楊路宗,張陳麟,朱洪生

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圍手術(shù)期電針干預(yù)髖關(guān)節(jié)置換術(shù)后患者譫妄臨床研究

楊路宗,張陳麟,朱洪生

(上海中醫(yī)藥大學(xué)附屬龍華醫(yī)院,上海 200032)

目的 觀察圍手術(shù)期電針干預(yù)髖關(guān)節(jié)置換術(shù)后患者譫妄(POD)的臨床療效。方法 將128例行髖關(guān)節(jié)置換術(shù)的患者隨機(jī)分為治療組和對(duì)照組,每組64例。治療組在圍手術(shù)期采用電針治療,對(duì)照組進(jìn)行常規(guī)術(shù)前準(zhǔn)備及術(shù)后治療。觀察兩組患者術(shù)前1 d、手術(shù)結(jié)束時(shí)及術(shù)后1 d血清星形膠質(zhì)源性蛋白(S100b)的濃度變化,并比較兩組術(shù)后3 d POD的發(fā)生率。結(jié)果 兩組術(shù)后1 d POD發(fā)生率與同組出恢復(fù)室時(shí)比較,差異均具有統(tǒng)計(jì)學(xué)意義(＜0.01)。治療組術(shù)后2、3 d POD發(fā)生率明顯低于同組術(shù)后1 d(均＜0.05),治療組術(shù)后3 d POD發(fā)生率明顯低于同組術(shù)后2 d(＜0.05)。治療組不同時(shí)間點(diǎn)(出恢復(fù)室及術(shù)后1～3 d)POD發(fā)生率與對(duì)照組比較,差異均具有統(tǒng)計(jì)學(xué)意義(＜0.01)。兩組手術(shù)結(jié)束時(shí)及術(shù)后1 d S100b濃度與同組術(shù)前比較,差異均具有統(tǒng)計(jì)學(xué)意義 (＜0.05)。治療組術(shù)后1 d S100b濃度與同組手術(shù)結(jié)束時(shí)比較,差異具有統(tǒng)計(jì)學(xué)意義(＜0.05)。治療組手術(shù)結(jié)束時(shí)及術(shù)后1 d S100b濃度與對(duì)照組比較,差異均具有統(tǒng)計(jì)學(xué)意義(＜0.05)。結(jié)論 圍手術(shù)期電針治療能有效降低髖關(guān)節(jié)置換術(shù)后患者譫妄的發(fā)生率,并減少其持續(xù)時(shí)間。

針刺療法;電針;譫妄;髖關(guān)節(jié)置換術(shù);手術(shù)后并發(fā)癥

譫妄是老年患者外科重癥術(shù)后常見的神經(jīng)系統(tǒng)并發(fā)癥,臨床表現(xiàn)為意識(shí)、注意力、認(rèn)知力等的短暫波動(dòng)性障礙。術(shù)后譫妄(postoperative delirium, POD)使患者住院時(shí)間延長(zhǎng),醫(yī)療費(fèi)用增加[1],還能導(dǎo)致圍手術(shù)期短期和遠(yuǎn)期并發(fā)癥(包括術(shù)后認(rèn)知功能障礙)增加。目前有Meta分析[2]證實(shí)針灸作為具有獨(dú)特理論的非藥物療法,可以減少患者神經(jīng)功能的缺損程度,提高日常生活能力。筆者在圍手術(shù)期采用電針干預(yù)行髖關(guān)節(jié)置換術(shù)患者64例,并與常規(guī)治療64例相比較,觀察兩組POD的發(fā)生率,現(xiàn)報(bào)告如下。

1 臨床資料

128例患者均為上海中醫(yī)藥大學(xué)附屬龍華醫(yī)院骨傷科住院患者,均為股骨頸骨折,擬在全身麻醉下行髖關(guān)節(jié)置換術(shù),排除智力障礙和精神障礙。按就診先后順序采用查隨機(jī)數(shù)字表法將患者隨機(jī)分為治療組和對(duì)照組,每組64例。治療組中男14例,女50例;年齡最小65歲,最大93歲,平均(81±9)歲。對(duì)照組中男12例,女52例;年齡最小68歲,最大95歲,平均(82±8)歲。兩組性別及年齡比較,差異無統(tǒng)計(jì)學(xué)意義(＞0.05),具有可比性。

