【摘要】：本課題以擇期全麻腹腔鏡手術(shù)老年患者為研究對(duì)象,探討改良抬胸Trendelenburg位對(duì)患者腦功能的影響,主要研究?jī)?nèi)容分為以下兩部分:第一部分:改良抬胸Trendelenburg位對(duì)婦科腹腔鏡手術(shù)老年患者顱內(nèi)壓和腦循環(huán)的影響【研究目的】應(yīng)用超聲觀察改良抬胸位時(shí)婦科腹腔鏡手術(shù)老年患者的顱內(nèi)壓(ICP)和腦血流動(dòng)力學(xué)的變化�！狙芯糠椒ā考{入2014年1月至2015年10月在第二軍醫(yī)大學(xué)附屬長(zhǎng)海醫(yī)院和南京醫(yī)科大學(xué)附屬無(wú)錫人民醫(yī)院擇期擬行婦科腹腔鏡手術(shù)患者40例,年齡60歲以上,BMI指數(shù)19~24,ASAⅠ~Ⅱ級(jí),隨機(jī)分為2組(n=20):研究組(M組)加用定制體位墊使患者呈改良抬胸Trendelenburg體位(簡(jiǎn)稱T位),對(duì)照組(T組)采用T位手術(shù)。于常規(guī)全麻插管后平臥位5 min(T1),氣腹改良抬胸T位/T位即刻(T2)、30 min(T3)、60 min(T4)和90 min(T5)、氣腹放氣平臥位15min(T6)時(shí)分別測(cè)量視神經(jīng)鞘直徑(ONSD)、大腦中動(dòng)脈時(shí)間平均峰值(TAP)流速、搏動(dòng)指數(shù)(PI)和阻力指數(shù)(RI)。采用SPSS 19.0統(tǒng)計(jì)學(xué)軟件進(jìn)行分析,計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,組間比較和組內(nèi)氣腹前后比較采用方差分析,P㩳0.05為差異有統(tǒng)計(jì)學(xué)意義,P㩳0.01為差異有高度統(tǒng)計(jì)學(xué)意義�！窘Y(jié)果】與T1時(shí)比較,兩組患者T2~5時(shí)TAP和PI升高,M組T4,5時(shí)ONSD和RI升高;T組T3~6時(shí)ONSD和RI升高,T6時(shí)PI升高(P㩳0.05)。與T組比較,M組T3和T6時(shí)ONSD和RI減小,T2時(shí)TAP和PI降低(P㩳0.05)�！窘Y(jié)論】改良抬胸T位可延緩顱內(nèi)壓和腦血流量(CBF)升高的發(fā)生,且氣腹結(jié)束后較早恢復(fù)正常,可能有利于較長(zhǎng)時(shí)間腹腔鏡手術(shù)老年患者的安全。第二部分:改良抬胸Trendelenburg位對(duì)腹腔鏡結(jié)直腸癌根治術(shù)老年患者腦氧代謝和術(shù)后早期認(rèn)知功能的影響【研究目的】觀察改良抬胸位對(duì)腹腔鏡結(jié)直腸癌根治術(shù)老年患者的腦氧代謝和術(shù)后早期認(rèn)知功能的影響�！狙芯糠椒ā考{入2014年1月至2015年10月在第二軍醫(yī)大學(xué)附屬長(zhǎng)海醫(yī)院和南京醫(yī)科大學(xué)附屬無(wú)錫人民醫(yī)院擇期擬行腹腔鏡結(jié)直腸癌根治術(shù)患者80例,年齡60歲以上,BMI指數(shù)19~25,ASAⅠ~Ⅱ級(jí),性別不限,按隨機(jī)數(shù)字表法分為2組(每組40例):M組加用定制體位墊使患者呈改良抬胸Trendelenburg體位(簡(jiǎn)稱T位),T組采用T位手術(shù)。于常規(guī)全身麻醉插管后平臥位5 min(T1),氣腹改良抬胸T位/T位即刻(T2)、30 min(T3)、60 min(T4)和90 min(T5)、氣腹放氣平臥位15 min(T6)時(shí)分別采集橈動(dòng)脈和頸靜脈球血樣,記錄血?dú)夥治�、血糖、乳酸以及MAP等,計(jì)算腦動(dòng)靜脈氧含量差(Ca-jvD02)及腦葡萄糖攝取(Da-jvglu)等;并于麻醉前,麻醉結(jié)束后2、6、24、48 h和72 h時(shí),采用簡(jiǎn)易智能量表(MMSE)進(jìn)行認(rèn)知功能評(píng)分。應(yīng)用SPSS 19.0軟件進(jìn)行統(tǒng)計(jì)學(xué)處理,計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,組間比較和組內(nèi)氣腹前后比較采用方差分析,P㩳0.05認(rèn)為差異有統(tǒng)計(jì)學(xué)意義,P㩳0.01為差異有高度統(tǒng)計(jì)學(xué)意義�！窘Y(jié)果】與Tl時(shí)比較,兩組患者動(dòng)脈血二氧化碳分壓(Pa CO2)T3~6均顯著升高,MAP在T2時(shí)顯著降低,T3~5時(shí)頸靜脈球血氧分壓(PjvO2)顯著升高,T4~5時(shí)頸靜脈球血氧飽合度(Sjv02)顯著升高;M組MAP在T4~6時(shí)顯著升高,T組在T3~6時(shí)顯著升高;T組在T6時(shí)Sjv02顯著升高,T5時(shí)Ca-jvD02顯著下降而頸靜脈球血乳酸(Lacjv)顯著上升(P㩳0.05)。與T組比較,M組MAP在T4~6時(shí)上升較慢;Ca-jvD02在T5時(shí)無(wú)明顯下降,Da-jvglu氣腹前后差異無(wú)統(tǒng)計(jì)學(xué)意義,Sjv02和Lacjv無(wú)顯著上升而Pa CO2在T6時(shí)顯著降低(P㩳0.05)。與T組比較,M組麻醉結(jié)束后6、24 h時(shí)MMSE評(píng)分明顯較高;與麻醉前比較,麻醉結(jié)束后2 h兩組MMSE評(píng)分顯著降低(P㩳0.01)�！窘Y(jié)論】改良抬胸T位可緩解氣腹后期腦氧供需失衡,麻醉結(jié)束后24 h內(nèi)認(rèn)知功能下降的發(fā)生率明顯降低,可能有利于較長(zhǎng)時(shí)間腹腔鏡手術(shù)老年患者的安全。
[Abstract]:In this study, elderly patients undergoing elective laparoscopic surgery under general anesthesia were studied to investigate the effect of modified Trendelenburg position on brain function. The main contents were divided into the following two parts: Part I: The effect of modified Trendelenburg position on intracranial pressure and cerebral circulation in elderly patients undergoing gynecological laparoscopic surgery. The changes of intracranial pressure (ICP) and cerebral hemodynamics in elderly patients undergoing gynecological laparoscopic surgery were observed by ultrasonography. [Methods] From January 2014 to October 2015, 40 patients who were scheduled to undergo gynecological laparoscopic surgery in Changhai Hospital Affiliated to Second Military Medical University and Wuxi People's Hospital Affiliated to Nanjing Medical University were enrolled. BMI index 19-24 and ASA I-II were randomly divided into two groups (n=20). Patients in study group (M) were treated with modified Trendelenburg position (T position) and patients in control group (T position). Patients in control group (T position) were treated with T position surgery. After general anesthesia intubation, patients in the horizontal position were treated with 5 min (T1) and in the pneumoperitoneal modified T/T position (T2), 30 min (T3), 60 min (T4) and 90 min (T position). (T5) Optic sheath diameter (ONSD), mean