膝关节置换患者术后谵妄的危险因素分析

The incidence and risk factors of postoperative delirium in patients undergoing total knee arthroplasty

目的探讨60岁以上膝关节置换患者术后谵妄的危险因素。方法选择择期行单侧膝关节置换术患者369例,男73例,女296例,年龄>60岁,ASAⅠ或Ⅱ级。诱导前所有患者均在神经刺激器定位下行股神经阻滞,给予0.4%罗哌卡因25ml后置入连续股神经置管用于术后镇痛,术中采用静-吸复合全麻。术后3d内每天两次使用ICU专用谵妄评估表(confusion assessment method-intensive care unit,CAM-ICU)评估患者是否发生谵妄并记录术后非谵妄并发症发生情况。以是否发生谵妄分组,筛选出术后谵妄的可能危险因素,包括术中使用静脉麻醉药物种类、性别、年龄、文化程度;术前合并高血压、冠心病、心律失常、脑卒中、呼吸道疾病、糖尿病、肾功能异常,术前ASA分级;术中出血、术中输血、总输血量;术后疼痛程度及术后是否使用哌替啶。将所有观察因素进行多因素Logistic回归分析。结果本研究中有62例患者(16.8%)在术后3d内发生谵妄。患者年龄增高(OR=2.116,P=0.035)、受教育程度低(OR=0.091,P<0.001)、术前合并慢性阻塞性肺疾病(COPD)(OR=12.500,P=0.002)、ASA分级(OR=22.333,P=0.005)、总输血量增加(OR=4.500,P<0.001)以及术后使用哌替啶(OR=22.372,P=0.001)为患者发生术后谵妄的独立危险因素。结论 60岁以上患者年龄、受教育程度、术前合并COPD、ASA分级、总输血量和术后使用哌替啶为患者发生术后谵妄的独立危险因素。

Objective To explore the incidence and risk factors for postoperative delirium patients over 60 years undergoing total knee arthroplasty.Methods Three hundred and sixty-nine patients（73males,296 females,aged over 60 years,ASA Ⅰ orⅡ）undergoing unilateral total knee arthroplasty were chosen.Before induction of anesthesia,femoral nerve block by nerve stimulator was performed for all patients,25 ml of 0.4% ropivacaine was injected to the continuous femoral nerve catheter for postoperative analgesia,all patients received intravenous-inhalation anesthesia during the operative.The confusion assessment method-intensive care unit（CAM-ICU）was used twice a day to evaluate whether the postoperative delirium had happened for patients within 3 days after operation,and record the case of complication besides postoperative delirium.To analysis the perioperative indicators depend on whether the postoperative delirium had happened for patients,then to screen out the probable risk factors for postoperative delirium,which include the kind of intravenous anesthesia drugs during operation,gender,age group,level of education;preoperative hypertension,coronary heart disease,arrhythmia,stroke,respiratory disease,diabetes,abnormal renal function and the ASA grade;the bleeding and blood transfusion volume during operative and the total amount of blood transfusion;degree of postoperative pain and whether used pethidine after operative.Put all observed factors to be analyzed by the Logistic regression model.Results Sixty-two patients（16.8%）had delirium within 3days after operation.The results of multi-factor Logistic regression analysis indicates that the patients＇ increasing age（OR=2.116,P=0.035）,low level of education（OR=0.091,P〈0.001）,preoperative chronic obstructive pulmonary diseases（COPD）（OR=12.500,P=0.002）,high ASA grade（OR=22.333,P =0.005）,increasing total amount of blood transfusion（OR=4.500,P〈0.001）and postoperative used pethidine（OR=22.372,P=0.001）were the independent risk factors for postoperative delirium.Conclusion The patients＇ age,level of education,preoperative COPD,high ASA grade,increasing total amount of blood transfusion and postoperative used pethidine are the independent risk factors for postoperative delirium.