2 治療方法

2.1 麻醉方法

患者進(jìn)入手術(shù)室后,開放中心靜脈通路,建立心電圖、脈搏、血氧飽和度、有創(chuàng)血壓等基本監(jiān)護(hù)。采用靜脈復(fù)合吸入全身麻醉,靜脈滴注鹽酸右美托咪定注射液(0.5mg/kg)15 min后,在靜脈注射枸櫞酸芬太尼注射液(2～3mg/kg)、注射用順苯磺酸阿曲庫銨(0.15～0.2 mg/kg)及丙泊酚注射液(1～1.5 mg/kg)的快速誘導(dǎo)下行氣管插管。機(jī)械通氣參數(shù)為潮氣量6～8 mL/kg,呼吸頻率為12～15次/min。術(shù)中采用七氟醚吸入維持麻醉,按需追加枸櫞酸芬太尼注射液和注射用順苯磺酸阿曲庫銨以維持生命體征平穩(wěn)。手術(shù)后中心靜脈通路接自控鎮(zhèn)痛泵鎮(zhèn)痛。

2.2 治療組

取神庭、百會(huì)、內(nèi)關(guān)。常規(guī)消毒后,采用0.30 mm×40 mm毫針進(jìn)行針刺,得氣后接G9805-C型電針儀(上海醫(yī)用電子儀器廠),采用疏密波(密波20 Hz,疏波2 Hz),強(qiáng)度以針柄微顫為度,留針20 min。每日1次,自手術(shù)前3 d開始至手術(shù)后3 d,共治療7 d。

2.3 對(duì)照組

采用常規(guī)術(shù)前準(zhǔn)備;術(shù)后外科進(jìn)行常規(guī)抗感染、抗凝及保護(hù)胃黏膜治療,麻醉科隨訪3 d,隨訪內(nèi)容同治療組。

3 治療效果

3.1 觀察指標(biāo)

3.1.1 護(hù)理譫妄篩選評(píng)分(Nu-DESC)[3]

Nu-DESC常用于圍手術(shù)期譫妄篩選,通過與患者簡(jiǎn)單交流得到其定向、行為、交流及感覺等方面的信息。兩組患者分別于出恢復(fù)室時(shí)及術(shù)后1～3 d進(jìn)行Nu-DESC評(píng)分,每個(gè)癥狀依據(jù)其嚴(yán)重程度記為0～2分,最高為10分,總評(píng)分≥2分即可診斷為POD。

3.1.2 血清星形膠質(zhì)源性蛋白(S100b)

兩組患者分別于術(shù)前1 d、手術(shù)結(jié)束時(shí)及術(shù)后1 d抽取靜脈血,采用試劑盒檢測(cè)S100b濃度,操作嚴(yán)格按照說明書。

3.2 統(tǒng)計(jì)學(xué)方法

采用SPSS19.0軟件進(jìn)行統(tǒng)計(jì)分析。計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差表示,采用檢驗(yàn);計(jì)數(shù)資料用卡方檢驗(yàn)。

3.3 治療結(jié)果

3.3.1 兩組不同時(shí)間點(diǎn)POD發(fā)生率比較

表1 兩組不同時(shí)間點(diǎn)POD發(fā)生率比較 [例(%)]

注:與對(duì)照組比較1)＜0.01;與同組出恢復(fù)室比較2)＜0.01;與同組術(shù)后1 d比較3)＜0.05;與同組術(shù)后2 d比較4)＜0.05

由表1可見,兩組術(shù)后1 d POD發(fā)生率與同組出恢復(fù)室時(shí)比較,差異均具有統(tǒng)計(jì)學(xué)意義(＜0.01)。治療組術(shù)后2、3 d POD發(fā)生率明顯低于同組術(shù)后1 d (均＜0.05),治療組術(shù)后3 d POD發(fā)生率明顯低于同組術(shù)后2 d(＜0.05)。對(duì)照組術(shù)后1～3 d POD發(fā)生率比較,差異均無統(tǒng)計(jì)學(xué)意義(＞0.05)。治療組不同時(shí)間點(diǎn)(出恢復(fù)室及術(shù)后1～3 d)POD發(fā)生率與對(duì)照組比較,差異均具有統(tǒng)計(jì)學(xué)意義(＜0.01)。

