围手术期经皮穴位电刺激预防老年全膝关节置换术后认知功能障碍的临床研究

金晓伟; 周森; 周奇韬; 蒋毅

doi:10.16766/j.cnki.issn.1674-4152.003373

围手术期经皮穴位电刺激预防老年全膝关节置换术后认知功能障碍的临床研究

doi: 10.16766/j.cnki.issn.1674-4152.003373

温州市中西医结合医院麻醉手术科，浙江温州 325000

基金项目:

浙江省医药卫生科技计划项目 2023KY1160

详细信息

通讯作者:
金晓伟，E-mail: xiaoweijinwz@163.com

中图分类号: R687.4 R614.2
计量
- 文章访问数: 38
- HTML全文浏览量: 11
- PDF下载量: 2
- 被引次数: 0
出版历程
- 收稿日期: 2023-10-07
- 网络出版日期: 2024-03-27

Study on the effect of percutaneous acupoint electrical stimulation during perioperative period to prevent cognitive impairment after total knee arthroplasty in the elderly

Department of Anesthesia and Surgery, Wenzhou Integrated Traditional Chinese and Western Medicine Hospital, Wenzhou, Zhejiang 325000, China

摘要

摘要: 目的探索围手术期经皮穴位电刺激对老年全膝关节置换术(TKA)患者术后认知功能障碍(POCD)的预防作用。方法纳入2020年1月—2023年6月158例于温州市中西医结合医院择期行单侧TKA的膝关节骨性关节炎老年患者，采用随机数表法将患者分为对照组(79例)和观察组(79例)，对照组行全麻条件下TKA，观察组增加经皮穴位电刺激干预。记录手术及麻醉恢复指标，监测血流动力学变化，分析血清细胞因子及脑神经生化指标，随访术后5 d POCD的发生情况。结果 2组患者术中出血量、术中总输液量、手术持续时间、麻醉苏醒时间和拔除气管导管时间比较差异均无统计学意义(P>0.05)。2组切皮时和自体膝关节摘除后即刻心率、平均动脉压均低于麻醉诱导前30 min(P < 0.001)。观察组术后5 d血清肿瘤坏死因子-α、白细胞介素6和白细胞介素1β均低于对照组(P < 0.001)。观察组术后5 d血清S-100β蛋白和神经元特异性烯醇化酶均低于对照组，而脑源性神经营养因子高于对照组(P < 0.001)。观察组术后5 d POCD发生率(11.39%，9/79)低于对照组(25.32%, 20/79)，差异有统计学意义(P < 0.05)。结论围手术期经皮穴位电刺激可抑制老年TKA患者神经细胞免疫反应，缓解神经细胞损伤，调节神经代谢功能，预防POCD的发生。
- 全膝关节置换术 /
- 经皮穴位电刺激 /
- 老年 /
- 炎症反应 /
- 神经损伤 /
- 术后认知功能障碍
Abstract: Objective The purpose of this study is to explore the preventive effect of perioperative percutaneous acupoint electrical stimulation on postoperative cognitive dysfunction (POCD) in elderly patients undergoing total knee arthroplasty (TKA). Methods A total of 158 elderly patients with knee joint osteoarthritis who underwent elective unilateral TKA at Wenzhou Integrated Traditional Chinese and Western Medicine Hospital from January 2020 to June 2023 were randomly assigned to a control group (79 cases) and an observation group (79 cases) by random number table method. The control group received TKA under general anesthesia, and the observation group received additional perioperative percutaneous acupoint electrical stimulation intervention. The surgical and anesthesia recovery indicators were recorded, perioperative hemodynamic changes were monitored, serum cytokines and brain neurobiochemical indicators were analyzed, and POCD occurrence was followed up 5 days after surgery. Results There was no statistically significant difference in intraoperative bleeding volume, total intraoperative infusion volume, surgical duration, anesthesia recovery time, and tracheal intubation time between the two groups (P>0.05). The HR and MAP values of the two groups during skin resection and immediately after autologous knee joint removal were lower than those of 30 minutes before anesthesia induction (P < 0.001). The content of serum TNF-α, IL-6 and IL-1β in the observation group were lower than those in the control group 5 days after surgery (P < 0.001). The content of serum S-100β and NSE in the observation group were lower than those in the control group 5 days after surgery, while BDNF content was higher than that in the control group (P < 0.001). The incidence of POCD 5 days after surgery in the observation group (11.39%, 9/79) was lower than that in the control group (25.32%, 20/79), and the difference was statistically significant (P < 0.05). Conclusion Perioperative percutaneous acupoint electrical stimulation can inhibit neuroinflammatory response, alleviate brain tissue damage, regulate brain nerve metabolism function, and can prevent the occurrence of POCD.
- Total knee arthroplasty /
- Transcutaneous acupoint electrical stimulation /
- Old age /
- Inflammatory response /
- Nerve injury /
- Postoperative cognitive dysfunction

