少年儿童非心脏手术术后早期认知功能障碍发生率及危险因素分析
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摘要
目的研究少年儿童非心脏手术术后早期认知功能障碍的发生率,分析其相关危险因素。
方法选择择期非心脏手术4-16岁少年儿童110例作为手术组(O组),随机选择同年龄段健康受试者50例作为对照组(C组)。记录出生方式、受教育程度和既往手术史等；术后1-3天随访O组术后并发症情况并记录。两组分别于术前1天,术后3天采用“韦氏幼儿智力量表”或“韦氏儿童智力量表修订版”中的知识、词汇、算术、领悟、数字广度及编码共6项分测验进行神经心理学测试,记录原始分对应的量表分。按Z计分法计算术后认知功能障碍(postoperative cognitive dysfunction, POCD)的发生率。采用多因素Logistic回归分析POCD的独立危险因素。
结果O组100例,C组43例完成本研究。O组术后3天POCD的发生率是15.0%,C组为2.3%,差异有统计学意义(P<0.05)；与C组相比,O组术后知识、算术、领悟及编码4项分测验得分均明显降低(P<0.05)；POCD与既往麻醉手术史、气管插管全身麻醉、麻醉持续时间及术后感染相关；logistic回归分析结果显示：既往麻醉手术史与术后感染为少年儿童非心脏手术POCD的独立危险因素(P<0.05)。
结论少年儿童非心脏手术术后早期认知功能障碍发生率为15.0%,具有麻醉手术史和／或出现术后感染的少年儿童行非心脏手术后更容易发生POCD。
Objective To investigate the occurrence and risk factors of early postoperative cognitive dysfunction (POCD) in children and juvenile after non-cardiac surgery.
Methods110noncardiac surgical patients aged between4～16yr, ASA Ⅰ～Ⅱ, were collected as operation group (O group), and50healthy age-matched children were collected as control group (C group). Children's childbirth history, education history, preoperative operation with anesthesia, and complication of surgical patients were recorded. A battery of6neuropsychological tests in Wechsler Preschool and Primary Scale of Intelligence (WPPSI) or Wechsler Intelligence Scale for Children-Revised (WISC-R) were completed1day before and3days after surgery. POCD was calculated as a combined Z-score. Multivariate Logistic regression analyses were used to identify independent risk factors of POCD.
Results100in O group and43in C group completed the study. POCD was confirmed in15/100(15.0%) in O group compared with1/43(2.3%) in C group3days after surgery. There were significantly differences from patients in their scores of information, comprehension, arithmetic, and coding at later testing sessions compared with the controls. POCD was associated with surgical history, general anesthesia, duration of anesthesia, and postoperative infection. Logistic regression analysis revealed that the history of operation and postoperative infection were independent risk factors of POCD (P<0.05)
Conclusions The occurrence rate of early POCD after non-cardiac surgery in children and juvenile is15.0%. Children and juvenile who had some exposure to operation before and postoperative infection are more prone to develop POCD.
方法选择择期非心脏手术4-16岁少年儿童110例作为手术组(O组),随机选择同年龄段健康受试者50例作为对照组(C组)。记录出生方式、受教育程度和既往手术史等；术后1-3天随访O组术后并发症情况并记录。两组分别于术前1天,术后3天采用“韦氏幼儿智力量表”或“韦氏儿童智力量表修订版”中的知识、词汇、算术、领悟、数字广度及编码共6项分测验进行神经心理学测试,记录原始分对应的量表分。按Z计分法计算术后认知功能障碍(postoperative cognitive dysfunction, POCD)的发生率。采用多因素Logistic回归分析POCD的独立危险因素。
结果O组100例,C组43例完成本研究。O组术后3天POCD的发生率是15.0%,C组为2.3%,差异有统计学意义(P<0.05)；与C组相比,O组术后知识、算术、领悟及编码4项分测验得分均明显降低(P<0.05)；POCD与既往麻醉手术史、气管插管全身麻醉、麻醉持续时间及术后感染相关；logistic回归分析结果显示：既往麻醉手术史与术后感染为少年儿童非心脏手术POCD的独立危险因素(P<0.05)。
结论少年儿童非心脏手术术后早期认知功能障碍发生率为15.0%,具有麻醉手术史和／或出现术后感染的少年儿童行非心脏手术后更容易发生POCD。
Objective To investigate the occurrence and risk factors of early postoperative cognitive dysfunction (POCD) in children and juvenile after non-cardiac surgery.
Methods110noncardiac surgical patients aged between4～16yr, ASA Ⅰ～Ⅱ, were collected as operation group (O group), and50healthy age-matched children were collected as control group (C group). Children's childbirth history, education history, preoperative operation with anesthesia, and complication of surgical patients were recorded. A battery of6neuropsychological tests in Wechsler Preschool and Primary Scale of Intelligence (WPPSI) or Wechsler Intelligence Scale for Children-Revised (WISC-R) were completed1day before and3days after surgery. POCD was calculated as a combined Z-score. Multivariate Logistic regression analyses were used to identify independent risk factors of POCD.
Results100in O group and43in C group completed the study. POCD was confirmed in15/100(15.0%) in O group compared with1/43(2.3%) in C group3days after surgery. There were significantly differences from patients in their scores of information, comprehension, arithmetic, and coding at later testing sessions compared with the controls. POCD was associated with surgical history, general anesthesia, duration of anesthesia, and postoperative infection. Logistic regression analysis revealed that the history of operation and postoperative infection were independent risk factors of POCD (P<0.05)
Conclusions The occurrence rate of early POCD after non-cardiac surgery in children and juvenile is15.0%. Children and juvenile who had some exposure to operation before and postoperative infection are more prone to develop POCD.
