【作者】 毕燕琳；

【导师】 王月兰；

【作者基本信息】 山东大学 ， 临床医学（专业学位）， 2014， 博士

【摘要】 背景目前已知术前无精神障碍的老年病人,受多种因素的影响麻醉和手术后可出现大脑功能紊乱导致在术后发生的可逆的和波动性的急性精神紊乱综合症称为术后认知功能障碍(postoperative cognitive dysfunction, POCD),表现为精神错乱、焦虑、记忆受损、人格的改变和社会整合能力改变等,严重者出现痴呆。以前研究表明,老年人心脏手术后认知功能障碍总的发生率为10%-50%,非心脏手术术后7天的发生率为25.8%,有些人群在术后三个月还有表现(>70岁,14%)如果不能及早诊治,其发病率及死亡率会增高。POCD的病因和发病机制至今尚不清楚,与术前、术中以及手术因素相关。目前认为,术后认知功能障碍是老年病人中枢神经系统退化的基础上,有手术和麻醉诱发,多种因素联合作用所致的神经功能减退,涉及到中枢神经系统、内分泌和免疫系统的紊乱。本研究在临床角度探讨POCD的预警指标、药物的干预,并采用回顾性分析进行相关危险因素的总结,另外从基础研究进一步探讨POCD的发病机制,为临床早期预防、早期治疗寻找出路。第一部分临床研究一、老年患者髋关节置换术后急性认知功能减退的预警目的探讨老年患者髋关节置换术后急性认知功能减退(POCD)的发生及神经退行变、神经炎症指标的表达。方法选择择期行髋关节置换术的患者66例,年龄65-85岁,ASA Ⅰ～Ⅱ级。选择硬膜外联合蛛网膜下腔阻滞,穿刺成功后抽取脑脊液2m1,麻醉前、术后1、3、7天采取静脉血8m1。采用ELISA法检测脑脊液及血浆中人Aβ1-40、高迁移率族蛋白B1(HMGB1)水平,采用荧光定量PCR法检测全血Aβ1-40前体蛋白(APP)、HMGB1、IL-1β mRNA表达水平,并分别在术前、术后7天进行神经认知功能测定。结果：66例患者术后7d有16例发生POCD, POCD的发生率为24.2%。POCD组脑脊液中Aβ1-40、HMGB1浓度与非认知功能减退(NPOCD)组相比,无显著性差异(P>0.05)。POCD组术后1、3、7d血浆HMGB1浓度均较术前明显升高,Ap1-40浓度术后3、7d较术前明显降低,具有统计学差异(P<0.05)；NPOCD组术后3天血浆Aβ1-40、HMGB1浓度较术前升高,术后7d均基本恢复术前水平,Ap1-40术后3、7d均升高。所有患者术后1、3d全血APP、HMGB1、IL-1βmRNA表达水平均较术前明显升高,术后7d基本恢复术前水平。组间比较,两组术后1d血浆A β1-40浓度、术后7d各指标的mRNA相比较,无显著性差异(P>0.05)；POCD组3、7d血浆A β1-40浓度低于NPOCD组,其余指标各时间血浆浓度及全血mRNA均明显高于NPOCD组(P<0.05)。结论老年患者在硬膜外联合蛛网膜下腔阻滞行髋关节置换术后POCD组全血中HMGB1、IL-1β浓度升高,Aβ1-40的降低,可能预示POCD的发生与外周和中枢炎症有关。二、髋关节置换老年患者术后谵妄和术后认知功能障碍的危险因素目的筛查髋关节置换老年患者术后谵妄(POD)和术后认知功能障碍(POCD)的危险因素。方法选择本院2010年5月-2012年8月期间择期硬膜外麻醉下行髋关节置换患者200例,年龄>65岁,性别不限,体重50-70kg,ASA分级II或III级。术后1-2d根据患者是否发生谵妄分为术后谵妄组(POD)和术后非谵妄组(NPOD),术后3-7d根据患者是否发生认知功能障碍分为术后认知功能障碍组(POCD)和术后非认知功能障碍(NPOCD)组。记录患者年龄、性别、体重、受伤时间、每周饮酒量、受教育程度、术前是否抑郁、合并高血压、糖尿病、冠心病、手术时间、术中出血量、术中低血压次数、术后VAS评分。筛查髋关节置换术老年患者POD和POCD的危险因素以及对危险因素进行排序。结果31例患者发生术后谵妄,发生率18.3%,56例患者发生术后认知功能障碍,发生率38.9%。Logistic回归分析结果显示：术后谵妄危险因素前四位的是年龄、受伤时间、术前抑郁、术前合并糖尿病；术后认知功能障碍的危险因素前四位的是年龄、术中低血压、受伤时间、术前抑郁(P＜0.05)。结论术后谵妄危险因素前四位的是年龄、受伤时间、术前抑郁、术前合并糖尿病；术后认知功能障碍的危险因素前四位的是年龄、术中低血压、受伤时间、术前抑郁,其中年龄、受伤时间以及术前抑郁是术后谵妄和术后认知功能障碍的共同危险因素。三、帕瑞昔布钠对老年股骨头置换术患者血清神经元特异性烯醇化酶、S-100β蛋白及术后认知功能的影响目的探讨帕瑞昔布钠围术期对老年股骨头置换术患者血清神经元特异性烯醇化酶(NSE)、S-100β蛋白与术后谵妄(POD)、术后认知功能障碍(POCD)发生率的影响。方法经医院伦理学委员会同意并与患者家属签订知情同意书,选择2011年1月至2012年5月在青岛市市立医院东院与青岛市海慈医疗集团骨科腰麻-硬膜外联合麻醉下急诊股骨头置换术老年患者80例,性别不限,年龄>70岁,美国麻醉医师协会体格情况分级Ⅱ-Ⅲ级,随机数字法分为2组(rF40)：吗啡围术期镇痛对照组(C组)及帕瑞昔布钠围术期镇痛组(P组)。P组患者将帕瑞昔布钠20mg或40mg(体质量50kg为区分依据)以生理盐水2ml稀释静脉注射镇痛,每12h1次,连续6次；C组首次静脉注射吗啡2mg或4mg作为对照。2组均额外根据患者镇痛需要每次追加吗啡2mg使疼痛视觉模拟评分(VAS)达3分以下。主要观察指标：(1)2组术后住院时间,吗啡追加量；(2)2组POD的发生率与术后3d(T1)、1周(T2)、3个月(T3)及6个月(T4)患者POCD的发生率；(3)2组各随机抽取20例于采取镇痛措施前(t0)、麻醉前(t1)、术毕(t2)、术后6h(t3)、24h(t4)及48h(t5)检测血清神经元特异性烯醇化酶(NSE)、S-100β蛋白浓度；(4)其他严重并发症。结果与C组相比较,P组吗啡追加量及术后住院时间降低[(7.9±2.6mg)比(31.3±3.9mg),(11.4±1.5)d比(12.3±1.6)d,P均<0.05]； P组POD及T1～T4POCD发生率降低(22.5%比45%,17.5%、12.5%、7.5%、2.5%比37.5%、32.5%、25%、17.5%,P均<0.05)； P组血清NSE浓度在t2-t5时降低[(7.1±2.7)μg/L、(9.5±3.6)μg/L、(8.4±3.6)μg/L、(7.2±2.8)μg/L比(9.4±4.1)μg/L、(13.6±5.0)μg/L、(11.1±3.7)μg/L.