time peak velocity (TAP), pulsatility index (PI) and resistance index (RI) were measured in pneumoperitoneum degassing supine position for 15 minutes (T6). SPSS 19.0 software was used to analyze the data. The measurement data were expressed by mean (+) standard deviation (x (+) s). Variance scores were used for inter-group comparison and intra-group comparison before and after pneumoperitoneum. Analysis, P? 0.05 was statistically significant, P? 0.01 was highly statistically significant. [Results] Compared with T1, TAP and PI increased at T2-5 in both groups, while ONSD and RI increased at T4 and 5 in M group; ONSD and RI increased at T3-6 in T group, and PI increased at T6 (P? 0.05). Compared with T group, ONSD and RI decreased at T3 and T6 in M group, and TAP and PI decreased at T2 (P? 0.05). [Conclusion] Modified chest lifting T-position can delay the occurrence of intracranial pressure and cerebral blood flow (CBF) elevation, and restore to normal early after pneumoperitoneum, which may be conducive to the safety of elderly patients undergoing long-term laparoscopic surgery. Part II: Modified chest lifting Trendelenburg position in elderly patients undergoing laparoscopic colorectal cancer radical surgery for cerebral oxygen metabolism and early postoperative cognitive function [Objective] To observe the effect of modified thoracic elevation on cerebral oxygen metabolism and early postoperative cognitive function in elderly patients undergoing laparoscopic radical resection of colorectal cancer. Eighty patients with colorectal cancer undergoing radical resection were divided into two groups according to the random number table. The patients in group M were treated with modified Trendelenburg position (T position) and in group T were treated with T position operation. Blood samples of radial artery and jugular bulb were collected immediately (T2), 30 min (T3), 60 min (T4) and 90 min (T5) at T / T position, 15 min (T6) at pneumoperitoneal degassing and lying position, respectively. Blood gas analysis, blood glucose, lactic acid and MAP were recorded. Cerebral arteriovenous oxygen content difference (Ca-jvD02) and cerebral glucose uptake (Da-jvglu) were calculated. Simple Intelligence Scale (MMSE) was used to assess cognitive function at 48 h and 72 h. SPSS 19.0 software was used for statistical analysis. The measurement data were expressed as mean (+) standard deviation (x (+) s). The analysis of variance was used for comparison between groups and before and after pneumoperitoneum. P? 0.05 showed that there was significant difference, P? 0.01 was highly significant difference. [Conclusion] Results: Compared with Tl, the arterial partial pressure of carbon dioxide (Pa CO2) T3~6 was significantly increased, the MAP was significantly decreased at T2, the jugular bulb partial pressure of oxygen (PjvO2) was significantly increased at T3~5, the jugular bulb oxygen saturation (Sjv02) was significantly increased at T4~5, the MAP in M group was significantly increased at T4~6, and the MAP in T group was significantly increased at T6. Compared with T group, MAP in M group increased slowly at T4-6, Ca-jvD02 did not decrease significantly at T5, and there was no significant difference between Da-jvglu pneumoperitoneum and Da-jvglu pneumoperitoneum. Sjv02 and Lacjv did not increase significantly but Pa CO2 decreased significantly at T6 (P?0.05). The MMSE score was significantly higher at 6 and 24 hours after anesthesia, and significantly lower at 2 hours after anesthesia than that before anesthesia (P? 0.01). [Conclusion] Modified chest lifting T-position can relieve the imbalance of cerebral oxygen supply and demand in the late pneumoperitoneum, and the incidence of cognitive decline within 24 hours after anesthesia is significantly lower, which may be beneficial to the elderly patients undergoing long-term laparoscopic surgery. It's safe.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R614

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