血管内低温对高血压脑出血手...者神经功能与心理的影响分析_王艳.pdf

基金 项 目 四 川 省 自 然 科 学 基 金 资 助 项 目(编 号:2022NSFC0710)通讯作者邓先平血血管管内内低低温温对对高高血血压压脑脑出出血血手手术术患患者者神神经经功功能能与与心心理理的的影影响响分分析析王 艳1,彭 凤1,周 慧1,邓先平2(1.成都医学院第一附属医院手术室,四川 成都 610500;2.重庆市巴南区人民医院中医(风湿免疫/老年)科,重庆 401320)摘要 目的 研究血管内低温(IVHT)对高血压脑出血(HCH)手术患者神经功能、运动功能及心理状态的影响。方法 选择 2020 年 7 月至2022 年6 月于我院行手术治疗的 HCH 患者90 例,依据随机数字表法将患者分为 IVHT 组(n=45)与对照组(n=45),对照组行常规亚低温干预,IVHT 组行 IVHT。观察两组患者术前、复温 30 d 后神经功能、运动功能、心理状态,并发症等指标。结果 复温 30 d 后,IVHT 组 NIHSS 评分、Rankin 评分均低于对照组,Fugl-Meyer 评分、BBS 评分均高于对照组,SCL-90 各分项评分均低于对照组(P0.05);IVHT 组并发症发生率低于对照组(P0.05)。结论 IVHT 可改善 HCH 手术患者神经功能、运动功能及心理状态,且并发症发生率低,安全性高,可推荐于临床。关键词 血管内低温;高血压脑出血;手术;神经功能;运动功能;心理中图分类号 R473.6 文献标志码 A 文章编号 1672-6170(2023)03-0141-05The effects of intravascular hypothermia on neurological function and psychology in patientsundergoing hypertensive cerebral hemorrhage WANG Yan1,PENG Feng1,ZHOU Hui1,DENG Xian鄄ping2(1.Operating Room,The First Affiliated Hospital of Chengdu Medical College,Chengdu 610500,China;2.Department of TCM(Rheumatic Immunology/Geriatrics),Banan District People s Hospital,Chongqing 401320,China)Corresponding author DENG Xian鄄pingAbstract Objective To investigate the effects of intravascular hypothermia(IVHT)on neurological function,motor functionand psychology of operative patients with hypertensive cerebral hemorrhage(HCH).Methods Ninety patients with HCH whounderwent surgical treatment in our hospital from July 2020 to June 2022 were selected.The patients were divided into an IVHT groupand a control group according to random number table method,45 in each group.The control group received routine mild hypothermiaintervention and the IVHT group received IVHT.Neurological function,motor function and mental state as well as complications wereobserved in the two groups before operation and after 30 days of rewarming.Results After 30 days of rewarming,NIHSS score andRankin score were lower,Fugl-Meyer score and BBS score were higher and SCL-90 scores were lower in the IVHT group than those inthe control group(P0.05).The incidence of complications in the IVHT group was lower than that in the control group(P0.05)。见表 1。本研究经本院医院伦理委员会批准(编号:2023LL005)。表 1 两组基线资料比较项目IVHT 组(n=45)对照组(n=45)统计量P性别(男/女)25/2028/172=0.4090.523年龄(岁)64.786.6964.906.76t=0.0850.933发病至手术时间(h)7.480.767.530.82t=0.3000.765GCS 评分(分)8.880.918.920.95t=0.2040.839血肿量(ml)49.955.3451.135.40t=1.0420.300意识障碍(轻度/中度/昏迷)5/29/116/30/92=0.5600.7561.2 方法 对照组行常规亚低温干预。术毕,以降温毯、冰帽等进行降温,将导尿管(已安装温度探头)置于患者膀胱内,持续检测膀胱温度,维持膀胱温度35,时间3 5 d,以自然复温法复温,复温控制 0.10 0.25 /h,至患者体温达 36.5 为复温完成。降温时发生寒战者给予50 mg 氯丙嗪+50 mg异丙嗪+100 mg 哌替啶静注。IVHT 组:行 IVHT。使用血管内温度控制系统(GoolGard)进行降温、维持低体温及复温。