不同剂量艾司氯胺酮联合丙泊酚全身麻醉诱导对老年患者术后早期POCD及血清学指标的影响

Effects of different doses of esketamine combined with propofol for induction of general anesthesia on early POCD and serological indicators in elderly patients undergoing surgery

摘要:

目的 探讨不同剂量艾司氯胺酮联合丙泊酚全身麻醉（以下简称全麻）诱导对老年手术患者术后早期认知功能障碍（POCD）及血清肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）、S100B钙结合蛋白β（S100β）、神经元特异性烯醇化酶（NSE）水平的影响。方法 选取2021年10月—2022年12月贵阳市第一人民医院收治的105例老年全麻手术患者，并随机分成AKL组、AKM组和AKH组，每组35例。3组患者分别采用0.3、0.4和0.5 mg/kg艾司氯胺酮联合丙泊酚行全麻诱导，待患者意识消失后，静脉注射舒芬太尼0.25 μg/kg，顺阿曲库铵0.2 mg/kg，肌肉松弛时进行气管插管。3组患者均使用七氟烷加瑞芬太尼维持麻醉，七氟烷肺泡最低有效浓度（MAC）值为0.5～0.8，瑞芬太尼靶控输注（TCI）血浆浓度为2～4 ng/mL，每隔40 min追加顺式阿曲铵0.6 mg/kg。监测3组患者全麻诱导前（T₀）、诱导药物注射结束时（T₁）、气管插管前（T₂）、气管插管即刻（T₃）、气管插管后5 min（T₄）血流动力学变化，同时测定术前第1天（D₀）、术后即刻（D₁）、术后第1天（D₂）、术后3天（D₃）及术后5天（D₄）血清TNF-α、IL-6、S100β、NSE水平，并统计POCD发生率。结果 3组T₀、T₁、T₂、T₃、T₄时收缩压（SBP）、舒张压（DBP）、心率（HR）比较，经重复测量设计的方差分析，结果 ①不同时间点的SBP、DBP、HR有差异（P <0.05）；②3组SBP、DBP、HR有差异（P <0.05）；③3组SBP、HR变化趋势无差异（P >0.05），DBP变化趋势有差异（P <0.05）。3组D₀、D₁、D₂、D₃、D₄时血清TNF-α、IL-6、S100β、NSE水平比较，经重复测量设计的方差分析，结果 ①不同时间点血清TNF-α、IL-6、S100β、NSE水平有差异（P <0.05）；②3组血清TNF-α、IL-6、S100β、NSE水平有差异（P <0.05）；③3组血清TNF-α、IL-6变化趋势有差异（P <0.05），S100β、NSE变化趋势无差异（P >0.05）。AKH组D₂、D₃时POCD发生率低于AKL组、AKM组。3组D₄时POCD发生率比较，差异无统计学意义（P >0.05）。3组术后谵妄、口咽分泌物增多发生率比较，差异无统计学意义（P >0.05）。结论 0.5 mg/kg艾司氯胺酮联合丙泊酚行全麻诱导可有效稳定术中血流动力学，明显减少术后炎症因子产生，显著降低术后血清S100β、NSE表达水平及早期POCD发生风险。

Abstract:

Objective To investigate the effects of different doses of esketamine combined with propofol for induction of general anesthesia on early postoperative cognitive dysfunction (POCD) and serum levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), S100B calcium-binding protein (S-100β) and neuron specific enolase (NSE) in elderly patients undergoing surgery.Methods A total of 105 elderly patients undergoing surgery under general anesthesia in the First People's Hospital of Guiyang from October 2021 to December 2022 were selected and randomly divided into AKL group (n = 35), AKM group (n = 35) and AKH group (n = 35), where general anesthesia was induced by 0.3 mg/kg, 0.4 mg/kg and 0.5 mg/kg of Esketamine combined with propofol, respectively. When the patients became unconscious, 0.25 μg/kg of sufentanil and 0.2 mg/kg of cisatracurium were intravenously injected, and tracheal intubation was performed when the muscles of patients were relaxed. Sevoflurane plus remifentanil was used to maintain anesthesia in all three groups. The minimum alveolar concentration (MAC) of sevoflurane was 0.5 to 0.8, the plasma concentration of remifentanil via target-controlled infusion (TCI) was 2 to 4 ng/mL, and 0.6 mg/kg of cisatracurium was supplemented every 40 minutes. The hemodynamic changes of the three groups before induction of general anesthesia (T₀), at the end of drug injection for induction of general anesthesia (T₁), before tracheal intubation (T₂), immediately after tracheal intubation (T₃), and 5 minutes after tracheal intubation (T₄) were monitored. In the meanwhile, the serum levels of TNF-α, IL-6, S100β and NSE were measured on the first day before operation (D₀), immediately after operation (D₁), 1 day after operation (D₂), 2 days after operation (D₃) and 3 days after operation (D₄). Besides, the incidence of POCD was also analyzed.Results The systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) at T₀, T₁, T₂, T₃ and T₄ were compared among the three groups via the repeated measures ANOVA, which showed that there were differences in SBP, DBP and HR at different time points (P < 0.05) and among the three groups (P < 0.05), and that there was no difference in the change trends of SBP and HR among the three groups (P > 0.05) but there was a difference in the change trend of DBP among the three groups (P < 0.05). The serum levels of TNF-α, IL-6, S100β and NSE at D₀, D₁, D₂, D₃ and D₄ were also compared among the three groups via the repeated measures ANOVA. The results demonstrated that the serum levels of TNF-α, IL-6, S100β and NSE were different at different time points (P <0.05) and among the three groups (P < 0.05), and that the change trends of the serum levels of TNF-α and IL-6 (P < 0.05) rather than those of S100β and NSE (P > 0.05) were different among three groups. The incidence of POCD at D₂ and D₃ in the AKH group was significantly lower than that in the AKL and AKM groups (P < 0.05), while the incidence of POCD at D₄ was not different among the three groups (P > 0.05). There was no significant difference in the incidence of postoperative delirium and increased oropharyngeal secretions among the three groups (P > 0.05).Conclusions For induction of general anesthesia, 0.5 mg/kg of esketamine combined with propofol can effectively stabilize the hemodynamics during operation, significantly reduce the production of inflammatory factors as well as the serum levels of S100β and NSE after operation, and lower the risk of early POCD.