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

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

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