引文
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[1]Fodale V,Santamaria LB, Schifilliti D, et al. Anaesthetics and postoperative cognitive dysfunction:a pathological mechanism mimicking Alzheimer's disease. Anaesthesia,2010, 65(4):388-395.
[2]Vanderweyde T, Bednar MM, Forman SA, et al. Iatrogenic risk factors for Alzheimer's disease:surgery and anesthesia. J Alzheimers Dis,2010,22(Suppl3):91-104.
[3]Hardy J,Selkoe DJ.The amyloid hypothesis of Alzheimer's disease:progress and problems on the road to therapeutics.Science,2002,297(5580):353-356.
[4]Yin LL, Li W, Chu YQ, et al. ERK pathway activation is required for amyloid-beta(1-40)-induced neurotoxicity of THP-1 human monocytes towards SK-N-SH neuroblastoma. Brain Res,2011,1378:9-17.
[5]Blanco A, Alvarez S, Fresno M, et al. Amyloid-beta induces cyclooxygenase-2 and PGE2 release in human astrocytes in NF-kappa B dependent manner. J Alzheimers Dis,2010, 22(2):493-505.
[6]McDonagh DL, Mathew JP, White WD, et al. Cognitive function after major noncardiac surgery,a polipoprotein E4 genotype, and biomarkers of braininjury. Anesthesiology,2010, 112(4):852-859.
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[11]Cao XZ, Ma H, Wang JK, et al. Postoperative cognitive deficits and neuroinflammation in the hippocampus triggered by surgical trauma are exacerbated in aged rats. Prog Neuropsychopharmacol Biol Psychiatry,2010,34(8):1426-1432.
[12]Cibelli M, Fidalgo AR, Terrando N, et al. Role of interleukin-lbeta in postoperative cognitive dysfunction. Ann Neurol,2010,68(3):360-368.
[13]Meneses A, Manuel-Apolinar L, Rocha L, et al. Expression of the 5-HT receptors in rat brain during memory consolidation. Behav Brain Res,2004,152(2):425-436.
[14]Roberts RD, Fibuch EE, Elisabeth Heal M, et al. Production of a novel neuromelanin at the sevoflurane-water interface.Biochem Biophys Res Commun,2007,363(1):77-81.
[15]Miller ED, Fibuch EE, Seidler NW. Toxicity of a serotonin-derived neuromelanin. Biochem Biophys Res Commun,2010,391 (2):1297-1300.
[16]Brownrigg TD, Theisen CS, Fibuch EE, et al. Carnosine protects against the neurotoxic effects of a serotonin-derived melanoid. Neurochem Res,2011,36(3):467-475.
[17]Mandal PK, Simplaceanu V, Fodale V. Intravenous anesthetic diazepam does not induce amyloid-beta peptide oligomerization but diazepam co-administered with halothane oligomerizes amyloid-beta peptide:an NMR study. J Alzheimers Dis,2010,20(1):127-134.
[18]Planel E, Bretteville A, Liu L, et al. Acceleration and persistence of neurofibrillary pathology in a mouse model of tauopathy following anesthesia. FASEB J,2009,23 (8): 2595-2604.
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[21]Wang Q, Liang G, Yang H, et al. The common inhaled anesthetic isoflurane increases aggregation of Huntingtin and alters calcium homeostasis in a cell model of huntington's disease. Toxicol Appl Pharmacol,2011,250(3):291-298.
[22]Whittington RA, Virag L. Isoflurane decreases extracellular serotonin in the mouse hippocampus.Anesth Analg,2006,103(1):92-98.
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[2]Radtke FM,Franck M,Herbig TS,et al., Incidence and risk factors for cognitive dysfunction in patients with severe systemic disease. J Int Med Res,2012,40(2):612-620.
[3]Bekker AY,Weeks EJ, Cognitive function after anaesthesia in the elderly. Best Pract Res Clin Anaesthesiol,2003,17(2):259-272.
[4]Rasmussen LS,Johansson T,Kuipers HM, Investigators, does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 eldrerly patients Acta Anaesthesiol Scand,2003,47(3):260-266.
[5]Vingerhoets G,Soete G,Jannes C, Subjective complaints versus neuropsychological test performance after cardiopulmonary bypass. J Psychosomatic Res,1995,39(7):843-853.
[6]张静,田鸣,老年患者术后认知功能障碍病理生理机制的研究进展.国际麻醉学与复苏杂志,2011,32(1)：78-81.
[7]Hanning CD, Postoperative cognitive dysfunction. Br J Anaesth,2005,95(1):82-87.
[8]Shaw PJ,Bates D,cartlidge NE, Early intellectual dysfunction following coronary bypass surgery. Q J Med,1986,58(225):59-68.
[9]Sarageau JA,Stanton BA,Jenkins CD, Neuropaychological dysfunction following elective cardiac operation. Early assessment. J Thorac Cardiovasc Surg,1982,84(4):585-594.
[10]Moller JT,Cluitmans P,Rasmussen LS,et al., Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study.ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet,1998,351 (9106):857-861.
[11]Li YC,Xi CH,An YF,et al., Perioperative inflammatory response and protein S-100beta concentrations-relationship with post-operative cognitive dysfunction in elderly patients. Acta Anaesthesiol Scand,2012,11 (6):11-16.
[12]Suon S,Zhao J,Villarreal SA,et al., Systemic treatment with liver X receptor agonists raises apolipoprotein E, cholesterol, and amyloid-beta peptides in the cerebral spinal fluid of rats. Mol Neurodegener,2010,5(44):44-58.
[13]倪诚,贾东林,许挺,等,脊柱手术患者术后谵妄和术后认知功能障碍的危险因素.中华麻醉学杂忠,2012,32(5)：541-544.
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