Mu Dong-Liang, Zhang Da-Zhi, Wang Dong-Xin, Wang Geng, Li Chun-Jing, Meng Zhao-Ting, Li Ya-Wei, Liu Chao, Li Xue-Ying
From the Departments of *Anesthesiology and Critical Care Medicine; ‡Department of Biostatistics, Peking University First Hospital, Beijing, China; and †Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China.
Anesth Analg. 2017 Jun;124(6):1992-2000. doi: 10.1213/ANE.0000000000002095.
Severe pain and high-dose opioids are both associated with increased risk of postoperative delirium. The authors investigated whether parecoxib-supplemented IV morphine analgesia could decrease the incidence of delirium in elderly patients after total hip or knee replacement surgery.
In a randomized, double-blind, 2-center trial, patients of 60 years or older who underwent elective total hip or knee replacement surgery were assigned in a 1:1 ratio to receive either parecoxib (40 mg at the end of surgery and then every 12 hours for 3 days) or placebo (normal saline). All patients received combined spinal-epidural anesthesia during surgery and IV morphine for postoperative analgesia. The primary outcome was the incidence of delirium within 5 days after surgery.
Between January 2011 and May 2013, 620 patients were enrolled and were included in the intention-to-treat and safety analyses. The incidence of delirium was significantly reduced from 11.0% (34/310) with placebo to 6.2% (19/310) with parecoxib (relative risk 0.56, 95% confidence interval 0.33-0.96, P = .031). The severity of pain and the cumulative consumptions of morphine at 24, 48, and 72 hours after surgery were significantly lower with parecoxib than with placebo (all P < .001), although the differences were small. There was no difference in the incidence of postoperative complications between the 2 groups (12.3% [38/310] with placebo versus 11.6% [36/310] with parecoxib; P = .80).
For low-risk elderly patients undergoing elective total hip or knee replacement surgery, multidose parecoxib supplemented to IV morphine decreased the incidence of postoperative delirium without increasing adverse events.
严重疼痛和高剂量阿片类药物均与术后谵妄风险增加相关。作者调查了补充帕瑞昔布的静脉注射吗啡镇痛是否能降低老年患者全髋关节或膝关节置换术后谵妄的发生率。
在一项随机、双盲、2中心试验中，将60岁及以上接受择期全髋关节或膝关节置换手术的患者按1:1比例分配，分别接受帕瑞昔布（手术结束时40mg，然后每12小时一次，共3天）或安慰剂（生理盐水）。所有患者在手术期间接受腰麻-硬膜外联合麻醉，并在术后接受静脉注射吗啡镇痛。主要结局是术后5天内谵妄的发生率。
2011年1月至2013年5月，共纳入620例患者并纳入意向性分析和安全性分析。谵妄发生率从安慰剂组的11.0%（34/310）显著降低至帕瑞昔布组的6.2%（19/310）（相对风险0.56，95%置信区间0.33-0.96，P = 0.031）。尽管差异较小，但帕瑞昔布组术后疼痛严重程度以及术后24、48和72小时吗啡累积用量均显著低于安慰剂组（均P < 0.001）。两组术后并发症发生率无差异（安慰剂组为12.3%[38/310]，帕瑞昔布组为11.6%[36/310]；P = 0.80）。
对于接受择期全髋关节或膝关节置换手术的低风险老年患者，补充多剂量帕瑞昔布的静脉注射吗啡可降低术后谵妄发生率，且不增加不良事件。
