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目的：探讨氢吗啡酮超前镇痛对老年全髋关节置换术后认知功能及炎性细胞因子的影响。方法：90例 ASAⅠ～Ⅱ级择期行全髋关节置换术的老年患者，采用随机数字表法，将患者随机分为氢吗啡酮组（H 组）和对照组（C 组）（n ＝45）。全麻诱导前，H 组静脉注射氢吗啡酮2 mg，C 组给予等容量生理盐水。术后行PCIA，药物为舒芬太尼，镇痛效果不佳时静注地佐辛0．1 mg／kg。分别于术前（T0）、术毕（T1）、术后6 h（T2）、术后24 h（T3）和术后3 d（T4）检测血清 C 反应蛋白、肿瘤坏死因子、白介素－6浓度；并采用简易精神状态量表评价认知功能，记录术后舒芬太尼用量和地佐辛补救用药情况。结果：与 C 组比较， H组术后血清 C 反应蛋白、肿瘤坏死因子、白介素－6浓度降低，舒芬太尼用量和地佐辛补救用药率均降低，认知功能障碍发生率降低（P ＜0．05）。结论：氢吗啡酮2 mg 超前镇痛可降低老年患者术后认知功能障碍的发生。

目的本研究评估氟比洛芬酯术后镇痛对老年髋关节置换术患者术后血浆S-100B蛋白、神经特异性烯醇化酶(NSE)浓度及术后认知功能的影响。方法 240例接受髋关节置换术老年患者,随机分为氟比洛芬酯联合芬太尼镇痛组(KF组)和芬太尼镇痛组(F组),每组120例。分别于术后6、24和48h采用VAS疼痛评分法对镇痛效果进行评估,记录术中、术后芬太尼用量及自控镇痛次数。分别于术前1d、术后3、5d记录简易智力状态检查法(MMSE)评分,并静脉采血测定血浆S-100B蛋白、NSE浓度;记录术后恶心呕吐及皮肤瘙痒的情况。结果两组患者术后各时点VAS评分差异无统计学意义,术后3、5dKF组的MMSE评分明显高于F组(P0.05),KF组术后认知功能障碍(POCD)的发生率为19.3%明显低于F组为37.3%(P0.05)。术后3d血浆S-100B蛋白、NSE浓度明显低于F组(P0.05),术后镇痛的芬太尼用量KF组明显低于F组(P0.05)。结论氟比洛芬酯可降低术后血浆S-100B蛋白、NSE浓度,降低POCD的发生率,降低术后恶心呕吐及皮肤瘙痒发生率。

Abstract Cognitive deterioration can reliably be measured after procedures requiring anesthesia and surgery. Cardiac surgery has had the spotlight because of the high reported incidence of postoperative cognitive dysfunction in early studies, but such effects occur after other surgical procedures as well. "Early" postoperative cognitive dysfunction should be considered as a different phenomenon, relating to acute pharmacological, physiological, and stress-related recovery. The focus should be on what is affecting patients at 3 months, 12 months, and 5 years later. Like with many other aspects of perioperative risk, a significant element is the patient's preoperative cognitive status. We now know that up to one-third of overtly "normal" elective cardiac surgical patients enter surgery with some degree of pre-existing cognitive impairment or, when applying psychogeriatric measures, mild cognitive impairment. The latter is a known prodrome or early stage of the amyloid associated Alzheimer's disease dementia. Inflammatory responses during cardiac surgery have been recognized for years, but our understanding of the complexity of systemic inflammatory response has grown significantly with the ability to assay neurohumoral markers such as interleukins. The blood-brain barrier is made vulnerable by both pre-existing disorders (mild cognitive impairment/amyloid; vascular disease) and by the inflammatory response to surgery and cardiopulmonary bypass. Inflammation affecting the brain at this time may set in motion accelerated neurological and hence cognitive decline that, despite an initial recovery and even functional improvement, may proceed to further long-term decline at an accelerated rate in susceptible individuals. Clinical data are emerging from longer-term studies to support this concern, but evidence for effective preventive or therapeutic strategies is limited.

