谭刚;郭向阳;罗爱伦;黄宇光;徐建青;
TAN Gang1,GUO Xiang-yang2,LUO Ai-lun1,HUANG Yu-guang1,XU Jian-qing1 1Department of Anesthesiology,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College,Beijing 100730,China 2Department of Anesthesiology,Third Hospital of Peking University,Beijing 100191,China

• 1:中国医学科学院北京协和医学院北京协和医院麻醉科
• 2:北京大学第三医院麻醉科

摘要(Abstract)：

目的探讨老年非心脏手术患者术后谵妄的发病情况,分析谵妄发病围手术期危险因素。方法采用整群抽样调查方法,计算预计样本量为712例。选择2006年8月至12月北京协和医院65岁以上全麻或区域麻醉下行择期非心脏手术普通病房住院患者,术前1d及术后1、2、3d密切随访患者,谵妄诊断标准参照美国精神病学会制订的意识错乱评估方法(confusion assessment method,CAM)。按设计调查表详细记录术前病史、合并症,术中麻醉方式、麻醉用药,术中、术后并发症,术后镇痛等各项内容,建立数据库。所有数据用SAS8.2软件进行统计分析。结果共718例患者纳入研究,其中80例术后发生谵妄,发病率为11.1%;80例谵妄患者中68例(85%)为一过性谵妄(<24h),另12例(15%)持续性谵妄患者中8例为术后转重症监护病房(intensive care unit,ICU)需呼吸支持治疗的患者。多因素Logistic逐步回归分析结果表明高龄(OR:1.480,95%CI:1.070～2.046)、脑血管意外病史(OR:2.862,95%CI:1.432～5.720)、东莨菪碱(OR:2.537,95%CI:1.523～4.227)、哌替啶(OR:3.196,95%CI:1.574～6.488)、术中低血压(OR:1.780,95%CI:1.070～2.960)、手术时间超过3h(OR:2.610,95%CI:1.538～4.431)、术后转入ICU(OR:2.187,95%CI:1.077～4.442)等为术后谵妄的危险因素。结论高龄、既往脑血管意外病史患者是术后谵妄的易感人群,围手术期尽量避免低血压的发生、减少东莨菪碱及哌替啶的使用,缩短手术时间可能会降低谵妄的发生率。
Objective To investigate the incidence of delirium after noncardiac surgery among elderly patients and explore the possible perioperative risk factors.Methods In this cross-sectional study using cluster sampling,totally 718 patients aged 65 or older who had undergone elective noncardiac surgeries in our hospital from August to December 2006 were enrolled.Patients were interviewed at the day before surgery and an informed consent was obtained.The same interviewer evaluated the patients prospectively for delirium with the Confusion Assessment Method(CAM) on the preoperative day 1,postoperative day 1,day 2,and day 3.Other information including previous medical history,comorbidities,anesthetics,and perioperative medications were also recorded.Results Delirium occurred in 80 patients(11.1%) at during the first three postoperative days,among whom transient symptoms were more frequent than continuous delirium status(68,85% vs.12,15%).The Logistic stepwise regression analysis indicated that the perioperative risk factors of delirium included advanced age(OR:1.480,95%CI:1.070-2.046),history of stroke(OR:2.862,95%CI:1.432-5.720),use of meperidine(OR:3.196,95%CI:1.574-6.488) or scopolamine(OR:2.537,95% CI:1.523-4.227),hypotention during the operation(OR:1.780,95%CI:1.070-2.960),long-duration operations(≥3 h)(OR:2.610,95%CI:1.538-4.431),and ICU admission after surgeries(OR:2.187,95%CI:1.077-4.442).Conclusions Advanced age or previous history of stroke are the most important risk factors of postoperative delirium.The incidence of postoperative delirium may be decreased by avoiding other risk factors such as perioperative hypotension,usage of meperidine and scopolamine,and long-duration operation.

