【摘要】：眾所周知，術(shù)后認(rèn)知功能障礙（postoperative cognitive dysfunction,POCD）是手術(shù)后常見(jiàn)的并發(fā)癥之一。POCD廣義上是指麻醉和外科手術(shù)后，精神心理狀態(tài)發(fā)生改變，表現(xiàn)為學(xué)習(xí)記憶力、感知力、注意力、抽象思維能力、精神運(yùn)動(dòng)速率、執(zhí)行力、視覺(jué)構(gòu)造能力以及睡眠質(zhì)量等方面功能障礙，同時(shí)伴有社會(huì)活動(dòng)能力減退，即人格、社交能力和技能的改變。在過(guò)去的幾十年中，大家都致力于對(duì)POCD發(fā)生機(jī)制和病因?qū)W的研究，人們提出了諸多假說(shuō)，并針對(duì)一些因素進(jìn)行驗(yàn)證、討論，但是，關(guān)于POCD更深層次的相關(guān)因素與發(fā)生機(jī)制有待進(jìn)一步研究。本課題就心臟手術(shù)后認(rèn)知功能障礙的發(fā)生率、風(fēng)險(xiǎn)因素以及遠(yuǎn)期影響做一分析討論。 本研究主要通過(guò)對(duì)接受冠脈搭橋手術(shù)的患者的臨床資料進(jìn)行整理、統(tǒng)計(jì)和分析，總結(jié)冠脈搭橋術(shù)后發(fā)生認(rèn)知功能障礙的獨(dú)立危險(xiǎn)因素，并加以分析討論。本項(xiàng)研究課題嚴(yán)格遵循統(tǒng)計(jì)學(xué)實(shí)驗(yàn)設(shè)計(jì)的基本原則，對(duì)自2012年8月至2013年11月，在河北醫(yī)科大學(xué)第二醫(yī)院心臟大血管外科，接受冠脈搭橋手術(shù)的患者進(jìn)行臨床資料的收集，對(duì)其術(shù)前、術(shù)中以及術(shù)后相關(guān)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)處理，得到結(jié)果并加以分析，最終得出結(jié)論。 目的： 中樞神經(jīng)系統(tǒng)的并發(fā)癥是心臟手術(shù)后常見(jiàn)的并發(fā)癥之一，它會(huì)直接影響到病人心臟手術(shù)的預(yù)后和生存率。本研究的目的是對(duì)冠脈搭橋手術(shù)后早期發(fā)生認(rèn)知功能障礙的獨(dú)立危險(xiǎn)因素進(jìn)行篩選和分析。 方法： 從2012年8月至2013年11月，共102例，其中男性78例，女性24例，，術(shù)前合并糖尿病的23例，免疫系統(tǒng)疾病的23例。102例病人中，3例因術(shù)后心臟相關(guān)并發(fā)癥死亡，剩余99例病人中93例行不停跳非體外循環(huán)冠脈搭橋術(shù)（OPCABG）。6例冠心病合并心臟瓣膜病，3例行體外循環(huán)冠脈搭橋術(shù)（CCABG）+二尖瓣置換術(shù)，2例行體外循環(huán)冠脈搭橋術(shù)+主動(dòng)脈瓣置換術(shù)，1例行體外循環(huán)冠脈搭橋術(shù)+左房粘液瘤切除術(shù)。 術(shù)前各項(xiàng)檢查均在正常范圍內(nèi)。術(shù)前遵醫(yī)囑用藥將病人的各項(xiàng)指標(biāo)調(diào)整至合適的范圍。麻醉術(shù)前常規(guī)用藥，地西泮片0.08~0.15mg/kg術(shù)前晚及術(shù)日晨口服，酒石酸美托洛爾片12.5~37.5mg術(shù)日晨口服，鹽酸嗎啡注射液0.15~0.2mg/kg術(shù)前30分鐘肌注，氫溴酸東莨菪堿注射液0.3mg術(shù)前30分鐘肌注，根據(jù)病人具體情況調(diào)整用藥劑量。麻醉誘導(dǎo)時(shí)，靜脈注射咪達(dá)唑侖0.05~0.1mg/kg，芬太尼5μg/kg，依托咪酯0.2mg/kg，羅庫(kù)溴銨0.6mg/kg，，術(shù)中麻醉維持，微量泵靜脈輸注丙泊酚2~5mg·kg-1·h-1，瑞芬太尼0.1~0.3ug·kg-1·min-1。行冠脈搭橋術(shù)，需要心臟瓣膜置換的病人還需行體外循環(huán)輔助。常規(guī)進(jìn)行心電圖、脈搏血氧飽和度、有創(chuàng)動(dòng)脈壓、中心靜脈壓、鼻咽溫、呼氣末二氧化碳監(jiān)測(cè)、BIS監(jiān)護(hù)。維持呼吸循環(huán)穩(wěn)定。于術(shù)前1天、術(shù)后3天、7天，分別對(duì)患者進(jìn)行神經(jīng)心理學(xué)評(píng)估，采用簡(jiǎn)易智能量表（MMSE）測(cè)試評(píng)估。 結(jié)果： 術(shù)后認(rèn)知功能障礙的發(fā)生率為35.4%。將手術(shù)后3天、7天發(fā)生認(rèn)知功能障礙的病人與未發(fā)生認(rèn)知功能障礙的病人的相關(guān)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析得出，體外循環(huán)（P=0.023），術(shù)前合并糖尿病（P0.001），ICU持續(xù)輸注咪達(dá)唑侖（P0.001），BIS值（P=0.042）及術(shù)后拔除氣管插管時(shí)間（P0.001）是術(shù)后早期發(fā)生認(rèn)知功能障礙的獨(dú)立危險(xiǎn)因素。 結(jié)論： 體外循環(huán)，術(shù)前合并糖尿病，心外ICU持續(xù)泵入咪達(dá)唑侖，BIS值和術(shù)后拔除氣管插管時(shí)間是術(shù)后早期認(rèn)知功能障礙發(fā)生的獨(dú)立危險(xiǎn)因素。
[Abstract]:It is well known that post-operative cognitive dysfunction (POCD) is one of the most common complications following surgery. The general term of POCD means that after the anesthesia and the surgery, the mental state of mental state changes, which is manifested as the function of learning memory, feeling of understanding, attention, abstract thinking ability, mental movement rate, executive ability, visual construction ability and sleep quality, etc. At the same time, there is a decline in social activities, that is, the change of personality, social skills and skills. In the past few decades, we have been committed to the study of the mechanism and etiology of POCD, and many hypotheses have been put forward, and some factors have been validated and discussed. However, the more profound correlation and mechanism of POCD have to be further studied. This topic discusses the incidence, risk factors and long-term effects of cognitive dysfunction after cardiac surgery. This study is to summarize and analyze the clinical data of patients undergoing coronary artery bypass surgery, and to sum up the independent risk factors of cognitive impairment after coronary artery bypass surgery, and to analyze and discuss them. On the basis of the basic principle of statistical experimental design, the clinical data were collected from