Biological rhythms are essential for the regulation of many life processes. Disturbances of the circadian rhythm are known to affect human health, performance and well-being and the negative consequences are numerous and widespread. Cognitive dysfunction, fatigue, pain, sleep disturbances and mood disorders, such as anxiety and depression, are common problems arising around the time of surgery or in the course of a cancer diagnosis and subsequent treatment period. The importance of investigating prevention or treatment possibilities in these populations is significant due to the extent of the problems and the derived consequences on morbidity and mortality. Genetic predisposition to these problems is also an issue in focus. In this thesis we initially investigated whether the specific clock gene genotype PER(5/5) was associated with the development of postoperative cognitive dysfunction one week after non-cardiac surgery. We did not find any association, although this could have been due to the size of the study. Yet, if PER3(5/5) is associated with a higher incidence of postoperative cognitive dysfunction, the risk seems to be only modestly increased and by less than 10%. Melatonin is a hormone with well-known chronobiotic and hypnotic effects. In addition, exogenous melatonin is also known to have anxiolytic, analgesic, antidepressant and positive cognitive effects. Based on the lack of studies investigating these effects of melatonin, we conducted the MELODY trial in which we investigated the effect of 6 mg oral melatonin on depressive symptoms, anxiety, sleep, cognitive function and fatigue in patients with breast cancer in a three month time period after surgery. Melatonin had an effect on reducing the risk of developing depressive symptoms and also increased sleep efficiency perioperatively and total sleep time postoperatively. No effect was found on anxiety, sleep quality, sleepiness, general well-being or pain, however melatonin seemed to positively influence the ability to complete trial participation compared to placebo. Postoperative cognitive dysfunction was not a problem in this limited population. With regard to safety in our study, melatonin treatment for three months did not cause any serious adverse effects. Finally, we systematically reviewed the literature on the prophylactic or therapeutic effect of melatonin for depression or depressive symptoms in adult patients and assessed the safety of melatonin in these studies. The quantity, size and quality of trials investigating this question were not high and there was no clear evidence of an effect, although some studies were positive. In conclusion, further research is warranted with regard to the prophylactic effect and treatment effect of melatonin in depression, depressive symptoms, cognitive disturbances and symptom clusters of cancer patients in general. In addition, more hypothesis-generating studies with regard to the genetic heritability of POCD are needed.

目的探讨综合护理干预对老年术 后认知功能障碍(POCD)患者认知功能的影响。方法对42例全麻手术后出现POCD的老年患者进行综合护理干预,包括心理护理和认知功能训练等。结果所 有患者的认知功能均恢复至正常水平,住院18~26d出院。结论对POCD的全面认识和积极的护理干预可有效减轻老年POCD患者的认知损害,促进其认知 功能的恢复。

［摘要］　目的　探讨围手术期干预对骨科老年患者术后认知功能障碍（POCD）的影响。方法　将100例老年患者随机分为观察组和对照组各50例。观察组50例在予以相应的围术期常规护理的基础上，采取针对POCD的系统护理干预，对照组50例予以相应的围术期常规护理。分别记录两组患者术前、术后2 d、术后7 d简易精神智能状态量表（MMSE）评分及两组患者POCD发生率及情况等。结果　观察组患者术后POCD发生率低于对照组，术后2 d、7 d的MMSE评分明显高于对照组，差异有统计学意义（P<0.05）。结论　围手术期采取针对POCD的系统护理干预，能够有效避免或减少POCD的发生。

目的探讨盐酸氢吗啡酮联合罗哌卡因用于患者自控硬膜外镇痛(PCEA)的临床效果。方法选择骨科择期在腰硬联合麻醉下行下肢手术并要求术后镇痛的患者120例,采用随机数字表法,随机分为吗啡酮组(H组)和吗啡组(M组)各60例。H组术后镇痛给予镇痛泵,60μg·m L-1甲磺酸罗哌卡因+10μg·m L-1盐酸氢吗啡酮,背景输注速度4 m L·h-1,追加剂量4 m L,锁时10 min;M组术后镇痛给予镇痛泵,60μg·m L-1甲磺酸罗哌卡因+50μg·m L-1盐酸吗啡,背景输注速度4 m L·h-1,追加剂量4 m L,锁时10 min。观察并记录患者镇痛开始2 h(t0),4 h(t1),8 h(t2),12 h(t3),24 h(t4)及撤泵后2 h(t5)视觉模拟评分(VAS)、平均动脉压(MAP)、血氧饱和度(Sp O2)、呼吸频率(RR)、心率(HR)、总按压次数、总用药量和不良反应。结果 t3时,H组静息状态VAS小于M组,差异有统计学意义(P0.05),其他时刻两组患者静息和运动状态下VAS差异无统计学意义。t5时两组VAS评分均明显高于t4,差异有统计学意义(P0.05);两组患者各时间点MAP、SPO2、RR、HR、总按压次数和总用药量差异无统计学意义;M组皮肤瘙痒3例,H组未见不良反应,M组瘙痒发生率高于H组(P0.05)。结论盐酸氢吗啡酮联合罗哌卡因用于下肢手术患者PCEA安全有效,不良反应发生率低于吗啡。

目的 探讨羟考酮与氢吗啡酮对腹腔镜胆囊切除术后疼痛及炎症细胞因子的影响,为合理使用麻醉镇痛药,有效缓解术后疼痛及细胞因子失衡提供科学依据.方法 选取拟行腹腔镜胆囊切除术患者40例,随机分为羟考酮组(A组)、氢吗啡酮组(B组),每组各20例.手术结束时,A组给予羟考酮0.1 mg/kg,B组给予氢吗啡酮2 mg,C组给予生理盐水2ml.记录3组患者术后4、6、12和24 h的VAS评分,并在麻醉前和术后4、12和24 h检测血清IL-6和IL-10的水平.结果 A组与B组术后不同时间点VAS评分、Ramsay评分、血清IL-6、血清IL-10组内比较,差异有统计学意义(P＜0 05);A组与B组相比,VAS评分、Ramsay评分、血清IL-6、血清IL-10组内整体比较,差异无统计学意义(P＞0.05);麻醉后,A组与B组血流动力学指标比较,差异有统计学意义(P＜0.05),B组患者优于A组.结论 羟考酮与氢吗啡酮各自均可有效缓解腹腔镜胆囊切除术患者的术后疼痛,同时能够调节促炎与抗炎细胞因子平衡,减弱炎症反应,促进术后康复.

