| [Objective]To investigate the effect of remote ischemic precondition(ripc)combined with ulinastatin on cognitive impairment in elderly patients with one lung ventilation.[Methods]The study was approved by the Ethics Committee of the Third Clinical College of Kunming Medical University,and each patient signed the informed consent.Choice during April 2019 to December 2019 imaging and fiber bronchoscope examination diagnosis of non-small cell lung cancer Ⅰ-Ⅱ period and in the chest or quasi under thoracoscope lung resection patients 76 aged 60～75 years old,45～75 kg Body weight,Body Mass Index,Body Mass Index,BMI)18.5～23.9 kg/m2,ASA sizing<Ⅲ level.New York Heart Association NYHA rating Ⅰ;There was no severe respiratory dysfunction(PaO2>60mmHg or 50%of the predicted>value of forced expiratory volume in the first second),and the coagulation function was normal.There was no hypertension,diabetes mellitus,cerebrovascular disease or peripheral vascular disease before operation.No history of chemotherapy,radiotherapy or immunotherapy;No corticosteroid had been used within 3 months;No central nervous system degenerative diseases(Alzheimer’s disease,Parkinson’s disease,etc.);All patients have received junior high school education or above,without serious audiovisual impairment,and can communicate with doctors normally.A mini-Mental State Examination(MMSE)was used to assess the baseline cognitive function of the patients one day before the operation.All patients without the use of preoperative medication,home after conventional detection of heart rate,blood pressure,pulse oxygen saturation,vital signs,such as the lower right subclavian vein puncture had the catheter,right internal jugular vein retrograde catheter,incision of lateral radial artery,the tube will be in accordance with the principle of randomized double-blind controlled by a 76 patients anesthesia nurses were divided into control group(group C)and experimental group(R+U).The control group was given 100ml of normal saline by intravenous drip.The experimental group was given 200000 U ulinastatin dissolved into 100ml normal saline intravenous drip.Midazolam 0.05～0.1mg/kg,Sufentanil injection 0.6 g/kg,etomidate injection 0.2mg/kg,vecuronium injection 0.3mg/kg were slowly injected intravenously for anesthesia induction.All patients were inserted into the left bronchial double lumen tube,and fibrobronchoscope was used to determine the correct location of the catheter,ensuring intraoperative SpO2(?)95%.Before the operation,the anesthesia nurse bound the pressurized tourniquet in the right lower limb femoral part of the two groups of patients.The pressure of the pressurized tourniquet was maintained at zero throughout the study in the control group,and distal ischemic preconditioning was performed in the experimental group.Distal lack of preconditioning:after pressurized tourniquet inflating pressure to 200 mmHg produces ischemia for 5min,release tourniquet pressure to zero produces reperfusion for 5min,and repeat for 3 cycles for a total of 30min.Patients in both groups were assigned to another anesthesiologist,who did not know the group,for follow-up studies.Propofol 4～8 mg·kg-1·h-1 and Remifentanil 0.1～0.2 g·kg-1·h-1 were continuously injected intravenously with micro pump,and 1.5～2.0%sevoflurane was inhaled with intermittent intravenous injection of 2～4mg vecuronium for maintenance anesthesia.The BIS value during the maintenance of anesthetic dosage was adjusted to 40～60,and the respiratory parameters were adjusted to maintain PaCO2 to 35～45 mmHg(1mmHg=0.133 kPa).The same standardized fluid was used to control fluid intake during one-lung ventilation.Intraoperative MAP≥65mmHg,HR≥50 times/min.All patients respectively before anesthesia induction(T1),OLV 30 min(T2),restore double lung ventilation(the TLV)15 min(T3),restore the TLV 60 min(T4),pull out 60 min after double lumen(T5)extraction arterial blood and jugular vein ball ministry blood for blood gas analysis,calculating oxygenation index(Pa02/FiO2),determination and calculation of cerebral oxygen metabolism related indicators(Da-jvO2,CjvO2,CaO2,CERO2);The subclavian venous blood was extracted at the above time point and the inflammatory cytokines(IL-6,TNF-,IL-10)were measured by flow cytometry.Blood samples from the jugular bulb were taken for S100 protein before anesthesia induction(T1),60min(T5)and 24h(T6).Confusion Assessment Method(CAM)was used to assess delirium 60min(T5),1 day(T6),2 days(T7),3 days(T8),and 4 days(T9)after the withdrawal of the double-lumen tube.[Results]70 patients entered the final research and data statistical analysis,two groups of patients’ age,gender,composition ratio,record of formal schooling than(university/high school/junior high school),BMI,ASA grade ratio,amount of blood loss,rehydration,operation way(thoracotomy/thoracoscope),0 1v time,operation time had no obvious difference,two groups of patients with the corresponding time point of the MAP,HR has no statistical significance.Although there was no significant difference in SaO2 between the two groups at the corresponding time points,PaO2 and Pa02/FiO2 in the experimental group were significantly increased at the corresponding time points(P<0.05).The Pa02/FiO2 in the experimental group was 314.68±69.37mmHg 60min(T5)after extubation,returning to the level before anesthesia induction(T1).Compared with T1,two groups of PjvO2,SjvO2 in T2,T3,T4,T5,,were significantly higher(P<0.05),but the experimental group PjvO2,SjvO2 at the corresponding time points higher than the control group significantly(P<0.05),compared with the T1,two groups of Da-jvO2 and CERO2 in T2,T3,T4,T5,were significantly lower(P<0.05),and the corresponding time point group reduced obviously than the control group(P<0.05);Compared with T1,i1-6 and TNF-in both groups were significantly increased at T2,T3,T4 and T5(P<0.05),but there was no statistical difference at T2(P>0.05).At T3,T4 and T5,the levels of IL-6 in the control group were 40.78±9.13,43.6±5.49 and 51.21±7.4 pg/ml,respectively,and those in the experimental group were 35.52±8.74,40.17±7.11 and 43.73±4.89 pg/ml,respectively.There were statistically significant differences between the two groups at corresponding time points(P<0.05),and the levels of IL-6 and TNF-in the experimental group were lower than those in the control group.Compared with T1,i1-10 in both groups was significantly increased at T2,T3,T4 and T5(P<0.05),but there was no statistical difference at T2(P>0.05).At T3,T4 and T5,the i1-10 of the control group was 39.42±4.16,42.11±4.41 and 43.97±4.21 pg/ml,respectively,and that of the experimental group was 40.96±4.28,45.23±6.15 and 45.41 ±5.23 pg/ml,respectively.Compared with the corresponding time point,there was statistical difference between the two groups(P<0.05),and the increase of IL-10 in the experimental group was significantly higher than that in the control group.The level of S100 protein in the control group at T6 was significantly increased compared with that at T1(P<0.05),while the level of S-100 protein in the experimental group at T6 was not significantly changed compared with that at T1,and the difference was significant compared with that at T6(P<0.05).Delirium occurred in 6 patients in the control group(17.1%)and 3 patients in the experimental group(8.5%)during the postoperative observation period,with significant differences between the two groups(P<0.05).[Conclusion]Distal ischemic preconditioning combined with ulinastatin iv infusion can significantly reduce inflammation,maintain a better balance of cerebral oxygen metabolism,and stabilize S-100 protein levels in elderly patients with OLV by improving lung tissue oxygenation during OLV,thus helping to reduce postoperative delirium in elderly patients with OLV. |
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