3.3.2 兩組不同時(shí)間點(diǎn)S100b濃度比較

由表2可見,兩組術(shù)前S100b濃度比較,差異均無統(tǒng)計(jì)學(xué)意義(＞0.05)。兩組手術(shù)結(jié)束時(shí)及術(shù)后1 d S100b濃度與同組術(shù)前比較,差異均具有統(tǒng)計(jì)學(xué)意義(＜0.05)。治療組術(shù)后1 d S100b濃度與同組手術(shù)結(jié)束時(shí)比較,差異具有統(tǒng)計(jì)學(xué)意義(＜0.05)。治療組手術(shù)結(jié)束時(shí)及術(shù)后1 d S100b濃度與對(duì)照組比較,差異均具有統(tǒng)計(jì)學(xué)意義(＜0.05)。

表2 兩組不同時(shí)間點(diǎn)S100b蛋白濃度比較 (±s,mg/L)

表2 兩組不同時(shí)間點(diǎn)S100b蛋白濃度比較 (±s,mg/L)

組別例數(shù)術(shù)前手術(shù)結(jié)束時(shí)術(shù)后1 d 治療組640.118±0.0200.147±0.0181)3)0.130±0.0211)2)3) 對(duì)照組640.121±0.0190.198±0.0211)0.182±0.0231)

注:與同組術(shù)前比較1)＜0.05;與同組手術(shù)結(jié)束時(shí)比較2)＜0.05;與對(duì)照組比較3)＜0.05

4 討論

譫妄是急性認(rèn)知功能改變,表現(xiàn)為隨時(shí)間波動(dòng)的意識(shí)改變和注意力不集中。POD是指患者在經(jīng)歷外科手術(shù)后出現(xiàn)的譫妄,其發(fā)生具有明顯的時(shí)間特點(diǎn),主要發(fā)生在術(shù)后24～72 h[1]。POD的發(fā)生機(jī)制目前仍不明了,西醫(yī)目前有膽堿能學(xué)說、應(yīng)激反應(yīng)學(xué)說和炎性反應(yīng)學(xué)說等假說。中醫(yī)學(xué)認(rèn)為譫妄等認(rèn)知功能的障礙多由于臟腑虛衰、氣血陰陽虧損、腦失所養(yǎng)、神明無主所致,病在腦、心?！澳X為元神之府”,經(jīng)絡(luò)系統(tǒng)中,督脈與腦的關(guān)系最為密切,有“督為腦之經(jīng)脈”之說,神庭、百會(huì)二穴同屬督脈。神庭穴所主正是與精神智慧相關(guān)的神志、認(rèn)知病,故“神者,智之淵也”。百會(huì)穴主要用于治療頭目及心神病癥,《千金要方》:“狂癇不識(shí)人,癲病眩亂,灸百會(huì)九壯?！庇纱丝梢?神庭、百會(huì)二穴與腦的認(rèn)知功能直接相關(guān),故而對(duì)POD具有治療作用。此外,心藏神主神志,“心腦同病”,因此屬于心包經(jīng)的內(nèi)關(guān)穴也可治療腦疾。內(nèi)關(guān)具有寧心安神、通絡(luò)止痛的功效,能有效穩(wěn)定心腦血管狀態(tài),增強(qiáng)疼痛治療效果,提高患者對(duì)手術(shù)的耐受性[4],這些都是有效減緩或消除POD的易感和促發(fā)因素。本研究結(jié)果顯示,在圍手術(shù)期1星期內(nèi)電針百會(huì)、神庭、內(nèi)關(guān)穴,可顯著降低接受髖關(guān)節(jié)置換術(shù)的老年患者POD的發(fā)生率,并縮短POD的持續(xù)時(shí)間,有效促進(jìn)患者認(rèn)知功能的恢復(fù)。

S100b是常用的檢測(cè)腦損傷的指標(biāo),可用于評(píng)價(jià)認(rèn)知障礙的發(fā)生率、病程及結(jié)局。有研究[5-7]表明,血清S100b濃度升高對(duì)預(yù)測(cè)POD的發(fā)生有一定臨床意義,van Munster BC等[6]進(jìn)一步證實(shí)血清S100b濃度變化與炎性因子IL-6和IL-8濃度變化相關(guān),認(rèn)為神經(jīng)炎性反應(yīng)與腦功能紊亂有關(guān)。本研究顯示,治療組S100b濃度升高程度小,回落速度快,表明電針百會(huì)、神庭、內(nèi)關(guān)穴能有效減輕中樞神經(jīng)元的損傷,加快損傷修復(fù),改善髖關(guān)節(jié)置換術(shù)患者圍手術(shù)期腦神經(jīng)系統(tǒng)炎性反應(yīng)程度,從而降低了POD的發(fā)生率。