(9.4±3.3)μg/L,P均<0.05],血清S-100β蛋白浓度在t1-t。时降低[(0.61±0.27)μg/L、(0.99±0.38)μg/L、(0.73±0.25)μg/L、(0.65±0.28)μg/L、(0.87±0.32)μg/L比(0.83±0.36)μg/L、(1.48±0.57)μg/L、(0.98±0.37)μg/L、(0.88±0.29)μg/L、(1.12±0.45)μg/L,P均<0.05],其他时间点2组比较差异无统计学意义(P＞0.05)；2组均无严重并发症发生。结论帕瑞昔布钠围术期镇痛减轻中枢神经系统损伤,改善老年患者术后认知功能,利于患者康复。第二部分实验研究一、老年大鼠脾切除术后认知功能的改变与其海马组织腺苷酸活化蛋白激酶的表达目的评价海马腺苷酸活化蛋白激酶(AMPK)及炎性因子的表达与老龄大鼠脾切除术后认知功能障碍(POCD)的关系。方法健康清洁级雄性老龄SD大鼠90只,体重480～550g,采用随机数字表法,将其分为3组：对照组(C组,n=10,注射生理盐水)、麻醉组(A组,n=40,只进行麻醉)和手术组(S组,n=40麻醉后进行脾切除手术)。A组用10%水合氯醛进行麻醉,S组在进行与A组相同的麻醉后进行脾切除手术。A组和S组在处理前及模型建立后1、3、5、7d进行Morris水迷宫测试并在测试后随机处死10只老鼠取海马组织。水迷宫测试记录逃避潜伏期和游泳距离。海马组织则采用Western blot法测定AMPK、磷酸化AMPK (p-AMPK)、NF-κB、IL-1β、TNF-α的表达水平。结果水迷宫测试结果显示与C组、A组相比S组术后1、3、5d逃避潜伏期和游泳距离延长(P<0.05)；与C组、A组相比S组术后1、3、5、7d AMPK表达上调(p＜0.05),p-AMPK术后1、3、5d表达上调(P＜0.05)；与C组比较,S组术后1、3、5dNF-κB表达上调(p＜0.05)；IL-1β术后1、3、5、7d均上调(p＜0.05),TNF-α术后1、3d上调(P<0.05)。结论脾切除术后腺苷酸活化蛋白激酶被激活,且炎性因子表达量增加。老年大鼠脾切除术后腺甘酸活化蛋白激酶及炎性因子表达增加是出现术后认知功能改变的适应性调节机制。[关键词]老年人；手术；认知；丝氨酸／苏氨酸蛋白激酶类；海马二、手术创伤对老年大鼠海马区腺苷酸活化激酶mRNA表达及星形胶质细胞活性影响目的探讨手术创伤对老年大鼠海马区腺苷酸活化激酶(AMPK) mRNA表达及星形胶质细胞活化的影响。方法18月龄SD雄性大鼠70只随机分为两组：手术组(S组,n=35)、对照组(C组,n=35),S组用水合氯醛麻醉后进行脾切除手术,C组仅进行水合氯醛麻醉。两组再根据观察时间点(手术前1天和麻醉和手术后1、3、5和7天)分为5个亚组：SO、S1、S3、S5、S7组和CO、C1、C3、C5、C7组,每组7只,用Morris水迷宫测试老年大鼠的认知功能,rt-PCR定量法测量海马区AMPK mRNA的表达,免疫组化计数法测量海马星形胶质细胞GFAP的表达。结果与术前比较,S1和S3组Morris水迷宫测试逃避潜伏期和总路程明显延长(p<0.05),S1、S3和S5AMPK mRNA表达出现明显增高；星形胶质细胞GFAP的表达在S1和S3增高明显(P<0.05)；与C组比较,S1和S3组Morris水迷宫测试逃避潜伏期和总路程明显延长(P＜0.05),S1、S3和S5AMPK mRNA表达出现明显增高；星形胶质细胞GFAP的表达在S1和S3增高明显(P＜0.05),在整个过程中C组和术前相比差异不显著(P＞0.05)。结论大鼠脾切除术后出现了短暂认知功能的损伤,海马区AMPK mRNA表达增高,星形胶质细胞胞浆GFAP表达增加。更多还原

【Abstract】 BackgroundNo mental disorder can occur after the surgery before now known elderly patients affected by a variety of factors anesthesia and surgical results in reversible brain dysfunction and volatility of postoperative acute mental disorder syndrome called postoperative cognitive dysfunction (postoperative cognitive dysfunction, POCD), the performance of mental disorder, anxiety, impaired memory, changes in personality and social integration such as the ability to change, severe dementia. Previous study showed that the likelihood of occurrence of POCD is10%～50%among senior patients with cardiac surgery and25.8%among senior patients within7days after non-cardiac surgery. POCD can occur among patients aged over70with a possibility of14%3months after operation. The morbidity and mortality rate of POCD can increase if it is not diagnosed and treated in time.The etiology and pathogenesis of POCD is still unclear, with the preoperative, intraoperative, and surgery-related factors.Now that POCD in elderly patients is the basis for the degradation of the central nervous system, induced by the surgery and anesthesia, due to the combined effects of multiple factors nerve