麻醉深度监测不能减少老年关节置换患者术后谵妄

doi:10.3877/cma.j.issn.1674-134X.2020.04.009

目的

本研究旨在明确Narcotrend(Nt)麻醉深度的监测是否可降低行髋膝关节置换手术老年患者术后谵妄(POD)的发生率。

方法

纳入于重庆医科大学附属第一医院行单侧髋或膝关节置换手术且年龄≥60岁的老年患者，排除术前认知功能不全、合并中枢神经系统疾病、交流困难、术后转入ICU或行二次手术的患者。并按随机数字表法随机分为监测组(Nt组65例，按照Nt指数控制麻醉深度于D1-E0)及对照组(71例，依据麻醉医生经验调整麻醉深度)，记录所有患者手术部位、文化程度、术中全麻药物使用剂量、是否行神经阻滞、手术日至出院日的天数等基本资料，随访其术后第1、3天意识模糊评估表(CAM)评分值、恶心呕吐发生率，并按照知情同意原则，监测患者术前1 d、术后1、3、5 d血清CRP及术前1 d、术后3、5 d血清IL-6值。根据资料类型，选择独立样本t检验或卡方检验进行组间差异比较，炎症因子水平的差异采用秩和检验，相关性分析采用spearman及二元logistics回归分析。

结果

术后第1天NT组及对照组POD发生率为9.2% vs21.1%(χ²＝3.678，P>0.05)；术后第3天POD发生率为18.5% vs 22.5%(χ²＝0.344，P>0.05)。Nt监测可降低丙泊酚用量(245.63±84.48)mg vs (303.64±127.38)mg(t＝-3.131，P<0.01)。术后各时间点血清IL-6(U＝505、590、445,均为P>0.05)及CRP(U＝2 090、2 165、1 687、505，均为P>0.05)水平在Nt组与对照组间差异均无统计学意义。回归分析提示未行神经阻滞及高龄可独立增加患者发生POD的风险。

结论

与常规监护相比，Nt监测可降低行髋膝关节置换手术老年患者围术期丙泊酚的用量，但不能降低POD的发生率。

关键词: 脑电描记术, 谵妄, 老年人, 关节成形术

Objective

To explore the effect of Narcotrend (Nt) monitoring on postoperative delirium in the elderly after hip and knee replacements.

Methods

The patients with unilateral hip or knee arthroplasty in the First Affiliated Hospital of Chongqing Medical University and aged over 60 years were included in the study. They were randomly divided into the Nt monitoring group (n=65, the anesthesia depth was controlled by the Nt index to D1-E0) and the control group (n=71, the anesthesia depth was controlled by the experience of anesthesiologists). The data were recorded, including the operation position, education level, the dosage of general anesthesia, nerve block rate, the postoperative hospital stay, the confusion assessment method(CAM) scores and incidence of postoperative nausea and vomiting on the postoperative first and third day, the level of serum CRP on the first day before operation and the first, third and fifth day after operation, and the level of serum IL-6 on the first day before operation and the third and fifth day postoperation. According to the type of data, independent-sample t test or chi-square test were used to compare the differences between groups. Rank sum test was used to analyze the difference of inflammatory factors. Spearman and binary logistic regression analysis were used for correlation analysis.

Results

When compared with the control group, the POD in the Nt group on the first and third day after operation had no difference 21.1% vs 9.2% (χ²=3.678, P >0.05)on the first postoperative day; 22.5%vs 18.5% on the third postoperative day (χ²=0.344, P >0.05). The dosage of propofol in Nt group was less than that in the control group (245.63±84.48)mg vs (303.64±127.38)mg(t=-3.131, P<0.01). There was no difference in the levels of serum IL-6(U=505, 590, 445, all P>0.05) and CRP(U=2 090, 2 165, 1 687, 505, all P>0.05) after operation between Nt group and the control group. Regression analysis suggested that nerve block and age could independently influence the risk of POD.

Conclusion

Nt monitoring can reduce the dosage of propofol when compared with usual monitoring for the hip and knee replacement in the elderly, but it can not decrease the incidence of POD.

