术前脑脊液/血清白蛋白比值与椎管内麻醉患者术后谵妄的关系

Relationship between preoperative cerebrospinal fluid/serum albumin ratio and postoperative delirium in patients undergoing neuraxial anesthesia

目的评价术前脑脊液/血清白蛋白比值(Q-alb)与椎管内麻醉患者术后谵妄(POD)的关系。方法收集2018年1月至2020年12月本院择期在脊椎-硬膜外联合阻滞下行膝/髋关节置换术患者,年龄40~90岁,ASA分级Ⅰ或Ⅱ级。入室后采集静脉血样本及脑脊液样本,采用ELISA法检测脑脊液白蛋白、β-淀粉样蛋白(Aβ)1-42、Aβ1-40、总Tau蛋白(t-Tau)、磷酸化Tau蛋白(p-Tau)及血清白蛋白水平。计算Q-alb,Q-alb>10.2为存在血脑屏障功能障碍。于术前1 d采用MMSE量表评估认知水平,术后1~7 d采用谵妄量表分析系统及攻击行为量表评估POD的发生情况和程度。根据是否发生POD将患者分为POD组(P组)及非POD组(NP组)。采用线性回归分析Q-alb与Aβ1-42、Aβ1-40、t-Tau、p-Tau的相关性,采用二元logistic回归分析Q-alb与POD的关系。采用受试者工作特征(ROC)曲线评价Q-alb预测POD的准确性。结果P组49例,NP组49例。与NP组比较,P组脑脊液Aβ1-42、Aβ1-40浓度降低,t-Tau、p-Tau、白蛋白浓度升高,Q-alb和血脑屏障功能障碍比率升高(P<0.05)。混杂因素校正前和校正后,Q-alb、脑脊液Aβ1-42、Aβ1-40、t-Tau、p-Tau浓度均为POD的危险因素(P<0.05)。Q-alb与脑脊液t-Tau、p-Tau浓度呈正线性回归关系(t-Tau:β=0.587,P<0.001;p-Tau:β=0.427,P<0.001),与脑脊液Aβ1-42、Aβ1-40浓度呈负线性回归关系(Aβ1-42:β=-0.762,P<0.001;Aβ1-40:β=-0.531,P<0.001)。P组中Q-alb与脑脊液p-Tau浓度无线性回归关系(P=0.121);NP组中Q-alb与脑脊液Aβ1-40浓度无线性回归关系(P=0.467)。Q-alb预测POD的ROC曲线下面积为0.827(95%可信区间0.738~0.896)。结论术前较高的Q-alb是椎管内麻醉患者POD的危险因素,且预测POD的准确性较高。

Objective To evaluate the relationship between preoperative cerebrospinal fluid/serum albumin ratio(Q-alb)and postoperative delirium(POD)in patients undergoing neuraxial anesthesia.Methods The patients,aged 40-90 yr,of American Society of Anesthesiologists physical statusⅠorⅡ,underwent total knee/hip replacement under combined spinal-epidural block in our hospital from January 2018 to December 2020,were collected.After admission to the operating room,venous blood and cerebrospinal fluid samples were collected for determination of cerebrospinal fluid albumin,β-amyloid(Aβ)1-42,Aβ1-40,total tau protein(t-Tau),phosphorylated tau protein(p-Tau)and serum albumin levels(by enzyme-linked immunosorbent assay)and for calculation of Q-alb.When Q-alb was more than 10.2,the patient was considered to have blood-brain barrier disruption.Mini-Mental State Examination scale was used to evaluate the cognitive level on 1 day before surgery.The development of POD was evaluated using Confusion Assessment Method Chinese Reversion and Memorial Delirium Assessment Scale at 1-7 days after surgery.The patients were divided into POD group(P group)and non-POD(NP group)according to whether POD occurred.The receiver operating characteristic(ROC)curve was used to analyze the accuracy of Q-alb in predicting POD.Results There were 49 cases in each group.Compared with group NP,concentrations of Aβ1-42 and Aβ1-40 were significantly decreased,concentrations of t-Tau and p-Tau albumin were increased,the ratio of Q-alb and blood-brain barrier disruption was increased in group P(P<0.05).Before and after adjusting for confounding factors,Q-alb,cerebrospinal fluid Aβ1-42,Aβ1-40,t-Tau and p-Tau levels were risk factors for POD(P<0.05).There was a positive linear regression relationship between Q-alb and levels of t-Tau and p-Tauin cerebrospinal fluid(t-Tau:β=0.587,P<0.001;p-Tau:β=0.427,P<0.001),and there was a negative linear regression relationship between Q-alb and levels of Aβ1-42 and Aβ1-40 in cerebrospinal fluid(Aβ1-42:β=-0.762,P<0.001;Aβ1-40:β=-0.531,P<0.001).There was no linear regression relationship between Q-alb and level of p-Tau in group P(P=0.121).There was no linear regression relationship between Q-alb and level of Aβ1-40 in group NP(P=0.467).The results of ROC curve analysis showed that the area under the curve for Q-alb in predicting POD(95%confidence interval)was 0.827(0.738-0.896).Conclusion Preoperative higher Q-alb is the risk factor for POD in patients undergoing neuraxial anesthesia,and is more accurate in predicting POD.