另外,在圍手術(shù)期1星期的時(shí)間內(nèi),在電針軀體治療的同時(shí),醫(yī)護(hù)人員耐心的詢問、陪伴和安慰對(duì)患者也起到較顯著的心理疏導(dǎo)和治療作用,這也是POD非藥物防治的重要措施。入組的患者絕大多數(shù)是高齡患者,他們對(duì)針灸等中醫(yī)學(xué)的認(rèn)知和接受程度較高,能更好地發(fā)揮電針的治療功效。

[1] 中華醫(yī)學(xué)會(huì)麻醉學(xué)分會(huì).中國(guó)麻醉學(xué)指南與專家共識(shí)(2014版)[S].北京:人民衛(wèi)生出版社,2014:311-318.

[2] 袁思斯,張樹怡.針灸治療腦卒中后認(rèn)知障礙的Meta分析[J].中國(guó)民族民間醫(yī)藥,2010,19(9):47-48.

[3] Gaudreau JD, Gagnon P, Harel F,. Fast, systematic, and continuous delirium assessment in hospitalized patients: the nursing delirium screening scale[J]., 2005,29(4):368-375.

[4] Li YC, Xi CH, An YF,. Perioperative inflammatory response and protein S-100bconcentrations - relationship with post-operative cognitive dysfunction in elderly patients[J]., 2012,56(5):595- 600.

[5] 方開云,朱炎,馮亞平,等.血清S-100b蛋白和NSE水平預(yù)測(cè)不同年齡患者術(shù)后譫妄的準(zhǔn)確性[J].中華麻醉學(xué)雜志,2012,32(1):27-30.

[6] van Munster BC, Korse CM, de Rooij SE,. Markers of cerebral damage during delirium in elderly patients with hip fracture[J]., 2009,9(1):21-25.

[7] 楊路宗,陸黎,朱洪生.針刺麻醉應(yīng)用于經(jīng)皮椎體后凸成形術(shù)療效觀察[J].上海針灸雜志,2011,30(12):850 -852.

Clinical Study of Perioperative Electroacupuncture Intervention in Postoperative Delirium in Hip Replacement Surgery Patients

-,-,-.

,200032,

Objective To investigate the clinical effect of perioperative electroacupuncture intervention on postoperative delirium (POD) in hip replacement surgery patients. Method One hundred and twenty-eight patients who would undergo hip replacement surgery were randomly allocated to treatment and control groups, 64 cases each. The treatment group received perioperative electroacupuncture and the control group, routine preoperative preparation and postoperative treatment. Serum S100bprotein concentration was measured in the two groups of patients at one day before, the end of and one day after surgery. The incidences of POD were compared between the two groups at one, two and three days after surgery. Result There was a statistically significant difference in the incidence of POD between at one day after surgery and recovery from anesthesia in the two groups (＜0.01). In the treatment group, the incidence of POD was significantly lower at two and three days than at one day after surgery (both＜0.05) and at three days than at two days after surgery (both＜0.05). There was a statistically significant difference in the incidence of POD between the treatment and control groups at different time points (recovery from anesthesia, and one, two and three days after surgery) (＜0.01). In the treatment group, there was a statistically significant difference in S100bprotein concentration between at one day after and the end of surgery (＜0.05). There was a statistically significant difference in S100bprotein concentration between the treatment and control groups at the end of and one day after surgery (＜0.05). Conclusions Perioperative electroacupuncture treatment can effectively decrease postoperative incidence of delirium and its duration in hip replacement surgery patients.

Acupuncture therapy; Electroacupuncture; Delirium; Hip replacement surgery; Postoperative complications

1005-0957(2017)03-0300-03

R246.2

A

10.13460/j.issn.1005-0957.2017.03.0300

楊路宗(1977—),男,主治醫(yī)師,Email:quentin.y@tom.com

2016-11-02