摘要
目的探讨急性Stanford A型主动脉夹层手术患者术中局部脑氧饱和度(rScO_(2))和神经损伤标记物与术后神经功能障碍(PND)的相关性。方法选取2020年7月至2021年5月于河南省胸科医院手术室急诊行体外循环(CPB)下Stanford A型主动脉夹层手术的患者57例, 性别不限, 年龄35~64岁, 体质量58.0~90.0 kg, 美国麻醉医师协会(ASA)分级Ⅱ-Ⅲ级。术中以近红外光谱仪(NIRS)连续监测患者双侧rScO_(2)。分别于麻醉诱导前10 min(T0)、麻醉诱导后10 min(T1)、CPB开始即刻(T2)、CPB结束时(T3)、术毕(T4)、转出ICU时(T5)、术后1天(T6)、2天(T7)和3天(T8)抽取中心静脉血并测定血清中神经损伤标志物特异性蛋白100β(S100β蛋白)和神经元特异性烯醇化酶(neuron specific enolase, NSE)浓度。术后3天随访, 评估PND的发生情况, 比较PND组和无PND (NPND)组患者术中rScO_(2)值和血清S100β蛋白及NSE浓度的变化, 分析PND发生的危险因素及其与术中rScO_(2)和血清S100β蛋白和NSE浓度的相关性。统计并分析两组患者预后的相关指标。结果 3例患者因术后接受二次手术、二次气管内插管和ECMO(各1例)被剔除出该研究。术后3天12例(22.2%)发生PND(PND组), 42例(77.8%)未发生PND(NPND组)。与NPND组比较, PND组患者CPB中平均动脉压最小值、CPB中rScO_(2)最小值明显降低(P<0.05), CPB中动脉-脑氧饱和度差(da-rScO_(2))最大值明显升高(P<0.05), CPB中rScO_(2)降低幅度>25%持续时间、CPB中rScO_(2)<0.50持续时间、CPB中rScO_(2)<0.40持续时间、CPB中da-rScO_(2)>0.50持续时间、CPB中da-rScO_(2)>0.40持续时间均明显延长(P<0.05)。T2~T8时, 与NPND组比较, PND组血清学神经损伤标志物S100β蛋白和NSE水平均显著升高(P<0.05)。Logistic回归分析示, CPB中rScO_(2)降低幅度>25%持续时间(P=0.033)、CPB过程中rScO_(2)<0.40持续时间(P=0.007)和CPB过程中da-rScO_(2)>0.50持续时间(P=0.001)是发生PND的危险因素。与NPND组比较, PND组患者术后机械通气、ICU滞留、术后住院天数和PND恢复时间均显著延长(P<0.05), 医疗费用显著增加(P<0.05)。结论 CPB过程中rScO_(2)降低幅度>25%持续时间、rScO_(2)<0.40持续时间和da-rScO_(2)>0.50持续时间是CPB下急性Stanford A型主动脉夹层手术患者发生PND的危险因素。血清S100β蛋白和NSE水平的显著升高与PND的发生有关。PND的发生对患者早期临床预后产生显著的不良影响。
Objective To explore the correlation between intraoperative regional cerebral oxygen saturation(rScO_(2))and nerve damage markers with postoperative neurological dysfunction(PND)in patients undergoing acute Stanford type A aortic dissection surgery.Methods A total of 57 patients undergoing acute Stanford type A aortic dissection surgery under cardiopulmonary bypass(CPB)in the operating room of Henan Provincial Hospital from July 2020 to May 2021 were enrolled,regardless of gender,aged 35-64 years old,weighed 58.0-90.0 kg and with American Association of Anesthesiologists(ASA)classification status withⅡ-Ⅲ.A near infrared spectrometer(NIRS)was used to continuously monitor the bilateral rScO_(2) of the patients during the surgery.Central venous blood was drawn 10 min before induction of anesthesia(T0),10 min after induction of anesthesia(T1),immediately after CPB started(T2),when CPB ended(T3),at the end of the operation(T4),and when exiting ICU(T5),1 day(T6),2 days(T7)and 3 days(T8)after operation,and the levels of nerve injury marker S100 calcium binding protein(S100βprotein)and neuron-specific enolase(NSE)in serum were measured.Follow up was performed on postoperative 3 to evaluate the occurrence of PND.The value of intraoperative rScO_(2) and the concentrations serum S100βprotein and NSE were compared between the PND group and the NND(NPND)group.The changes of intraoperative rScO_(2) value,the concentrations of serum S100βprotein and NSE between the PND group and NPND group were compared.The risk factors of PND and its correlation with the intraoperative rScO_(2) value,and the concentrations of serum S100βprotein and NSE were analyzed.The prognostic indicators of the two groups of patients were statistically analyzed.Results Three patients were excluded from the study.A total of 12 patients(22.2%)developed PND(PND group),and 42 patients(77.8%)did not develop PND(NPND group)on postoperative 3 day.Compared with the NPND group,the minimum mean arterial pressure and the minimum rScO_(2) during CPB were significantly decreased(P<0.05),the maximum da-rScO_(2) during CPB was significantly increased(P<0.05),and duration of da-rScO_(2)>0.50,duration of da-rScO_(2)>0.40,duration of rScO_(2) reduction>25%,rScO_(2)<0.50,rScO_(2)<0.40,during CPB were significantly prolonged(P<0.05)in the PND group.The levels of serum S100βand NSE in the PND group were significantly increased,compared with the NPND group at T2-8,respectively.Logistic regression analysis showed that the reduction of rScO_(2) more than 25%(P=0.033),during of rScO_(2)<0.40(P=0.007)and duration of da-rScO_(2)>0.50(P=0.001)during CPB were risk factors of PND.Conclusion Compared with the NPND group,the postoperative mechanical ventilation time,duration of ICU stay,postoperative hospital stay and PND recovery time were significantly prolonged(P<0.05),and the medical expenses were increased significantly(P<0.05)in the PND group.The duration of the reduction of rScO_(2)>25%,the duration of rScO_(2)<0.40 and the duration of da-rScO_(2)>0.50 during CPB are the risk factors of PND in patients with acute Stanford type A aortic dissection under CPB.Significantly increased levels of serum nerve injury markers S100βand NSE are related to the occurrence of PND.The occurrence of PND has a significant adverse effect on the early clinical prognosis of patients.
作者
周俊辉
高洁
孟宪慧
Zhou Junhui;Gao Jie;Meng Xianhui(Department of Anesthesiology,Henan Provincial Chest Hospital,Zhengzhou 450008,China;Department of Anesthesiology,Fuwai Hospital,Chinese Academy of Medical Sciences,Beijing 100037,China)
出处
《中华胸心血管外科杂志》
CSCD
北大核心
2023年第1期26-31,共6页
Chinese Journal of Thoracic and Cardiovascular Surgery
基金
河南省医学科技攻关计划联合共建项目(LHGJ20200220)
河南省重点研发与推广专项(科技攻关)项目(212102310720)。
