From the Department of General Anesthesia (E.F., M.Y.A., J.E., K.M., W.A.S.E.) Department of Outcomes Research (E.F., C.L., E.J.M., K.M., D.I.S.) Department of Cardiothoracic Anesthesia (C.A.T.) Anesthesiology Institute, and the Department of Quantitative Health Sciences (C.L., E.J.M.), Cleveland Clinic, Cleveland, Ohio.
Anesthesiology. 2020 Jul;133(1):119-132. doi: 10.1097/ALN.0000000000003329.
Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve cognitive function. The authors therefore tested the primary hypothesis that preoperative use of angiotensin inhibitors is associated with less delirium in critical care patients. Post hoc, the association between postoperative use of angiotensin system inhibitors and delirium was assessed.
The authors conducted a single-site cohort study of adults admitted to Cleveland Clinic critical care units after noncardiac procedures between 2013 and 2018 who had at least one Confusion Assessment Method delirium assessment. Patients with preexisting dementia, Alzheimer's disease or other cognitive decline, and patients who had neurosurgical procedures were excluded. For the primary analysis, the confounder-adjusted association between preoperative angiotensin inhibitor use and the incidence of postoperative delirium was assessed. Post hoc, the confounder-adjusted association between postoperative angiotensin system inhibitor use and the incidence of delirium was assessed.
The incidence of delirium was 39% (551 of 1,396) among patients who were treated preoperatively with angiotensin system inhibitors and 39% (1,344 of 3,468) in patients who were not. The adjusted odds ratio of experiencing delirium during critical care was 0.98 (95% CI, 0.86 to 1.10; P = 0.700) for preoperative use of angiotensin system inhibitors versus control. Delirium was observed in 23% (100 of 440) of patients who used angiotensin system inhibitors postoperatively before intensive care discharge, and in 41% (1,795 of 4,424) of patients who did not (unadjusted P < 0.001). The confounder-adjusted odds ratio for experiencing delirium in patients who used angiotensin system inhibitors postoperatively was 0.55 (95% CI, 0.43 to 0.72; P < 0.001).
Preoperative use of angiotensin system inhibitors is not associated with reduced postoperative delirium. In contrast, treatment during intensive care was associated with lower odds of delirium. Randomized trials of postoperative angiotensin-converting enzymes inhibitors and angiotensin receptor blockers seem justified.
血管紧张素转换酶抑制剂和血管紧张素受体阻滞剂可改善认知功能。因此，作者检验了一个主要假设，即术前使用血管紧张素抑制剂与重症监护患者的谵妄发生率降低有关。之后，评估了术后使用血管紧张素系统抑制剂与谵妄之间的关联。
作者进行了一项单中心队列研究，纳入了 2013 年至 2018 年间在克利夫兰诊所接受非心脏手术后入住重症监护病房的成年人，这些患者至少接受了一次意识混乱评估方法（Confusion Assessment Method）的谵妄评估。排除了有预先存在的痴呆、阿尔茨海默病或其他认知能力下降以及接受神经外科手术的患者。在主要分析中，评估了术前使用血管紧张素抑制剂与术后谵妄发生率之间的混杂因素调整后关联。之后，评估了术后使用血管紧张素系统抑制剂与谵妄发生率之间的混杂因素调整后关联。
在接受血管紧张素系统抑制剂治疗的患者中，谵妄发生率为 39%（551/1396），而未接受治疗的患者中为 39%（1344/3468）。与对照组相比，术前使用血管紧张素系统抑制剂的患者在重症监护期间发生谵妄的调整后优势比为 0.98（95%CI，0.86 至 1.10；P=0.700）。在重症监护出院前，有 23%（100/440）使用血管紧张素系统抑制剂的患者发生了谵妄，而未使用的患者中则有 41%（1795/4424）发生了谵妄（未调整 P<0.001）。术后使用血管紧张素系统抑制剂的患者发生谵妄的调整后优势比为 0.55（95%CI，0.43 至 0.72；P<0.001）。
术前使用血管紧张素系统抑制剂与降低术后谵妄发生率无关。相反，在重症监护期间治疗与谵妄发生率降低有关。术后血管紧张素转换酶抑制剂和血管紧张素受体阻滞剂的随机试验似乎是合理的。
