以镇静深度为干预目标降低术后谵妄发生率：老年患者术后谵妄发生率降低策略随机临床试验的死亡率和功能结局。
Depth of sedation as an interventional target to reduce postoperative delirium: mortality and functional outcomes of the Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients randomised clinical trial.
机构信息
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
出版信息
Br J Anaesth. 2019 Apr;122(4):480-489. doi: 10.1016/j.bja.2018.12.021. Epub 2019 Feb 4.
BACKGROUND
The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function.
METHODS
Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0-2] or lighter (OAA/S 3-5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan-Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return.
RESULTS
One-year mortality was 14% in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95% confidence interval (CI), 1.02-1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95% CI, 0.60-0.91; P=0.005], BMI [HR=0.91, 95% CI 0.84-0.998; P=0.04], and delirium severity [HR=1.20, 95% CI, 1.03-1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64%, 30%, and 6% of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95% CI, 0.24-2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95% CI, 0.53-0.97; P=0.03] and delirium [OR=0.32, 95% CI, 0.10-0.97; P=0.04].
CONCLUSIONS
This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery.
CLINICAL TRIAL REGISTRATION
ClinicalTrials.gov NCT00590707.
背景
减少老年人术后谵妄发生率的策略试验检验了这样一个假设，即在脊髓麻醉期间限制镇静可以降低髋部骨折修复后住院期间的术后谵妄发生率。本文报告了该试验的次要结果，包括死亡率和功能。
方法
200 名（≥65 岁）接受脊髓麻醉的髋部骨折修复患者被随机分为较重（改良的观察者评估警觉/镇静评分（OAA/S）0-2）或较轻（OAA/S 3-5）镇静组，并评估术后谵妄。次要结果包括 1 年时的死亡率和恢复到骨折前的步行水平。采用 Kaplan-Meier 分析、多变量 Cox 比例风险模型和 logistic 回归来评估干预措施对死亡率和恢复步行的几率的影响。
结果
两组 1 年死亡率均为 14%（对数秩 P=0.96）。1 年死亡率的独立危险因素包括：Charlson 合并症指数[风险比（HR）=1.23，95%置信区间（CI），1.02-1.49；P=0.03]、工具性日常生活活动[HR=0.74，95%CI，0.60-0.91；P=0.005]、BMI[HR=0.91，95%CI 0.84-0.998；P=0.04]和谵妄严重程度[HR=1.20，95%CI，1.03-1.41；P=0.02]。1 年幸存者中分别有 64%、30%和 6%的人恢复到骨折前的步行水平、恶化或未获得步行能力。较轻的镇静并不能提高 1 年时的步行恢复几率[比值比（OR）=0.76，95%CI，0.24-2.4；P=0.63]。步行恢复的独立危险因素包括 Charlson 合并症指数[OR=0.71，95%CI，0.53-0.97；P=0.03]和谵妄[OR=0.32，95%CI，0.10-0.97；P=0.04]。
结论
本研究发现，在接受脊髓麻醉联合异丙酚镇静的老年髋部骨折手术患者中，术中较重的镇静与术后 1 年死亡率或恢复到骨折前步行水平之间无显著差异。
临床试验注册
ClinicalTrials.gov NCT00590707。
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