Key words: Electroencephalography, Delirium, Aged, Arthroplasty

表1 两组患者基线资料比较

		Nt组	对照组	统计值	P值
例数		65	71
性别(男/女)		22/43	30/41	χ²＝1.016	>0.05
文化程度(例)
	高中及以下	52	68	χ²＝8.134	<0.05
	专科及以上	13	3	χ²＝8.134	<0.05
手术部位
	髋	33	32	χ²＝0.442	>0.05
	膝	32	39	χ²＝0.442	>0.05
术后镇痛类型(例)
	PCIA	24	36	χ²＝2.056	>0.05
	PCNA	41	35	χ²＝2.056	>0.05
是否神经阻滞(例)
	是	62	60	χ²＝4.348	<0.05
	否	3	11	χ²＝4.348	<0.05
ASA分级(例)
	2级	21	19	χ²＝0.503	>0.05
	3级	44	52	χ²＝0.503	>0.05
年龄[岁，(±s)]		74.2±8.4	72.8±6.5	t＝1.115	>0.05
术前MMSE扣分[分，(±s)]		3.2±1.4	3.2±1.7	t＝-0.072	>0.05
麻醉时长[min，(±s)]		127.9±36.3	127.5±51.7	t＝0.059	>0.05
出血量[ml，(±s)]		85.8±24.4	82.8±21.9	t＝0.212	>0.05

表1 两组患者基线资料比较

		Nt组	对照组	统计值	P值
例数		65	71
性别(男/女)		22/43	30/41	χ²＝1.016	>0.05
文化程度(例)
	高中及以下	52	68	χ²＝8.134	<0.05
	专科及以上	13	3	χ²＝8.134	<0.05
手术部位
	髋	33	32	χ²＝0.442	>0.05
	膝	32	39	χ²＝0.442	>0.05
术后镇痛类型(例)
	PCIA	24	36	χ²＝2.056	>0.05
	PCNA	41	35	χ²＝2.056	>0.05
是否神经阻滞(例)
	是	62	60	χ²＝4.348	<0.05
	否	3	11	χ²＝4.348	<0.05
ASA分级(例)
	2级	21	19	χ²＝0.503	>0.05
	3级	44	52	χ²＝0.503	>0.05
年龄[岁，(±s)]		74.2±8.4	72.8±6.5	t＝1.115	>0.05
术前MMSE扣分[分，(±s)]		3.2±1.4	3.2±1.7	t＝-0.072	>0.05
麻醉时长[min，(±s)]		127.9±36.3	127.5±51.7	t＝0.059	>0.05
出血量[ml，(±s)]		85.8±24.4	82.8±21.9	t＝0.212	>0.05

表2 POD发生率[例(%)]

分组	例数	术后第1天	术后第3天
Nt组	65	6(9.2)	12(18.5)
对照组	71	15(21.1)	16(22.5)
χ²值		3.678	0.344
P值		>0.05	>0.05

表2 POD发生率[例(%)]

分组	例数	术后第1天	术后第3天
Nt组	65	6(9.2)	12(18.5)
对照组	71	15(21.1)	16(22.5)
χ²值		3.678	0.344
P值		>0.05	>0.05

表3 血清IL-6与CRP在各时点水平[ng/L，M(P₂₅，P₇₅]

组别	例数	IL-6			CRP
组别	例数	术前1 d	术后3 d	术后5 d	术前1 d	术后1 d	术后3 d	术后5 d
Nt组	33	6.1(2.9，14.9)	15.8(8.6，22.6)	10.5(6.6，22.5)	4.4(2.3，13.2)	18.3(11.6，36.2)	34.4(15.2，77.4)	30.4(13.9，62.6)
对照组	34	4.3(2.9，7.9)	14.9(7.9，41.8)	13.2(7.8，19.6)	4.7(2.6，12.5)	19.4(13.2，33.6)	57.9(22.4，81.3)	24.1(11.2，50.6)
组间	U值	505	590	445	2 090	2 165	1 687	505
	P值	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05
组内	Z值	-	3.909^a	2.939^a	-	7.807^b	8.568^b	5.192^b
	P值	-	<0.05^a	<0.05^a	-	<0.05^b	<0.05^b	<0.05^b

表3 血清IL-6与CRP在各时点水平[ng/L，M(P₂₅，P₇₅]

