目的 探讨右美托咪定（dexmedetomidine,Dex）联合地佐辛术后患者静脉自控镇痛（patient-controlled intravenous analgesia,PCIA）对高龄椎管内麻醉骨科患者术后睡眠质量及早期认知功能的影响。方法 择期实施椎管内麻醉的骨科高龄患者,年龄80~96岁,采用随机数字表法分成两组：地佐辛组、地佐辛+ Dex组。最终入组65例,地佐辛组32例,地佐辛+Dex组33例。于术前、术后24 h、48 h及出院前进行匹兹堡睡眠质量指数（PSQI）评分,术后4、8、12、24和48 h的视觉模拟评分（VAS）及镇静（Ramsay）评分。并于术前1 d和术后1、3、7 d分别测定简易精神状态评价量表（MMSE）评分和术后认知功能障碍的发生情况。评价术后恶心、呕吐、嗜睡及导尿管不适等的发生率。结果 地佐辛+ DEX组患者术后24 h、48 h和出院前PSQI评分明显低于地佐辛组（P<0.05）。地佐辛+ DEX组术后Ramsay评分明显高于地佐辛组（P<0.05）;地佐辛+DEX组术后MMSE评分较高,POCD发生率低于地佐辛组（P<0.05）。地佐辛+ DEX组VAS评分降低,术后恶心、呕吐及导尿管不适等副作用发生率较低（P<0.05）。结论 高龄手术患者术后应用Dex联合地佐辛PCIA有利于改善患者术后睡眠障碍,且认知功能障碍发生率低。
Objective To investigate the effect of dexmedetomidine （Dex） combined with dezocine in patient-controlled intravenous analgesia （PCIA） on the quality of sleep and the early cognitive function of elderly patients with spinal anesthesia after operation. Methods Sixty-five elderly patients aged 80-96 years undergoing spinal anesthesia from the department of orthopedics were randomly divided into two groups by random table method： dezocine group （group C, n=32） and dezocine plus Dex group （group D, n=33）. Pittsburgh sleep quality index （PSQI） was assessed at preoperation, 24 h and 48 h postoperation, and before discharge, respectively. Visual Analogue Scale （VAS） score and Ramsay score were observed 4, 8, 12, 24, and 48 h after surgery, respectively. Mini-Mental Status Examination （MMSE） score was recorded at 1d before surgery and 1, 3, 7 d after surgery, respectively, and the incidence rate of postoperative cognitive dysfunction was evaluated as well. The postoperative incidence rates of nausea, vomiting, somnolence, and urinary catheter discomfort were also evaluated. Results The PSQIs in the group D at postoperative 24 h and 48 h and before discharge were significantly lower than those in the group C （P<0.05）. The postoperative Ramsay score in the group D was significantly higher than that in the group C （P<0.05）. The postoperative MMSE scores in the group D were also significantly higher （P<0.05）, and the incidence rate of POPD was lower （P<0.05）. The group D showed a lower VAS score, and less nausea, vomiting, urinary catheter discomfort incidence rates （P<0.05）. Conclusion Dex combined with dezocine in PCIA help improve the quality of sleep and reduce postoperative cognitive dysfunction in elderly patients.
[1] Mckeown JL.Pain management issues for the geriatric surgical patient[J]. Anesthesiol Clin, 2015, 33(3): 563-576.
[2] Zywiel MG, Prabhu A, Perruccio AV.The influence of anesthesia and pain management on cognitive dysfunction after joint arthroplasty: a systematic review[J]. Clin Orthop Relat Res, 2014,472(5):1453-1466.
[3] 卢飞飞,冯秀梅,刘静,等.右美托咪定联合地佐辛患者自控静脉镇痛对腹腔镜阴式子宫切除患者镇痛和睡眠质量的影响[J].国际麻醉学与复苏杂志,2019,40(3):199-203.
[4] 曹国平,张家敏,牛聪,朱美华.右美托咪定对老年患者骨科手术后睡眠质量的影响[J].临床麻醉学杂志,2018,34(7):689-692.
[5] Smolensky MH, Hermida RC, Reinberg A, et al.Circadian disruption: New clinical perspective of disease pathology and basis for chronotherapeutic intervention[J]. Chronobiol Int, 2016,33(8):1101-1119.
[6] 赵晓丽,王明菲,刚宝芝.认知障碍与睡眠障碍的研究现状[J].脑与神经疾病杂志,2017,25(9):589-592.
[7] 郑虹,张兆岩,王庆美,等.高龄老人睡眠节律对睡眠质量及认知的影响[J].中华保健医学杂志,2019,21(1):5-8.
[8] 李洁,曲海霞,董非.右美托咪定对老年主动脉夹层患者术后谵妄的影响研究[J].中国药物与临床,2019,19(8):1296-1297.
[9] Song B, Li Y, Teng X, et al.The effect of intraoperative use of dexmedetomidine during the daytime operation vs the nighttime operation on postoperative sleep quality and pain under general anesthesia[J]. Nat Sci Sleep, 2019,11(3): 207-215.
[10] 黄青青,袁立邦,巩固.右美托咪定脑保护作用及其信号通路研究进展[J].西南国防医药,2019,29(6):720-722.
[11] 毛姗姗,黄群不同剂量右美托咪啶对高龄患者下肢手术椎管内麻醉镇静效果及术后认知功能的影响[J].外科研究与新技术,2018,7(2):101-104.
[12] 顼晋昆,叶京英,曹鑫,等.右美托咪定诱导睡眠与自然睡眠多道睡眠监测参数的对比研究[J].中华耳鼻咽喉头颈外科杂志,2019,54(6):405-409.
[13] Zhang X, Xin X, Dong Y, et al.Surgical incision-induced nociception causes cognitive impairment and reduction in synaptic NMDA receptor 2B in mice[J]. J Neurosci, 2013,33(45):17737-17748.
[14] Chi H, Kawano T, Tamura T, et al.Postoperative pain impairs subsequent performance on a spatial memory task via effects on N-methyl-D-aspartate receptor in aged rats[J]. Life Sci, 2013,93(25-26):986-993.
[15] Tang C, Huang X, Kang F, et al.Intranasal dexmedetomidine on stress hormones, inflammatory markers, and postoperative analgesia after functional endoscopic sinus surgery[J]. Mediators Inflamm, 2015,2015(20):939431.
[16] Zhang Z, Ferretti V, Guntan I, et al.Neuronal ensembles sufficient for recovery sleep and these dative actions of α2 adrenergic agonists[J]. Nat Neurosci, 2015,18(4):553-561.
[17] 谭兴中,岳永猛,王炎,等.舒芬太尼联合右美托咪定对子宫切除术后患者SIRS评分及睡眠的影响[J].东南大学学报(医学版),2019,38(3):402-406.
[18] Gilsanz P, Lacy ME, Beeri MS, et al.Sleep quality and cognitive function in type 1 diabetes: findings from the Study of Longevity in Diabetes (SOLID)[J]. Alzheimer Dis Assoc Disord, 2019,34(1):18-24.