dysfunction, disorders related to the central nervous system, endocrine and immune system. This study investigated the clinical point of early warning indicators of POCD, drug intervention, and a retrospective analysis of risk factors related to summarize, another from basic research to further explore the pathogenesis of POCD, and lay the foundation for early clinical prevention.Part I Clinical Studies1. Early predictors of acute postoperative cognitive dysfunction in elderly patients undergoing hip fracture surgeryObjective To investigate the early predictors of acute postoperative cognitive dysfunction in elderly patients undergoing hip fracture surgery. Methods Sixty-six ASA I or II patients,aged65～85yr, scheduled for elective hip fracture surgery under epidural combined spinal anesthesia. After puncture into subarachnoid space,2ml CSF was drawed and stored in-70℃.Before anesthesia, after1,3,7days, blood was collected. Aβ1-40and HMGB1content of CSF and plasma was measured by ELISA. The expression of APP,HMGB1and IL-1βmRNA were detected by FQ-PCR. Before operation and postoperative day7, neurocognitive function test were performed. Results The incidence of POCD was24.2%(16/66) in postoperative day7. There were no satistically difference in content of Aβ1-40and HMGB1in CSF between group POCD and NPOCD(P＞0.05). Compared with preopration, the plasma HMGB1contents in postoperative day1,3,7were higher in group POCD, but the plasma Aβ1-40content was lower in postoperative day3,7, the expression of APP,HMGB1and IL-1βmRNA were evidently higher (P＜0.05). The plasma Aβ1-40content in group POCD was lower than those in group NPOCD in postoperative day3,7(P＜0.05). Conclusion The increase of plasma HMGB1contents and decrease of plasma Aβ1-40content predicted the incidence of POCD in elderly patients undergoing hip fracture surgery during epidural combined spinal anesthesia. 2. Risk factors of post-operative delirium and cognitive dysfunction in elderly patients undergoing hip joint replacement surgeryObjective To determine the risk factors for post-operative delirium (POD)and post-operative cognitive dysfunction (POCD)in elderly patients undergoing hip joint replacement surgery. Methods We selected200elderly patients under epidural anesthesia and scheduled for hip joint replacement surgery from May2010to August2012in Qingdao Municipal Hospital. POD was assessed by CAM at2days after operation.Cognitive function was assessed by MMSE at7days after operation. The factor was analyzed using multi-factor logistic regression to select risk factor for incidence of POD and POCD. Results Thirty-one patients developed POD (15.5%).Fifty-six patients developed POCD (28.0%).The results of multivariate logistic analysis showed that risk factors for postoperative delirium are the age＞75years old, injury time＞15h,education＜9years、preoperative depression, diabetes, intraoperative hypotension and risk factors for postoperative cognitivedys function are the age>80years old, injury time＞15h, intraoperative hypotension, preoperative depression, alcohol comsumption per week>5U, education＞12years,diabetes,VAS score4.