{"id":16900,"date":"2019-04-04T05:03:18","date_gmt":"2019-04-03T21:03:18","guid":{"rendered":"http:\/\/csccm.org.cn\/?p=16900"},"modified":"2019-06-02T06:38:31","modified_gmt":"2019-06-01T22:38:31","slug":"jama%e5%8f%91%e8%a1%a8%e8%ae%ba%e6%96%87","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=16900","title":{"rendered":"[JAMA\u53d1\u8868\u8bba\u6587]\uff1a\u9759\u8109\u5bf9\u4e59\u9170\u6c28\u57fa\u915a\u4e0e\u5b89\u6170\u5242\u8054\u5408\u5f02\u4e19\u915a\u6216\u53f3\u7f8e\u6258\u54aa\u5b9a\u5bf9\u8001\u5e74\u60a3\u8005\u5fc3\u810f\u624b\u672f\u540e\u8c35\u5984\u7684\u5f71\u54cd"},"content":{"rendered":"\n

Preliminary Communication | February 19, 2019<\/h3>\n\n\n\n

Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial<\/h1>\n\n\n\n

Balachundhar Subramaniam, Puja Shankar, Shahzad Shaefi, et al<\/h3>\n\n\n\n

JAMA. <\/em>2019;321(7):686-696. doi:10.1001\/jama.2019.0234<\/h3>\n\n\n\n

Abstract<\/h2>\n\n\n\n

Importance<\/strong> \u80cc\u666f<\/h2>\n\n\n\n

Postoperative delirium is common following cardiac surgery and may be affected by choice of analgesic and sedative.<\/p>\n\n\n\n

\u5fc3\u810f\u624b\u672f\u540e\u8c35\u5984\u975e\u5e38\u666e\u904d\uff0c\u53ef\u80fd\u53d7\u5230\u9ebb\u9189\u836f\u7269\u53ca\u9547\u9759\u836f\u7269\u9009\u62e9\u7684\u5f71\u54cd\u3002<\/p>\n\n\n\n

Objective<\/strong> \u76ee\u7684<\/h2>\n\n\n\n

To evaluate the effect of postoperative intravenous (IV) acetaminophen (paracetamol) vs placebo combined with IV propofol vs dexmedetomidine on postoperative delirium among older patients undergoing cardiac surgery.<\/p>\n\n\n\n

\u8bc4\u4ef7\u672f\u540e\u9759\u8109(IV)\u5bf9\u4e59\u9170\u6c28\u57fa\u915a\u4e0e\u5b89\u6170\u5242\u8054\u5408IV\u5f02\u4e19\u915a\u4e0e\u53f3\u7f8e\u6258\u54aa\u5b9a\u5bf9\u8001\u5e74\u60a3\u8005\u5fc3\u810f\u624b\u672f\u540e\u8c35\u5984\u7684\u5f71\u54cd\u3002<\/p>\n\n\n\n

Design, Setting, and Participants<\/strong> \u8bbe\u8ba1\uff0c\u573a\u666f\u53ca\u7814\u7a76\u4eba\u7fa4<\/h2>\n\n\n\n

Randomized, placebo-controlled, factorial clinical trial among 120 patients aged 60 years or older undergoing on-pump coronary artery bypass graft (CABG) surgery or combined CABG\/valve surgeries at a US center. Enrollment was September 2015 to April 2018, with follow-up ending in April 2018.<\/p>\n\n\n\n

\u7f8e\u56fd\u4e00\u4e2a\u4e2d\u5fc3\u8fdb\u884c\u7684\u968f\u673a\u3001\u5b89\u6170\u5242\u5bf9\u7167\u3001\u6790\u56e0\u8bbe\u8ba1\u4e34\u5e8a\u8bd5\u9a8c\uff0c\u7eb3\u516560\u5c81\u53ca\u4ee5\u4e0a\u63a5\u53d7\u4f53\u5916\u5faa\u73af\u51a0\u8109\u642d\u6865\u624b\u672f(CABG)\u6216CABG\u8054\u5408\u74e3\u819c\u624b\u672f\u7684\u60a3\u8005\u30022015\u5e749\u6708\u81f32018\u5e744\u6708\u5165\u9009\u60a3\u8005\uff0c\u968f\u8bbf\u622a\u6b62\u4e8e2018\u5e744\u6708\u3002<\/p>\n\n\n\n

Interventions<\/strong> \u5e72\u9884\u63aa\u65bd<\/h2>\n\n\n\n

Patients were randomized to 1 of 4 groups receiving postoperative analgesia with IV acetaminophen or placebo every 6 hours for 48 hours and postoperative sedation with dexmedetomidine or propofol starting at chest closure and continued for up to 6 hours (acetaminophen and dexmedetomidine: n\u2009=\u200929; placebo and dexmedetomidine: n\u2009=\u200930; acetaminophen and propofol: n\u2009=\u200931; placebo and propofol: n\u2009=\u200930).<\/p>\n\n\n\n

