| Background:Attention deficit is related to postoperative cognitive impairment(POCD)closely and plays an important role in the occurrence of POCD.The purpose of this study was to investigate the effect of anesthesia depth and methods on three attention network function by recording the response time(RT)and accuracy of attention network test(ANT)(alerting,orienting and executive control).To explore the potential pathogenesis of POCD by investigating the change of attentional network function,the value of attentional network test in cognitive assessment of elderly patients during perioperative period,and the correlation between the three attention network functions and POCD.Objective:The purpose of this study was to explore the following issues: 1)The feasibility and reliability of the application of attention network test(ANT)in perioperative patients;2)To detect the depth of Bispectral index(BIS)monitoring on anesthesia early postoperative attention network function.Influence and cognitive function in elderly patients.3)To examine the effects of different anesthesia methods on early postoperative attention network function and cognitive function in elderly orthopaedic patients.4)To explore the correlation between the three attentional network function: alertness,orientation and executive control and the occurrence of POCD,and to speculate the neurogenesis mechanism of POCD.Methods:Part I: A prospective,double-blind cohort study was designed to randomize elderly patients into high BIS group(H group)and low BIS group(L group)and non-BIS group(N group)underwent knee arthroplasty over 65 years of age.The depth of anesthesia was adjusted according to BIS monitoring in group H and L group,and the depth of anesthesia was adjusted according to anesthesiologist’s experience and hemodynamics in the N group.Three groups of patients were combined with sciatic nerve and femoral nerve block B under ultrasound.The BIS value of H group was set at 50-60,L group was set at 40-50,and N group was adjusted according to clinical experience and intraoperative hemodynamic changes.Heart rate(HR),systolic blood pressure(SBP),diastolic blood pressure(DBP),mean arterial pressure(MAP)and BIS value were recorded before anesthesia induction,1 minute after intubation,1 hour during operation and 5 minutes after extubation.Intraoperative infusion volume,urine volume,blood loss,blood transfusion,propofol,remifentanil and sufentanil average dosage,operation and anesthesia time,vasoactive drug dosage,withdrawal time,withdrawal time,withdrawal to recovery(out of the operating room),Steward score,the average length of hospital duration and total adverse events were recorded.The incidence of delirium in hospital(POD)and the incidence of POCD was calculated at 7 days and 30 days after surgery.Attention Network Test(ANT)was used to compare the response time and accuracy of attention network(alerting,orienting,execution control)1 day before surgery,7 days and 30 days after surgery in the three groups,and to calculate and compare the effects of BIS on the postoperative attention network function in the three groups.The primary end point were efficiency of attentional networks(alerting,orienting,executive control);The secondary end point were the incidence of POD and POCD.Part II: A prospective,double-blind cohort study was designed to enroll consecutive elderly patients with ASA grade I to III who needed elective knee arthroplasty over 65 years of age and were randomly divided into two groups,general intravenous anesthesia group(G group)and epidural anesthesia group(E group).Heart rate(HR),systolic blood pressure(SBP),diastolic blood pressure(DBP)and mean arterial pressure(MAP)were recorded before anesthesia induction,1 minute after intubation,1 hour during operation and 5 minutes after extubation.Intraoperative infusion volume,urine volume,blood loss,blood transfusion,propofol,remifentanil and sufentanil average dosage,anesthesia and operation duration,the total number of adverse events,average hospitalization duration and the incidence of delirium(POD)were recorded,and the incidence of POCD was calculated 7 days and 30 days after operation.Attention Network Test(ANT)was used to compare the response time and accuracy of attention network(alerting,orienting,executive control)between the two groups 1day before surgery,7 days and 30 days after surgery.attention network function of two different anesthetic methods on anesthesia and postoperaion in elderly patients were examined.The primary end point was the efficiency of attentional networks(alerting,orienting,executive control);The secondary end point was the incidence of POD and POCD.Results:Part I: A total of 332 patients were enrolled successfully.117 patients were in the HBIS group,108 patients were in the LBIS group,107 patients were in the N group.The dosage of sufentanil and remifentanil had no difference in three groups.The dosage of propofol in group H was significantly lower than that in group L and group N.There was no significant difference in the dosage of vasoactive drugs between the three groups.There was a significant difference in BIS value between group H and group L and group N.In group H,eye opening time,extubation time,anesthesia recovery time and PACU time after operation were shorter than those in N group and L group.The executive control network of the three groups was significantly impaired 7 days after operation(P < 0.001 vs.1 day before suygery).Alerting(P = 0.511 vs.1 day before suygery,P = 0.575 vs.1 day before suygery)and orienting(P = 0.846 vs.1 day before suygery,P = 0.476 vs.1 day before suygery)of the H and L groups were recovered,but the alerting and orienting of the N groups were unrecovered(P < 0.001 vs.1 day before suygery).Executive control still not restored to the preoperative level((P < 0.05 vs.1 day before suygery)in the H and L group 30 days after surgery,but improved compared with that of 7 days after surgery.In group N,the orienting(P = 0.476 vs.1 day before surgery)was recovered 30 days after suegery,and the alerting and execution control were still not recovered(P < 0.001 vs.1 day before suygery).Compared with L group and N group,the efficiency of attention network(alerting,orienting,executive control)recovered significantly faster in group H 7 days and 30 days after operation(P< 0.05).The incidence of POD was different significantly among the three groups during hospitalization.There was no significant difference in the incidence of postoperative cognitive impairment on the 7 days(F = 3.949,P = 0.135),and on the 30 days after surgery(F = 7.540,P = 0.023).Part II: A total of 317 patients were successfully included in the statistical analysis.165 cases of epidural anesthesia(E)and 152 cases of intravenous general anesthesia(G).Executive control of the two groups were significantly impaired on the 7th day after surgery(P< 0.001 vs.1 day before surgery).Alerting(P = 0.543)and orientation(P = 0.462)of group E were restored,alerting and orienting of group G were not restored(P < 0.05),alerting(Z = 6.352,P < 0.001)and orienting(Z = 3.480,P = 0.001),and the executive control(Z = 0.244,P = 0.807)between group E and group G.On the 30 th day after operation,the executive control did not return to the preoperative level(P< 0.001 vs.1 day before surgery),orienting(P = 0.142)has been restored,alerting and executive control were not restored(P < 0.001)after general anesthesia in group E.Compared with group G,the efficiency of attention network(alerting,orienting,executive control)recovered significantly faster in group E 7 days and 30 days after surgery(P < 0.05).There was no significant difference in the incidence of POD between the two groups during hospitalization.There was no significant difference in the incidence of postoperative cognitive impairment on the 7th day after surgery(P = 0.231),and there was a significant difference on the 30th day after surgery(P = 0.027).Conclusion:1、ANT is a convenient and feasible method to detect the attention function of elderly patients.2、Intraoperative BIS depth monitoring is helpful for early recovery of postoperative attention function.3、Separate the attention components related to anesthesia.Total intravenous anesthesia has a long-term effect on the attention network,and deep anesthesia can affect the alert function.4、Epidural anesthesia can help to early recovery of the network.5、Application of the ANT further improves the understanding of the mechanism of POCD for the elderly surgical patients. |
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