关键词(KeyWords)： 谵妄;麻醉;手术;发病率;危险因素
delirium;anesthesia;surgery;incidence rate;risk factors

Abstract:

Keywords:

基金项目(Foundation): 人事部、教育部归国人员启动基金;; 北京协和医院基金

作者(Authors): 谭刚;郭向阳;罗爱伦;黄宇光;徐建青;
TAN Gang1,GUO Xiang-yang2,LUO Ai-lun1,HUANG Yu-guang1,XU Jian-qing1 1Department of Anesthesiology,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College,Beijing 100730,China 2Department of Anesthesiology,Third Hospital of Peking University,Beijing 100191,China

参考文献(References)：

• [1]Noimark D.Predicting the onset of delirium in the post-operative patient[J].Age Ageing,2009,38:368-373.
• [2]Inouye SK,Bogardus ST,Charpentier PA,et al.A multicomponent intervention to prevent delirium in hospitalized older patients[J].N Engl J Med,1999,340:669-676.
• [3]聂绍发.临床流行病学.高等医药院校教材[M].武汉:湖北科学技术出版社,2003:36-38.
• [4]American Psychiatric Association.Diagnostic and statistical manual of mental disorders IV-TR Edition[M].Washington(DC):American Psychiatric Association,2000.
• [5]Dasgupta M,Dumbrell AC.Preoperative risk assessment for delirium after noncardiac surgery:a systematic review[J].J Am Geriatr Soc,2006,54:1578-1589.
• [6]Tei M,Ikeda M,Haraguchi N,et al.Risk factors for postoperative delirium in elderly patients with colorectal cancer[J].Surg Endosc,2010,24:2135-2139.
• [7]Afonso A,Scurlock C,Reich D,et al.Predictive model for postoperative delirium in cardiac surgical patients[J].Semin Cardiothorac Vasc Anesth,2010,14:212-217.
• [8]Marcantonio ER,Goldman L,Maryione CM,et al.A clinical prediction rule for delirium after elective non-cardiac surgery[J].JAMA,1994,71:l34-139.
• [9]Minden SL,Carbone LA,Barsky A,et al.Predictors and outcomes of delirium[J].General Hospital Psychiatry,2005,27:209-214.
• [10]Inouye SK,van Dyck CH,Alessi CA,et al.Clarifying confusion:the confusion assessment method[J].Ann Intern Med,1990,113:941-948.
• [11]Galanakis P,Bickel H,Gradinger R,et al.Acute confusional state in the elderly following hip surgery:incidence,risk factors and complications[J].Int J Geriatr Psychiatry,2001,16:349-355.
• [12]Leung JM,Sands LP,Mullen EA,et al.Are preoperative depressive symptoms associated with postoperative delirium in geriatric surgical patients?[J].J Gerontol A Biol Sci Med Sci,2005,60:1563-1568.
• [13]Greene NH,Attix DK,Weldon BC,et al.Measures of executive function and depression identify patients at risk for postoperative delirium[J].Anesthesiology,2009,110:788-795.
• [14]Vaurio LE,Sands LP,Wang Y,et al.Postoperative delirium:the importance of pain and pain management[J].Anesth Analg,2006,102:1267-1273.
• [15]Litaker D,Locala J,Franco K,et al.Preoperative risk factors for postoperative delirium[J].Gen Hosp Psychiatry,2001,23:84-89.
• [16]Ancelin ML,De Roquefeuil G,Ritchie K,et al.Anesthesia and postoperative cognitive dysfunction in the elderly:a review of clinical and epidemiological observations[J].Rev Epidemiol Sante Publique,2000,48:459-472.
• [17]Fong HK,Sands LP,Leung JM.The role of postoperative analgesia in delirium and cognitive decline in elderly patients:a system review[J].Anesth Analg,2006,102:1255-1266.
• [18]Marcantonio E,Goldman L,Orav E,et al.The association of intraoperative factors with the development of postoperative delirium[J].Am J Med,1998,105:380-384.
• [19]Rosenberg J,Kehlet H.Postoperative mental confusion:association with postoperative hypoxemia[J].Surgery,1993,114:76-81.
• [20]Slor CJ,de Jonghe JF,Vreeswijk R,et al.Anesthesia and postoperative delirium in older adults undergoing hip surgery [J].J Am Geriatr Soc,2011,59:1313-1319.
• [21]Mason SE,Noel-Storr A,Ritchie CW.The impact of general and regional anesthesia on the incidence of post-operative cognitive dysfunction and post-operative delirium:a systematic review with meta-analysis[J].J Alzheimers Dis,2010,22 Supp l3:67-79.