(P＜0.05).ConclusionAge,injurytime,preoperative depression,diabetes,education and intraoperative hypotension is common risk factors of postoperative delirium and postoperative cognitive dysfunction. 3. Effects of parecoxib sodium analgesia on serum NSE and S-100β concentrations and postoperative cognitive function of the elderly patients undergoing acute replacement of femoral head.Objective To investigate the effects of parecoxib sodium analgesia on serum NSE and S-100βconcentrations and postoperative cognitive function of the elderly patients undergoing acute replacement of femoral head. Methods After IRB approval and informed consent, Eighty patients of both sexes, older than70years, American Society of Anesthesiologists physical status2-3,undergoing acute replacement of femoral head, combined spinal and epidural anesthesia and midazolam sedation,in Qingdao Municipal Hospital and Qingdao Hiser Medical Center, from January2011to May2012, were randomly assigned to control group (group C,n=40) and parecoxib group (group P,n=40). In group P, parecoxib sodium20mg or40mg(based on weight50kg) diluted with2ml saline was given by intravenous injection after admission with12hours intervals for six times. In group C, morphine2mg or4mg(based on weight50kg) was given at the first time. Additional morphine2mg was given to keep the pain visual analog scale (VAS) of3points or less in both groups. Primary observation indexes:(1)the postoperative time, additional amount of morphine;(2)the rate of postoperative delirium(POD) and postoperative cognitive dysfunction(POCD) at3days,1week,3months and6months after surgery(T1-T4);(3) serum level of NSE and S-100βwas measured at the time before analgesia (t0), before anesthesia(t1),the end of surgery(t2) and6hours,24hours,48hours after the surgery (t3-t5);(4)the other serious complications. Results Compared with group C, the additional amount of morphine,postoperative time, the rate of POD and POCD at T1-T4, the level of NSE was lower at t2-t5and the level of S-100βwas lower at tl-t5in group P(P＜0.05).No other serious complications were observed. Conclusion Parecoxib sodium analgesia can reduce the rate of POD and POCD in the elderly patients with neuroprotective effects. Part II Experimental Studies1.The expression of adenosine monophosphate activated kinase at hippocampus in postoperative cognitive dysfunction after splenectomy in aged rats. Objective To investigate the expression of adenosine monophosphate