自股静脉将 Icy 导管置入,直至下腔静脉,将导尿管(已安装温度探头)置于患者膀胱内,打开 GoolGard,使生理盐水经封闭循环系统通过下腔静脉,持续检测膀胱温度,维持膀胱温度 35,时间3 5 d,复温速率0.10 0.25 /h,至患者体温达 36.5 为复温完成。生理盐水温度为 4 40。寒战处理同对照组。1.3 观察指标 观察两组术前、复温 30 d 后神经功能,运动功能,心理状态,并发症等指标。神经功能以美国国立卫生研究院卒中量表(NIHSS)8及改良 Rankin 量表评价9。NIHSS 包括 12 个项目,满分42 分,得分越高说明神经功能越差。改良 Rankin量表包括 6 个等级,评分 0 5 分,得分越高症状越严重。运动功能以简式 Fugl-Meyer 量表10及 Berg平衡量表(BBS)11评价。简式 Fugl-Meyer 量表包括上肢、下肢两部分评分,上肢部分包括 10 个大项,33 个小项,下肢部分 7 个大项,17 个小项,评分 0 2 分,得分越高运动功能越好。BBS 包括 14 个项目,评分 0 4 分,得分越高平衡功能越好。心理状态以 SCL-90 评分症状自评量表12进行评价,包括90 个项目,评分 0 4 分,得分越高代表患者心理状态越差。1.4 统计学方法 应用 SPSS 19.0 统计软件分析数据。计量资料以均数标准差描述,组内比较行配对 t 检验,两组间比较行独立样本 t 检验;计数资料以例数(百分率)表示,组间比较行 2检验。检验水准=0.05。2 结果2.1 两组神经功能评分比较 术前两组 NIHSS 评分及 Rankin 评分差异无统计学意义(P0.05);复温 30 d 后,两组 NIHSS 及 Rankin 评分均降低,且IVHT 组评分低于对照组,差异有统计学意义(P0.05)。见表 2。表 2 两组神经功能评分比较(分)指标 时间IVHT 组(n=45)对照组(n=45)tPNIHSS 评分术前21.982.4621.892.440.17420.8621复温 30 d 后11.851.35*15.531.76*11.12930.0000Rankin 评分术前4.570.484.500.460.70630.4819复温 30 d 后1.960.21*2.480.27*10.19800.0000*与术前比较,P0.05);复温30 d 后,两组 Fugl-Meyer 及 BBS 评分均增加,且 IVHT 组评分高于对照组,差异有统计学意义(P0.05);复温 30 d后,两组 SCL-90 各分项评分均降低,且 IVHT 组各分项评分均低于对照组,差异有统计学意义(P0.05)。见表 4。241 实用医院临床杂志 2023 年 5 月第 20 卷第 3 期 表 3 两组运动功能评分比较(分)指标 时间IVHT 组(n=45)对照组(n=45)tPFugl-Meyer 评分术前30.753.3631.183.390.60430.5472复温 30 d 后63.966.58*45.464.83*15.20400.0000BBS 评分术前36.093.8936.143.917.26350.0000复温 30 d 后49.955.22*42.584.56*7.13290.0000*与术前比较,P0.05表 4 两组 SCL-90 各项评分比较(分)指标 时间IVHT 组(n=45)对照组(n=45)tP焦虑术前3.480.373.450.360.38980.6976复温 30 d 后1.380.17*1.720.19*8.94600.0000抑郁术前3.220.353.190.330.41840.6767复温 30d 后1.200.14*1.640.19*12.50640.0000恐怖术前3.340.363.320.340.27090.7871复温 30 d 后1.720.19*2.110.24*8.54680.0000敌对术前3.220.363.190.340.40640.6854复温 30 d 后1.340.16*1.860.20*13.61940.0000躯体化术前3.560.383.530.360.38450.7016复温 30 d 后1.580.17*1.960.22*9.16850.0000精神病性术前3.160.333.130.310.44450.6578复温 30 d 后1.520.18*1.940.20*10.47100.0000*与术前比较,P0.052.4 两组并发症比较 IVHT 组并发症发生率低于对照组,差异有统计学意义(2=4.005,P0.05)。见表 5。表 5 两组并发症发生情况比较 n(%)并发症IVHT 组对照组颅内感染1(2.22)2(4.44)脑积水0(0.00)2(4.44)迟发性血肿0(0.00)2(4.44)电解质紊乱1(2.22)2(4.44)合计2(4.44)8(17.78)3 讨论快速清除颅内血肿,降低颅内压,避免神经损伤是临床治疗 HCH 的关键13。手术治疗 HCH 尽管可达到上述目的,但仍难以避免脑组织继发性损伤,影响患者预后14。研究证明,降低机体核心体温可抑制血管源性水肿,提高血脑屏障的稳定性,减少氧自由基及毒性神经递质生成,避免过度消耗氧及能量以缓解炎症反应,纠正神经细胞异常代谢,避免神经细胞凋亡15。降低机体核心体温可抑制机体代谢,避免因乳酸堆积导致的神经细胞酸中毒发生,从而保护神经细胞16。资料显示,尽管常规亚低温干预可降低 HCH 患者核心体温,但却具有核心体温稳定性差,降温速度慢等缺点,临床应用常不尽满意17。本研究复温 30 d 后,IVHT 组 NIHSS 及 Rankin评分均低于对照组,Fugl-Meyer 评分、BBS 评分均高于对照组,说明 IVHT 可有效降低患者核心体温,改善患者神经功能,增强其运动功能。研究发现,快速稳定降低颅脑损伤患者核心体温对神经组织具有良好的保护作用18。IVHT 可快速降低核心体温,使核心体温降低时间减少1 5 h,从而使神经细胞术后早期即可获得保护,对于避免其损伤具有积极意义19。寒战是机体寒冷状态下产热的重要机制20。IVHT 可有效避免寒战发生,促进核心体温快速达到标准21。IVHT 可维持较低核心体温的稳定性,使其能够在较长的时间处于一定的温度区间,发挥对神经细胞的保护作用22。IVHT 可稳定复温,避免过快复温导致的颅内压反跳及脑水肿发生,从而保护脑细胞,促进神经功能恢复。神经功能恢复是增强运动功能的关键23。