目的 探讨允许性高碳酸血症对老年糖尿病患者术后认知功能的影响.方法 选择全麻下行腹腔镜上腹部手术的老年糖尿病患者 60 例,将患者随机分为两组:允许性高碳酸血症通气糖尿病组(DH组)和常规通气糖尿病组(DR组),每组 30 例.另选择全麻下行腹腔镜上腹部手术非糖尿病老年患者 60 例,将患者随机分为两组:允许性高碳酸血症通气非糖尿病组(NH组)和常规通气非糖尿病组(NR组),每组 30 例.麻醉诱导后行机械通气,调控呼吸参数使DH组和NH组维持PaCO2 45～65 mmHg,DR组和NR组维持PaCO2 35～45 mmHg.记录气腹前 5 min及气腹后 5、15、30 min的PETCO2,并采集以上时点桡动脉、颈内静脉血样行血气分析,记录pH值、PaCO2,计算动脉-颈内静脉血氧含量差(Da-jvO2)和脑氧摄取率(CERO2).检测麻醉诱导前及术后 3d的血清S100β蛋白浓度.记录术前 1d和术后 1、3、7 d的蒙特利尔认知评估量表(MoCA)评分和术后认知功能障碍(POCD)的发生情况.结果 与气腹前 5 min比较,四组气腹后 5、15、30 min时PETCO2 和PaCO2 明显升高,pH值、Da-jvO2 和CERO2 明显降低(P＜0.05).与麻醉诱导前比较,四组术后 3d血清S100β蛋白浓度均明显升高(P＜0.05).与术前 1d 比较,四组术后 1、3 d MoCA 评分均明显降低(P＜0.05).与DR组比较,DH 组气腹前 5 min 及气腹后 5、15、30 min 时 PET CO2 明显升高,pH 值、Da-jvO2和CERO2 明显降低,术后 3d血清S100β蛋白浓度明显降低,术后 1、3 d MoCA评分明显升高,POCD发生率明显降低(P＜0.05).与NR组比较,NH组气腹前 5 min及气腹后 5、15、30 min时PETCO2明显升高,pH值、Da-jvO2 和CERO2 明显降低,术后 3d血清S100β蛋白浓度明显降低,术后1、3 d MoCA评分明显升高,POCD发生率明显降低(P＜0.05).与NH组比较,DH组气腹前 5 min及气腹后5、15、30 min时Da-jvO2 和CERO2 明显升高,术后3d血清S100β蛋白浓度明显升高,术后1、3 d MoCA评分明显降低(P＜0.05).结论 允许性高碳酸血症可改善老年糖尿病患者术中脑氧代谢,降低术后血清S100β蛋白浓度,降低术后认知功能障碍的发生率.
Effects of permissive hypercapnia on postoperative cognitive function in elderly patients with diabetes mellitus
Objective To explore the effects of permissive hypercapnia on postoperative cognitive function in elderly patients with diabetes mellitus.Methods Sixty elderly patients with diabetes mellitus scheduled for laparoscopic upper abdominal surgery under general anesthesia,were randomly divided into two groups:the permissive hypercapnia ventilation diabetes mellitus group(group DH)and the routine ven-tilation diabetes mellitus group(group DR),30 patients in each group.Another sixty elderly patients with non-diabetes mellitus scheduled for laparoscopic upper abdominal surgery under general anesthesia,were randomly divided into two groups:the permissive hypercapnia ventilation non-diabetes mellitus group(group NH)and the routine ventilation group(group NR),30 patients in each group.All patients in four groups were performed with tracheal intubation and mechanical ventilation after anesthesia induction.The respiratory parameters were adjusted to maintain PaCO2 in a range of 45-65 mmHg in groups DH and NH,and PaCO2 in a range of 35-45 mmHg in groups DR and NR.PETCO2 was recorded 5 minutes before pneu-moperitoneum,5,15,and 30 minutes after pneumoperitoneum.Blood samples were taken from the radial artery and jugular bulb for blood gas analysis 5 minutes before pneumoperitoneum,5,15,and 30 minutes after pneumoperitoneum.pH value and PaCO2 were recorded and arterial internal jugular vein bulbar oxygen difference(Da-jvO2)and cerebral oxygen extraction rate(CERO2)were calculated at the same time.The serum S100β protein concentration were detected before anesthesia induction and 3 days after operation.Montreal cognitive assessment(MoCA)scores and occurrence of postoperative cognitive dysfunction were recorded 1 day before operation,and 1 day,3 days and 7 days after operation.Results Compared with the baseline value 5 minutes before pneumoperitoneum,PETCO2 and PaCO2 were significantly increased,pH value,Da-jvO2 and CERO2 were significantly decreased 5,15,and 30 minutes after pneumoperitoneum in the four groups(P＜0.05).Compared with before anesthesia induction,the serum S100β protein concen-tration were significantly increased 3 days after operation in the four groups(P＜0.05).Compared with the last day before operation,MoCA scores were significantly decreased 1 day and 3 days after operation in the four groups(P＜0.05).Compared with group DR,PETCO2 was significantly increased,pH value,Da-jvO2,and CERO2 were significantly decreased 5 minutes before pneumoperitoneum,5,15,and 30 mi-nutes after pneumoperitoneum,the serum S100β protein concentration was significantly decreased 3 days af-ter operation,MoCA scores were significantly increased 1 day and 3 days after operation,the incidence rate of POCD was significantly decreased in group DH(P＜0.05).Compared with group NR,PETCO2 was sig-nificantly increased,pH value,Da-jvO2,and CERO2 were significantly decreased 5 minutes before pneu-moperitoneum,5,15,and 30 minutes after pneumoperitoneum,the serum S100β protein concentration was significantly decreased 3 days after operation,MoCA scores were significantly increased 1 day and 3 days af-ter operation,the incidence rate of POCD was significantly decreased in group NH(P＜0.05).Compared with group NH,Da-jvO2 and CERO2 were significantly increased 5 minutes before pneumoperitoneum,5,15,and 30 minutes after pneumoperitoneum,the serum S100β protein concentration was significantly in-creased 3 days after operation,MoCA scores were significantly decreased 1 day and 3 days after operation in group DH(P＜0.05).Conclusion Permissive hypercapnia can improve the cerebral oxygen metabolism during operation,reduce postoperative serum S100β protein concentration and reduce the incidence rate of POCD in the elderly patients with diabetes mellitus.
AgedHypercapniaPostoperative cognitive dysfunctionDiabetes mellitusS100β protein
万方数据
维普
