老年骨科患者术后高活动性谵妄危险因素的巢式病例对照研究

Nested case-control study on risk factors of postoperative hyperactive-type delirium in geriatric orthopedic patients

目的采用巢式病例对照研究探讨老年骨科患者术后高活动性谵妄（PHTD）发生的危险因素。方法回顾性分析2008年1月至2013年12月温州医科大学附属第二医院行骨科手术的老年患者病例资料，年龄I〉65岁、美国麻醉医师协会（ASA）分级为Ⅰ ～Ⅳ级，且病历资料齐全、明确诊断为PHTD的患者共74例作为病例组；采用巢式病例对照研究按1：6频数匹配同期同类无PHTD发生的患者444例作为对照组，收集患者年龄、性别、ASA分级、术前／术后电解质、术前血糖、术前／术后血浆白蛋白、术前／术后红细胞比容（Hct）、是否使用非甾体类镇痛药、抗胆碱能药物或苯二氮革类药物、麻醉方式、麻醉时间、术后镇痛差异等资料，筛选PHTD发生的危险因素。结果单因素Logistic分析显示性别、年龄、ASA分级、术前电解质、麻醉时间、手术时间、术中低血压、术后镇痛差异是PHTD发生的危险因素。多因素Logistic回归分析显示性别（OR=2．562，95％CI：1．438～4．564，P：0．001）、年龄（OR=3．929，95％CI：1．788～8．633，P=0．001）和术前电解质（OR=3．714，95％CI：2．068～6．670，P〈0．001）是PHTD发生的独立危险因素。结论男性、高龄、术前电解质异常是老年骨科患者PHTD发生的独立危险因素。

Objective To investigate the risk factors of postoperative hyperactive-type delirium （PHTD） in geriatric orthopedic patients using nested case-control study. Methods Seventy-four patients who underwent orthopedic surgeries in the Second Affiliated Hospital of Wenzhou Medical University from January 2008 to December 2013, aged 65 or above, American Society of Anesthesiologists （ASA） physical status Ⅰ - Ⅳ, with complete medical records and confirmed diagnosis of PHTD were selected as case group. A control group of 444 patients, on the basis of 1 ： 6 versus nested case group, from the same cohort but without PHTD was established. Data patterns such as patient age, gender, ASA classification, status of preoperative/postoperative electrolytes, preoperative blood glucose, preoperative/postoperative plasma albumin and preoperative/postoperative hematocrit （ Hct）, uses of non-steroidal analgesics, anticholinergic drugs and benzodiazepines drugs, type of anesthesia, anesthesia duration, difference in postoperative analgesia were collected and analyzed. Results Univariate Logistic regression analysis showed that gender, age, ASA grade, preoperative electrolytes, anesthesia duration, operative duration, intraoperative hypotension and the difference of postoperative analgesia were risk factors for PHTD. Multiple Logistic regression analysis showed that gender （ OR = 2. 562, 95% CI： 1. 438 - 4. 564, P = 0. 001 ） , age （ OR = 3. 929, 95% CI： 1. 788 - 8. 633, P = 0. 001 ） , preoperative electrolytes （ OR = 3.714, 95% CI： 2. 068 - 6. 670, P 〈 0. 001 ）were the independent risk factors for PHTD. Conclusion Male, elderly patients and abnormalities of preoperative electrolyte are the independent risk factors for PHTD in geriatric orthopedic patients.