\u60a3\u8005\u88ab\u968f\u673a\u5206\u81f34\u7ec4\u4e2d\u76841\u7ec4\uff0c\u672f\u540e\u5206\u522b\u63a5\u53d7IV\u5bf9\u4e59\u9170\u6c28\u57fa\u915a\u6216\u5b89\u6170\u5242\uff08\u6bcf6\u5c0f\u65f6\u7ed9\u836f\uff0c\u7597\u7a0b48\u5c0f\u65f6\uff09\u9547\u75db\uff0c\u4ece\u5173\u80f8\u5f00\u59cb\u81f3\u672f\u540e\u4f7f\u7528\u53f3\u7f8e\u6258\u54aa\u5b9a\u6216\u5f02\u4e19\u915a\u9547\u9759\uff0c\u6301\u7eed\u4e0d\u8d85\u8fc76\u5c0f\u65f6\uff08\u5bf9\u4e59\u9170\u6c28\u57fa\u915a\u548c\u53f3\u7f8e\u6258\u54aa\u5b9a\uff1an\u2009=\u200929\uff1b\u5b89\u6170\u5242\u548c\u53f3\u7f8e\u6258\u54aa\u5b9a\uff1an\u2009=\u200930\uff1b\u5bf9\u4e59\u9170\u6c28\u57fa\u915a\u548c\u5f02\u4e19\u915a\uff1an\u2009=\u200931\uff1b\u5b89\u6170\u5242\u548c\u5f02\u4e19\u915a\uff1an\u2009=\u200930\uff09\u3002<\/p>\n\n\n\n

Main Outcomes and Measures<\/strong> \u4e3b\u8981\u9884\u540e\u6307\u6807<\/h2>\n\n\n\n

The primary outcome was incidence of postoperative in-hospital delirium by the Confusion Assessment Method. Secondary outcomes included delirium duration, cognitive decline, breakthrough analgesia within the first 48 hours, and ICU and hospital length of stay.<\/p>\n\n\n\n

\u4e3b\u8981\u9884\u540e\u6307\u6807\u4e3a\u6839\u636eCAM\u6cd5\u8bc4\u4f30\u7684\u672f\u540e\u4f4f\u9662\u671f\u95f4\u8c35\u5984\u53d1\u751f\u7387\u3002\u6b21\u8981\u9884\u540e\u6307\u6807\u5305\u62ec\u8c35\u5984\u6301\u7eed\u65f6\u95f4\uff0c\u8ba4\u77e5\u4e0b\u964d\uff0c\u6700\u521d48\u5c0f\u65f6\u5185\u7a81\u7834\u6027\u9547\u75db\u836f\u7269\u4f7f\u7528\uff0cICU\u4f4f\u9662\u65e5\u53ca\u603b\u4f4f\u9662\u65e5\u3002<\/p>\n\n\n\n

Results<\/strong> \u7ed3\u679c<\/h2>\n\n\n\n

Among 121 patients randomized (median age, 69 years; 19 women [15.8%]), 120 completed the trial. Patients treated with IV acetaminophen had a significant reduction in delirium (10% vs 28% placebo; difference, \u221218% [95% CI, \u221232% to \u22125%]; P<\/em>\u2009=\u2009.01; HR, 2.8 [95% CI, 1.1-7.8]). Patients receiving dexmedetomidine vs propofol had no significant difference in delirium (17% vs 21%; difference, \u22124% [95% CI, \u221218% to 10%]; P<\/em>\u2009=\u2009.54; HR, 0.8 [95% CI, 0.4-1.9]). There were significant differences favoring acetaminophen vs placebo for 3 prespecified secondary outcomes: delirium duration (median, 1 vs 2 days; difference, \u22121 [95% CI, \u22122 to 0]), ICU length of stay (median, 29.5 vs 46.7 hours; difference, \u221216.7 [95% CI, \u221220.3 to \u22120.8]), and breakthrough analgesia (median, 322.5 vs 405.3 \u00b5g morphine equivalents; difference, \u221283 [95% CI, \u2212154 to \u221214]). For dexmedetomidine vs propofol, only breakthrough analgesia was significantly different (median, 328.8 vs 397.5 \u00b5g; difference, \u221269 [95% CI, \u2212155 to \u22124]; P<\/em>\u2009=\u2009.04). Fourteen patients in both the placebo-dexmedetomidine and acetaminophen-propofol groups (46% and 45%) and 7 in the acetaminophen-dexmedetomidine and placebo-propofol groups (24% and 23%) had hypotension.<\/p>\n\n\n\n