IVHT 可保护HCH 手术患者神经功能,有助于患者术后早期即可进行肢体运动,恢复、增强其运动功能24。IVHT 的持续时间通常为24 h,但本研究 IVHT 持续时间为35 d,且患者并未出现显著异常,说明 IVHT 的持续时间仍有延长的空间。在复温过程中,要尽量将时间控制在 1 2 d 或更长时间,并以恢复至正常体温341 实用医院临床杂志 2023 年 5 月第 20 卷第 3 期 为目标,以避免过快恢复体温或复温过高导致颅内压升高或加重脑水肿。故在复温过程中,可加强对颅内压的监测,或以此为依据调整复温时间。本研究结果显示,复温 30 d 后 IVHT 组 SCL-90各分项评分均低于对照组,说明 IVHT 有助于改善HCH 手术患者心理功能。受 HCH 影响,患者术后多存在神经功能损伤,致使患者产生程度不同的负性情绪,部分患者甚至因此抗拒治疗25。此外,负性情绪还可导致交感神经兴奋,致使心跳加速,脑血流灌注增加,促进脑出血26。IVHT 可减少 HCH手术患者神经功能损伤,尽早恢复其运动功能,提高其生活能力,从而有效缓解患者负性情绪,减轻其心理压力,使其更乐于参与术后功能锻炼,从而实现良性循环,真正改善其心理状况27。此外,IVHT 组并发症发生率低于对照组,说明 IVHT 可有效避免并发症,提高安全性。综上,IVHT 可显著改善 HCH 手术患者的神经系统、运动及心理功能,且并发症发生率低,安全性高。但是,由于深度低温可导致患者死亡,在 IVHT的实施过程中,要加强患者体温及其他生命体征的监测,一旦发现患者出现深度体温,要立即复温,并进行对症处理,以避免安全事件发生。参考文献1 黄艳丽,张海垠.高血压脑出血患者应用依达拉奉联合局部亚低温治疗对患者神经损伤和认知功能的影响J.实用医院临床杂志,2020,17(1):88-92.2 Yuan H,Feng J,Lin X,et al.The effect of early vs.late CT-guided stereotactic hematoma aspiration on neurological functionrecovery in patients with hypertensive cerebral hemorrhage in thebasal ganglia:a retrospective comparative cohort studyJ.AnnPalliat Med,2022,11(9):2923-2929.3 李雪粉,邸阜生.肥胖与缺血性脑血管病关系的研究进展J.西南医科大学学报,2022,45(4):282-287.4AlneT.TherapeuticHypothermia:ComparingSurfacevsIntravascular CoolingJ.Dimens Crit Care Nurs,2020,39(1):12-22.5 Rosman J,Hentzien M,Dram M,et al.A comparison between in-travascular and traditional cooling for inducing and maintainingtemperature control in patients following cardiac arrestJ.AnaesthCrit Care Pain Med,2018,37(2):129-134.6 Koenig MA.Cerebral Edema and Elevated Intracranial PressureJ.Continuum(Minneap Minn),2018,24(6):1588-1602.7 中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组.中国脑出血诊治指南(2019)J.中华神经科杂志,2019,52(12):994-1005.8 Adams H,Davis P,Leira E,et a1.Baseline NIH Stroke Scale Scorestrongly predict outcome after stroke:A Report of the Trial of ors10172 in Acute Stroke Treatment(TOAST)J.Neurology,1999,53(1):126-131.9 范玉华,姬晓昙,蓝琳芳.国内脑卒中临床试验疗效判断方法中改良 Rankin 评分的应用现状J.中国神经精神疾病杂志,2015,41(7):412-415.10 Fugl-Meyer AR,Jsk L,Leyman I,et al.The post-strokehemiplegic patient.a method for evaluation of physical performanceJ.Scand J Rehabil Med,1975,7(1):13-31.11金冬梅,燕铁斌.Berg 平衡量表及其临床应用J.中国康复理论与实践,2002,8(3):155-157.12王征宇.症状自评量表 SCL-90J.上海精神医学,1984,2(2):68-70.13Mao Y,Shen Z,Zhu H,et al.Observation on therapeutic effect ofstereotactic soft channel puncture and drainage on hypertensivecerebral hemorrhage J.Ann Palliat Med,2020,9(2):339-345.14Wang X,Chen Y,Wang Z,et al.Clinical Research of EarlyHyperbaric Oxygen Therapy on Patients with Hypertensive CerebralHemorrhage After CraniotomyJ.Turk Neurosurg,2020,30(3):361-365.15Prashantha YN,Suman Rao PN,Nesargi S,et al.Therapeutic hy-pothermiaformoderateandseverehypoxicischaemicencephalopathy in newborns