HTML全文

表 1 2组膝关节骨性关节炎患者一般资料比较

Table 1. Comparison of general data between the two groups of patients with knee osteoarthritis

组别	例数	年龄 (x±s，岁)	性别(例)		ASA分级(例)		体重指数 (x±s)	术中出血量 (x±s，mL)	术中总输液量 (x±s，mL)	手术持续时间 (x±s，min)
组别	例数	年龄 (x±s，岁)	男性	女性	Ⅰ级	Ⅱ级	体重指数 (x±s)	术中出血量 (x±s，mL)	术中总输液量 (x±s，mL)	手术持续时间 (x±s，min)
对照组	79	73.09±4.86	38	41	36	43	22.41±1.59	169.82±12.91	1 782.64±253.71	121.39±10.57
观察组	79	73.27±5.03	36	43	37	42	22.26±1.46	172.45±13.36	1 749.57±249.03	119.68±10.14
统计量		0.229^a	0.102^b		0.025^b		0.618^a	1.258^a	0.827^a	1.038^a
P值		0.819	0.750		0.873		0.539	0.210	0.409	0.301
注：^a为t值，^b为χ²值。

下载: 导出CSV

表 2 2组膝关节骨性关节炎患者围手术期血流动力学指标比较(x±s)

Table 2. Comparison of perioperative hemodynamic parameters between the two groups of knee osteoarthritis patients (x±s)

组别	例数	HR(次/min)
组别	例数	T1	T2	T3	T4	T5
对照组	79	82.68±5.91	71.23±5.83^a	77.64±5.46^a	80.73±5.72	83.16±5.68
观察组	79	83.14±5.76	70.89±5.69^a	78.35±5.72^a	81.09±5.58	82.65±5.79
F值		0.482	0.563	0.608	0.451	0.536
P值		0.574	0.491	0.443	0.618	0.519

组别	例数	MAP(mmHg)
组别	例数	T1	T2	T3	T4	T5
对照组	79	97.42±7.29	82.47±7.95^a	90.27±8.26^a	95.23±7.41	96.51±7.63
观察组	79	97.18±7.05	81.92±8.14^a	91.06±8.31^a	94.66±7.69	96.84±7.42
F值		0.362	0.419	0.627	0.491	0.381
P值		0.692	0.635	0.424	0.563	0.674

组别	例数	SPO₂(%)
组别	例数	T1	T2	T3	T4	T5
对照组	79	97.28±1.11	96.79±0.96	97.32±1.06	97.11±0.99	97.36±1.03
观察组	79	96.94±1.03	97.12±1.02	96.89±1.02	96.97±1.05	96.92±0.98
F值		0.591	0.537	0.639	0.452	0.503
P值		0.464	0.518	0.415	0.603	0.541
注：与T1时刻比较，^aP < 0.05。

下载: 导出CSV

表 3 2组膝关节骨性关节炎患者麻醉恢复指标比较(x±s，min)

Table 3. Comparison of anesthesia recovery indexes between the two groups of patients with knee osteoarthritis (x±s, min)

组别	例数	麻醉苏醒时间	拔除气管导管时间
对照组	79	10.95±1.47	15.42±1.56
观察组	79	10.68±1.39	15.76±1.61
t值		1.186	1.348
P值		0.237	0.179

下载: 导出CSV

表 4 2组膝关节骨性关节炎患者血清炎症因子水平比较(x±s，ng/L)

Table 4. Comparison of serum inflammatory factors between the two groups of patients with knee osteoarthritis (x±s, ng/L)

组别	例数	TNF-α		IL-6		IL-1β
组别	例数	麻醉诱导前30 min	术后5 d	麻醉诱导前30 min	术后5 d	麻醉诱导前30 min	术后5 d
对照组	79	24.96±5.37	35.84±6.17^a	16.85±2.43	27.91±3.26^a	20.65±2.97	29.42±3.74^a
观察组	79	25.34±5.48	27.62±5.59	17.24±2.61	18.37±2.74	19.94±2.81	21.28±3.15
t值		0.457	7.629	0.972	19.911	1.544	14.797
P值		0.598	< 0.001	0.332	< 0.001	0.125	< 0.001
注：与同组麻醉诱导前比较，^aP < 0.05。

