Hughes Christopher G, Patel Mayur B, Jackson James C, Girard Timothy D, Geevarghese Sunil K, Norman Brett C, Thompson Jennifer L, Chandrasekhar Rameela, Brummel Nathan E, May Addison K, Elstad Mark R, Wasserstein Mitzi L, Goodman Richard B, Moons Karel G, Dittus Robert S, Ely E Wesley, Pandharipande Pratik P
*Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine and Center for Health Services Research, Vanderbilt University Medical Center, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee †Section of Surgical Sciences, Departments of Surgery, Neurosurgery and Hearing and Speech Sciences, Division of Trauma and, Surgical Critical Care, and Emergency General Surgery, Vanderbilt Brain Institute, Center for Health Services Research, Vanderbilt University Medical Center, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee ‡Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Health Services Research, Vanderbilt University Medical Center, Research Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee §Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Health Services Research, Vanderbilt University Medical Center, Geriatric Research, Education and Clinical Center Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee ¶Department of Surgery, Radiology, and Radiological Sciences, Vanderbilt University Medical Center, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee ||Department of Medicine, Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee **Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee ††Department of Medicine, Division of Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee ‡‡Section of Surgical Sciences, Department of Surgery, Division of Trauma and Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee §§Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, George E. Wahlen Department of Veterans Affairs Medical Center, Veterans Administration Salt Lake City Health Care System, Salt Lake City, Utah ¶¶George E. Wahlen Department of Veterans Affairs Medical Center, Veterans Administration Salt Lake City Health Care System, Salt Lake City, Utah ||||Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle Division, Veterans Affairs Puget Sound Health Care System, Seattle, Washington ***Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands †††Departments of Anesthesiology and Surgery, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee.
Ann Surg. 2017 Jun;265(6):1126-1133. doi: 10.1097/SLA.0000000000001885.
The aim of this study was to determine whether surgery and anesthesia exposure is an independent risk factor for cognitive impairment after major noncardiac surgery associated with critical illness.
Postoperative cognitive impairment is a prevalent individual and public health problem. Data are inconclusive as to whether this impairment is attributable to surgery and anesthesia exposure versus patients' baseline factors and hospital course.
In a multicenter prospective cohort study, we enrolled ICU patients with major noncardiac surgery during hospital admission and with nonsurgical medical illness. At 3 and 12 months, we assessed survivors' global cognitive function with the Repeatable Battery for the Assessment of Neuropsychological Status and executive function with the Trail Making Test, Part B. We performed multivariable linear regression to study the independent association of surgery/anesthesia exposure with cognitive outcomes, adjusting initially for baseline covariates and subsequently for in-hospital covariates.
We enrolled 1040 patients, 402 (39%) with surgery/anesthesia exposure. Median global cognition scores were similar in patients with surgery/anesthesia exposure compared with those without exposure at 3 months (79 vs 80) and 12 months (82 vs 82). Median executive function scores were also similar at 3 months (41 vs 40) and 12 months (43 vs 42). Surgery/anesthesia exposure was not associated with worse global cognition or executive function at 3 or 12 months in models incorporating baseline or in-hospital covariates (P > 0.2). Higher baseline education level was associated with better global cognition at 3 and 12 months (P < 0.001), and longer in-hospital delirium duration was associated with worse global cognition (P < 0.02) and executive function (P < 0.01) at 3 and 12 months.
Cognitive impairment after major noncardiac surgery and critical illness is not associated with the surgery and anesthesia exposure but is predicted by baseline education level and in-hospital delirium.
本研究旨在确定手术和麻醉暴露是否是与危重症相关的非心脏大手术后认知障碍的独立危险因素。
术后认知障碍是一个普遍存在的个人和公共卫生问题。关于这种障碍是归因于手术和麻醉暴露还是患者的基线因素及住院病程，数据尚无定论。
在一项多中心前瞻性队列研究中，我们纳入了住院期间接受非心脏大手术且患有非手术性内科疾病的ICU患者。在3个月和12个月时，我们使用可重复神经心理状态评估量表评估幸存者的整体认知功能，并使用连线测验B部分评估执行功能。我们进行多变量线性回归以研究手术/麻醉暴露与认知结果的独立关联，最初对基线协变量进行调整，随后对住院期间协变量进行调整。
我们纳入了1040例患者，其中402例（39%）有手术/麻醉暴露。有手术/麻醉暴露的患者与无暴露的患者相比，在3个月时（79对80）和12个月时（82对82）的整体认知评分中位数相似。在3个月时（41对40）和12个月时（43对42）的执行功能评分中位数也相似。在纳入基线或住院期间协变量的模型中，手术/麻醉暴露在3个月或12个月时与更差的整体认知或执行功能无关（P>0.2）。较高的基线教育水平与3个月和12个月时更好的整体认知相关（P<0.001），而住院期间谵妄持续时间较长与3个月和12个月时更差的整体认知（P<0.02）和执行功能（P<0.01）相关。
非心脏大手术和危重症后的认知障碍与手术和麻醉暴露无关，但可由基线教育水平和住院期间谵妄预测。