using low-cost devices-ice packs andphase changing materialJ.Paediatr Int Child Health,2019,39(4):234-239.16Wang DM,Lin ZZ,Wang SN,et al.Basilar artery occlusionsuccessfully treated with delayed intravascular intervention and mildhypothermiaJ.Chin Med J(Engl),2019,132(6):723-725.17Smith T,Couillard P,McBeth P,et al.Esophageal Cooling forHypoxic Ischemic Encephalopathy:A Feasibility StudyJ.TherHypothermia Temp Manag,2021,11(3):179-184.18 Iseler J,Riedel L,Pathak D,et al.Intravascular TargetedTemperature Management:One Hospitals ExperienceJ.TherHypothermia Temp Manag,2021,11(4):197-200.19Konovalov AN,Pilipenko YV,Tsarukaev BA,et al.Intravascularhypothermia for cerebral ischemia after microsurgical clipping ofcomplex MCA aneurysms J.Zh Vopr Neirokhir Im N NBurdenko,2022,86(2):36-44.20Zusman BE,Kochanek PM,Jha RM.Cerebral Edema in TraumaticBrain Injury:a Historical Framework for Current TherapyJ.CurrTreat Options Neurol,2020,22(3):9.21 Ramadanov N,Arrich J,Klein R,et al.Intravascular VersusSurface Cooling in Patients Resuscitated From Cardiac Arrest:ASystematic Review and Network Meta-Analysis With Focus onTemperature Feedback J.Crit Care Med,2022,50(6):999-1009.22 Kim JG,Shin H,Choi HY,et al.Prognostic factors forneurological outcomes in Korean targeted temperature managementrecipients with return of spontaneous circulation after out-of-hospitalcardiac arrests:A nationwide observational study J.Medicine(Baltimore),2020,99(15):e19581.23Drumheller BC,Stein DM,Scalea TM.Use of an intravascular tem-perature control catheter for rewarming of hypothermic traumapatients with ongoing hemorrhagic shock after combined damagecontrol thoracotomy and laparotomy:A case series J.Injury,2018,49(9):1668-1674.441 实用医院临床杂志 2023 年 5 月第 20 卷第 3 期 24高英,廖利萍,何琦,等.血管内低温治疗对重型颅脑损伤标准大骨瓣减压术后患者短期疗效的影响J.中国中西医结合急救杂志,2022,29(2):163-166.25Wang G,Liu W,Li C,et al.Effect of minimally invasive surgerycombined with intracranial pressure monitoring on neurologicalfunction recovery and quality of life in patients with hypertensivecerebral hemorrhage J.Am J Transl Res,2021,13(7):8076-8084.26Castello JP,Pasi M,Kubiszewski P,et al.Cerebral Small VesselDisease and Depression Among Intracerebral Hemorrhage SurvivorsJ.Stroke,2022,53(2):523-531.27韩近超,孟晨,解强.针灸电刺激联合血管内亚低温治疗对重症颅脑外伤患者血清脑组织损害标志物水平的影响J.川北医学院学报,2022,37(6):708-711.(收稿日期:2023-01-11;修回日期:2023-02-20)(本文编辑:彭 羽)多多学学科科协协作作干干预预对对骨骨科科围围手手术术期期睡睡眠眠障障碍碍患患者者疼疼痛痛状状况况、恢恢复复效效果果的的影影响响肖祥华a,王 凤b,张姣姣a,舒家云c,魏 英d,罗 娟e(成都市新都区人民医院 a.骨科,b.行政科,c.麻醉科,d.精神科,e.中西医结合病区,四川 成都 610000)摘要 目的 分析多学科协作干预在骨科围手术期患者疼痛引起睡眠障碍中的应用效果。方法 收集 2021 年 9 月至 2022 年 7 月我院骨科收治的 120 例手术疼痛引起睡眠障碍的患者,根据随机数字表法分为对照组和观察组各 60 例,围术期对照组予以常规干预,观察组予以多学科协作干预,比较两组患者的疼痛程度、睡眠质量与术后康复水平。