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Epidemiological Survey on Postoperative Delirium in Elderly Noncardiac Surgical Patients
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摘要:
目的 探讨老年非心脏手术患者术后谵妄的发病情况, 分析谵妄发病围手术期危险因素。 方法 采用整群抽样调查方法, 计算预计样本量为712例。选择2006年8月至12月北京协和医院65岁以上全麻或区域麻醉下行择期非心脏手术普通病房住院患者, 术前1 d及术后1、2、3 d密切随访患者, 谵妄诊断标准参照美国精神病学会制订的意识错乱评估方法(confusion assessment method, CAM)。按设计调查表详细记录术前病史、合并症, 术中麻醉方式、麻醉用药, 术中、术后并发症, 术后镇痛等各项内容, 建立数据库。所有数据用SAS 8.2软件进行统计分析。 结果 共718例患者纳入研究, 其中80例术后发生谵妄, 发病率为11.1%;80例谵妄患者中68例(85%)为一过性谵妄(< 24 h), 另12例(15%)持续性谵妄患者中8例为术后转重症监护病房(intensive care unit, ICU)需呼吸支持治疗的患者。多因素Logistic逐步回归分析结果表明高龄(OR:1.480, 95% CI:1.070~2.046)、脑血管意外病史(OR:2.862, 95% CI:1.432~5.720)、东莨菪碱(OR:2.537, 95% CI:1.523~4.227)、哌替啶(OR:3.196, 95% CI:1.574~6.488)、术中低血压(OR:1.780, 95% CI:1.070~2.960)、手术时间超过3 h(OR:2.610, 95% CI:1.538~4.431)、术后转入ICU(OR:2.187, 95% CI:1.077~4.442)等为术后谵妄的危险因素。 结论 高龄、既往脑血管意外病史患者是术后谵妄的易感人群, 围手术期尽量避免低血压的发生、减少东莨菪碱及哌替啶的使用, 缩短手术时间可能会降低谵妄的发生率。 Abstract:Objective To investigate the incidence of delirium after noncardiac surgery among elderly patients and explore the possible perioperative risk factors. Methods In this cross-sectional study using cluster sampling, totally 718 patients aged 65 or older who had undergone elective noncardiac surgeries in our hospital from August to December 2006 were enrolled. Patients were interviewed at the day before surgery and an informed consent was obtained. The same interviewer evaluated the patients prospectively for delirium with the Confusion Assessment Method (CAM) on the preoperative day 1, postoperative day 1, day 2, and day 3. Other information including previous medical history, comorbidities, anesthetics, and perioperative medications were also recorded. Results Delirium occurred in 80 patients (11.1%) at during the first three postoperative days, among whom transient symptoms were more frequent than continuous delirium status (68, 85% vs. 12, 15%). The Logistic stepwise regression analysis indicated that the perioperative risk factors of delirium included advanced age (OR:1.480, 95% CI:1.070-2.046), history of stroke (OR:2.862, 95% CI:1.432-5.720), use of meperidine (OR:3.196, 95% CI:1.574-6.488) or scopolamine (OR:2.537, 95% CI:1.523-4.227), hypotention during the operation (OR:1.780, 95% CI:1.070-2.960), long-duration operations (≥ 3 h) (OR:2.610, 95% CI:1.538-4.431), and ICU admission