目的 比较3种麻醉药物椎管内超前镇痛对剖宫产术后镇痛效果的影响.方法 选取2015年5月至2016年5月在张家口市第五医院接受剖官产且术后接受镇痛的480例产妇为研究对象,依据镇痛方法分为盐酸氢吗啡酮组280例、吗啡组100例及布比卡因组100例.3组产妇均做术前常规准备,L2～3间隙腰-硬联合麻醉,分别于手术结束15 min前以盐酸氢吗啡酮0.20 mg、吗啡2.00 mg、布比卡因18.75 mg,加入9g·L-1氯化钠8 mL硬膜外导管单次注入,术毕拔除硬膜外导管,常规行术后静脉镇痛;于入室时及气管导管拔除后5 min抽取肘静脉血测定血浆多巴胺(DA)、肾上腺素(E)、去甲肾上腺素(NE)水平,术后6、12、24、48 h采用视觉模拟评分(VAS)记录镇痛效果,Ram-say镇静评分记录镇静效果.结果 盐酸氢吗啡酮组产妇术后6、12、24、48 h VAS评分优于吗啡组和布比卡因组(P＜0.05),且吗啡组低于布比卡因组(P＜0.05);3组产妇术后6、12、24、48 h Ramsay评分比较差异无统计学意义(P＞0.05).气管导管拔除后5 min 3组产妇DA、E、NE水平较麻醉前均升高(P＜0.05),且盐酸氢吗啡酮组显著低于吗啡组和布比卡因组(P＜0.05).结论 椎管内盐酸氢吗啡酮单次给药超前镇痛效果较吗啡和布比卡因好,且不影响术后苏醒质量,并能降低应激反应.

目的在过表达β淀粉样前体蛋白的SH-SY5Y细胞上(SH-SY5Y/APP695)观察葛根素对β淀粉样蛋白(β-amyloid protein,Aβ)生成的作用,探讨其防治阿尔茨海默病的机制。方法葛根素2.5,5和10μmol·L-1处理SH-SY5Y/APP细胞24 h,MTT法检测细胞活力,ELISA试剂盒测定细胞外Aβ1-40和Aβ1-42水平;Western blot蛋白质印迹法检测APP及β-分泌酶的蛋白表达变化;荧光法测β-分泌酶的活性;RT-PCR法检测β-分泌酶转录的变化。结果葛根素可剂量依赖性的减少SH-SY5Y/APP695细胞外Aβ1-40、Aβ1-42的水平;酶活性分析显示2.5,5和10μmol·L-1的葛根素分别抑制了15%,30%和40%β-分泌酶的活性。Western blot印迹结果显示,葛根素能剂量依赖性抑制β-分泌酶蛋白表达,2.5,5和10μmol·L-1的葛根素使β-分泌酶的蛋白表达分别减少至82%,71%和45%,与空白对照组比较差异均具有统计学意义(P0.05)。结论葛根素通过下调β-分泌酶蛋白的表达、抑制β-分泌酶的活性减少Aβ的形成,这可能是葛根素防治阿尔茨海默病作用的重要机制之一。

There are many risk factors for the cause of postoperative cognitive dysfunction (POCD), however, the anesthesia selection always trigger controversy for the POCD occurrence. This study aims to explore the relationship between the anesthesia and the occurrence of POCD in elder patients, and also investigate the mechanism of the POCD. One hundred elder patients with hip replacement were included in this study, which were divided into general anesthesia (GA) and epidural analgesia (EA) group. Minimum mental state examination (MMSE) method was employed to assess the nervous and mental function (POCD) in both analgesia group patients. Aβ and tau protein levels in blood were detected by using the ELISA assay. The correlation between MMSE in POCD patients and Aβ or tau was analyzed by employing the Spearman rank correlation method. The results indicated that epidural analgesia decreases the MMSE scoring compared to general analgesia (P < 0.05). General analgesia enhanced the Aβ and tau level compared to epidural analgesia (P < 0.05). Aβ and tau level were increased in the patients with POCD. The POCD occurrence rate in GA group was significantly higher compared to EA group (P < 0.05). MMSE scores of POCD patients positively correlated with Aβ or tau level (P < 0.05). In conclusion, the epidural analgesia method was better than general analgesia method for the hip replacement in elder patients. The mechanism of the POCD may be caused by the enhancement of Aβ and Tau protein.