术后脑功能障碍与麻醉

昆明医学院第一附属医院衡新华术后脑功能障碍与麻醉病例一女性病人76岁，在全身麻醉下行直肠癌根治术，术前无特殊，能骑自行车。术后出现严重的精神障碍,表现为反应迟钝，呆滞和少言等，曾请神经内科和麻醉科会诊，头颅CT提示有陈旧性腔梗。2月后症状有所缓解，以后缺乏随访。病例二女性，75岁，因左股骨颈骨折，在硬膜外麻醉下行股骨头置换术，术后病人出现妄想，自言多语和幻觉失语等，曾请精神科会诊。一周后恢复。1、发生了什么？2、为什么会发生与新近的研究？3、预防措施与麻醉管理？一、发生了什么？AdverseCerebralEffectsofAnesthesiaonOldPeopleReviewofrecordsof1193patients:Age50yearsorolderOperationunderGAMentaldeteriorationin120(10%)patientsConclusionsCognitivedeclinerelatedtoanestheticagentsandhypotension“Operationsonelderlypeopleshouldbeconfinedtounequivocallynecessarycases”Bedford.TheLancet1955;2:259PoorMemoryCommonAfterSurgeryNEWYORK(Reuters)–Ifyou'veeverfeltfuzzyoroutofsortsafterhavinggeneralanesthesia,you'renotalone.Astudysuggeststhatasmanyasoneoutoffourpeopleoverage60haveproblemswithmemory,concentration,andotherintellectualskillsaftersurgery,aclusterofproblemsknownascognitivedysfunction.Theproblemcanpersistforweeksormonths,accordingtoareportinTheLancet…----1998术后谵妄PostoperativeDelirium（PD）术后认知功能障碍PostoperativeCognitiveDisorders（POCD）术后谵妄（PD）临床表现特点是以注意力紊乱，对周围环境的认知度减低为主要症状的精神状态的改变。它起病急，持续数小时至数天，病情起伏波动，伴随不能集中注意力等认知障碍综合征（如迷惘、一系列记忆功能障碍）、感知能力紊乱、幻觉及睡眠周期紊乱等。术后认知功能障碍（POCD）POCD是一个与手术相关的认知恶化，评价这些表现形式多样的POCD有赖于有效的术前术后认知功能的评价、精神心理的测试。InternationalstudyPostoperativeCognitiveDysfunctionISPOCDISPOCD-1wasaninternationalstudyonpostoperativecognitivedysfunction(POCD),i.e.problemswithmemory,learningandtheabilitytoconcentrateemergingaftersurgery.Thefollow-upstudy,ISPOCD-2,istheongoingquestforinvestigatingetiological,pathophysiologicalandepidemiologicalaspectsofPOCD.InternationalStudyofPOCDLong-termpostoperativecognitivedysfunctionintheelderly:ISPOCD1studyJTMollerPCluitmansLSRasmussenPHouxHRasmussenJCanetPRabbittJJollesKLarsenCDHanningOLangeronTJohnsonPMLauvenPAKristensenABiedlerHvanBeemOFraidakis,JHSilversteinJEWBenekenJSGravensteinfortheISPOCDinvestigatorsTHELANCET1998Vol.351No.9106Pages857-861Collaborativeresearcheffort:Membersfrom8EuropeancountriesandUSA13hospitalsResearchconductedfrom1994-1996IncidenceofPOCDinPatientsandControls:Patients60y.o.Lancet1998;351:857051015202530Percentage(%)EarlyLateControlsPatients*10%*p0.00426%一项前瞻性的研究评价年龄与POCD的关系Singlesite-UniversityofFlorida:1999-20021200patientsundergoingelectivesurgeryYoung-18to39yearsofageMiddle-aged-40to59yearsofageElderly-60yearsandolderControls-primaryfamilymembersStudydesignidenticaltoISPOCDstudySamepsychometrictestbatteryOutcomeEndpoints:POCD(primary)andmortality(secondary)Monketal.Anesthesiology2001;95:A-50IncidenceofPOCDinAdultPatients:发