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目的 探讨帕瑞昔布钠复合右美托咪定对老年病人术后颈内静脉球部血浆兴奋性氨基酸和β淀粉样蛋白水平的影响.方法 择期行股骨骨折切开复位内固定术和髋关节置换术的病人135例,年龄65~79岁,体重47~76 kg,性别不限,ASA分级Ⅱ或Ⅲ级,采用随机数字表法分为3组(n=45):帕瑞昔布钠组(P组)、右美托咪定组(D组)和帕瑞昔布钠复合右美托咪定组(PD组).麻醉诱导前15 min时,P组静脉注射帕瑞昔布钠40 mg(用生理盐水稀释至5 ml);D组经15 min静脉输注右美托咪定负荷剂量0.5 μg∕kg,随后以0.5 μg · kg -1· h -1的速率静脉输注至术毕;PD组静脉注射帕瑞昔布钠40 mg(用生理盐水稀释至5 ml),同时经15 min静脉输注右美托咪定负荷剂量05 μg∕kg,随后以0.5 μg · kg -1· h -1的速率静脉输注至术毕.分别于麻醉诱导前15 min(T0)、术毕即刻(T1)、术后24 h(T2)、48 h(T3)和72 h(T4)时取颈内静脉球部血样,采用反相高效液相色谱荧光法检测血浆谷氨酸和天冬氨酸的浓度,采用ELISA法测定β淀粉样蛋白浓度.于术前1 d和术后7 d时行韦氏记忆量表、数字广度、视觉认知和联想学习、韦氏成人智力量表、循迹连线测试A等测验,记录术后7 d时术后认知功能障碍的发生情况.结果 与P组和D组比较,PD组T2,3时血浆谷氨酸浓度、T2时血浆天冬氨酸浓度、T1时血浆β淀粉样蛋白浓度和术后认知功能障碍发生率降低(P<005).结论 帕瑞昔布钠复合右美托咪定降低老年患者术后认知功能障碍发生的机制可能与抑制脑组织兴奋性氨基酸和β淀粉样蛋白的水平有关.

Objective To investigate the effect of parecoxib sodium combined with dexmedetomi-dine on postoperative levels of plasma excitatory aminoacid and beta-amyloid protein(β-AP)in jugular bulb venous of elderly patients. Methods A total of 135 patients of either sex, aged 65-79 yr, weighing 47-76 kg, of American Society of Anesthesiologists physical status Ⅱ or Ⅲ, undergoing elective open reduc-tion and internal fixation after tibial fracture and hip replacement, were divided into 3 groups(n=45 each) using a random number table: parecoxib sodium group(group P), dexmedetomidine group(group D)and parecoxib sodium combined with dexmedetomidine group(group PD). In group P, parecoxib sodium 40 mg (diluted to 5 ml in normal saline)was injected intravenously at 15 min before induction of anesthesia. In group D, dexmedetomidine was intravenously infused at a loading dose of 05 μg∕kg over 15 min starting from 15 min before induction of anesthesia, followed by an infusion of 05 μg·kg-1·h-1until the end of surgery. In group PD, parecoxib sodium 40 mg(diluted to 5 ml in normal saline)was intravenously injec-ted at 15 min before induction of anesthesia, and dexmedetomidine was intravenously infused at a loading dose of 05 μg∕kg over 15 min followed by an infusion of 05 μg·kg-1·h-1until the end of surgery at the same time. At 15 min before induction of anesthesia(T0), at the end of surgery(T1)and at 24, 48 and 72 h after surgery(T2-4), jugular bulb venous blood samples were taken for determination of concentrations of glutamate and aspartate in plasma(by reversed phase high-performance liquid chromatography)and β-AP(by enzyme-linked immunosorbent assay). Cognitive function was assessed at 1 day before surgery and 7 days after surgery using a battery of neuropsychologic tests including Wechsler Memory Scale, Digit Span (Forward and Backward), visual recognition and associative learning, Wechsler Adult Intelligence Scale and Trail Making Test Part A. The occurrence of postoperative cognitive dysfunction was recorded at 7 days after surgery. Results Compared with P and D groups, the concentrations of plasma glutamate at T2-3, plasma aspartate at T2and β-AP at T1and incidence of postoperative cognitive dysfunction were significantly decreased in group PD(P< 005). Conclusion The mechanism by which parecoxib sodium combined with dexmedetomidine decreases the occurrence of POCD may be related to inhibiting the levels of excitatory aminoacid and β-AP in brain tissues of elderly patients.