心脏手术中氧浓度与神经认知相关性的随机临床试验
在这项随机对照试验中，与术中高氧相比，在接受心脏手术的老年患者中，术中常氧并不能减少术后认知功能障碍。
心脏手术中氧浓度与神经认知相关性的随机临床试验
贵州医科大学 高鸿教授课题组
翻译：任文鑫 编辑：佟睿 审校：曹莹
尽管有证据表明围手术期高氧血症的有害影响，但高氧血症在心脏手术中仍然很常见。高氧可增加氧化损伤和神经元损伤，导致术后神经认知的潜在差异。因此，这项研究验证的主要假设为：与高氧相比，术中常氧可以减少老年心脏手术患者术后的认知功能障碍。
选择65岁或以上接受在体外循环下行冠状动脉旁路移植术的患者进行了一项随机双盲试验。共有100名患者被随机分别分入两种术中氧输送策略组。常氧组患者(n=50)在体外循环前后吸入至少0.35%的氧气，以维持PaO2在70 mmHg以上，体外循环期间保持PaO2在100-150 mmHg之间。高氧组患者(n=50)在整个手术过程中吸入1.0%的氧气，而不考虑PaO2水平。主要观察指标是在术后第2天使用电话蒙特利尔认知评估测量神经认知功能。次要观察指标包括1、3和6个月时的神经认知功能，以及术后瞻望、死亡率、机械通气时间、重症监护病房住院时间和住院时间。
中位年龄为71岁(四分位数范围为68至75)，中位基线神经认知评分为17分(16至19分)。高氧组术中PaO2中位值为309（285~352）mm Hg，常氧组为153（133~168）mm Hg(P<0.001)。高氧组术后第2天的中位电话蒙特利尔认知评估评分为18（16至20)，常氧组为18(14至20）(P=0.42)。在1、3和6个月的神经认知功能，以及次要观察指标，没有统计学差异。
在这项随机对照试验中，与术中高氧相比，在接受心脏手术的老年患者中，术中常氧并不能减少术后认知功能障碍。尽管术中最佳氧合策略仍不确定，但结果表明，术中高氧不会加重心脏手术后的认知功能。
Shahzad Shaefi,Puja Shankar,Ariel L. Mueller, et al.Intraoperative Oxygen Concentration and Neurocognition after Cardiac Surgery A Randomized Clinical Trial.Anesthesiology 2021; 134:189–201.
Concentration and Neurocognition after Cardiac Surgery A Randomized Clinical Trial
Background: Despite evidence suggesting detrimental effects of perioperative hyperoxia, hyperoxygenation remains commonplace in cardiac surgery. Hyperoxygenation may increase oxidative damage and neuronal injury leading to potential differences in postoperative neurocognition. Therefore, this study tested the primary hypothesis that intraoperative normoxia, as compared to hyperoxia, reduces postoperative cognitive dysfunction in older patients having cardiac surgery.
Methods: A randomized double-blind trial was conducted in patients aged 65 yr or older having coronary artery bypass graft surgery with cardiopulmonary bypass. A total of 100 patients were randomized to one of two intraoperative oxygen delivery strategies. Normoxic patients (n = 50) received a minimum fraction of inspired oxygen of 0.35 to maintain a Pao2 above 70 mmHg before and after cardiopulmonary bypass and between 100 and 150 mmHg during cardiopulmonary bypass. Hyperoxic patients (n = 50) received a fraction of inspired oxygen of 1.0 throughout surgery, irrespective of Pao2 levels. The primary outcome was neurocognitive function measured on postoperative day 2 using the Telephonic Montreal Cognitive Assessment. Secondary outcomes included neurocognitive function at 1, 3, and 6 months, as well as postoperative delirium, mortality, and durations of mechanical ventilation, intensive care unit stay, and hospital stay.
Results: The median age was 71 yr (interquartile range, 68 to 75), and the median baseline neurocognitive score was 17 (16 to 19). The median
intraoperative Pao2 was 309 (285 to 352) mmHg in the hyperoxia group and 153 (133 to 168) mmHg in the normoxia group (P < 0.001). The median Telephonic Montreal Cognitive Assessment score on postoperative day 2 was 18 (16 to 20) in the hyperoxia group and 18 (14 to 20) in the normoxia group (P = 0.42). Neurocognitive function at 1, 3, and 6 months, as well as secondary outcomes, were not statistically different between groups.
Conclusions: In this randomized controlled trial, intraoperative normoxia did not reduce postoperative cognitive dysfunction when compared to intraoperative hyperoxia in older patients having cardiac surgery. Although the optimal intraoperative oxygenation strategy remains uncertain, the results indicate that intraoperative.
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