右美托咪定对腔隙性脑梗死患者术后谵妄的影响1)郑州大学第二附属医院麻醉科，河南郑州450014：2)郑州大学第一附属医院麻醉科，河南郑州450052摘要：目的评价右美托咪定对腔隙性脑梗死患者术后谵妄的影响。方法择期行髋关节置换术的腔隙性脑梗死患者60例，分为2组(=30)：右美托咪定组(D至术毕，C组泵注等容量生理盐水。于麻醉诱导前(T0)、术毕(T1)和术后24h(T2)抽取颈内静脉球部血样，采用ELISA法测定血清S100β蛋白和脑源性神经营养因子(BDNF)的浓度，并评估术后3d内谵妄的发生情况。结果与C组比较，D组T1、T2时S100B降低(P<0.05),BDNF升高(P<0.05),与T0时比较，2组T1、T2时血清S100β蛋白浓度升高(P≈0.05)，BDNF浓度降低(P<0.05)。D组术后谵妄发生率降低，术后谵妄发生的时间推迟(P<0.05)以及术后谵妄持续时间缩短(P<0.05)。结论右美托咪定可减轻腔隙性脑梗死患者脑损伤，预防和改善其术后谵妄的发生。关键词：右美托咪定：腔隙性脑梗死；谵妄Effect of dexmedetomidine on postoperative delirium in lacunar infarctionpatientsMao Xiaoyu,Zhang Wei2),Lu Wenliang,Li Shan,Dong Tieli1)Department of Anesthesiology,the Second Affiliated Hospital of ZhengzhouUniversity 450014:2)Department of Anesthesiology,the First Affiliated Hospital ofZhengzhou University,450052Abstract:Objective To evaluate the effect of dexmedetomidine on postoperativedelirium (POD)in lacunar infarction patients.Methods Sixty patients with lacunarinfarction,scheduled for elective artificial hip replacement,were randomly dividedinto 2 groups (n=30):group D,0.5ugkg.h dexmedetomidine injected fromanesthesia induction to the end of surgery,group C,the equal volume of normal salinewas given instead .Blood samples were collected from the jugular bulb beforeanesthesia induction (To)and at the end of surgery(T1),24 hours after thesurgery(T2),S100B protein and brain-derived neurotrophic factor (BDNF)in serumwere measured by enzyme-linked immunosorbent assay.Evaluate the occurrence ofPOD within 3 days after operation.Results Compared with group C,S100B weredecreased (P<0.05)and BDNF were increased(P<0.05)at T1 T2,the incidence of PODwas decreased (P<0.05).Compared with group To,S100B were increased (P<0.05)andBDNF were decreased (P<0.05)at T1 T2.The incidence of POD in group D wasdecreased,in group D the onset time of delirium was delate(P<0.05)and duration ofdelirium was shorten(P<0.05).Conclusion Dexmedetomidine can reducing patientswith lacunar infarction brain injury and prevent the development of PODKey words Dexmedetomidine;lacunar infarction;delirium术后谵妄(postoperative delirium,POD)是指患者在经历手术后出现急性认知功能改变，主要表现为注意力、思维、感受、记忆、精神运动及睡眠周期障碍的短暂性器质性脑综合征。腔隙性脑梗死多发于中老年人，其特点为分布于脑深部灰质、脑白质或脑干的直径<2cm的小梗死山，占所有缺血性脑梗死的25%，已成为老年手术患者中常见的并存疾病。有研究显示腔隙性脑梗死可使患者术后谵妄发生的风险增加2~引。右美托咪定是一种高选择性2受体激动剂，现已广泛用于临床麻醉中，有一定的神经保护作用。目前对右美托咪定是否可以改善腔隙性脑梗死患者术后谵妄尚未有研究，本研究旨在评价右美托咪定对腔隙性脑梗死患者术后谵妄的影响，为临床用药提供依据。1资料与方法1.1一般资料选取择期行髋关节置换术的腔隙性脑梗死患者60例，年龄60~80岁，ASA分级Ⅱ或Ⅲ级，体重指数18~25kgm2,无肝、肾功能异常，长期应用镇静药物史，无顿脑外伤及酗酒史，可正常交流，术前经MMSE检测无认知功能障碍。采用随机数字表法分为2组(=30)：右美托咪定组(D组)，对照组(C组)。1.2麻醉方法所有患者均术前6禁食2h禁饮，入室后开放静脉通路，局麻下行桡动脉穿刺置管监测直接动脉压，监测SO2、ECG和BIS值。超声引导下行颈内静脉穿刺置管并输注复方氯化钠10 ml.kg.h。麻醉诱导：静脉注射咪达唑仑0.06mgkg,依托咪酯0.2-0.4mg/kg,舒芬太尼0.3-0.4μgkg,顺阿曲库铵0.15-0.2mgg,待肌肉松弛后行气管插管机械通气，潮气量8ml/kg,呼吸频率12~l6次min,吸呼比1：2，PetC02控制在35-45mmHg,麻醉维持：静脉输注丙泊酚48mgkg,静脉输注瑞芬太尼0.2~0.3 ug.kg.min,D组于麻醉诱导后持续静脉泵注右美托咪定0.5gkgh至术毕，C组输注等容量生理盐水。维持BIS值40~60。必要时术中给予血管活性药物稳定血压，心率。2组患者术后均使用自控电子镇痛泵。配方：舒芬太尼2μgkg十布托啡诺8mg十托烷司琼10mg+丙帕他莫3g用生理盐水稀释至100ml,背景剂量2mlh,自控按压剂量2ml,锁定时间15min。1.3观察指标于麻醉诱导前(T0)、术毕(T1)和术后24h(T2)抽取颈内静脉球部血样5ml,采用ELISA法测定血清S100B蛋白和脑源性神经营养因子(BDNF)的浓度：评估术后3d内谵妄的例数，术后谵妄发生的时间以及术后谵妄持续时间。1.4统计学处理采用SPSS22.0统计学软件进行统计分析。符合正态分布的计量资料以均数±标准差(x士s)表示，随机区组设计的计量资料比较采用t检验，重复测量设计的计量资料比较采用方差分析：计数资料比较采用卡方检验。P<0.05为差异有统计学意义。2结果2.1两组患者一般资料比较两组患者一般资料各指标差异无统计学意义(P>0.05),见表1。表1两组患者一般资料的比较Tab.1 Comparison of the general information between the two groups组别性别（男/年龄/岁BMI(kg/mASA分级构成情况（例，手术时间hC组17/1368.3±3.621.0±0.624/62.8±0.4D组18/1266.9±5.320.8±0.825/52.60.52.2两组患者各时点S100B、BDNF的比较与C组比较，D组T1、T2时血清