下肢关节置换术患者术后后谵妄危险因素分析
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Risk factors for postoperative delirium in patients undergoing lower extremity joint arthroplasty: a retrospective population-based cohort study
背景与目的
随着人口老龄化，对全关节置换术的需求以及导致术后谵妄的相应负担可能会增加。鉴于缺乏大规模数据支持，本项研究主要探讨围术期风险因素与关节置换术后谵妄之间的关系。
方 法
这项基于人群的回顾性队列研究利用Premier Healthcare数据库数据，其中包含全美国> 25％住院治疗的详细账单信息。选择了接受择期全髋/膝关节置换手术（2006-2016）的患者。主要研究目标为术后谵妄，而潜在的危险因素包括年龄、性别、种族、保险类型和可改变的暴露因素，包括麻醉类型、阿片类药物处方剂量（低/中/高）、苯二氮䓬类药物、哌替啶、非苯二氮䓬类催眠药、氯胺酮、皮质类固醇和加巴喷丁。
结 果
研究所观察的1 694 795例对象中，术后谵妄发生在2.6％（14 785/564 226）的髋关节置换术患者和2.9％（32 384/1 130 569）的膝关节置换术患者中，总体发生情况呈现下降趋势。多变量模型显示，长效（OR 2.10; CI 1.82-2.42）联合长/短效苯二氮䓬类药物（OR 1.74; CI 1.56-1.94）和加巴喷丁类药物（OR 1.26; CI 1.16-1.36）的使用与术后谵妄概率增加有关。使用非甾体类抗炎药（OR 0.85; CI 0.79-0.91）、环氧合酶-2抑制剂（OR 0.82; CI 0.77-0.89），以及相对于全身麻醉而言，椎管内麻醉（OR 0.81; CI 0.70-0.93）术后谵妄的发生概率较低。年龄分层分析结果显示，65岁以上患者中，阿片类药物剂量较高与阿片类药物剂量较低者相比谵妄发生率较低（OR 0.86; CI 0.76-0.98）。髋关节和膝关节置换术的结果一致。
结 论
在此项涉及大数据量的国家级队列研究中，研究者确认了术后谵妄的各种可改变的危险因素（包括麻醉类型和药物），指出了可能的预防方式与途径。
原始文献摘要
Memtsoudis S, Cozowicz C, Zubizarreta N, et al.Risk factors for postoperative delirium in patients undergoing lower extremity joint arthroplasty: a retrospective population-based cohort study. Reg Anesth Pain Med. 2019 Jul 12. pii: rapm-2019-100700. doi: 10.1136/rapm-2019-100700.
Background With an ageing population, the demand for joint arthroplasties and the burden of postoperative delirium is likely to increase. Given the lack of large-scale data, we investigated associations between perioperative risk factors and postoperative delirium in arthroplasty surgery.
Methods This retrospective population-based cohort study, utilized national claims data from the all-payer Premier Healthcare database containing detailed billing information from >25% nationwide hospitalizations. Patients undergoing elective total hip/knee arthroplasty surgery (2006–2016) were included. The primary outcome was postoperative delirium, while potential risk factors included age, gender, race, insurance type, and modifiable exposures including anesthesia type, opioid prescription dose (low/medium/ high), benzodiazepines, meperidine, non-benzodiazepine hypnotics, ketamine, corticosteroids, and gabapentinoids.
Results Among 1 694 795 patients’ postoperative delirium was seen in 2.6% (14 785/564 226) of hip and 2.9% (32 384/1 130 569) of knee arthroplasties. Multivariable models revealed that the utilization of long acting (OR 2.10 CI 1.82 to 2.42), combined long/ short acting benzodiazepines (OR 1.74 CI 1.56 to 1.94), and gabapentinoids (OR 1.26 CI 1.16 to 1.36) was associated with increased odds of postoperative delirium. Lower odds of postoperative delirium were seen for neuraxial versus general anesthesia (OR 0.81 CI 0.70 to 0.93) and with the utilization of non-steroidal anti-inflammatory drugs (OR 0.85 CI 0.79 to 0.91) as well as cyclooxygenase-2 inhibitors (OR 0.82 CI 0.77 to 0.89). Age-stratified analysis revealed lower odds with high versuslow opioid dose (OR 0.86 CI 0.76 to 0.98) in patients >65 years. Findings were consistent between hip and knee arthroplasties.
Conclusions In this large national cohort, we identified various modifiable risk factors (including anesthesia type and pharmaceutical agents) for postoperative delirium, demonstrating possible prevention pathways.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：李华宇
编辑：何幼芹 审校：王贵龙