下载: 导出CSV

表 5 2组膝关节骨性关节炎患者血清脑神经生化指标比较(x±s，μg/L)

Table 5. Comparison of serum cranial nerve biochemical indexes between the two groups of patients with knee osteoarthritis (x±s, μg/L)

组别	例数	S-100β		NSE		BDNF
组别	例数	麻醉诱导前30 min	术后5 d	麻醉诱导前30 min	术后5 d	麻醉诱导前30 min	术后5 d
对照组	79	0.29±0.07	0.48±0.11^a	3.71±0.61	5.36±0.82^a	7.49±1.27	6.15±1.24^a
观察组	79	0.31±0.08	0.35±0.09	3.65±0.59	3.87±0.63	7.56±1.32	7.34±1.29
t值		1.672	8.614	0.628	12.527	0.347	5.963
P值		0.097	< 0.001	0.531	< 0.001	0.708	< 0.001
注：与同组麻醉诱导前比较，^aP < 0.05。

下载: 导出CSV

参考文献(20)

[1]	韦晨浦, 郁丽娜, 李金峰, 等. 经皮穴位电刺激"鬼穴"对老年全膝关节置换术患者术后认知恢复延迟的影响[J]. 中国老年学杂志, 2022, 42(10): 2400-2403. https://www.cnki.com.cn/Article/CJFDTOTAL-ZLXZ202210026.htm WEI C P, YU L N, LI J F, et al. The effect of percutaneous acupoint electrical stimulation on delayed cognitive recovery in elderly patients undergoing total knee arthroplasty[J]. Chinese Journal of Gerontology, 2022, 42(10): 2400-2403. https://www.cnki.com.cn/Article/CJFDTOTAL-ZLXZ202210026.htm
[2]	梁艳彩, 崔健, 杨旭, 等. 北京地区全膝关节置换术患者术前预康复实施现状及影响因素分析: 多中心横断面调查研究[J]. 中华骨与关节外科杂志, 2021, 14(11): 954-957. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGJW202111010.htm LIANG Y C, CUI J, YANG X, et al. Implementation and influencing factors of preoperative rehabilitation in patientsundergoing total knee arthroplasty in Beijing: A multi-center cross-sectional study[J]. Chinese Journal of Bone and Joint Surgery, 2021, 14(11): 954-957. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGJW202111010.htm
[3]	聂杰, 周书转, 曹煜, 等. B超引导下股神经阻滞对老年人全膝关节置换术患者认知功能及术后早期康复的影响[J]. 广州医科大学学报, 2021, 49(1): 58-61. https://www.cnki.com.cn/Article/CJFDTOTAL-GZXI202101016.htm NIE J, ZHOU S Z, CAO Y, et al. Effects of femoral nerve block guided by B-ultrasound on cognitive function and early postoperative rehabilitation in elderly patients with total knee arthroplasty[J]. Academic Journal of Guangzhou Medical University, 2021, 49(1): 58-61. https://www.cnki.com.cn/Article/CJFDTOTAL-GZXI202101016.htm
[4]	汪世高, 王菊, 肖志强, 等. 经皮穴位电刺激对老年髋部骨折术后认知功能的影响[J]. 中国社区医师, 2022, 38(8): 58-60. https://www.cnki.com.cn/Article/CJFDTOTAL-XCYS202208020.htm WANG S G, WANG J, XIAO Z Q, et al. The effect of percutaneous acupoint electrical stimulation on postoperative cognitive function in elderly patients with hip fractures[J]. Chinese Community Doctors, 2022, 38(8): 58-60. https://www.cnki.com.cn/Article/CJFDTOTAL-XCYS202208020.htm
[5]	袁娟, 李明, 张珏. 经皮穴位电刺激联合全身麻醉在微创肺癌手术术中镇静及术后镇痛分析[J]. 中华肺部疾病杂志(电子版), 2021, 14(5): 644-646. https://www.cnki.com.cn/Article/CJFDTOTAL-ZFBD202105027.htm YUAN J, LI M, ZHANG J. Analysis of sedation and postoperative analgesia in minimally invasive lung cancer surgery by percutaneous acupoint electrical stimulation combined with general anesthesia[J]. Chinese Journal of Lung Diseases (Electronic Edition), 2021, 14(5): 644-646. https://www.cnki.com.cn/Article/CJFDTOTAL-ZFBD202105027.htm
