Urban Michael K, Sasaki Mayu, Schmucker Abigail M, Magid Steven K
Department of Anesthesiology, Hospital for Special Surgery, New York, NY 10021, United States.
Quality Research Center, Hospital for Special Surgery, New York, NY 10021, United States.
World J Orthop. 2020 Feb 18;11(2):90-106. doi: 10.5312/wjo.v11.i2.90.
Postoperative delirium (POD) is one of the most common complications in older adult patients undergoing elective surgery. Few studies have compared, within the same institution, the type of surgery, risk factors and type of anesthesia and analgesia associated with the development of POD.
To investigate the following three questions: (1) What is the incidence of POD after non-ambulatory orthopedic surgery at a high-volume orthopedic specialty hospital? (2) Does surgical procedure influence incidence of POD after non-ambulatory orthopedic surgery? And (3) For POD after non-ambulatory orthopedic surgery, what are modifiable risk factors?
A retrospective cohort study was conducted of all non-ambulatory orthopedic surgeries at a single orthopedic specialty hospital between 2009 and 2014. Patients under 18 years were excluded from the cohort. Patient characteristics and medical history were obtained from electronic medical records. Patients with POD were identified using International Classification of Diseases, 9 Revision (ICD-9) codes that were not present on admission. For incidence analyses, the cohort was grouped into total hip arthroplasty (THA), bilateral THA, total knee arthroplasty (TKA), bilateral TKA, spine fusion, other spine procedures, femur/pelvic fracture, and other procedures using ICD-9 codes. For descriptive and regression analyses, the cohort was grouped, using ICD-9 codes, into THA, TKA, spinal fusions, and all procedures.
Of 78492 surgical inpatient surgeries, the incidence from 2009 to 2014 was 1.2% with 959 diagnosed with POD. The incidence of POD was higher in patients undergoing spinal fusions (3.3%) than for patients undergoing THA (0.8%); THA patients had the lowest incidence. Also, urgent and/or emergent procedures, defined by femoral and pelvic fractures, had the highest incidence of POD (7.2%) than all other procedures. General anesthesia was not seen as a significant risk factor for POD for any procedure type; however, IV patient-controlled analgesia was a significant risk factor for patients undergoing THA [Odds ratio (OR) = 1.98, 95% confidence interval (CI): 1.19 to 3.28, = 0.008]. Significant risk factors for POD included advanced age (for THA, OR = 4.9, 95%CI: 3.0-7.9, < 0.001; for TKA, OR = 2.16, 95%CI: 1.58-2.94, < 0.001), American Society of Anesthesiologists score of 3 or higher (for THA, OR = 2.01, 95%CI: 1.33-3.05, < 0.001), multiple medical comorbidities, hyponatremia (for THA, OR = 2.36, 95%CI: 1.54 to 3.64, < 0.001), parenteral diazepam (for THA, OR = 5.05, 95%CI: 1.5-16.97, = 0.009; for TKA, OR = 4.40, 95%CI: 1.52-12.75, = 0.007; for spine fusion, OR = 2.17, 95%CI: 1.19-3.97, = 0.01), chronic opioid dependence (for THA, OR = 7.11, 95%CI: 3.26-15.51, < 0.001; for TKA, OR = 2.98, 95%CI: 1.38-6.41, = 0.005) and alcohol dependence (for THA, OR = 5.05, 95%CI: 2.72-9.37, < 0.001; for TKA, OR = 6.40, 95%CI: 4.00-10.26, < 0.001; for spine fusion, OR = 6.64, 95%CI: 3.72-11.85, < 0.001).
POD is lower (1.2%) than previously reported; likely due to the use of multi-modal regional anesthesia and early ambulation. Both fixed and modifiable factors are identified.
术后谵妄（POD）是择期手术老年患者中最常见的并发症之一。在同一机构内，很少有研究比较与POD发生相关的手术类型、危险因素以及麻醉和镇痛类型。
调查以下三个问题：（1）在一家大型骨科专科医院，非门诊骨科手术后POD的发生率是多少？（2）手术操作是否会影响非门诊骨科手术后POD的发生率？以及（3）对于非门诊骨科手术后的POD，可改变的危险因素有哪些？
对一家骨科专科医院2009年至2014年期间所有非门诊骨科手术进行回顾性队列研究。18岁以下患者被排除在队列之外。患者特征和病史从电子病历中获取。使用入院时不存在的国际疾病分类第9版（ICD - 9）编码来识别发生POD的患者。对于发生率分析，根据ICD - 9编码将队列分为全髋关节置换术（THA）、双侧THA、全膝关节置换术（TKA）、双侧TKA、脊柱融合术、其他脊柱手术、股骨/骨盆骨折以及其他手术。对于描述性和回归分析，根据ICD - 9编码将队列分为THA、TKA、脊柱融合术以及所有手术。
在78492例外科住院手术中，2009年至2014年的发生率为1.2%，有959例被诊断为POD。脊柱融合术患者的POD发生率（3.3%）高于THA患者（0.8%）；THA患者的发生率最低。此外，由股骨和骨盆骨折定义的急诊和/或紧急手术的POD发生率最高（7.2%），高于所有其他手术。对于任何手术类型，全身麻醉都未被视为POD的显著危险因素；然而，静脉自控镇痛是THA患者发生POD的显著危险因素[比值比（OR）= 1.98，95%置信区间（CI）：1.19至3.28，P = 0.008]。POD的显著危险因素包括高龄（对于THA，OR = 4.9，95%CI：3.0 - 7.9，P < 0.001；对于TKA，OR = 2.16，95%CI：1.58 - 2.94，P < 0.001）、美国麻醉医师协会评分为3或更高（对于THA，OR = 2.01，95%CI：1.33 - 3.05，P < 0.001）、多种内科合并症、低钠血症（对于THA，OR = 2.36，95%CI：1.54至3.64，P < 0.001）、胃肠外给予地西泮（对于THA，OR = 5.05，95%CI：1.5 - 16.97，P = 0.009；对于TKA，OR = 4.40，95%CI：1.52 - 12.75，P = 0.007；对于脊柱融合术，OR = 2.17，95%CI：1.19 - 3.97，P = 0.01）、慢性阿片类药物依赖（对于THA，OR = 7.11，95%CI：3.26 - 15.51，P < 0.001；对于TKA，OR = 2.98，95%CI：1.38 - 6.41，P = 0.005）和酒精依赖（对于THA，OR = 5.05，95%CI：2.72 - 9.37，P < 0.001；对于TKA，OR = 6.40，95%CI：4.00 - 10.26，P < 0.001；对于脊柱融合术，OR = 6.64，95%CI：3.72 - 11.85，P < 0.001）。
POD发生率（1.2%）低于先前报道；可能是由于使用了多模式区域麻醉和早期活动。已确定了固定因素和可改变因素。
