The role of postoperative analgesia in delirium and cognitive decline in elderly patients: a systematic review

Postoperative delirium and cognitive decline are adverse events that occur frequently in elderly patients. Preexisting patient factors, medications, and various intraoperative and postoperative causes have been implicated in the development of postoperative delirium and cognitive decline. Despite previous studies identifying postoperative pain as a risk factor, relatively few clinical studies have compared the effect of common postoperative pain management techniques (IV and epidural) or opioid analgesics on postoperative cognitive status. A systematic search of the PubMed and CINAHL databases identified six studies comparing different opioid analgesics on postoperative delirium and cognitive decline and five studies comparing IV and epidural routes of administering analgesia. Meperidine was consistently associated with an increased risk of delirium in elderly surgical patients, but the current evidence has not shown a significant difference in postoperative delirium or cognitive decline among other more frequently used postoperative opioids such as morphine, fentanyl, or hydromorphone. The available studies also suggest that IV or epidural techniques do not influence cognitive function differently. However, future investigations of sufficient study size and more standardized methods of defining outcomes are necessary to confirm the current findings.     

脑电双频指数监测对老年慢性贫血患者术后谵妄发生率的影响

目的 探讨BIS监测对老年慢性贫血患者腹部手术术后谵妄(postoperative delirium,POD)发生率的影响. 方法 180例择期行全身麻醉手术患者,按随机数字表法分为两组(每组90例):BIS监测组及对照组,对照组采用常规麻醉,BIS监测组维持BIS值于40～60.记录患者入室后(T0)、诱导后(T1)、插管即刻(T2)、插管后3 min(T3)、切皮(T4)、术中1h(T5)及手术结束(T6)各时间点的血流动力学指标.观察记录患者麻醉期间丙泊酚用量、手术时间、拔管时间、清醒时间,及POD发生情况. 结果 BIS监测组谵妄总发生率17.8％,低于对照组的31.1％(P＜0.05);其中,BIS监测组谵妄第1天发生率13.3％,明显低于对照组的28.9％(P＜0.05),第2天发生率5.6％,低于对照组的14.4％(P＜0.05);BIS监测组谵妄持续时间明显低于对照组(P＜0.05).BIS监测组术后清醒拔管时间[(26±8) min]及住院时间[(11.5±2.3)d]显著短于对照组[(41±12) min、(12.6±4.4)d](P＜0.05). 结论 BIS监测下麻醉可降低老年合并慢性贫血患者POD发生率,减少谵妄持续时间.     

Nitrous oxide does not change the incidence of postoperative delirium or cognitive decline in elderly surgical patients

Background. Postoperative delirium and cognitive decline arecommon in elderly surgical patients after non-cardiac surgery.Despite this prevalence and clinical importance, no specificaetiological factor has been identified for postoperative deliriumand cognitive decline. In experimental setting in a rat model,nitrous oxide (N₂O) produces neurotoxic effect at high concentrationsand in an age-dependent manner. Whether this neurotoxic responsemay be observed clinically has not been previously determined.We hypothesized that in the elderly patients undergoing non-cardiacsurgery, exposure to N₂O resulted in an increased incidenceof postoperative delirium than would be expected for patientsnot receiving N₂O. Methods. Patients who were 65 yr of age, undergoing non-cardiacsurgery and requiring general anaesthesia were randomized toreceive an inhalational agent and either N₂O with oxygen oroxygen alone. A structured interview was conducted before operationand for the first two postoperative days to determine the presenceof delirium using the Confusion Assessment Method. Results. A total of 228 patients were studied with a mean (range)age of 73.9 (65–95) yr. After operation, 43.8% of patientsdeveloped delirium. By multivariate logistic regression, age[odds ratio (OR) 1.07; 95% confidence interval (CI) 1.02–1.26],dependence on performing one or more independent activitiesof daily living (OR 1.54; 95% CI 1.01–2.35), use of patient-controlledanalgesia for postoperative pain control (OR 3.75; 95% CI 1.27–11.01)and postoperative use of benzodiazepine (OR 2.29; 95% CI 1.21–4.36)were independently associated with an increased risk for postoperativedelirium. In contrast, the use of N₂O had no association withpostoperative delirium. Conclusions. Exposure to N₂O resulted in an equal incidenceof postoperative delirium when compared with no exposure toN₂O. ⁴Present address: Staff Statistician, University of Pittsburgh,PA 15213, USA     