[6]	卢乐苗, 田昕. 经皮穴位电刺激在改善重症脑血管病患者营养和胃动力及预后中的应用[J]. 中华全科医学, 2022, 20(4): 669-672. doi: 10.16766/j.cnki.issn.1674-4152.002426 LU L M, TIAN X. Application of transcutaneous electrical acupoint stimulation in improving nutrition, gastric motility and prognosis of patients with severe cerebrovascular disease[J]. Chinese Journal of General Practice, 2022, 20(4): 669-672. doi: 10.16766/j.cnki.issn.1674-4152.002426
[7]	赵力, 杜秋. 星状神经节阻滞改善老年髋关节置换术患者后早期认知功能障碍的观察[J]. 宁夏医科大学学报, 2021, 43(9): 914-917. https://www.cnki.com.cn/Article/CJFDTOTAL-XNXY202109007.htm ZHAO L, DU Q. The improvement effect of stellate ganglion block on the early postoperative cognitive dysfunction after hip replacement in elderly patients[J]. Journal of Ningxia Medical University, 2021, 43(9): 914-917. https://www.cnki.com.cn/Article/CJFDTOTAL-XNXY202109007.htm
[8]	周森, 金晓伟, 张归帆, 等. 老年椎体压缩性骨折术后认知功能障碍的危险因素分析[J]. 中华全科医学, 2023, 21(8): 1326-1328, 1342. doi: 10.16766/j.cnki.issn.1674-4152.003114 ZHOU S, JIN X W, ZHANG G F, et al. Analysis of risk factors of cognitive dysfunction after senile vertebral compression fracture surgery[J]. Chinese Journal of General Practice, 2023, 21(8): 1326-1328, 1342. doi: 10.16766/j.cnki.issn.1674-4152.003114
[9]	CZYŻ-SZYPENBEJL K, MEDRZYCKA-DABROWSKA W, KWIECIE Ń-JAGUŚ K, et al. The occurrence of postoperative cognitive dysfunction (POCD): systematic review[J]. Psychiatr Pol, 2019, 53(1): 145-160. doi: 10.12740/PP/90648
[10]	YANG X, HUANG X W, LI M, et al. Identification of individuals at risk for postoperative cognitive dysfunction (POCD)[J]. Ther Adv Neurol Disord, 2022, 15: 17562864221114356. DOI: 10.1177/17562864221114356.
[11]	薛丁豪, 王龙, 刘露玉, 等. 老年全膝关节置换术后患者认知功能障碍的关联因素分析及预测模型构建[J]. 解放军医学院学报, 2023, 44(6): 618-623. https://www.cnki.com.cn/Article/CJFDTOTAL-JYJX202306008.htm XUE D H, WANG L, LIU L Y, et al. Associated factors and predictive model of postoperative cognitive dysfunction in elderly patients undergoing total knee arthroplasty[J]. Academic Journal of Chinese PLA Medical School, 2023, 44(6): 618-623. https://www.cnki.com.cn/Article/CJFDTOTAL-JYJX202306008.htm
[12]	ZARBO C, BRIVIO M, BRUGNERA A, et al. Post-operative cognitive decline (POCD) after gynaecologic surgery: current opinions and future applications[J]. Arch Gynecol Obstet, 2018, 297(3): 551-554. doi: 10.1007/s00404-017-4630-3
[13]	李秀丽, 朱志华, 杨哲, 等. 术后认知功能障碍的炎症病因学研究进展[J]. 中国实验诊断学, 2019, 23(10): 1841-1844. https://www.cnki.com.cn/Article/CJFDTOTAL-ZSZD201910058.htm LI X L, ZHU Z H, YANG Z, et al. Progress in inflammatory etiology of postoperative cognitive impairment[J]. Chinese Journal of Laboratory Diagnosis, 2019, 23(10): 1841-1844. https://www.cnki.com.cn/Article/CJFDTOTAL-ZSZD201910058.htm
