【作者】 张奇；

【导师】 刘铁成；

【作者基本信息】 吉林大学 ， 临床医学， 2012， 硕士

【摘要】 背景：术后认知功能障碍（postoperative cognitive Dysfunction，POCD）是指手术后出现的中枢神经系统并发症，一般表现为认知能力减退、焦虑、记忆减退、语言理解能力和社会融合能力减退等负面效应。有关非体外循环下冠状动脉旁路移植术(Off-pump coronary artery bypass grafting，OPCABG) POCD的研究，病理生理学解释主要集中在神经中枢的损伤，以及微血栓，低灌注和系统性炎症反应等。术中合理用药可以有效降低POCD的发生率，尽量减少因麻醉用药对患者所造成的社会活动、工作及生活自理能力等方面的降低或丧失。盐酸右美托咪啶(dexmedetomidine，Dex)是一种新型的α2-肾上腺素受体激动剂美托咪定的右旋异构体，具有半衰期短，用量小，中枢α2-肾上腺素受体激动的选择性强(α2: α1=1620:1)的特点。它在麻醉镇静和镇痛方面的辅助作用已经得到广泛的肯定，同时它对血流动力学影响比较小也是优点之一。本研究将右美托咪啶用于非体外循环下冠状动脉旁路移植术患者手术当中，与生理盐水对照组对比其对患者术后认知功能方面的影响，为临床用药提供依据。目的：本研究旨在观察右美托咪啶对非体外循环下冠状动脉旁路移植术病人术后认识功能的影响，为临床实践提供指导依据。方法：选择择期手术的非体外循环下冠状动脉旁路移植术患者64例，性别不限，年龄45—65岁，ASAII～III级，心功能I～II级。随机分为对照组(C组)和盐酸右美托咪啶组(D组)，每组32例。D组患者麻醉诱导前持续静脉输注盐酸右美托咪啶，速度为50ng/kg/min，输注时间为30min；麻醉诱导开始后，持续静脉输注盐酸右美托咪啶，速度为7ng/kg/min，直至手术结束，C组患者持续静脉输注等容量0.9%生理盐水。分别在术前、术后第7日对所有患者进行神经心理学测试，观察非体外循环下冠状动脉旁路移植术患者认知功能恢复情况。结果：两组患者术前神经心理学测试的比较差异无统计学意义（P>0.05）；和术前相比，C组术后第7天数字符号评分升高，数字广度—逆向、小故事—甲评分降低，差异具有统计学意义（P <0.05）；D组术后第7天数字广度—逆向评分降低，差异具有统计学意义（P <0.05）。和C组相比，D组患者T1、T2、T3时刻HR、SBP、DBP无明显变化（P＞0.05），T4时刻HR、SBP、DBP降低，差异具有统计学意义（P<0.05）；和T1时刻相比，C组患者T4时刻HR、SBP、DBP升高，差异具有统计学意义（P<0.05）。和C组相比，D组患者术中静脉输注丙泊酚和舒芬太尼总量降低，差异具有统计学意义（P<0.05）。C，D两组患者术后麻醉苏醒后，均有不同程度的认知功能障碍发生， C组患者有6例发生了术后认知功能障碍，发生率为18.8%；D组患者有2例发生了术后认知功能障碍，发生率为6.3%；和C组相比，D组术后认知功能障碍发生率降低，差异具有统计学意义（P <0.05），术后躁动，谵妄等发生率均较低；D组疼痛，躁动，认知功能不全发生率较低于C组。结论：盐酸右美托咪啶对于非体外循环下冠状动脉旁路移植术病人安全有效，能够维持稳定的血流动力学，其疼痛、躁动、认知功能不全发生率明显降低；能够有效抑制气管插管引起的应激反应，提供稳定的血流动力学；能够有效辅助镇痛并减少患者阿片类镇痛药和丙泊酚的用量，值得临床推广。更多还原