病率*p0.05Monketal.Anesthesiology2001;95:A-500102030405060%ofPatientsEarly(AtHospitalDischarge)Late(3moPO))Young(18-39yrs)MiddleAged(40-59yrs)Elderly(60yrsandolder%ofPatients13%PredictorsofPOCD:3MonthsAfterSurgeryNS0.046HistoryofMINS0.021BaselineComorbidityNS0.009ASAPhysicalStatusNS0.003HistoryofStroke2.51(p=0.057)0.001Age0.86(p=0.028)0.001YearsofEducationNS0.028NYHAStatusNSNSAnesthesiaTimeNSNSBaselineMMSENSNSGenderNSNSSurgeryTypeMultivariateOddsRatioUnivariatePvalueRiskFactorsforPOCDMultivariatec-statistic=0.671(p=0.003)Monketal.Anesthesiology2001;95:A-50OneYearMortalityRateandPOCDinElderlyPatients3.4%2.4%6.5%8.1%0%2%4%6%8%10%HospitalDischargeThreeMonthsNoDeclineCognitiveDecline****P=0.027vs.NoDecline;**P=0.014vs.NoDeclineMonketal.Anesthesiology2001;95:A-50IndependentMultivariatePredictorsofOne-YearMortalityRiskFactorsRelativeRiskPValueBaselineComorbidity16.860.001Volatilevs.TIVA2.970.022IntraoperativeBetaBlocker1.670.004ChronicBetaBlocker1.530.019CumulativeDeepAnesthesiaTime(BIS45,perhour)1.340.007SystolicBloodPressure80mmHg(perminute)1.040.008Multivariatec-statistic=0.806(p0.001)Monketal.Anesthesiology2001;95:A-50IsMortalityDataReproducible?Multi-centerProspectiveTrial(Sweden)5,057GeneralAnesthetics,Non-cardiacSurgerySimilar1YearMortalityRateDeepanesthesiatimeisasignificantindependentpredictorofmortalityIncreasedRelativeRisk:19.7%/hr.vs.34.1%inMonk’sPOCD/MortalityStudyLennmarkenetal,Anesthesiology2003;99:A-303二、为什么会发生？器官功能与年龄器官机能储备与器官能力安全限度IncreasedBolusDrugEffectDecreasedproteinbindingHigherfree,unboundplasmadruglevelsDecreasedvolumeofdistributionSlowerredistributionofdrugALLoftheseINCREASEtargetorganlevels!Examples:Thiopental,Propofol年龄对药物的反应性改变IncreasedBrainSensitivityElderlybrainismoresensitivetoagivenCNSlevelofadrugMechanism??SlowedDrugMetabolism:ClearancedecreasesasLiverbloodflowdecreasesLivermassdecreasesKidneyfunctiondecreasesVolumeofdistributionincreaseswithIncreasedbodyfatDecreasedalbuminlevels脑平均重量、神经原减少15%—50%神经原缩小，密度减少30%脑血流减少10%—20%年龄与CNS结构改变脑灌流减少，脑氧代谢下降神经递质、受体减少精神神经系统功能减退ThresholdTheoryforCognitiveDeclineLesionLesionProtectiveFactorCaseACaseBBrainReserveCapacityA:Protectivefactor(greaterbrainreservecapacity),lowertestsensitivity,noimpairmentB:Vulnerabilityfactor(lessbrainreservecapacity),highertestsensitivity,impairmentSatzNeuropsychology1993:(7);273.ContinuumfromNormalAgingthroughMildCognitiveImpairmenttoDementiaMildcognitiveimpairmentDementiaAgeFunctionNormalAgingPOCD潜在的机制病人---High-riskpatients-“FunctionalCliff”手术与术中生理变化-