。 3.血流動(dòng)力學(xué)變化情況：術(shù)畢及拔管期，A組患者較B、C兩組MAP、HR變化較大（P0.05）；組內(nèi)比較，A組血流動(dòng)力學(xué)變化較大，以術(shù)畢和拔管期明顯。 4. SEVO用量：A組大于B、C兩組，差異有統(tǒng)計(jì)學(xué)意義（P0.05）。 5. NE用量：B、C兩組大于A組，差異有統(tǒng)計(jì)學(xué)意義（P0.05）。 6.血糖值及皮質(zhì)醇含量：與術(shù)前水平相比，三組患者拔管后均顯著增加（P0.05），其中A組增幅明顯大于B、C兩組（P0.05）。 7. TNF-α變化情況：與術(shù)前水平相比，三組術(shù)后24h均顯著增加（P0.05），其中，A組增幅明顯大于B、C兩組（P0.05）。 8. S-100β蛋白、NSE變化情況：與術(shù)前水平相比，三組術(shù)后24h均顯著增加（P0.05），其中，A組S-100β蛋白增幅明顯大于B、C兩組（P0.05）；三組間術(shù)后24h NSE指標(biāo)無顯著差異。 9. VAS疼痛評(píng)分：術(shù)后6h， C組顯著低于A、B兩組（P0.05）；術(shù)后12h，B、C兩組顯著低于A組（P0.05）；術(shù)后24h，三組間無顯著差異。 10. Spearman相關(guān)分析顯示：POCD的發(fā)生與術(shù)中SEVO用量，，術(shù)后VAS評(píng)分，拔管后血糖值、皮質(zhì)醇濃度及術(shù)后1d S-100β蛋白、TNF-α濃度呈正相關(guān)；與術(shù)中血流動(dòng)力學(xué)的穩(wěn)定性及術(shù)中NE用量呈負(fù)相關(guān)。 【結(jié)論】 1.麻醉及ORG，對(duì)老年患者認(rèn)知功能均有一定程度的損害。全身麻醉聯(lián)合硬膜外麻醉+PCEA較全身麻醉+PCIA及全身麻醉聯(lián)合硬膜外麻醉+PCIA對(duì)行ORG的老年患者術(shù)后早期認(rèn)知功能損害最小。 2.全身麻醉聯(lián)合硬膜外麻醉+PCEA對(duì)術(shù)后早期認(rèn)知功能的正面影響可能與其術(shù)中硬膜外阻滯和PCEA從脊髓水平抑制傷害性刺激反射弧的上行傳導(dǎo)，同時(shí)，全身麻醉使患者在整個(gè)手術(shù)過程中意識(shí)喪失，消除了患者術(shù)中的心理應(yīng)激，有效阻斷了手術(shù)操作等傷害性刺激傳入引起的應(yīng)激反應(yīng)，從而更好地抑制神經(jīng)炎癥反應(yīng)，穩(wěn)定神經(jīng)系統(tǒng)功能，降低腦損傷有關(guān)。
[Abstract]:Purpose of the project

To study the effects of general anesthesia combined with epidural anesthesia + postoperative epidural anesthesia ( PCIA ) , general anesthesia combined with epidural anesthesia + postoperative intravenous analgesia ( PCIA ) on early cognitive function in elderly patients receiving open gastric cancer radical operation ( ORG ) .

Methodology

1 . From March 2013 to January 2014 , 90 elderly patients with ORG were selected , age > 65 years , ASA grade I ~ III , all subjects informed consent to the experimental and treatment regimens , and approved by the Ethics Committee of the Hospital .

2 . It was divided into three groups ( n = 30 ) : general anesthesia + PCIA group ( group A ) , general anesthesia combined with epidural anesthesia + PCIA group ( group B ) , general anesthesia combined with epidural anesthesia + PCEA group ( group C ) .

3 . MMSE was used to evaluate the cognitive function in 1d and 6h , 12h , 2d , 3d and 5d after operation respectively .
HR and MAP were recorded at each time point of the tracheal catheter ( T3 ) before induction of anesthesia for 10 minutes ( T0 ) , 1 hour ( T1 ) after skin incision , 1 min ( T2 ) in the abdomen , and immediately ( T3 ) of the tracheal catheter .
Blood samples of central venous blood ( heparin anticoagulant ) were collected for 30 min before induction of anesthesia , and blood glucose and cortisol were measured .
The central venous blood sample ( heparin anticoagulant ) was collected 24 hours after induction of anesthesia , and the concentration of S - 100尾 , NSE and TNF - 偽 was determined by enzyme - linked immunosorbent assay .
The amount of SEVO and active agents in the procedure was recorded .
VAS pain scores at 6 , 12 h , 24 h post - operation were recorded and recorded .

The result is not valid .

1 . General situation : The age , sex , ASA grade , BMI , duration of operation and the level of preoperative cognitive function in three groups showed no statistical significance .

2 . The incidence of POCD : 6h , 12h , group C were significantly lower than that in group A and group B ( P0.05 ) , there was no significant difference between group A and group B .
There was no significant difference between group B and group A and C in group B and group A ( P0.05 ) .
The postoperative 3d , 5d , B and C were significantly lower than that in group A ( P0.05 ) . There was no significant difference between group B and group C .

3 . Changes of hemodynamics : The MAP and HR in group A were significantly higher than those in group B and C ( P0.05 ) .
The hemodynamic changes in group A were larger in group A than in group A .

4 . The dosage of SEVO : group A was more than group B and C , the difference was statistically significant ( P0.05 ) .

5.NE dosage : group B and group C were more than that in group A , the difference was statistically significant ( P0.05 ) .

6 . Blood glucose and cortisol levels : Compared with the preoperative level , the three groups increased significantly ( P0.05 ) , in which group A was significantly larger than that in group B and C ( P0.05 ) .

7 . Changes of TNF - 偽 : Compared with preoperative level , the group A was significantly higher than that in group B and group C ( P0.05 ) .

8 . The changes of S - 100尾protein and NSE in group A were significantly higher than those before operation ( P0.05 ) , and the increase of S - 100 尾 protein in group A was significantly higher than that in group B and C ( P0.05 ) .
There was no significant difference in NSE between the three groups .

9 . VAS pain score : 6 hours after operation , group C was significantly lower than that in group A and group B ( P0.05 ) ;
At 12 h , group B and C were significantly lower than those in group A ( P0.05 ) .
24 hours after operation , there was no significant difference among the three groups .

10 . The correlation analysis showed that the incidence of POCD was positively correlated with the amount of SEVO used in the operation , VAS score after operation , blood glucose level after extraction , cortisol concentration and the concentration of 1d S - 100尾protein and TNF - 偽 after operation .
There was a negative correlation between the stability of hemodynamics and the amount of NE in operation .

Conclusion

1 . Anesthesia and ORG had a certain degree of damage to the cognitive function of elderly patients . General anesthesia combined with epidural anesthesia + PCEA combined with epidural anesthesia + PCIA combined with epidural anesthesia + PCIA had minimal impairment of cognitive function in elderly patients undergoing ORG .

2 . The positive effects of general anesthesia combined with epidural anesthesia + PCEA on early postoperative cognitive function may be related to the effect of epidural block and PCEA on the ascending conduction of the reflex arc from the spinal level . At the same time , general anesthesia makes the patient lose consciousness during the whole operation , eliminates the psychological stress in the operation of the patient , effectively blocks the stress response caused by the harmful stimulation of the operation of the operation and the like , thereby better inhibiting the neuroinflammatory reaction , stabilizing the nervous system function and reducing the brain injury .
【學(xué)位授予單位】：福建醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R614

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