脑电双频指数指导下不同麻醉深度对老年创伤性髋部骨折患者术后谵妄的影响

Influence of different depth of anesthesia under BIS guidance on postoperative delirium in elderly patients with traumatic hip fracture

目的:探讨脑电双频指数(BIS)指导下不同麻醉深度对老年创伤性髋部骨折患者术后谵妄(POD)的影响,并探索最佳麻醉深度。方法:选择拟在全麻下行髋部手术治疗的老年患者75例,分为常规麻醉组(N组,根据生命体征变化调整用药并记录BIS值)、高目标值组(B1组,维持BIS值在51~60)和低目标值组(B2组,维持BIS值在40~50),每组25例。记录麻醉诱导前(T_(0))、切皮(T_(1))、术中(T_(2),自切皮起1 h)、拔管(T_(3))、离室时(T_(4))的平均动脉压(MAP)和心率(HR),入室及术毕时血糖变化情况,术中丙泊酚、瑞芬太尼用量,以及术后苏醒时间、苏醒时Steward评分和离室时间。采用改良Brice调查问卷判断患者术中知晓发生情况。采用谵妄评定量表(CAM-CR)分别于术后24、48、72 h评估各组POD发生率。采用简易精神状态评价量表(MMSE)分别于术后24、72 h评估患者术后认知功能情况。采用视觉模拟评分量表(VAS)于术后8、12、24 h评估患者术后疼痛情况。记录术后恶心呕吐发生情况及术后住院天数。结果:术后24 h,B1组POD发生率低于N组及B2组,MMSE评分高于N组及B2组(均P<0.05)。三组术后48、72 h时POD发生率比较差异无统计意义(均P>0.05)。术后72 h时,MMSE评分B1组最高,B2组次之,N组最低(均P<0.05)。与N组比较,B2组患者术毕血糖水平低(P<0.05)。在T_(0)时点,三组MAP与HR比较差异无统计学意义(均P>0.05)。在T_(1)时点,N组MAP及HR高于B1、B2组(均P<0.05)。在T_(2)时点,B1组MAP最高,N组次之,B2组最低(均P<0.05);N组及B1组HR高于B2组(均P<0.05)。在T_(3)时点,N组及B2组MAP及HR高于B1组(均P<0.05)。在T_(4)时点,三组患者MAP及HR比较差异无统计学意义(均P>0.05)。相较于B1组,N组和B2组丙泊酚用量增加(均P<0.05)。三组瑞芬太尼用量比较差异无统计学意义(P>0.05)。相较于B1组,N组与B2组苏醒时Steward评分降低,苏醒时间和离室时间增加(均P<0.05)。三组均未发生术中知晓。三组术后恶心呕吐及VAS评分比较差异无统计学意义(均P>0.05)。B1组术后住院天数低于N组、B2组(均P<0.05)。结论:术中行BIS监测可减少老年创伤性髋部骨折患者POD发生率,且BIS值维持在51~60为其最佳麻醉深度。

Objective:To investigate the influence of different depth of anesthesia under Bispectral Index(BIS)guidance on postoperative delirium(POD)in elderly patients with traumatic hip fracture,and to explore the best anesthesia depth.Methods:Seventy-five elderly patients scheduled for hip surgery under general anesthesia were divided into conventional anesthesia group(group N,medication was adjusted according to changes in vital signs and BIS value was recorded),high-target group(group B1,maintaining BIS value between 51 to 60)and low-target group(group B2,maintaining BIS value between 40 to 50),with 25 patients in each group.The MAP and HR were recorded before anesthesia induction(T_(0)),skin incision(T_(1)),during operation(T_(2),1 hour from skin incision),extubation(T_(3)),and leaving the room(T_(4)).The changes of blood glucose at admission and at the end of operation,the consumption of propofol and remifentanil during operation,and postoperative awakening time,Steward score at awakening,and time to leave the room were recorded.The modified Brice questionnaire was used to determine the occurrence of intraoperative awareness of patients.CAM-CR was used to evaluate the incidence of POD at 24,48 and 72 hours after operation.MMSE was used to evaluate the postoperative cognitive function of patients at 24 and 72 hours after operation.VAS was used to evaluate the postoperative pain at 8,12 and 24 hours after operation.The occurrence of postoperative nausea and vomiting and the length of postoperative hospital stay were recorded.Results:At 24 hours after operation,the incidence of POD in group B1 was lower than that in group N and group B2,and the MMSE score was higher than that in group N and group B2(all P<0.05).There was no significant difference in the incidence of POD among the three groups at 48 and 72 hours after operation(all P>0.05).At 72 hours after operation,the MMSE score was the highest in group B1,followed by group B2 and group N(all P<0.05).Compared with group N,the blood glucose level at the end of operation was significantly lower in group B2(P<0.05).At T_(0),there was no significant difference in MAP and HR among the three groups(all P>0.05).At T_(1),MAP and HR in group N were higher than those in groups B1 and B2(all P<0.05).At T_(2),MAP was the highest in group B1,followed by group N and group B2(all P<0.05).HR in group N and group B1 was higher than that in group B2(all P<0.05).At T_(3),MAP and HR in group N and group B2 were higher than those in group B1(all P<0.05).At T_(4),there were no significant differences in MAP and HR among the three groups(all P>0.05).Compared with group B1,the consumption of propofol was increased in group N and group B2(all P<0.05).There was no significant difference in the dosage of remifentanil among the three groups(P>0.05).Compared with group B1,the Steward score of group N and group B2 was significantly decreased,and the awakening time and leaving room time were increased(all P<0.05).No intraoperative awareness occurred in the three groups.There were no significant differences in postoperative nausea and vomiting and VAS scores among the three groups(all P>0.05).The postoperative hospital stay in group B1 was lower than that in group N and group B2(all P<0.05).Conclusion:Intraoperative BIS monitoring can reduce the incidence of POD in elderly patients with traumatic hip fractures,and the optimal depth of anesthesia is to maintain BIS value at 51 to 60.