与髋部骨折复位术后谵妄相关的可控因素：年龄分层的回顾性队列研究
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与髋部骨折复位术后谵妄相关的可控因素：年龄分层的回顾性队列研究
翻译：牛振瑛 编辑：冯玉蓉 审校：曹莹
背景：谵妄是髋部骨折患者术后常见的并发症，发病率较高并会造成大量的医疗资源消耗。
目的：收集来自美国的数据，检验美国老年医学会关于老年人术后谵妄的最佳实践指南中提到的围术期因素(可控的)与术后谵妄之间的关系。按“低龄老年患者”(<80岁)和“高龄老年患者”(≥80岁)进行分层。
设计：2006年至2016年的回顾性队列研究。
设置：美国人口数据
研究对象：Premier Healthcare数据库中记录的2006年至2016年期间接受髋部骨折复位术的505 152名患者。
主要结果指标和方法：主要结果是术后谵妄发生率；可控因素包括围术期阿片类药物的使用量(高、中、低剂量口服吗啡当量的<25、25至75或>75百分位数)，麻醉类型(全麻、神经阻滞、二者联合)、苯二氮卓类(长效、短效、双效型)、哌替啶、非苯二氮类镇静药、氯胺酮、皮质类固醇和加巴喷丁的使用。用多水平模型评估这些因素与术后谵妄之间的关系，在全队列中，在年龄<80岁和≥80岁的人群中分别进行评估。报告了优势比(OR)和Bonferroni调整后的95%置信区间(95%CI)。
结果：总体而言，术后谵妄发生率为15.7%(n=79547)。在调整相关变量后，使用长效(OR 1.82，CI 1.74至1.89)以及联合使用短效和长效苯二氮卓类药物(OR 1.56，CI 1.48至1.63)和氯胺酮(OR 1.09，CI 1.03至1.15)与术后谵妄的发生率增加相关，而神经阻滞麻醉（OR 0.91CI 0.85-0.98）和阿片类药物（OR 0.95，CI 0.92-0.98和OR 0.88，CI 0.84-0.92中、高剂量组与低剂量组相比）的谵妄发生率较低，P值均<0.05；当按年龄组分别分析数据时，苯二氮卓类药物的影响仍然存在，而阿片类药物的使用只与80岁以下患者谵妄的发生有关。
结论：在接受髋部骨折复位手术的患者中，我们明确了与术后谵妄发生率相关的可控因素。
原始文献来源：Poeran J, Cozowicz C, Zubizarreta N,et al. Modifiable factors associated with postoperative delirium after hip fracture repair：An age-stratified retrospective cohort study[J].Eur J Anaesthesiol 2020 Aug;378(8) DOI：10.1097/EJA.0000000000001197
Modifiable factors associated with postoperative delirium after hip fracture repair：An age-stratified retrospective cohort study
BACKGROUND Postoperative delirium in hip fracture patients is common and is associated with substantial morbidity and consumption of resources.
OBJECTIVE Using data from the USA, we aimed to examine the relationship between postoperative delirium and (modifiable) peri-operative factors mentioned in the American Geriatrics Society Best Practice Statement on Postoperative Delirium in Older Adults, stratified by 'young old’ (<80 years) and 'old-old’ (?80 years) categories.
DESIGN Retrospective cohort study from 2006 to 2016.
SETTING Population-based claims data from the USA.
PARTICIPANTS Patients undergoing 505 152 hip fracture repairs between 2006 and 2016 as recorded in the Premier Healthcare Database.
MAIN OUTCOMES AND MEASURES The main outcome was postoperative delirium; modifiable factors of interest were peri-operative opioid use (high, medium or low;<25th, 25 to 75th or >75th percentile of oral morphine equiva-lents),anaesthesia type (general, neuraxial, both), use of benzodiazepines (long acting, short acting, both), pethidine, nonbenzodiazepine hypnotics, ketamine, corticosteroids and gabapentinoids. Multilevel models assessed associations between these factors and postoperative delirium, in the full cohort, and separately in those aged less than 80 and at least 80 years. Odds ratios (ORs) and Bonferroni-adjusted 95% confidence intervals (95% CIs) are reported.
RESULTS Overall, postoperative delirium incidence was 15.7% (n¼79 547). After adjustment for relevant covariates,the use of long-acting (OR 1.82, CI 1.74 to 1.89) and combined short and long-acting benzodiazepines (OR1.56, CI 1.48 to 1.63) and ketamine (OR 1.09, CI 1.03 to1.15), in particular, was associated with increased odds for postoperative delirium, while neuraxial anaesthesia (OR 0.91CI 0.85 to 0.98) and opioid use (OR 0.95, CI 0.92 to 0.98 and OR 0.88, CI 0.84 to 0.92 for medium and high dose compared with low dose) were associated with lower odds;all P<0.05. When analysing data separately by age group, effects of benzodiazepines persisted, while opioid use was only relevant in those aged less than 80 years.
CONCLUSION We identified modifiable factors associated with postoperative delirium incidence among patients under-going hip fracture repair surgery.
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