[14]	皇甫丽. rTMS联合运动疗法对抑郁症患者认知功能、IL-1β、IL-6、TNF-α水平的影响研究[J]. 中国实用医药, 2023, 18(6): 171-173. https://www.cnki.com.cn/Article/CJFDTOTAL-ZSSA202306051.htm HUANGFU L. Study on effect of rTMS combined with exercise therapy on cognitive function, IL-1β, IL-6 and TNF-α in patients with depression[J]. China Practical Medicine, 2023, 18(6): 171-173. https://www.cnki.com.cn/Article/CJFDTOTAL-ZSSA202306051.htm
[15]	霍彦, 姚丽珍, 王刚. 血清脑源性神经营养因子、B细胞活化因子、胶质酸性纤维蛋白与癫痫患者病情及认知功能的相关性分析[J]. 实用医院临床杂志, 2022, 19(6): 154-157. https://www.cnki.com.cn/Article/CJFDTOTAL-YYLC202206044.htm ZHAI Y, YAO L Z, WANG G. Correlation of serum BDNF, BAFF and GFAP with the condition and cognitive function of epilepsy patients[J]. Practical Journal of Clinical Medicine, 2022, 19(6): 154-157. https://www.cnki.com.cn/Article/CJFDTOTAL-YYLC202206044.htm
[16]	李卫青. 丁苯酞对脑梗死再灌注患者血清S-100β蛋白、NSE及神经功能缺损的影响[J]. 中国医学创新, 2022, 19(5): 61-64. https://www.cnki.com.cn/Article/CJFDTOTAL-ZYCX202205016.htm LI W Q. Effect of butylphthalide on serum S-100β protein, NSE and neurological deficit in patients with cerebral infarction and reperfusion[J]. Medical Innovation of China, 2022, 19(5): 61-64. https://www.cnki.com.cn/Article/CJFDTOTAL-ZYCX202205016.htm
[17]	施丹君, 柯玲珍, 李卫玲. 低频脉冲电刺激配合强化认知锻炼对后循环脑卒中患者认知功能障碍的影响[J]. 中国现代医生, 2022, 60(11): 25-28. https://www.cnki.com.cn/Article/CJFDTOTAL-ZDYS202211007.htm SHI D J, KE L Z, LI W L, et al. The effect of low-frequency pulsed electrical stimulation combined with intensive cognitive exercise on cognitive dysfunction in patients with pos-terior circulation stroke[J]. China Modern Doctor, 2022, 60(11): 25-28. https://www.cnki.com.cn/Article/CJFDTOTAL-ZDYS202211007.htm
[18]	王璐, 高晓平, 宋娟, 等. 脑电仿生电刺激对脑梗死后认知功能障碍的影响[J]. 中国实用神经疾病杂志, 2020, 23(1): 6-10. https://www.cnki.com.cn/Article/CJFDTOTAL-HNSJ202001002.htm WANG L GAO X P, SONG J, et al. The effects of electroencephalograph bionic electrical stimulation on cognitive ability in patients with cognitive impairment after ischemic stroke[J]. Chinese Journal of Practical Nervous Diseases, 2020, 23(1): 6-10. https://www.cnki.com.cn/Article/CJFDTOTAL-HNSJ202001002.htm
[19]	贺春侠, 刘永瑞, 王卫丽, 等. 正中神经电刺激对脑梗死后认知功能障碍患者的疗效[J]. 国际精神病学杂志, 2023, 50(2): 287-289. https://www.cnki.com.cn/Article/CJFDTOTAL-GWYJ202302018.htm HE C X, LIU Y R, WANG W L, et al. The efficacy of median nerve electrical stimulation in cognitive dysfunction patients after cerebral infarction[J]. Journal of International Psychiatry, 2023, 50(2): 287-289. https://www.cnki.com.cn/Article/CJFDTOTAL-GWYJ202302018.htm
[20]	秦晓宇, 逯晓婷, 段蓉蓉, 等. 电针复合全身麻醉对胃肠道肿瘤切除术后认知功能障碍影响的Meta分析[J]. 湖南中医杂志, 2022, 38(10): 122-128. https://www.cnki.com.cn/Article/CJFDTOTAL-HNZO202210034.htm QIN X Y, LU X T, DUAN R R, et al. Meta analysis of the effect of electroacupuncture combined with general anesthesia on cognitive impairment after gastrointestinal tumor resection[J]. Hunan Journal of Traditional Chinese Medicine, 2022, 38(10): 122-128. https://www.cnki.com.cn/Article/CJFDTOTAL-HNZO202210034.htm