心脏手术后认知功能障碍与术后谵妄的关系
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Association between delirium and cognitive change after cardiac surgery
背景与目的:既往研究未明确术后谵妄（POD）是否可作为术后认知功能障碍（POCD）的独立危险因素。本研究对心脏手术病人的POD和术后认知功能改变之间的关系进行分析，并评价术前认知功能评分与POD之间的关系
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方法：采用国际通用谵妄评分法（CAM）的ICU版本和常规版本进行术后谵妄的评估；于择期心脏手术前、术后1个月和术后1年使用神经心理学测试进行认知功能评估。认知改变程度使用可信改变指数（ RCI）进行计算，使用多元线性回归校正混杂因素。
结果：完成了评估的184名病人中，23名（12.5%）病人出现了POD。术后1个月，认知功能下降程度在POD病人中（RCI -1.00，IQR -1.67 ～ 0.28）较未出现POD的病人（RCI -0.04，IQR -0.70 ～0.63，P=0.02）更严重。而在术后1年，两组病人相对于基线水平（术前1d）认知功能均有所改善（POD组：RCI -0.25，IQR-0.42 ～1.31； 无POD组：RCI-0.92，IQR-0.18 ～1.53，P=0.08）。对病人年龄和教育水平进行校正，统计结果无意义。在术前测试（Trailmaking test A）中，发生POD的病人与未发生POD的病人相比得分较低（P=0.03）。
结论：心脏外科手术后，POD是术后1个月内认知功能减退的独立相关因素，但术后1年内认知功能通常会恢复。术后易发生POD的病人术前注意力表现很差。
Sauër AC, Veldhuijzen DS, Ottens TH, et al. Association between delirium and cognitive change after cardiac surgery. Br J Anaesth.Aug 1， 2017 ;119(2):308-315. doi:10.1093/bja/aex053.
Background:Previous studies provide inconsistent data on whether postoperative delirium (POD) is a risk factor for postoperative cognitive decline (POCD). We thus investigated the relationship between POD and cognitive change after cardiac surgery and assessed the relationship between preoperative cognitive domain scores and POD.
Methods: Postoperative deliriumwas assessed with the Confusion Assessment Method (CAM) adapted for the intensive care unit and the conventional CAM accompanied by chart review. Cognitive function was assessed with a neuropsychological test battery before elective cardiac surgery and 1 month and 1 yr afterwards. Cognitive change was calculated using the Reliable Change Index (RCI). Multiple linear regression was used to adjust for confounding.
Results:Of the 184 patients who completed baseline assessment, 23 (12.5%) developed POD. At 1 month, the decline in cognitive performance was worse in patients with POD [median composite RCI _1.00, interquartile range (IQR) _1.67 to 0.28] than in patients without POD (RCI _0.04, IQR _0.70 to 0.63, P=0.02). At 1 yr, both groups showed cognitive improvement on average compared with baseline (POD patients median composite RCI 0.25, IQR _0.42 to 1.31, vs non-POD patients RCI 0.92,IQR 0.18–1.53; P=0.08). Correction for differences in age and level of education did not change the results. Patients with POD performed less well than patients without POD on the preoperative Trailmaking test part A (P=0.03).
Conclusion:Postoperative delirium is independently associated with cognitive decline 1 month after surgery, but cognitive performance generally recovers in 1 yr. Patients with a predisposition to POD can be identified before surgery by worse performance in an attention task.
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