右美托咪定对老年重症患者术后谵妄的影响

目的观察右美托咪定老年重症患者术后谵妄发生的影响。方法 60例行择期硬膜外复合全麻下腹部手术术后入SICU患者,年龄≥65岁。随机均分为治疗组和对照组,治疗组持续静脉输注右美托咪定0.2μg·kg^-1·h^-1直至总剂量达200μg（用生理盐水稀释至50ml）;对照组给予等容量生理盐水。观察术后第1、2、3天静息和咳嗽时VAS疼痛评分和睡眠评分,术后6、12h、停药时、术后24、48h镇痛泵的按压次数和用药量情况及术后7d内谵妄发生率。结果两组低血压发生率、VAS疼痛评分差异无统计学意义。术后第1天睡眠评分治疗组（3.48±2.19）分,明显低于对照组的（4.67±2.44）分（P<0.05）。术后7d内对照组谵妄发生率9例（31.0%）,治疗组13例（44.8%）,两组差异无统计学意义。结论老年外科重症患者,持续静脉输注右美托咪定0.2μg·kg^-1·h^-1能改善睡眠质量,对术后镇痛及谵妄发生无明显影响。     

Causes of postoperative delirium after abdominal surgery in elderly patients

BACKGROUND: There are many causes for postoperative delirium in elderly patients. Hypotension is considered as one of the causes. In our retrospective study, hypotension during operation was not taken care of strictly. Slight hypotension was observed every so often. We recognized that the drop of cerebral blood flow due to hypotension and duration of hypotension were risk factors of postoperative delirium. METHODS: We did a retrospective study, covering the period between April 1, 2005 and March 31, 2006, in 30 elderly patients for elective laparotomy. We compared postoperative delirium group (D group) with no delirium group (ND group). RESULTS: There were great differences in transfusion, fluid infusion, anesthesia time, operation time, blood loss, extreme hypotension and the duration of hypotension between the two groups. CONCLUSIONS: Our results indicate that permissive hypotension induced the drop of cerebral blood flow and it can be a risk factor of postoperative delirium in elderly patients. To prevent extreme hypotension, to decrease duration of hypotension, and to raise the blood pressure quickly are very important to decrease postoperative delirium in elderly patients.     

乌司他丁对老年患者髋关节置换术后谵妄的影响

目的观察围术期应用乌司他丁对老年患者行髋关节置换术术后谵妄的影响。 方法选取择期髋关节置换术老年患者120例,美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级,年龄在65～90岁,无神经、精神系统疾病,无长期服用镇静、抗抑郁药,术前沟通、依从性好;能配合完成术后随访。应用随机数字表法分成4组：乌司他丁组(U₁、U₂、U₃组)和对照组(C组),每组30例,术中应用静吸复合全麻。手术切皮前分别予U₁组2 500 U/kg、U₂组5 000 U/kg、U₃组10 000 U/kg乌司他丁静脉维持1 h,术后第1、2天再继续静滴等量乌司他丁,C组等时静滴生理盐水。记录4组意识恢复时间、意识恢复后视觉模拟量表(VAS)评分、术后改良的警觉/镇静(OAA/S)评分和拔管后躁动评分;术后谵妄评定方法(CAM)评分;术后谵妄发生例数;记录术前和术后不同时点的白介素-6(IL-6)、S-100钙结合蛋白β亚单位(S-100β)和脑源性神经营养因子(BDNF)变化。一般情况、拔管时间及意识恢复质量评分采用单因素方差分析,CAM评分、IL-6、S-100β及BDNF数据采用重复测量资料方差分析,术后谵妄发生例数采用卡方检验进行统计学分析。 结果U₂组、U₃组较C组、U1组拔管后躁动评分低(F ＝34.41,P<0.05)、意识恢复时间短(F ＝8.45,P<0.05)、术后改良OAA/S评分低(F ＝7.33,P<0.05);术后3 d,乌司他丁组CAM评分均低于C组(F＝8.61,P<0.05);术后C组出现谵妄例数多(χ²＝8.76,P<0.05);术后6～24 h IL-6浓度U₁、U₂、U₃组低于C组(F＝16.84,P<0.05);术后6～24 h的S-100β浓度U₁、U₂、U₃组低于C组(F ＝7.613,P<0.05);术毕当时至术后12 h血清BDNF浓度U₁、U₂、U₃组明显高于C组(F ＝38.54,P<0.05)。 结论髋关节置换术围术期使用5 000 U/kg与10 000 U/kg乌司他丁量,可缩短意识恢复时间,减低拔管后躁动的发生,减轻老年人髋关节置换术后谵妄的发生;可能与乌司他丁影响炎症因子IL-6,从而减少S-100β和保持BDNF浓度有关。     

