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局部麻醉与全身麻醉相比并不能降低老年髋部骨折术后谵妄的发生率
作者:小柯机器人 发布时间:2021/12/24 23:31:55

温州医科大学附属第二医院连庆泉教授团队比较了局部麻醉与全身麻醉对老年髋部骨折术后谵妄发生率的影响。2021年12月20日出版的《美国医学会杂志》发表了这项成果。

在成人髋部骨折手术中,局部麻醉可减少术后谵妄,但其有效性尚不确定。为了探讨在髋关节骨折手术修复的老年人中,与全身麻醉相比,局部麻醉对术后谵妄发生率的影响,2014年10月至2018年11月,研究组在中国东南部的9所大学教学医院进行了一项随机、分配-隐藏、开放标签、多中心的临床试验,共招募了950名65岁及以上的患者,均需手术修复脆性髋部骨折,伴或不伴既往痴呆史。

将患者随机分为两组,其中476例接受局部麻醉(无镇静下的脊髓、硬膜外麻醉或两种技术结合),474例接受全身麻醉(静脉、吸入或联合麻醉)。主要结局是术后头7天谵妄的发生率。次要结局包括谵妄严重程度、持续时间和亚型;术后疼痛评分;住院时间;30天的全因死亡率;以及并发症。

950例患者的平均年龄为76.5岁,247例(26.8%)为男性;941例主要结局可评估(6例取消手术,3例撤回同意)。局麻组中有29例(6.2%)患者发生术后谵妄,全麻组中有24例(5.1%),组间差异不显著。局麻组和全麻组谵妄的平均严重程度评分分别为23.0分和24.1分,分别有16例(3.4%)和10例(2.1%)患者出现谵妄发作,组间差异均不显著。

局麻组谵妄低活性亚型有11例(37.9%),全麻组有5例(20.8%)。两组中位最疼痛评分均为0分,中位住院时间均为7天。局麻组有8例(1.7%)患者死亡,全麻组有4例(0.9%)。局麻组共发生不良事件106例,全麻组发生102例。最常见的不良事件是恶心和呕吐,分别为47例(44.3%)和34例(33.3%),术后低血压分别为13例(12.3%)和10例(9.8%)。

研究结果表明,对于65岁及以上的髋部骨折患者,与全麻相比,无镇静的局部麻醉并没有显著降低术后谵妄的发生率。

附:英文原文

Title: Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial

Author: Ting Li, Jun Li, Liyong Yuan, Jinze Wu, Chenchen Jiang, Jane Daniels, Rajnikant Laxmishanker Mehta, Mingcang Wang, Joyce Yeung, Thomas Jackson, Teresa Melody, Shengwei Jin, Yinguang Yao, Jimin Wu, Junping Chen, Fang Gao Smith, Qingquan Lian, RAGA Study Investigators, Han Lin, Jianfeng Ma, Wangning Shangguan, Xuntong Zhang, Yi Wang, Zuokai Xie, Lili He, Wenwen Lin, Yuyu Xiang, Jianlin Wang, Lingsi Kong, Tao Zhang, Yibing Wang, Nana Bao, Xuzhong Xu, Hao Cheng, Lipei Lei, Zengqiang Zhang, Lihua Fan, Yini Wu, Jianmin Wei, Zhonghua Shi, Wei Mei, Foquan Luo, Lili Zhao, Qin Zhang, Shibiao Chen, Xiaoyun Shi, Yuanbo Liang, Jian Xu, Weihe Zhou, Jingwei Zheng, Weiping Yuan, Yan Lin

Issue&Volume: 2021-12-20

Abstract:

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

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.

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.

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).

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.

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% to 3.8%; 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%]).

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.

DOI: 10.1001/jama.2021.22647

Source: https://jamanetwork.com/journals/jama/article-abstract/2787494

期刊信息

JAMA-Journal of The American Medical Association:《美国医学会杂志》,创刊于1883年。隶属于美国医学协会,最新IF:51.273
官方网址:https://jamanetwork.com/
投稿链接:http://manuscripts.jama.com/cgi-bin/main.plex