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[JAMA Surgery发表论文]:非急诊大手术后谵妄与远期认知功能的相关性
2019年05月09日 时讯速递, 进展交流 暂无评论

Original Investigation January 16, 2019

Association Between Postoperative Delirium and Long-term Cognitive Function After Major Nonemergent Surgery

C. Adrian Austin, Thomas O’Gorman, Elizabeth Stern, et al

JAMA Surg. 2019;154(4):328-334. doi:10.1001/jamasurg.2018.5093

Abstract

Importance 背景

Postoperative delirium is associated with decreases in long-term cognitive function in elderly populations.

老年人术后谵妄伴随远期认知功能减退。

Objective 目的

To determine whether postoperative delirium is associated with decreased long-term cognition in a younger, more heterogeneous population.

明确具有明显异质性的年轻人术后谵妄是否伴随远期认知功能减退。

Design, Setting, and Participants 试验设计、场景及研究人群

A prospective cohort study was conducted at a single academic medical center (≥800 beds) in the southeastern United States from September 5, 2017, through January 15, 2018. A total of 191 patients aged 18 years or older who were English-speaking and were anticipated to require at least 1 night of hospital admission after a scheduled major nonemergent surgery were included. Prisoners, individuals without baseline cognitive assessments, and those who could not provide informed consent were excluded. Ninety-day follow-up assessments were performed on 135 patients (70.7%).

在美国东南部的一个医学中心(≥800张床位)进行的一项前瞻性队列研究,研究从2017年9月5日至2018年1月15日。共有191名年龄18岁以上说英语的患者纳入研究,这些患者在择期非急诊大手术后至少需要住院一晚。排除囚犯、缺乏基线认知评价的患者,以及没有签署知情同意的患者。135名(70.7%)患者完成了90天随访。

Exposures 暴露因素

The primary exposure was postoperative delirium defined as any instance of delirium occurring 24 to 72 hours after an operation. Delirium was diagnosed by the research team using the Confusion Assessment Method (CAM).

主要暴露因素为术后谵妄,定义为术后24-72小时间发生的谵妄。研究团队根据CAM诊断谵妄。

Main Outcomes and Measures 主要预后指标

The primary outcome was change in cognition at 90 days after surgery compared with baseline, preoperative cognition. Cognition was measured using a telephone version of the Montreal Cognitive Assessment (T-MoCA) with cognitive impairment defined as a score less than 18 on a scale of 0 to 22.

主要预后指标为术后90天时认知功能较基线和术前的改变。采用蒙特利尔认知评估电话版本(T-MoCA)对认知功能进行评估,认知功能障碍定义为上述评分< 18分(评分范围0-22分)。

Results 结果

Of the 191 patients included in the study, 110 (57.6%) were women; the mean (SD) age was 56.8 (16.7) years. For the primary outcome of interest, patients with and without delirium had a small increase in T-MoCA scores at 90 days compared with baseline on unadjusted analysis (with delirium, 0.69; 95% CI, −0.34 to 1.73 vs without delirium, 0.67; 95% CI, 0.17-1.16). The initial multivariate linear regression model included age, preoperative American Society of Anesthesiologists Physical Status Classification System score, preoperative cognitive impairment, and duration of anesthesia. Preoperative cognitive impairment proved to be the only notable confounder: when adjusted for preoperative cognitive impairment, patients with delirium had a 0.70-point greater decrease in 90-day T-MoCA scores than those without delirium compared with their respective baseline scores (with delirium, 0.16; 95% CI, −0.63 to 0.94 vs without delirium, 0.86; 95% CI, 0.40-1.33).

纳入纳入191名患者,110名(57.6%)为女性;平均(SD)年龄为56.8 (16.7)岁。对于研究的主要预后指标而言,未进行校正的分析发现,与基线水平相比,伴随及不伴随谵妄的患者90天的T-MoCA评分均轻度升高(伴随谵妄,0.69; 95% CI, −0.34 to 1.73 vs 不伴随谵妄,0.67; 95% CI, 0.17-1.16)。最初的多因素线性回归模型包括年龄,术前ASA身体状态分级评分,术前认知功能障碍以及麻醉时间。术前认知功能障碍是唯一的混杂因素:针对术前认知功能障碍进行校正后,与各自基线评分相比,谵妄患者90天T-MoCA评分较非谵妄患者多降低0.70分(谵妄, 0.16; 95% CI, −0.63 to 0.94 vs 无谵妄, 0.86; 95% CI, 0.40-1.33)。

Conclusions and Relevance 结论与意义

Although a statistically significant association between 90-day cognition and postoperative delirium was not noted, patients with preoperative cognitive impairment appeared to have improvements in cognition 90 days after surgery; however, this finding was attenuated if they became delirious. Preoperative cognitive impairment alone should not preclude patients from undergoing indicated surgical procedures.

尽管我们未发现90天的认知功能与术后谵妄之间具有显著的统计学相关,但术前认知功能障碍患者术后90天的认知功能有所改善;然而,如果患者发生谵妄,上述改善即受到影响。不应单纯根据术前认知功能障碍拒绝手术治疗。

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