| Objective:Postoperative cognitive dysfunction(POCD)is a common complication of the central nervous system in patients after surgery,resulting in significant decreases in memory,language and social activity.Once POCD occurs,it is difficult to be cured completely,and it can progress from early stage to long-term or even permanent,seriously affecting the quality of life of patients.Therefore,early identification and timely prevention and treatment is particularly important.Clarifying the specific biochemical indicators and related risk factors of early POCD can quickly predict the occurrence of POCD at early stage,stratify patients according to the risk,and take timely measures to intervene the occurrence and development of the disease,so as to better prevent and cure POCD and improve the prognosis.Total arch replacement combined with stented elephant trunk implantation surgery is complicated and traumatic,accompanied by ischemia-reperfusion during cardiopulmonary bypass(CPB)and deep hypothermic circulatory arrest(DHCA),which can easily lead to related brain injury and neurological dysfunction.POCD is one of the most common complications after total arch replacement combined with stented elephant trunk implantation surgery.This study intends to explore the predictive value of plasma S100β protein,neuron-specific enolase(NSE),and neuroglobin(NGB)concentrations for early POCD in patients undergoing total arch replacement combined with stented elephant trunk implantation,and analyze related risk factors for early POCD,establish a risk prediction model and provide clinical guidance evidence.Methods:40 patients with elective total arch replacement combined with stented elephant trunk implantation were selected,aged 32-69,weight 48-107 kg,the New York heart association(NYHA)cardiac function grade Ⅱ-Ⅳ,the American society of anesthesiologists(ASA)anesthesia grade Ⅱ-Ⅳ.The cognitive function of the patients was evaluated by the mini-metal state examination(MMSE)before surgery,on the day after extubation and the 7th day after surgery respectively.The incidence of POCD was determined by 1 standard deviation method,and all patients were divided into POCD(POCD)group and non-POCD(NPOCD)group.3ml central venous blood was collected at 5 time points respectively before operation(T0),rewarming(nasopharyngeal temperature)to 36℃(T1),1h(T2),6h(T3)and 24h(T4)after CPB,enzyme-linked immuno sorbent assay(ELISA)was used to determine the plasma levels of S100β protein,NSE and NGB at different time points after centrifugal.The dynamic change rule of the concentration levels of the three biochemical indicators with time points and the difference between the POCD and NPOCD group was analyzed,the value of plasma S100β protein,NSE and NGB in predicting POCD after total arch replacement combined with stented elephant trunk implantation was evaluated.Basic information of patients undergoing total arch replacement combined with stented elephant trunk implantation were collected,including age,sex,education level,body mass index(BMI),smoking and drinking,basic diseases,history of surgery and anesthesia,cardiac function,anesthesia evaluation and medication.Perioperative variables were recorded,including anesthesia medication,core temperature and central venous pressure in DHCA,anterograde cerebral perfusion flow,occurrence of hypotension,perioperative blood intake and output,duration of each intraoperative and perioperative stage.The risk factors of early POCD after total arch replacement combined with stented elephant trunk implantation were screened,the risk prediction model was established and its prediction validity was evaluated.Results:1.There were 15 patients in POCD group and 25 patients in NPOCD group.The incidence of early POCD was 37.5%,17.5%on the day after extubation,and 20.0%on the 7th day after surgery.There was no difference between the two time points(P>0.05).There was no statistically significant difference between the two groups in MMSE scores before surgery and the day after extubation(P>0.05),and POCD group was lower than NPOCD group on the 7th day after surgery(P<0.05).2.Compared with T0,plasma concentrations of three indicators in POCD group all increased at T1-T3,while only NSE increased at T4(P<0.05).The concentrations of the three indicators in the NPOCD group all increased at T1,NSE and NGB increased at T2,and NSE increased at T3-T4(P<0.05).NSE and NGB peaked at T1 and S100β protein peaked at T2.Compared with NPOCD group,S100β at T1-T3 and NSE at T1-T4 increased significantly in POCD group(P<0.05),while NGB showed no significant differences at all time points(P>0.05).3.The peak value of S100(3 was significantly negatively correlated with MMSE score on the day after extubation(r=-0.44,P<0.01),but not with the score on the 7th day after surgery(P>0.05).The peak value of NSE was significantly negatively correlated with MMSE score on the 7th day after surgery(r=-0.51,P<0.01),but not with the score on the day after extubation(P>0.05).There was no significant correlation between the peak value of NGB and MMSE score on the day after extubation or the 7th day after surgery(P>0.05).4.The area under ROC curve(AUC)of early POCD predicted by the peak value of S100β protein was 0.71(95%CI 0.55-0.87,P<0.05),the sensitivity was 48%and the specificity was 87%.The AUC of the peak value of NSE was 0.77(95%CI 0.60-0.94,P<0.05),the sensitivity was 92%and the specificity was 67%,both S100β and NSE had certain predictive value and medium accuracy(AUC>0.7).The AUC of S100β combined with NSE was 0.81(95%CI 0.66-0.96,P<0.05),the sensitivity was 73%and the specificity was 80%,which had better predictive value(AUC>0.8).The AUC of NGB was 0.62(95%CI 0.43-0.80,P>0.05),which had no significant predictive value.5.Univariate analysis results showed that there were statistically significant differences between the two groups in gender,anal temperature of DHCA,occurrence of intraoperative hypotension,duration of surgery and mechanical ventilation(P<0.05).Multivariate Logistic regression analysis showed that the occurrence of intraoperative hypotension(OR=17.975,95%CI:1.292-250.081,P<0.05)and duration of mechanical ventilation(OR=1.032,95%CI:1.000-1.065,P<0.05)were independent risk factors for early POCD,and the anal temperature of DHCA was a protective factor(OR=0.422,95%CI:0.188-0.948,P<0.05).6.Logistic regression equation was:Logit(P)=18.412-0.862XDHCA anal temperature+2.889X intraoperative hypotension+0.032X mechanical ventilation duration.The AUC of this risk prediction model was 0.856(95%CI:0.738-0.973,P<0.01),the sensitivity was 80.0%and the specificity was 79.2%.The model had a good goodness of fit tested by Hosmer-Lemeshow and can predict early POCD,with medium accuracy(AUC>0.8).Conclusions:1.The plasma concentrations of S100β protein and NSE in total arch replacement combined with stented elephant trunk implantation can predict the occurrence of early POCD,and the combined prediction of S100β protein and NSE is more valuable,while NGB cannot predict early POCD.2.Occurrence of intraoperative hypotension and duration of mechanical ventilation were independent risk factors and anal temperature of DHCA was protective factor for early POCD in total arch replacement combined with stented elephant trunk implantation.The risk prediction model established in this study has a good predictive value for early POCD. |
PDF Full Text Request