activated kinase(AMPK) at hippocampus in postoperative cognitive dysfunction (POCD) in aged rats. Methods Sixty-three male aged Sprague-Dawley rat, weighting480-550g, were randomly divided into3groups(n=21each):control group(group C),anesthesia group(group A),surgery group(group S). Spatial learning and memory were evaluated in the Morris Water Maze(MWM) both before treatment and posttreatment. In anesthesia group,10%chloral hydrate was injected in abdominal cavity. In the surgery group, the splenectomy surgery was proceed after the same anesthesia as group A. The equal volume of saline was given in group C. Then these groups were tested in WMW on1,3,7days. The rats, after the test, were divided into group POCD and NPOCD according to their performance in the test. Then the rats were sacrificed and had their hippocampuses removed. Western-blot was used to detect the protein of AMPK and P-AMPK. Results Compared with group C,the level of AMPK was higher in group S at1,3and7d(P<0.05), P-AMPK was higher at1d and3d (P＜0.05).The expression of AMPK was higher in group POCD(P＜0.05). Conclusion The cognitive function was changed ephemeral and the level of AMPK and P-AMPK were higher simultaneously in hippocampus in aged rats after splenectomy. The increased expression of AMPK and P-AMPK were related to POCD. 2. Effect of surgical trauma on expression of adenosine monophosphate activated kinase and activation of astrocyte in hippocampus in aged ratsObjective To explore the effect of surgical trauma on expression of mRNA of adenosine monophosphate activated kinase and activation of astrocyte in hippocampus in aged rats.Methods Seventy rats aged18months were randomly divided into two groups:Groups S (anesthesia and splenectomy) and Groups C (anesthesia).Both of the groups were divided into5subgroup according to observation time(1day before operation or anesthesia,1、3、5and7day after operation or anesthesia),i.e.SO, S1, S3, S5, S7and CO, Cl, C3, C5, C7. Morris water maze test was used to observe cognition at1day before anesthesia or operation, days1,3,5and7after anesthesia or operation; rt-PCR was used to determine the expression of AMPK-α; Immunohistochemisty was used to determine the expression of GFAP in the astrocyte in hippocampus field. Results Compared to S0,the escape latency and the total distance was significantly extended on S1and S3(P＜0.05); AMPK-α was significantly increased on S1, S3and S5, furthermore, there were two peak on S1and S5(P＜0.05); The expression of GFAP in astrocyte was significatively increased on S1and S3(P＜0.05). Conclusion Cognitive function was decreased after splenectomy,while the increasion of AMPK in the astrocyte in hippocampus filed was significatively increased and the expression of GFAP in astrocyte was significatively increased更多还原