Rizk Paul, Morris William, Oladeji Philip, Huo Michael
Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
Department of Orthopedic Surgery, Case Western Reserve University, Cleveland, OH, USA.
Geriatr Orthop Surg Rehabil. 2016 Jun;7(2):100-5. doi: 10.1177/2151458516641162. Epub 2016 Apr 18.
Postoperative delirium is a serious complication following hip surgery in elderly patients that can adversely affect outcomes in both hip fracture and arthroplasty surgery. Recently, the incidence of hip fracture in the Medicare population was estimated at approximately 500 000 patients per year, with the majority treated surgically. The annual volume of total hip arthroplasty is nearly 450 000 patients and is projected to increase over the next 15 to 20 years. Subsequently, the incidence of postoperative delirium will rise. The incidence of postoperative delirium after hip surgery in the elderly patients ranges between 4% and 53%, and it is identified as the most common surgical complication of older patients. The most common risk factors include advanced age, hip fracture surgery (vs elective hip surgery), and preoperative delirium/cognitive impairment. Exact pathophysiology has not been fully defined. It is hypothesized that imbalances in cortical neurotransmitters or inflammatory cytokine pathway mechanisms contribute to delirium. Development of postoperative delirium is associated with longer hospital stay, increased medical complications, and poorer short-term functional outcome. Patients who develop postoperative delirium are also at increased risk for cognitive decline beyond the acute phase. Following acute care, postoperative delirium is associated with the need for a higher level of care, an additional cost. Management of postoperative delirium centers on prevention and early recognition. Medical prophylaxis has been demonstrated to have limited utility. Utilization of delirium detection methods contributed to early recognition. The most effective means of prevention involved a multidisciplinary team focused on adequate hydration, optimization of analgesia, reduction in polypharmacy, aggressive physiotherapy, and early recognition of the delirium symptoms.
术后谵妄是老年患者髋关节手术后的一种严重并发症，会对髋部骨折手术和关节置换手术的预后产生不利影响。最近，医疗保险人群中髋部骨折的发病率估计约为每年50万患者，大多数患者接受手术治疗。全髋关节置换术的年手术量接近45万例，预计在未来15至20年内还会增加。随后，术后谵妄的发病率将会上升。老年患者髋关节手术后谵妄的发病率在4%至53%之间，它被认为是老年患者最常见的手术并发症。最常见的风险因素包括高龄、髋部骨折手术（与择期髋关节手术相比）以及术前谵妄/认知障碍。确切的病理生理学尚未完全明确。据推测，皮质神经递质失衡或炎症细胞因子通路机制与谵妄有关。术后谵妄的发生与住院时间延长、医疗并发症增加以及短期功能预后较差有关。发生术后谵妄的患者在急性期过后认知能力下降的风险也会增加。在急性护理之后，术后谵妄与更高水平护理的需求以及额外费用相关。术后谵妄的管理以预防和早期识别为核心。药物预防的作用有限。使用谵妄检测方法有助于早期识别。最有效的预防方法是组建一个多学科团队，专注于充分补液、优化镇痛、减少多种药物联用、积极进行物理治疗以及早期识别谵妄症状。