结果 术后第1、2、3 天,观察组患者的数字疼痛评分(NRS)均低于对照组,匹兹堡睡眠质量指数(PSQI)评分低于对照组(P0.05);且在睡眠效率方面高于对照组,睡眠潜伏期、觉醒时间短于对照组,总睡眠时间长于对照组(P0.05);观察组中 40 项恢复质量评分量表(QoR-40)评分高于对照组(P0.05)。结论 多学科协作干预应用于骨科围手术期疼痛引起的睡眠障碍效果显著,不仅能缓解疼痛程度,改善患者睡眠质量,还可促进患者术后恢复。关键词 多学科协作干预;围手术期;睡眠障碍;睡眠质量中图分类号 R441.4;R816.8;R338.63 文献标志码 A 文章编号 1672-6170(2023)03-0145-04The effect of multidisciplinary collaborative intervention on pain status and recovery effect ofpatients with sleep disorders in orthopedic perioperative period XIAO Xiang鄄huaa,WANG Fengb,ZHANG Jiao鄄jiaoa,SHU Jia鄄yunc,Wei Yingd,LUO Juane(a.Department of Orthopedics,b.Department of Ad-ministration,c.Department of Anesthesiology,d.Psychiatric Department,e.Ward of Integrated Chinese andWestern Medicine,Xindu District Peoples Hospital,Chengdu 610000,China)Corresponding author LUO JuanAbstract Objective To analyze the application effect of multidisciplinary collaborative intervention on pain-induced sleepdisturbance in orthopedic perioperative patients.Methods One hundred and twenty patients with sleep disorders caused by surgicalpain in the department of orthopedics of our hospital from September 2021 to July 2022 were collected.The patients were divided into acontrol group and an observation group according to the random number table method,60 in each group.The control group receivedroutine intervention during perioperative period and the observation group received multidisciplinary collaborative intervention.The paindegree,sleep quality and postoperative rehabilitation level were compared between the two groups.Results The scores of NumericalRating Scale(NRS)and Pittsburgh Sleep Quality Index(PSQI)of the observation group were lower than those of the control group onthe 1st,2nd and 3rd day after surgery(P0.05).The sleep efficiency was higher,the sleep latency and wake time were shorter andtotal sleep time was longer in the observation group than those in the control group(P0.05).The Quality of Recovery Score(QoR-40)in the observation group was higher than that in the control group(P0.05).Conclusions Multidisciplinary collaborativeintervention can achieve significant results in sleep disorders caused by pain in perioperative orthopaedic patients.It can not onlyrelieve the pain and improve the sleep quality,but also promote the postoperative recovery.Key words Multidisciplinary collaborative intervention;Perioperative period;Sleep disorders;Sleep quality 手术为临床治疗骨科疾病患者的一种有效措施,受疾病、手术应激等因素影响,骨科手术患者围术期易出现疼痛反应,并引起多种并发症,睡眠障碍即为其中常见类型,不仅影响手术效果,而且不利于术后病情恢复,因此需加强围术期专业干预1,2。关于骨科手术患者,临床多以常见方案展开干预工作,缺乏针对性与严谨性,难以进一步缓解患者疼痛程度及提升睡眠质量,效果有限3。多学科协作干预为新型干预方案,即多个学科专业人员共同参与至干预工作中,相互协作,发挥各专业优势,为患者提供全方位、专业性干预服务,满足病情康复需求,提升干预质量4。2020 年 10 月至541 实用医院临床杂志 2023 年 5 月第 20 卷第 3 期