老龄髋关节置换术不同手术时机术后谵妄发生率的研究

目的研究老龄患者髋关节置换术，手术时机不同对其术后谵妄发生率的影响。 方法选择2013年2月至2017年2月在佛山市顺德区第二人民医院骨科，拟行髋关节置换手术的65岁以上患者83例，按手术方式分全髋关节置换(THR，39例)和股骨头置换(FHR，44例)；采用随机数字表法患者按手术时机分为48 h后手术(C组)及48 h内手术(T组)，最后分为THR-C组(25例)、THR-T组(14例)、FHR-C组(21例)、FHR-T组(23例)共4个研究组。均采用椎管内麻醉方式完成麻醉和手术。记录术前(T_p)、术中(T₀)、术后1～3 d(T₁～T₃)生命体征指标，包括心率(HR)、平均动脉压(MAP)、指脉搏氧饱和度(SpO₂)，记录患者各时点疼痛视觉模拟评分(VAS)；应用谵妄评估量表中文修订版(CAM-CR)对患者在各时点谵妄情况进行评估，记录各时点谵妄发生例数。对计数资料和正态分布的计量资料采用卡方检验，非正态分布的数据采用秩和检验。 结果术前各组患者均处于中重度疼痛(VAS为6～8)，血压偏高(MAP 110～99 mmHg)(VAS：H＝201.22；MAP：F＝576.348，P<0.05)。术后3 d谵妄发生率：48 h内手术治疗者发生率低于48 h后手术者(THR-C vs THR-T：χ²＝4.92；FHR-C vs. FHR-T：χ²＝7.58，均为P<0.05)，FHR者低于THR者(THR-C vs THR-T：χ²＝4.27，P<0.05)，其中THR-C组发生率最高，达56.0%，FHR-C组最低13.0%(χ²＝7.877，P<0.05)。48 h内行手术治疗者住院天数较对照组48 h后手术者明显短(THR-C vs THR-T：F＝6.892；FHR-C vs FHR-T：F＝127.489，P<0.05)，其中FHR-T组住院天数最短，为(14.8±7.6)d(F＝214.086，P<0.05)。术中及术后各指标明显改善(VAS：H＝201.22，MAP：F＝576.348，P<0.05)。 结论不同手术时机影响老龄髋关节置换术患者术后谵妄发生率，48 h内手术治疗能明显降低术后谵妄发生，缩短住院时间。

Relationship between delirium incidence and different operation timings of hip arthroplasty in elderly patients

ObjectiveTo study the effect of different timing of surgery on the incidence of postoperative delirium in elderly patients undergoing hip replacement. MethodAccording to the criteria of admission, a total of 83 patients undergoing hip replacement over 65 years old were selected in Shunde Second People’s Hospital from February 2013 to February 2017. The total hip replacement group (THR, 39 cases) and the femoral head replacement group (FHR, 44 cases) were divided into the total hip replacement group. The patients of different operation method were divided into the control group (C) and the experimental group (T) according to the operation time (later than 48 h or earlier than 48 h after injury). Finally, four groups of THR-C(25 cases)、THR-T(14 cases)、FHR-C(21 cases)、FHR-T(23 cases) were obtained. Anesthesia and operation were performed by intraspinal anesthesia. Heart rate (HR), mean arterial pressure (MAP), and surplus pulse O₂(SpO₂) were maintained before the operation (T_p), during the operation (T₀) and three days after theoperation(T₁~T₃), and pain score (VAS) at each time point was recorded. The confusion assessment method- Chinese reversion (CAM-CR) for delirium was used to assess the delirium at each time point and record the number of delirium at each time point. Chi-square test or rank sum test were used to analyse the data. ResultsBefore operation, all the patients were in moderate and severe pain (VAS: 6-8), high blood pressure (MAP: 110-99mmHg), and intraoperative and postoperative indexes improved significantly (VAS: H=201.22; MAP: F=576.348, P<0.05). The incidence of delirium on the 3^rd day after operation: the delirium incidence of surgical treatment within 48 h was less than that late than 48 h (THR-C vs THR-T: χ²=4.92; FHR-C vs FHR-T: χ²=7.58, both P<0.05); and the delirium incidence of FHR was lower than that of THR (THR-C vs THR-T: χ²=4.27, P<0.05); among them, THR-C group had the highest incidence of 56.0%, while FHR-T group had the lowest incidence of 13.0% (χ²=7.877, P<0.05). The duration of hospitalization the patients operated within 48 h was significantly shorter than the patients operated late than 48 h(THR-C vs THR-T: F=6.892; FHR-C vs FHR-T: F=127.489, P<0.05); the FHR-T group had the shortest length of hospital stay(14.8±7.6)d(F=214.086, P<0.05). The length of hospital stay in the patients operated within 48 h was significantly shorter than the patients operated late than 48 h (THR: F=6.892; FHR: F=127.489, both P<0.05). ConclusionThe incidence of postoperative delirium in the elderly patients with hip replacement is affected by the surgical timing, and surgical treatment within 48 h can significantly reduce the incidence of postoperative delirium and shorten the time of hospitalization.