【原】【文献阅读】区域麻醉与全身麻醉对老年髋部骨折术后谵妄发生率的影响

Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery

区域麻醉与全身麻醉对老年髋部骨折术后谵妄发生率的影响

IMPORTANCE

IMPORTANCE In adults undergoing hip fracture surgery, regional anesthesia may reduce postoperative delirium, but there is uncertainty about its effectiveness.

重要性 在接受髋部骨折手术的成年人中，区域麻醉可以减少术后谵妄，但其有效性尚不确定。

OBJECTIVE

OBJECTIVE To  investigate, in older adults undergoing surgical repair for hip fracture, the effects of regional anesthesia on the incidence of postoperative delirium compared with general anesthesia.

目的 研究在接受髋部骨折手术修复的老年人中，与全身麻醉相比，区域麻醉对术后谵妄发生率的影响。

DESIGN, SETTING, AND PARTICIPANTS

DESIGN, SETTING, AND PARTICIPANTS A randomized, allocation-concealed, open-label,

multicenter clinical trial of 950 patients, aged 65 years and older, with or without preexisting dementia, and a fragility hip fracture requiring surgical repair from 9 university teaching hospitals in Southeastern China. Participants were enrolled between October 2014 and September 2018; 30-day follow-up ended November 2018.

设计、设置和配对 随机、分配隐藏、开放标签、多中心的临床试验，研究对象为来自东南部中国的9所大学教学医院的950名年龄在65岁以上、有或没有既往痴呆的患者，以及需要手术修复的脆性髋部骨折患者。参与者在2014年10月至2018年9月之间登记，随后进行30天跟踪调查，截至2018年11月。

INTERVENTIONS

INTERVENTIONS Patients were randomized to receive either regional anesthesia (spinal,

epidural, or both techniques combined with no sedation; n = 476) or general anesthesia

(intravenous, inhalational, or combined anesthetic agents; n = 474).

干预：患者随机接受区域麻醉(腰麻、硬膜外麻醉或两种技术联合使用，不使用镇静剂，n=476)或全身麻醉(静脉、吸入或复合麻醉剂，n=474)。

MAIN OUTCOMES AND MEASURES

MAIN OUTCOMES AND MEASURES Primary outcome was incidence of delirium during the first 7 postoperative days. Secondary outcomes analyzed in this article include delirium severity,duration, and subtype; postoperative pain score; length of hospitalization; 30-day all-cause mortality; and complications.

主要结果和测量 主要结果是术后前7天内的谵妄的发生率。本文分析的次要结果包括谵妄的严重程度、持续时间和亚型；术后疼痛评分；住院时间；30天全因死亡率以及并发症。

RESULTS

RESULTS Among 950 randomized patients (mean age, 76.5 years; 247 [26.8%] male), 941 were evaluable for the primary outcome (6 canceled surgery and 3 withdrew consent). Postoperative delirium occurred in 29 (6.2%) in the regional anesthesia group vs 24 (5.1%) in the general anesthesia group (unadjusted risk difference [RD], 1.1%; 95% CI, –1.7% to3.8%;P= .48; unadjusted relative risk [RR], 1.2 [95% CI, 0.7 to 2.0];P= .57]). Mean severity score of delirium was 23.0 vs 24.1, respectively (unadjusted difference, –1.1; 95% CI, –4.6 to 3.1). A single delirium episode occurred in 16 (3.4%) vs 10 (2.1%) (unadjusted RD, 1.1%; 95% CI,–1.7% to 3.9%; RR, 1.6 [95% CI, 0.7 to 3.5]). Hypoactive subtype in 11 (37.9%) vs 5 (20.8%)(RD, 11.5; 95% CI, –11.0% to 35.7%; RR, 2.2 [95% CI, 0.8 to 6.3]). Median worst pain score was 0 (IQR, 0 to 20) vs 0 (IQR, 0 to 10) (difference 0; 95% CI, 0 to 0). Median length of hospitalization was 7 days (IQR, 5 to 10) vs 7 days (IQR, 6 to 10) (difference 0; 95% CI, 0 to 0). Death occurred in 8 (1.7%) vs 4 (0.9%) (unadjusted RD, –0.8%; 95% CI, –2.2% to 0.7%; RR, 2.0 [95% CI, 0.6 to 6.5]). Adverse events were reported in 106 episodes in the regional anesthesia group and 102 in the general anesthesia group; the most frequently reported adverse events were nausea and vomiting (47 [44.3%] vs 34 [33.3%]) and postoperative hypotension (13 [12.3%] vs 10 [9.8%]).

结果： 950例患者(平均年龄76.5岁；247例(26.8%)男性)，941例可评价主要结果(6例取消手术，3例撤回同意)。区域麻醉组有29例(6.2%)术后出现谵妄，全麻组有24例(5.1%)出现(未调整风险差异[RD]，1.1%；95%CI，-1.7%至3.8%；P=.48；未调整相对风险[RR]，1.2[95%CI，0.7至2.0]；P=.57])。谵妄的平均严重程度评分分别为23.0分和24.1分(未校正差值为-1.1；95%可信区间为-4.6~3.1)。16例(3.4%)对10例(2.1%)出现1次谵妄(未调整RD，1.1%；95%CI，-1.7%~3.9%；RR 1.6[95%CI，0.7~3.5])。低活跃型11例(37.9%)vs5例(20.8%)(RD，11.5；95%CI，-11.0%~35.7%；RR，2.2[95%CI，0.8~6.3])。最严重疼痛评分的中位数分别为0(IQR，0~20)和0(IQR，0~10)(差值为0；95%CI，0~0)。中位住院天数分别为7天(IQR，5~10)和7天(IQR，6~10)(差异0；95%CI，0~0)。死亡8例(1.7%)vs4例(0.9%)(未调整RD，-0.8%；95%CI，-2.2%至0.7%；RR，2.0[95%CI，0.6至6.5])。区域麻醉组和全身麻醉组分别报告了106次和102次不良事件，最常见的不良事件是恶心呕吐(47次[44.3%]比34次[33.3%])和术后低血压(13次[12.3%]比10次[9.8%])。

CONCLUSIONS AND RELEVANCE

CONCLUSIONS AND RELEVANCE In patients aged 65 years and older undergoing hip fracture surgery, regional anesthesia without sedation did not significantly reduce the incidence of postoperative delirium compared with general anesthesia.

结论及相关性：在65岁及以上接受髋部骨折手术的患者中，与全身麻醉相比，不使用镇静剂的区域麻醉并不能显著降低术后谵妄的发生率。

\ | /

★

研究对象招募及随访情况

统计结果

1、患者的基线特征

2、区域麻醉与全身麻醉下髋部骨折病人的术中特点

3主要结果、次要结果

4、并发症

effect of regional vs general anesthesia on incidenc .pdf

文章｜吴秀云

排版｜肉肉