组别	例数	IL-6			CRP
组别	例数	术前1 d	术后3 d	术后5 d	术前1 d	术后1 d	术后3 d	术后5 d
Nt组	33	6.1(2.9，14.9)	15.8(8.6，22.6)	10.5(6.6，22.5)	4.4(2.3，13.2)	18.3(11.6，36.2)	34.4(15.2，77.4)	30.4(13.9，62.6)
对照组	34	4.3(2.9，7.9)	14.9(7.9，41.8)	13.2(7.8，19.6)	4.7(2.6，12.5)	19.4(13.2，33.6)	57.9(22.4，81.3)	24.1(11.2，50.6)
组间	U值	505	590	445	2 090	2 165	1 687	505
	P值	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05
组内	Z值	-	3.909^a	2.939^a	-	7.807^b	8.568^b	5.192^b
	P值	-	<0.05^a	<0.05^a	-	<0.05^b	<0.05^b	<0.05^b

表4 两组患者术中全麻药物使用量、术后恶心呕吐发生率及住院时长比较

分组	例数	丙泊酚[mg, (±s)]	瑞芬太尼[mg, (±s)]	舒芬太尼[μg, (±s)]	恶心呕吐发生率[例(%)]	住院时长[d, (±s)]
Nt组	65	245.63±84.48	0.76±0.26	38.15±7.05	6(9.23%)	7.11±3.71
对照组	71	303.64±127.38	0.77±0.35	38.87±7.66	13(18.3%)	6.94±4.08
统计值		t＝-3.131	t＝-0.343	t＝-0.568	χ²＝2.327	t＝0.245
P值		<0.01	>0.05	>0.05	>0.05	>0.05

表4 两组患者术中全麻药物使用量、术后恶心呕吐发生率及住院时长比较

分组	例数	丙泊酚[mg, (±s)]	瑞芬太尼[mg, (±s)]	舒芬太尼[μg, (±s)]	恶心呕吐发生率[例(%)]	住院时长[d, (±s)]
Nt组	65	245.63±84.48	0.76±0.26	38.15±7.05	6(9.23%)	7.11±3.71
对照组	71	303.64±127.38	0.77±0.35	38.87±7.66	13(18.3%)	6.94±4.08
统计值		t＝-3.131	t＝-0.343	t＝-0.568	χ²＝2.327	t＝0.245
P值		<0.01	>0.05	>0.05	>0.05	>0.05

表5 各因素与POD的单变量分析

组别	例数	手术部位(例)		神经阻滞(例)		年龄[岁，(±s)]
组别	例数	膝关节	髋关节	是	否	年龄[岁，(±s)]
POD患者	38	14	24	30	8	76±6
非POD患者	98	57	41	92	6	73±8
统计值		χ²＝4.989		χ²＝6.610		t＝2.168
P值		<0.05		<0.05		<0.05

表5 各因素与POD的单变量分析

组别	例数	手术部位(例)		神经阻滞(例)		年龄[岁，(±s)]
组别	例数	膝关节	髋关节	是	否	年龄[岁，(±s)]
POD患者	38	14	24	30	8	76±6
非POD患者	98	57	41	92	6	73±8
统计值		χ²＝4.989		χ²＝6.610		t＝2.168
P值		<0.05		<0.05		<0.05

表6 各危险因素与POD的二元logistics回归分析

		OR	95%CI	P值
年龄
	60～69岁	1.00	-	-
	70～79岁	4.007	(1.444，11.122)	0.008^a
	≥80岁	4.228	(1.297，13.785)	0.017 ^a
神经阻滞
	是	1.00	-	-
	否	3.490	(1.069，11.394)	0.038^b

表6 各危险因素与POD的二元logistics回归分析

		OR	95%CI	P值
年龄
	60～69岁	1.00	-	-
	70～79岁	4.007	(1.444，11.122)	0.008^a
	≥80岁	4.228	(1.297，13.785)	0.017 ^a
神经阻滞
	是	1.00	-	-
	否	3.490	(1.069，11.394)	0.038^b