术前睡眠质量对老年患者术后谵妄发生的影响

目的探讨术前睡眠质量对老年患者术后谵妄(POD)发生的影响。方法选择择期全凭静脉麻醉下经腹行肿瘤根治术患者,年龄65~86岁,BMI 18~25kg/m2,ASAⅠ-Ⅲ级。术前根据匹兹堡睡眠质量指数(pittsburgh sleep quality index,PSQI)分为睡眠障碍组(≥5分,D组)和睡眠正常组(5分,C组),每组50例,男71例,女29例。两组均采用丙泊酚、舒芬太尼和罗库溴铵进行麻醉诱导和维持,麻醉深度维持在BIS值40~60。记录术中丙泊酚、舒芬太尼、阿托品、麻黄碱、艾司洛尔、硝酸甘油等使用情况,记录麻醉时间、手术时间、PACU停留时间和术后住院时间,记录术后1~5d数字疼痛(NRS)评分和恢复质量评分量表-40(QoR-40)总分。采用意识模糊评定量表(CAM)于术前1d和术后1~5d进行谵妄评估。结果 D组术前PSQI评分明显高于C组(P0.05)。两组患者术中丙泊酚、舒芬太尼用量和血管活性药使用例数差异无统计学意义,麻醉时间、手术时间和PACU停留时间差异无统计学意义。D组术后住院时间明显长于C组(P0.05)。术后1、2和3d,D组NRS评分明显高于C组,QoR-40总分明显低于C组(P0.05)。术后1~5d,两组总计21例(21.0%)发生POD,其中D组15例(30.0%)和C组6例(12.0%),D组POD发生率明显高于C组(P0.05)。D组POD患者的谵妄持续时间明显长于C组(P0.05)。术后2dD组POD发生率明显高于C组(P0.05)。结论术前睡眠障碍可增加老年患者POD发生率并对术后早期恢复质量产生负面影响,应引起重视。     

老年患者术后谵妄非药物预防措施的证据总结

目的评价和总结老年患者术后谵妄非药物预防措施的最佳证据。方法通过计算机检索BMJ最佳临床实践、Cochrane library、JBI循证卫生保健国际合作中心图书馆等文献中的所有证据,包括指南、证据总结、最佳实践信息册、推荐实践及系统评价。对符合质量标准的文献进行证据提取。结果共纳入8篇文献,其中临床指南3篇、证据总结3篇、系统评价1篇、推荐实践1篇。得到9项最佳证据为:提倡使用多方式、多学科团队协作,进行术后谵妄的预防和管理;对存在谵妄高风险患者及其家属进行相关健康教育;医疗机构的医护人员应接受谵妄相关知识教育培训;通过多种方式在患者术后进行感官刺激预防谵妄发生;早期活动有利于减少老年患者术后谵妄;术前对存在谵妄高风险患者进行老年科会诊;通过多种方式促进患者睡眠,维持正常的睡眠觉醒周期;推荐术后优化疼痛控制,进行疼痛评估和处理;尽可能减少谵妄发生的危险因素,如营养不良、体液失衡等。结论医护人员应评估临床实际环境与患者特点,制定术后谵望相应的预防性措施,进行证据的应用。     

个体化预测老年髋部骨折患者术后谵妄风险

[目的]通过分析老年髋部骨折患者术后谵妄的相关危险因素,建立并验证个体化预测老年髋部骨折术后谵妄风险的列线图模型。[方法]纳入2013年1月～2018年3月于淄博市中心医院行手术治疗的老年髋部骨折患者257例,收集临床资料。应用单因素及多因素Logistic回归模型,分析老年髋部骨折患者术后谵妄的独立危险因素。应用R软件构建预测老年髋部骨折患者术后谵妄风险的列线图模型,并进行验证。[结果]多因素Logistic回归分析显示,年龄(OR=1.143,95%CI:1.076～1.214)、2型糖尿病(OR=4.591,95%CI:2.14～9.846)、ASA评分III级(OR=4.262,95%CI:1.600～11.352)、ASA评分IV级(OR=5.396,95%CI:1.868～15.583)、全身麻醉(OR=1.281,95%CI:1.066～1.540)及手术时间(OR=1.018,95%CI:1.001～1.035)是老年髋部骨折患者术后谵妄的独立危险因素(P0.05)。对列线图模型进行验证,ROC曲线显示该模型预测老年髋部骨折患者术后谵妄风险的曲线下面积为0.818(95%CI:0.752～0.885);校准曲线为斜率接近于1的直线,Hosmer-Lemeshow拟合优度检验(x~2=8.760,P=0.363)均显示该模型预测老年髋部骨折患者术后谵妄风险具有良好准确度。[结论]本研究基于年龄、2型糖尿病、ASA分级、麻醉方式及手术时间这5项老年髋部骨折患者术后谵妄的独立危险因素,构建的预测老年髋部骨折患者术后谵妄风险的列线图模型,具有良好的区分度与准确度,可为临床个体化防治老年髋部骨折患者术后谵妄提供科学指导。     