【Abstract】 Background: Postoperative cognitive dysfunction (POCD) is the central nervoussystem complications after surgery, the general performance are cognitive declining, anxiety,impaired memory, the negative effect which the ability of language comprehension andsocial integration have diminished. For off-pump coronary artery bypass grafting,the studiesof POCD, and pathophysiology explained mainly concentrated in the nerve center of thedamage, and microthrombi, hypoperfusion, and systemic inflammatory response. Rationaldrug use in surgery can effectively reduce the incidence of POCD of minimizing the socialactivities caused by narcotic medication for patients, the reduction or loss of work andliving skills and other aspects.America care, the right of hydrochloric acid microphone set (patients todexmedetomidine, Dex) is a novel α2-adrenergic receptor agonist, beauty care given theright-handed isomers in microphone, has a short half-life, dosage, the hub of α2-adrenergicreceptor agonist selectivity (of α2: α1=1620:1) features. Supporting role in sedation andanalgesia has been widely recognized, while its hemodynamic effects are relatively small, isone of the advantages. To the right dexmedetomidine in this study for patients withnon-pump coronary artery bypass grafting surgery, its impact on postoperative cognitivefunction in patients with compared with the saline control group, to provide a basis forclinical treatment.Objective: This study aimed to investigate the influence of dexmedetomidine givencognitive function after coronary artery bypass grafting patients without cardiopulmonarybypass, provide a basis for guiding clinical practice.Methods:64cases of elective surgery patients with coronary artery bypass graftingwithout cardiopulmonary bypass, genderNot limited to, age45-65years old, ASAII III class, cardiac function I Level II. Wererandomly divided into control group (group C) and hydrochloric acid right dexmedetomidinegroup (D),32cases in each group. Group D patients before induction of anesthesiacontinuous intravenous infusion of hydrochloric acid right the prop microphone set speed50ng/kg/min, infusion time of30min; induction of anesthesia, after the start of continuousintravenous infusion of hydrochloric acid dexmedetomidine given speed7ng/kg/min, until the end of surgery, group C patients with sustained intravenous infusion and an equalvolume of0.9%saline. Respectively, in the preoperative and postoperative7days for allpatients with neuropsychological tests, observation of off-pump coronary artery bypassgrafting in patients with cognitive function in the recovery ofResults: The neuropsychological tests in two groups of patients before was nosignificant difference (P>0.05);Compared to the preoperative increase in group C after7days Digit Symbol score, digitspan-Reverse little story-A score lower, the difference was statistically significant (P<0.05); D group after7days, digital breadth-Reverse score lower, the difference wasstatistically significant (P <0.05).Compared to group C, group D patients with T1, T2, T3time the HR, SBP and DBP nosignificant change (P>005), T4moment the HR SBP and DBP decreased, the differencewas statistically significant (P <0.05); and T1time, group C patients with T4moment HRSBP and DBP increased, the difference was statistically significant (P <0.05).Compared to Group C Group D patients undergoing intravenous infusion of propofoland sufentanil total lower, the difference was statistically significant (P <0.05).C and D, two groups of patients after recovery from anesthesia, the varying degrees ofcognitive dysfunction, six cases of postoperative cognitive dysfunction group C patients, theincidence rate of18.8%; Group D patients had two cases postoperative cognitive dysfunction,the incidence rate of6.3%; and group C, D, postoperative cognitive dysfunction reduced theincidence of a statistically significant difference (P <0.05), postoperative agitation, delirium,etc. The low incidence; Group D pain, restlessness, low incidence of cognitive dysfunctionin the C group.Conclusion: dexmedetomidine hydrochloride given for the safety of off-pump coronaryartery bypass graft surgery patients, able to maintain stable hemodynamics, its pain, agitation,cognitive dysfunction was significantly reduced; can effectively inhibit the endotracheal tubecaused by the stress response and hemodynamic stability; able to effectively assist theanalgesic effect and reduce the amount of patients with opioid analgesics and propofol, andworthy of promotion.更多还原