目的: 观察氢吗啡酮联合右美托咪定对行腹腔镜手术的老年患者应激反应和围术期神经认知紊乱的影响。方法: 选取2020年9月-2021年8月在内蒙古科技大学包头医学院第一附属医院行择期腹腔镜手术的老年患者90例,男44例,女46例,年龄65岁以上,ASA分级Ⅱ～Ⅲ级,随机分为氢吗啡酮组(H)、联合组(DH)和对照组(Control group)三组,每组30例。在手术结束前30 min,H组经静脉注射氢吗啡酮(10 μg/kg),DH组经静脉注射氢吗啡酮(10 μg/kg)并静脉泵注右美托咪定(0.5 μg/kg溶于生理盐水20 mL,10 min内输入),Control组输注等量的生理盐水。记录麻醉诱导前(T0)、建立气腹后(T1)、术毕(T2)、拔管后3 min(T3)和拔管后6 h(T4)的平均动脉压(MAP)和心率(HR);采用蒙特利尔认知功能评估量表( Montreal cognitive assessment,MoCA)分别于术前1 d,拔管后24 h(T5)、拔管后48 h(T6) 进行MoCA评分。检测T0、T3、T4和T5时的血清去甲肾上腺素(NE)、皮质醇(Cor)和白细胞介素-6(IL-6)浓度;T0、T4、T5、T6时S100β蛋白浓度;记录自主呼吸恢复时间、睁眼时间和拔管时间;记录3组的不良反应发生率。结果: (1)H组和DH组T2、T3、T4时,HR、MAP均低于Control组,且DH组低于H组(P＜0.05);(2)各组NE、Cor和IL-6浓度在T3、T4时点与其T0时点相比均升高(P＜0.05),H组和DH组在T3、T4时点NE、Cor和IL-6浓度都低于Control组(P＜0.05),且DH组低于H组(P＜0.05);(3)各组T4、T5时S100β蛋白浓度与T0相比均升高(P＜0.05),H组和DH组都低于Control组(P＜0.05),且DH组比H组更低(P＜0.05);(4)各组术后MoCA评分与术前相比均降低,但DH组高于H组和Control组(P＜0.05);(5)DH组心动过缓发生率高于H组和Control组(P＜0.05),其他不良反应发生率比较差异无统计学意义(P＞0.05)。结论: 氢吗啡酮联合右美托咪定应用于老年患者腹腔镜术中能有效降低腹腔镜手术老年患者机体的应激反应和围术期神经认知紊乱的发生。

Objective: To observe the effects of Hydromorphone(HM) combined with Dexmedetomidine(Dex) on stress response and Perioperative neurocognitive disorders(PND) in elderly patients undergoing laparoscopic surgery. Methods: A total of 90 elderly patients (age 65 or older) who underwent elective laparoscopic surgery in our hospital from September 2020 to August 2021 were randomly divided into 3 groups ,the hydromorphone group (H), the combined group (DH) and the control group ,with 30 patients in each group, ASA grade Ⅱ~Ⅲ. 30min before the end of surgery, group H was intravenously injected with HM 10μg/kg, group DH was intravenously injected with HM 10 μg/kg and pumped with Dex 0.5 μg/kg plus normal saline 20 mL within 10min, and the control group was injected with the same amount of normal saline. Anesthesia and postoperative follow-up were performed in all three groups by the same anesthesiologist. Mean arterial pressure(MAP) and Heart rate(HR) were recorded before induction of anesthesia (T0), after establishment of pneumoperitoneum (T1), after operation (T2), 3 min after extubation (T3) and 6 h after extubation (T4). The Montreal Cognitive Assessment Scale (MoCA) was used for MoCA scores 1 d before surgery, 24 h after extubation (T5) and 48h after extubation (T6). Plasma Norepinephrine (NE), Cortisol (Cor) and Interleukin-6(IL-6)concentrations at T0, T3, T4 and T5 were measured. S100β protein concentration at T0, T4, T5 and T6; The recovery time of spontaneous breathing, eye-opening time and extubation time were recorded. The incidence of adverse reactions in three groups was recorded. Results: 1.At T2, T3 and T4, HR and MAP of group H and group DH were lower than those of the control group, and group DH was lower than those of group H (P＜0.05); 2.The concentrations of NE, Cor and IL-6 in each group were increased at T3 and T4 compared with T0 (P＜0.05), the concentrations of NE, Cor and IL-6 in H group and DH group were lower than those in Control group at T3 and T4 (P＜0.05), and the concentrations of DH group were lower than those in H group (P＜0.05); 3.Compared with T0, the concentrations of S100β protein in T4 and T5 groups were increased (P＜0.05), and those in H and DH groups were lower than those in Control group (P＜0.05), and those in DH group were lower than those in H group (P＜0.05); 4.MoCA score in all groups decreased after operation (P＜0.05), but DH group was higher than H group and Control group (P＜0.05); 5.The incidence of bradycardia in DH group was higher than that in H group and Control group (P＞0.05), but there was no significant difference in the incidence of other adverse reactions (P＞0.05). Conclusion: Hydromorphone combined with Dexmedetomidine can effectively reduce stress response and Perioperative neurocognitive disorders in elderly patients undergoing Laparoscopic surgery.