[1]	Evered L, Silbert B, Knopman DS, et al. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery-2018[J]. Acta AnaesthesiolScand, 2018, 62(10): 1473-1480.
[2]	Bai J, Liang Y, Zhang P, et al. Association between postoperative delirium and mortality in elderly patients undergoing hip fractures surgery: a meta-analysis[J]. Osteoporos Int, 2020, 31(2): 317-326.
[3]	American Geriatrics Society Expert Panel on Postoperative Delirium in Older A. Postoperative delirium in older adults: best practice statement from the American Geriatrics Society[J]. J Am Coll Surg, 2015, 220(2): 136-148 e1.
[4]	Amornyotin S, Chalayonnawin W, Kongphlay S. Deep sedation for endoscopic retrograde cholangiopancreatography: a comparison between clinical assessment and Narcotrend(TM) monitoring[J]. Med Devices (Auckl), 2011, 4(4): 43-49.
[5]	Punjasawadwong Y, Chau-In W, Laopaiboon M, et al. Processed electroencephalogram and evoked potential techniques for amelioration of postoperative delirium and cognitive dysfunction following non-cardiac and non-neurosurgical procedures in adults [J/OL]. Cochrane Database Syst Rev, 2018, 5(5): CD011283(1-57). doi: 10.1002/14651858.CD011283.pub2.
[6]	Wildes TS, Mickle AM, Ben Abdallah A, et al. Effect of Electroencephalography-Guided anesthetic administration on postoperative delirium among older adults undergoing major surgery: the ENGAGES randomized clinical trial[J]. JAMA, 2019, 321(5): 473-483.
[7]	中华医学会老年医学分会．老年患者术后谵妄防治中国专家共识[J]．中华老年医学杂志，2016，35(12):1257-1262.
[8]	Chan MT, Cheng BC, Lee TM, et al. BIS-guided anesthesia decreases postoperative delirium and cognitive decline[J]. J Neurosurg Anesthesiol, 2013, 25(1): 33-42.
[9]	Radtke FM, Franck M, Lendner J, et al. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction [J]. Br J Anaesth, 2013, 110(Suppl 1): i98-105.
[10]	Soehle M, Dittmann A, Ellerkmann RK, et al. Intraoperative burst suppression is associated with postoperative delirium following cardiac surgery: a prospective, observational study[J]. BMC Anesthesiol, 2015, 15(1): 61-69.
[11]	Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalised non-ICU patients [J/OL]. Cochrane Database Syst Rev, 2016, 3(3): CD005563(1-237).doi: 10.1002/14651858.CD005563.pub3.
[12]	Mackenzie KK, Britt-Spells AM, Sands LP, et al. Processed electroencephalogram monitoring and postoperative delirium: a systematic review and meta-analysis [J]. Anesthesiology, 2018, 129(3): 417-427.
[13]	Oliveira CR, Wm B, Nunes VM. [Benefit of general anesthesia monitored by bispectral index compared with monitoring guided only by clinical parameters. Systematic review and meta-analysis[J]. Rev Bras Anestesiol, 2017, 67(1): 72-84.
[14]	Kreuer S, Biedler A, Larsen R, et al. The narcotrend--a new EEG monitor designed to measure the depth of anaesthesia. a comparison with bispectral index monitoring during propofol remifentanil anaesthesia[J]. Anaesthesist, 2001, 50(12): 921-925.
[15]	Fritz BA, Kalarickal PL, Maybrier HR, et al. Intraoperative electroencephalogram suppression predicts postoperative delirium[J]. Anesth Analg, 2016, 122(1): 234-242.
[16]	Bruhn J, Bouillon TW, Shafer SI. Bispectral index (BIS) and burst suppression：revealing a part of the BIS algorithm[J]. J Clin Monit Comput, 2000, 16(8): 593-596.
[17]	Koch S, Radtke F, Spies C. A call for a more rigorous screening of postoperative delirium[J/OL]. Ann Transl Med, 2019, 7(Suppl 6): S192. doi: 10.21037/atm.2019.07.32.
[18]	Aldecoa C, Bettelli G, Bilotta F, et al. European society of anaesthesiology evidence-based and consensus-based guideline on postoperative delirium[J]. Eur J Anaesthesiol, 2017, 34(4): 192-214.
[19]	Grover S, Kate N, Sharma A, et al. Symptom profile of alcohol withdrawal delirium: factor analysis of Delirium Rating Scale-Revised-98 version[J]. Am J Drug Alcohol Abuse, 2016, 42(2): 196-202.
[20]	Cascella M, Muzio MR, Bimonte S, et al. Postoperative delirium and postoperative cognitive dysfunction: updates in pathophysiology, potential translational approaches to clinical practice and further research perspectives[J]. Minerva Anestesiol, 2018, 84(2): 246-260.
[21]	Van Munster BC, Bisschop PH, Zwinderman AH, et al. Cortisol, interleukins and S100B in delirium in the elderly[J]. Brain Cogn, 2010, 74(1): 18-23.
[22]	Liu XL, Yu Y, Zhu SM. Inflammatory markers in postoperative delirium (POD) and cognitive dysfunction (POCD): a meta-analysis of observational studies [J/OL]. PLoS One, 2018, 13(4): e0195659(1-22).doi: 10.1371/journal.pone.0195659. eCollection 2018.
[23]	Slor CJ, Witlox J, Adamis D, et al. The trajectory of C-reactive protein serum levels in older hip fracture patients with postoperative delirium[J]. Int J Geriatr Psychiatry, 2019, 34(10): 1438-1446.