右美托咪定预防老年患者术后谵妄的研究进展

术后谵妄(POD)是老年患者术后的常见并发症,此外,重症监护病房(ICU)患者和既往认知障碍患者也属于POD高危人群。然而,由于其机制尚不明确,目前尚缺乏有效治疗措施。近年来的研究表明右美托咪定可有效预防和减少老年患者POD的发生。本文综述了POD的概述、右美托咪定预防POD的相关机制及其预防老年患者POD的研究进展,以进一步优化围术期管理,减少POD的发生。     

The impact of postoperative complications on the recovery of elderly surgical patients

Background

While the negative impact of postoperative complications on hospital costs, survival, and cancer recurrence is well known, few studies have quantified the impact of postoperative complications on patient-centered outcomes such as functional status. The objective of this study was to estimate the impact of postoperative complications on recovery of functional status after elective abdominal surgery in elderly patients.

Methods

Elderly patients (70 years and older) undergoing elective abdominal surgery, with a planned length of stay >1 day, were prospectively enrolled between July 2012 and December 2014. The primary outcome was time to recovery to the preoperative functional status measured by the short physical performance battery (SPPB) preoperatively and at 1 week, 1, 3, and 6 months after surgery. The comprehensive complication index was calculated to grade the severity and number of postoperative complications. A Weibull survival model with interval censoring was performed, controlling for age, sex, body mass index (BMI), comorbidities (Charlson comorbidity index?CCI), frailty, presence of cancer, nutritional status, wound class, preoperative functional status, and surgical approach.

Results

Hundred and forty-nine patients (79 men and 70 women) were included in the analysis. Mean age was 77.7 ± 4.9 years, mean BMI was 27.2 ± 5.5 kg/m², and the median CCI was 3 (IQR 2–6). The mean preoperative SPPB score was 9.62 ± 2.33. A total of 52 patients (34.9 %) experienced one or more postoperative complications, including four mortalities, and a total of 72 complications. The mean comprehensive complication index score for these patients was 25.7 ± 23.8. In the presence of all other variables included in the model, a higher comprehensive complication index score was found to significantly decrease the hazard of recovery (HR 0.96, CI 0.94–0.98, p value = 0.0004) and hence increase the time to recovery.

Conclusion

Following elective abdominal surgery, elderly patients who experience a greater number and more severe postoperative complications take longer to return to their preoperative functional status.

     

右美托咪定对老年患者全髋关节置换术后谵妄的影响

目的观察右美托咪定对老年患者全髋关节置换术后谵妄的影响。方法择期行单侧全髋关节置换术患者140例,男62例,女78例,年龄65~83岁,ASAⅠ或Ⅱ级,随机分为两组:右美托咪定组(D组)和对照组(C组),每组70例。D组于麻醉诱导前静脉泵注0.5μg/kg右美托咪定,泵注时间15min。C组于麻醉诱导前静脉泵注等量生理盐水,手术结束后患者自控静脉镇痛(PCIA)。记录术前5min、拔管前5min、拔管后30min的HR和MAP,术后第1、2、3天静息及运动状态下VAS评分,术后7d内谵妄发生率及持续时间,住院天数,以及恶心、呕吐、嗜睡等不良反应。结果两组患者术后静息及运动下的VAS评分差异无统计学意义。拔管前5min、拔管后30min D组HR明显慢于,MAP明显低于C组(P0.05)。术后7d内C组谵妄发生20例(28.6%),明显高于D组8例(11.4%)(P0.05)。谵妄持续时间C组[(3.0±0.5)d]明显长于D组[(1.3±0.6)d](P0.05)。平均住院天数D组[(14.6±1.0)d]明显少于C组[(17.7±1.4)d](P0.05)。两组患者不良反应差异无统计学意义。结论麻醉诱导前静脉泵注0.5μg/kg右美托咪定可以降低老年患者全髋关节置换术后谵妄发生率,缩短谵妄持续时间,减少住院天数。     

