多模式镇痛对老年髋部骨折术后谵妄影响的研究

目的 探讨多模式镇痛对老年髋部骨折术后谵妄发生情况的影响.方法 2010年10月至2012年7月,前瞻性研究65岁以上髋部手术患者108例,按术后镇痛模式将患者分为多模式镇痛组和传统镇痛组.多模式镇痛组59例,男25例,女34例；年龄65～86岁,平均(72.91±5.42)岁；行全髋关节置换术35例,行股骨转子间骨折内固定术24例.传统镇痛组49例,男22例,女27例；年龄65～84岁,平均(72.14±4.93)岁；行全髋关节置换术29例,行股骨转子间骨折内固定术20例.根据美国精神疾病协会制定的意识错乱评估方法对患者精神状况进行评估.多模式镇痛组术中实施切口周围浸润阻滞,术后给予静脉镇痛泵,并常规静脉滴注非甾体类镇痛药3d.传统镇痛组在术后疼痛时给予同一常规剂量阿片类药物强化镇痛.对于发生术后谵妄的患者,两组均给予强化镇痛干预.结果 多模式镇痛组术后疼痛视觉模拟评分(visual analogue scale,VAS)静息及活动时分别为:第1天时(2.10±1.43)分、(4.74±1.45)分,第3天时(1.01±0.92)分、(3.31±1.36)分；传统镇痛组VAS分别为:第1天时(4.67±1.33)分、(7.44±1.59)分,3天时(2.24±1.39)分、(5.06±1.46)分.无论是静息还是活动状态,两组VAS评分比较差异均有统计学意义.术后3d内,传统镇痛组15例(30.6％,15/49)、多模式镇痛组7例(11.9％,7/59)发生谵妄.对发生谵妄的22例患者,肌内一次注射10 mg吗啡后,均有至少一项以上不良反应缓解.结论 应用多模式镇痛手段可减少术后谵妄发生,对已发生术后谵妄患者,强化镇痛可进一步缓解病情.

The study of multimodal analgesia on postoperative delirium in elder patients with hip fracture

Objective To study effects of multimodal analgesia on postoperative delirium (POD)in elder patients with hip fracture. Methods One hundred and eight elder patients with hip fractures were gathered in a prospective study. Fifty-nine cases were included in the group of multimodal analgesia(25 males, 34 females), with an average age of 72.91±5.42 years, and 35 were treated with hip replacements, the other 24 were internal fixations. Forty-nine cases were in the group of conventional analgesia (22 males, 27 females), with an average age of 72.14±4.93 years, 29 were treated with hip replacements, 20 were internal fixations. Assessments of delirium were based on confusion assessment method. Local infiltrated anesthesia, patient control intravenous analgesia, and intravenous nonsteroid anti-inflammatory drug were applied in the group of multimodal analgesia. For the other group, morphine would be given only when patient complained pain or there was POD. Postoperatively, visual analogue scale (VAS), onset of delirium, other correlative data were recorded by an independent researcher. All patients underwent POD were managed with intensive pain management, and then reevaluated. Results VAS in multimodal analgesia group [Day1: 2.10±1.43(resting), 4.74±1.45 (active) and Day 3: 1.01±0.92 (resting), 3.31±1.36 (active)] were significantly lower than that in the other group [Day1: 4.67±1.33 (resting), 7.44±1.59 (active)and Day 3: 2.24±1.39 (resting), 5.06±1.46 (active)]. PODs were detected in 15 (30.6%) in group of conventional analgesia; while in group of multimodal analgesia, there were 7 (11.9%). All POD were given intensive pain managements by injection of 10 mg morphine and achieved relief of deliriums. Conclusion Postoperative multimodal analgesia may reduce the incidence of POD. First aid of intensive pain management may help to control POD.