[1]	王相迎, 杨长生, 曲铁兵. 固定平台单髁置换假体合适位置的研究进展[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 638-645.
[2]	苏介茂, 齐岩松, 王永祥, 魏宝刚, 马秉贤, 张鹏飞, 魏兴华, 徐永胜. 关节镜手术在早中期膝骨关节炎治疗的应用进展[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 646-652.
[3]	郭艳波, 马亮, 李刚, 阎伟, 骆帝, 岳亮, 吴伟山. 全膝关节置换术后胫股关节脱位的研究进展[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 658-671.
[4]	陈翠萍, 李佩君, 杜景榕, 谢青梅, 许一宁, 卓姝妤, 李晓芳. 互联网联合上门护理在老年全髋关节置换术后的应用效果[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 676-681.
[5]	陈晓玲, 钟永洌, 刘巧梨, 李娜, 张志奇, 廖威明, 黄桂武. 超高龄髋膝关节术后谵妄及心血管并发症风险预测[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 575-584.
[6]	马桥桥, 张传开, 郭开今, 蒋涛, 王子豪, 刘勇, 郝亮. 可降解止血粉减少初次全膝关节置换术失血量的研究[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 585-589.
[7]	宋俊锋, 张珍珍. 单侧初发性腹股沟斜疝老年患者经腹腹膜前疝修补术中残余疝囊腹直肌下缘固定效果评估[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(06): 670-674.
[8]	张晋伟, 董永红, 王家璇. 基于GBD2021 数据库对中国与全球老年人疝疾病负担和健康不平等的分析比较[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(06): 708-716.
[9]	袁志静, 黄杰, 何国安, 方辉强. 罗哌卡因联合右美托咪定局部阻滞麻醉在老年腹腔镜下无张力疝修补术中的应用[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(05): 557-561.
[10]	袁延丽, 屈卓军, 崔会慧, 王菁, 高贝贝, 潘院. 原发性肺癌切除术后谵妄的危险因素及预后分析[J/OL]. 中华肺部疾病杂志(电子版), 2024, 17(05): 701-706.
[11]	邵世锋, 肖钦, 沈方龙, 张迅, 郝志鹏, 伍正彬, 谢晓娟, 王耀丽. 老年胸主动脉钝性伤的重症救治分析[J/OL]. 中华肺部疾病杂志(电子版), 2024, 17(05): 762-767.
[12]	王贝贝, 崔振义, 王静, 王晗妍, 吕红芝, 李秀婷. 老年股骨粗隆间骨折患者术后贫血预测模型的构建与验证[J/OL]. 中华老年骨科与康复电子杂志, 2024, 10(06): 355-362.
[13]	茹江英, 廖启宇, 温国洪, 潘思华, 刘栋, 张皓琛, 牛云飞. 直接前方入路和后外侧入路半髋关节置换治疗老年痴呆股骨颈骨折的疗效比较[J/OL]. 中华老年骨科与康复电子杂志, 2024, 10(05): 287-293.
[14]	崔健, 夏青, 林云, 李光玲, 李心娜, 王位. 血小板与淋巴细胞比值、免疫球蛋白、心肌酶谱及心电图对中老年肝硬化患者病情及预后的影响[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(05): 400-406.
[15]	王松雷, 张贻良, 孟浩, 宋威, 白林晨, 袁心, 张辉. 股骨前髁预截骨髓外定位技术在全膝关节置换术中的应用[J/OL]. 中华临床医师杂志(电子版), 2024, 18(09): 811-819.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Anesthesia depth monitoring cannot reduce postoperative delirium undergoing arthroplasty in elderly patients

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Anesthesia depth monitoring cannot reduce postoperative delirium undergoing arthroplasty in elderly patients