术后使用右美托咪定对老年髋部手术患者发生谵妄的临床研究

目的探讨术后使用右美托咪定对老年髋部手术患者发生谵妄的影响。 方法前瞻性收集2016年1月至2018年1月在海门市人民医院骨科行髋部手术的老年患者50例,采用随机数字表法将患者分为两组：右美托咪定组25例,术后在骨科常规治疗基础上给予右美托咪定静脉泵入注射用于术后镇痛,维持量0.5 μg/kg/hr;对照组25例,仅给予骨科常规治疗。比较两组谵妄的发生率、发生时间、持续时间。 结果全部患者均获得随访,随访时间为7~15 d,平均（10.0±1.4）d。右美托咪定组谵妄的发生率（6%）与对照组（13%）比较,差异无统计学意义（P>0.05）。右美托咪定组谵妄的发生时间为术后（26±6）h,晚于对照组的（7±3）h,差异有统计学意义（t=2.370,P<0.05）。右美托咪定组谵妄的持续时间为（2.4±0.8）d,短于对照组的（6.2±1.5）d,差异有统计学意义（t=-1.942,P<0.05）。 结论右美托咪定能延缓谵妄的发生,缩短谵妄的持续时间,但不能显著降低谵妄的发生率。     

术前睡眠障碍在老年术后谵妄中的作用研究进展

术后谵妄（postoperative delirium, POD）指术后短暂、可逆的急性中枢神经系统紊乱,可引起术后并发症增加、预后不良等,老年患者为其高危人群之一。近年相关研究显示,术前睡眠障碍为老年患者POD的危险因素之一。文章归纳总结近年术前睡眠障碍与老年患者POD关系的研究,描述了老年患者睡眠障碍及POD的流行...     

乌司他丁对老年患者髋部骨折术后谵妄的影响

目的评价围术期静脉输注乌司他丁对老年患者髋部骨折术后谵妄(POD)的影响。方法选择择期行髋部骨折手术的老年患者96例,男38例,女58例,年龄70~93岁,ASAⅡ或Ⅲ级,采用随机数字表法分为两组:乌司他丁组(U组)和对照组(C组),每组48例。麻醉方式均采用腰-硬联合麻醉+髂筋膜间隙阻滞。U组于切皮前、术后第1天和第2天静脉泵入乌司他丁5 000U/kg;C组给予等容积生理盐水。术后1~3d采用意识错乱评估法(CAM)评定POD的发生情况。分别于麻醉前(T0)、术毕(T_1)和术后第3天(T2)采集外周静脉血5ml,采用ELISA法检测血清IL-6和S100β的水平。结果 C组POD发生13例(28.2%),U组POD发生2例(4.3%),U组POD发生率明显低于C组(P0.05);与T0时比较,T_1、T_2时C组血清IL-6和IL-10水平明显升高(P0.05);T_1、T_2时U组血清IL-6水平明显低于C组(P0.05)。与T_0时比较,T_1时C组S100β水平明显升高(P0.05);T_1时U组血清S100β水平明显低于C组(P0.05)。结论乌司他丁降低老年髋部骨折患者POD发生率,机制可能与抑制血清促炎症因子IL-6和S100β的过度释放相关。     

高龄患者髋关节置换术后谵妄的发生率及危险因素分析

目的 探讨行髋关节置换术的高龄患者术后谵妄的发生率及危险因素.方法 选择2009年9月至2010年2月,择期行髋关节置换术患者120例.术前访视患者,术后当天,术后1、2、3d密切随访患者,用谵妄评定法进行谵妄评估.记录患者一般情况、病史、合并症、手术时间、术中失血量、术中输库存血量、术后疼痛评分及谵妄的发生情况,建立数据库.根据是否发生谵妄分为谵妄组和对照组.结果 术后发生谵妄28例,发生率为23.33%.多因素Logistic逐步回归分析高龄、术前合并肺心病、术前合并肺部感染、全身麻醉、术后低氧血症为谵妄的危险因素(P＜0.05).结论 高龄、术前合并肺心病、术前合并肺部感染、全身麻醉、术后低氧血症是术后谵妄的独立危险因素.     

Risk factors for postoperative delirium in elderly patients with colorectal cancer

Aims  

The aim of this retrospective study is to examine risk factors for postoperative delirium in elderly patients with colorectal cancer.