August, 2012 to November, 2013 in the second hospital of Hebei Medical University. Before, during and after operation, the relevant data were statistically processed, the results were obtained and analyzed, and finally the junction was obtained. On the other hand. Objective: The complications of the central nervous system are one of the most common complications following cardiac surgery, which can directly affect the pre-operation of the patient's heart. The purpose of this study is to carry out the independent risk factors of cognitive dysfunction in the early stage of coronary artery bypass surgery. Screening and Methods: From August, 2012 to November, 2013, there were 102 cases, including 78 male and 24 female, 23 cases of pre-operative diabetes, 23 cases of immune system disease, and 3 of 102 patients. The heart-related complications were associated with death, and 93 of the remaining 99 patients were non-circulating off-pump coronary artery bypass (OPCABG). 6 cases of coronary heart disease complicated with valvular heart disease, 3 cases of coronary artery bypass grafting (CABG) + mitral valve replacement, 2 cases of extracorporeal circulation coronary artery bypass and aortic valve replacement, 1 case Coronary artery bypass grafting with cardiopulmonary bypass + left atrial myxoma resection. Pre-operative All the examinations are within the normal range. All the patients will be treated with the medication before the procedure. The key parameters were adjusted to the appropriate range. The conventional medication before the operation, 0. 08-0. 15 mg/ kg, oral administration of metoprolol tartrate, 12. 5-37. 5 mg of metoprolol tartrate, 0. 15-0. 2 mg/ kg of morphine hydrochloride, 0. 15-0. 2 mg/ kg, intramuscular injection of 30 minutes before operation, and 0. 3 mg of hydrobromide for the first 30 minutes, according to the disease The dosage of the drug was adjusted in the specific case. In the induction of the anesthesia, the intravenous injection of prochloronil was 0. 05-0. 1 mg/ kg, the fentanyl was 5. m u.g/ kg, the etomidate was 0. 2mg/ kg, the content of the remifentanil was 0. 6mg/ kg, the anesthesia was maintained during the operation, and the intravenous infusion of propofol 2-5mg 路 kg-1 路 h-1 and remifentanil 0.1 ~ 0.32ug in the micropump. 路 kg-1 路 min-1. Coronary artery bypass is required, and heart valve replacement is required. The patient also needs to be assisted by cardiopulmonary bypass. Routine ECG, pulse blood oxygen saturation, invasive arterial pressure, central venous pressure, nasopharyngeal temperature, end of breath 2 Carbon oxide monitoring, BIS The patient underwent neuropsychological assessment on the first day of the operation, 3 days after the operation, and 7 days after the operation, and the simple and intelligent energy was used. Table (M MSE) test evaluation. Results: Post-operative recognition The incidence of cognitive dysfunction was 35. 4%. The data of the patients with cognitive impairment in 3 and 7 days after the operation were statistically analyzed, and the cardiopulmonary bypass (P = 0. 023), the pre-operative combined diabetes (P0.001) and the intensive care unit (ICU) were obtained. The time of reinfusion of Mimidalun (P0.001), BIS (P = 0. 042) and the time of postoperative tracheal intubation (P0.001) was the early postoperative period. to be recognized Conclusion: Extracorporeal circulation, pre-operation and pre-operation combined with diabetes, the continuous pumping of the extracardiac intensive care unit into the prochloronil, the BIS value and the time of the post-operative removal of the tracheal tube is
【學(xué)位授予單位】：河北醫(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

【引證文獻(xiàn)】

相關(guān)期刊論文 前1條

1 陶香君;丁舒;馮新偉;吳瑛;;心臟術(shù)后患者認(rèn)知功能障礙危險(xiǎn)因素的Meta分析[J];中華護(hù)理雜志;2016年07期

本文編號(hào)：2413033