全麻腰椎手术老年患者POCD的危险因素及预测模型

Risk factors for postoperative cognitive dysfunction and the predictive model in elderly patients undergoing lumbar surgery under general anesthesia

目的筛选全麻腰椎手术老年患者术后认知功能障碍(POCD)的危险因素,并建立预测模型。方法纳入2021年7月至2022年7月于本院择期行全麻下腰椎手术的老年患者,术后7 d采用MMSE和MoCA评估认知功能,2个量表评分均满足下降≥1标准差为发生POCD,根据是否发生POCD分为POCD组和非POCD组。采用倾向性评分匹配消除组间混杂偏倚,采用多因素logistic回归分析筛选POCD的危险因素;构建预测模型,绘制列线图进行可视化,采用受试者工作特征曲线、校准曲线、决策分析曲线分别对模型的区分度、一致性及临床有效性进行评价。结果本研究共纳入159例患者,POCD发生率31.4%。匹配后2组(n=32)术中输血比率、累积低血压时间、总输液量、手术时间差异有统计学意义(P<0.05)。多因素logistic回归分析结果显示,高龄、受教育年限、糖尿病、既往2次及以上全麻手术史、APTT、累积低血压时间是老年患者全麻腰椎手术发生POCD的独立危险因素(P<0.05)。根据上述危险因素构建模型式:LogitP=-15.878+0.263×年龄(岁)-0.122×受教育年限(年)+1.601×糖尿病+1.468×2次及以上全麻手术史+0.608×累计低血压时间(min)-0.140×APTT(s)。预测模型的受试者工作特征曲线下面积为0.930(95%CI 0.887~0.973),灵敏度0.920,特异度0.798,约登指数0.718。列线图对模型进行可视化后,经Hosmer-Lemeshow检验得到P=0.403,C指数为0.930,校正C指数为0.914。结论高龄、受教育年限、糖尿病、既往多次全麻手术史、APTT、累积低血压时间是全麻腰椎手术老年患者POCD发生的独立危险因素,基于此建立的疾病预测模型可有效预测POCD的发生。

Objective To identify the risk factors for postoperative cognitive dysfunction(POCD)and develop the prediction model in elderly patients undergoing lumbar surgery under general anesthesia.Methods The elderly patients undergoing elective lumbar surgery under general anesthesia in our hospital from July 2021 to July 2022 were enrolled.Cognitive function was assessed at 7 days after surgery using Mini-Mental State Examination and Montreal Cognitive Assessment.When the decrease in both scales≥1 standard deviation,the patients were considered as having POCD.The patients were divided into POCD group and non-POCD group according to whether POCD developed.The propensity score matching was used to balance the confounding bias between two groups.The multivariate logistic regression analysis was used to identify the risk factors for POCD.The prediction model was constructed,and a nomogram was drawn for visualization of the model.The receiver operating characteristic curve,calibration plot and decision curve analysis(DCA)were drawn to evaluate the differentiation,consistency and clinical validity of the model,respectively.Results A total of 159 patients were enrolled in this study,and the incidence of POCD was 31.4%.There were statistically significant differences in the ratio of intraoperative blood transfusion,cumulative time of hypotension,total infusion volume and operation time between two groups(n=32 each)after propensity score matching(P<0.05).The results of multivariate logistic regression showed that age,educational levels,diabetes mellitus,previous two or more operations under general anesthesia,APTT and cumulative time of hypotension were independent risk factors for POCD in elderly patients undergoing lumbar surgery under general anesthesia(P<0.05).A model was developed based on the risk factors mentioned above:LogitP=-15.878+0.263×Age(years)-0.122×Educational Level(years)+1.601×Diabetes Mellitus+1.468×History of General Anesthesia for 2 or more times+0.608×Cumulative Time of Hypotension(min)-0.140×APTT(s).The area under the receiver operating characteristic curve was 0.930(95%CI 0.887-0.973),the sensitivity was 0.920,specificity was 0.798 and Youden index was 0.718.After visualizing the model via nomogram,the model was verified by Hosmer-Lemeshow test,P=0.403,C index was 0.930,and corrected C index was 0.914.Conclusions Age,educational levels,diabetes mellitus,previous multiple operations under general anesthesia,APTT and cumulative time of hypotension are independent risk factors for POCD in elderly patients undergoing lumbar surgery under general anesthesia,and the established risk prediction model can effectively predict the occurrence of POCD in elderly patients undergoing lumbar surgery under general anesthesia.