\u603b\u5171121\u540d\u60a3\u8005\u63a5\u53d7\u968f\u673a\u5206\u7ec4\uff08\u4e2d\u4f4d\u5e74\u9f8469\u5c81\uff1b19\u540d\u5973\u6027\u60a3\u8005[15.8%]\uff09\uff0c120\u540d\u5b8c\u6210\u8bd5\u9a8c\u3002\u63a5\u53d7IV\u5bf9\u4e59\u9170\u6c28\u57fa\u915a\u6cbb\u7597\u7684\u60a3\u8005\u8c35\u5984\u53d1\u751f\u7387\u663e\u8457\u964d\u4f4e\uff0810% vs \u5b89\u6170\u524228%\uff1b\u5dee\u5f02\uff0c\u221218% [95% CI, \u221232% to \u22125%]\uff1bP<\/em>\u2009=\u2009.01\uff1bHR\uff0c2.8 [95% CI, 1.1-7.8]\uff09\u3002\u63a5\u53d7\u53f3\u7f8e\u6258\u54aa\u5b9a\u6216\u5f02\u4e19\u915a\u7684\u60a3\u8005\u8c35\u5984\u53d1\u751f\u7387\u65e0\u663e\u8457\u5dee\u5f02\uff0817% vs 21%\uff1b\u5dee\u5f02\uff0c\u22124% [95% CI, \u221218% to 10%]; P<\/em>\u2009=\u2009.54; HR, 0.8 [95% CI, 0.4-1.9]\uff09\u3002\u5bf9\u4e8e3\u9879\u9884\u5148\u786e\u5b9a\u7684\u6b21\u8981\u9884\u540e\u6307\u6807\u800c\u8a00\uff0c\u4e0e\u5b89\u6170\u5242\u5bf9\u7167\u76f8\u6bd4\uff0c\u5bf9\u4e59\u9170\u6c28\u57fa\u915a\u5e76\u65e0\u663e\u8457\u5dee\u5f02\uff1a\u8c35\u5984\u6301\u7eed\u65f6\u95f4\uff08\u4e2d\u4f4d\u65701 vs 2 \u5929\uff1b\u5dee\u5f02\uff0c\u22121 [95% CI, \u22122 to 0]\uff09\uff0cICU\u4f4f\u9662\u65e5\uff08\u4e2d\u4f4d\u6570 29.5 vs 46.7 \u5c0f\u65f6\uff1b\u5dee\u5f02\uff0c\u221216.7 [95% CI, \u221220.3 to \u22120.8]\uff09\uff0c\u7a81\u7834\u6027\u9547\u75db\u836f\u7269\u4f7f\u7528\uff08\u4e2d\u4f4d\u6570\uff0c322.5 vs 405.3 \u00b5g \u5417\u5561\u7b49\u6548\u5242\u91cf\uff1b\u5dee\u5f02\uff0c\u221283 [95% CI, \u2212154 to \u221214]\uff09\u3002\u53f3\u7f8e\u6258\u54aa\u5b9a\u4e0e\u5f02\u4e19\u915a\u76f8\u6bd4\uff0c\u4ec5\u6709\u7a81\u7834\u6027\u9547\u75db\u836f\u7269\u4f7f\u7528\u5b58\u5728\u663e\u8457\u5dee\u5f02\uff08\u4e2d\u4f4d\u6570\uff0c328.8 vs 397.5 \u00b5g\uff1b\u5dee\u5f02\uff0c\u221269 [95% CI, \u2212155 to \u22124]; P<\/em>\u2009=\u2009.04\uff09\u3002\u5b89\u6170\u5242-\u53f3\u7f8e\u6258\u54aa\u5b9a\u7ec4(46%)\u53ca\u5bf9\u4e59\u9170\u6c28\u57fa\u915a-\u5f02\u4e19\u915a\u7ec4(45%)\u5404\u670914\u540d\u60a3\u8005\u53ca\u5bf9\u4e59\u9170\u6c28\u57fa\u915a-\u53f3\u7f8e\u6258\u54aa\u5b9a\u7ec4(24%)\u548c\u5b89\u6170\u5242-\u5f02\u4e19\u915a\u7ec4(23%)\u5404\u67097\u540d\u60a3\u8005\u53d1\u751f\u4f4e\u8840\u538b\u3002<\/p>\n\n\n\n

\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n

Conclusions and Relevance<\/strong> \u7ed3\u8bba\u4e0e\u610f\u4e49<\/h2>\n\n\n\n

Among older patients undergoing cardiac surgery, postoperative scheduled IV acetaminophen, combined with IV propofol or dexmedetomidine, reduced in-hospital delirium vs placebo. Additional research, including comparison of IV vs oral acetaminophen and other potentially opioid-sparing analgesics, on the incidence of postoperative delirium is warranted.<\/p>\n\n\n\n

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Trial Registration<\/strong> \u7814\u7a76\u6ce8\u518c<\/h2>\n\n\n\n

ClinicalTrials.gov Identifier: NCT02546765<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

Preliminary Communication | February 19,&nbsp […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[32,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/16900"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=16900"}],"version-history":[{"count":2,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/16900\/revisions"}],"predecessor-version":[{"id":16902,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/16900\/revisions\/16902"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=16900"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=16900"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=16900"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}