after surgeries (OR:2.187, 95% CI:1.077-4.442). Conclusions Advanced age or previous history of stroke are the most important risk factors of postoperative delirium. The incidence of postoperative delirium may be decreased by avoiding other risk factors such as perioperative hypotension, usage of meperidine and scopolamine, and long-duration operation. -
Key words:
- delirium /
- anesthesia /
- surgery /
- incidence rate /
- risk factors
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表 1 调查因素及赋值说明
调查因素 赋值说明 年龄(岁) 65 ~ 69 = 1，70 ~ 74 = 2，≥75 = 3 性别 男= 1，女= 2 ASA分级 Ⅰ = 1，Ⅱ = 2，Ⅲ = 3，Ⅳ = 4，Ⅴ = 5 教育程度 小学以下= 1，初中= 2，高中= 3，大学以上= 4 吸烟 否= 0，是= 1 饮酒 否= 0，是= 1 高血压史 无= 0，有= 1 糖尿病史 无= 0，有= 1 冠心病史 无= 0，有= 1 高脂血症史 无= 0，有= 1 肺功能异常 无= 0，有= 1 既往手术史 无= 0，有= 1 脑血管病史 无= 0，有= 1 焦虑/抑郁史 无= 0，有= 1 老年痴呆史 无= 0，有= 1 服安眠药史 无= 0，有= 1 全身麻醉 否= 0，是= 1 高危手术 胸腹、脊柱、关节及大血管手术= 1，其他= 0 咪达唑仑 未用= 0，用= 1 东莨菪碱 未用= 0，用= 1 阿托品 未用= 0，用= 1 哌替啶 未用= 0，用= 1 肌松拮抗 未用= 0，用= 1 手术时间(h) ＜3 h = 0，≥3 h = 1 术中失血量(ml) ＜800 = 0，≥800 = 1 术中输血量(ml) ＜600 = 0，≥600 = 1 术中高血压 无= 0，有= 1 术中低血压 无= 0，有= 1 术中低氧血症 无= 0，有= 1 术中低体温 无= 0，有= 1 术后回ICU 否= 0，是= 1 PCA 无= 0，有= 1 PONV 无= 0，有= 1 谵妄 无= 1，有= 0 ASA:美国麻醉医师协会; ICU:重症监护病房; PCA:术后病人自控镇痛; PONV:术后恶心呕吐 
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表 2 手术类型及术后谵妄发病率
手术种类 观察病例
(人次)谵妄病例
(人次)谵妄发病率
(%)胸科手术 86 14 16. 3 上腹部手术 72 13 18. 1 脊柱、关节手术 105 16 15. 2 大血管手术 36 4 11. 1 开颅手术 7 4 57. 1 头颈部手术 56 4 7. 1 下腹部、体表手术 159 13 8. 2 内镜手术 197 12 6. 1 合计 718 80 11. 1
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表 3 术后谵妄的临床表现(n = 80)
临床表现 出现频率(例) 发生率(%) 意识清晰度降低 75 93. 8 烦躁不安 65 81. 3 言语紊乱、不连贯 53 66. 3 注意、定向、计算障碍* 55 68. 8 知觉错误、幻觉、错觉* 39 48. 8 精神运动兴奋 53 66. 3 精神运动减低 3 3. 75 睡眠-觉醒周期紊乱 74 92. 5 一过性谵妄(＜24 h) 68 85. 0 *严重意识障碍者无法评估
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表 4 术后谵妄危险因素分析
选入变量 回归系数 标准误 Wald卡方值 P OR 95% CI 常数项 － 4. 2444 0. 4464 90. 3967 ＜0. 0001 手术时间 0. 9595 0. 2700 12. 6302 0. 0004 2. 610 1. 538 ~ 4. 431 脑血管病史 1. 0516 0. 3533 8. 8615 0. 0029 2. 862 1. 432 ~ 5. 720 东莨菪碱 0. 9309 0. 2605 12. 7733 0. 0004 2. 537 1. 523 ~ 4. 227 哌替啶 1. 1619 0. 3613 10. 3451 0. 0013 3. 196 1. 574 ~ 6. 488 ICU 0. 7825 0. 3615 4. 6855 0. 0304 2. 187 1. 077 ~ 4. 442 年龄 0. 3918 0. 1654 5. 6102 0. 0179 1. 480 1. 070 ~ 2. 046 术中低血压 0. 5765 0. 2595 4. 9338 0. 0263 1. 780 1. 070 ~ 2. 960 Logistic逐步回归法(α入= 0. 10，α出= 0. 10); ICU:同表 1
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