Department of Anesthesiology, Reanimatology and Intensive Medicine, University Hospital "Sveti Duh", Zagreb, Croatia.
Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Croatia.
Med Arch. 2023 Feb;77(1):18-23. doi: 10.5455/medarh.2023.77.18-23.
Proximal femoral fractures (PrFF) are one of the most common causes of emergency admission in the elderly population. The majority of patients have pre-existing conditions that get worsened by unplanned surgery.
Purpose of this article was to evaluate if a is single shot of dexamethasone with levobupivacaine administered intrathecally reduces postoperative pain and cognitive complications in patients with proximal femoral fractures.
The study was performed at a level II trauma center which is a part of a teaching hospital with a catchment population of around 300,000 patients, the first author's affiliation. Around 500 PrFF are performed yearly in the center. All participants gave oral and written informed consent before randomization.
In total, 60 patients with a PrFF, ASA status 2 or 3 were randomized into two groups for spinal anaesthesia as DLSA study group (received 8 mg of dexamethasone and 12.5 mg of 0.5 % levobupivacaine) or LSA control group (received 12.5 mg of 0,5 % levobupivacaine). Postoperative cognitive disturbance was evaluated using simplified Confusion Assessment Method (CAM) scale, pain intensity was measured using Visual Analogue Scale (VAS) and blood samples for defining cortisol concentrations were taken before and after the surgical procedure. The primary outcomes were effects of intrathecal dexamethasone on plasma cortisol affecting cognitive disturbances. Secondary outcomes included pain scores and length of hospital stay. The DLSA group demonstrated a reduced incidence of postoperative cognitive dysfunction (POCD), p=0.043, longer analgesia duration, p<0.001, decreased cortisol levels and shorter hospitalization p=0.045. Intrathecal dexamethasone was the only significant predictor of postoperative delirium, OR 7.76, p=0.019.
Single shot intrathecal administration of dexamethasone with levobupivacaine used in anaesthesia for proximal femoral fractures reduces the stress response by decreasing plasma cortisol concentrations prolonging analgesia. Complications such as delirium and POCD occurred with significantly lower frequency allowing better postoperative rehabilitation and shortening the hospitalization.
股骨近端骨折（PrFF）是老年人群中最常见的急诊原因之一。大多数患者存在因计划外手术而恶化的预先存在的病症。
本文旨在评估单次鞘内给予地塞米松联合左旋布比卡因是否能减轻股骨近端骨折患者的术后疼痛和认知并发症。
该研究在一家二级创伤中心进行，该中心是一家教学医院的一部分，服务人群约为 30 万，第一作者的工作单位。该中心每年约有 500 例 PrFF 患者。所有参与者在随机分组前均签署了口头和书面知情同意书。
总共 60 例股骨近端骨折、ASA 分级 2 或 3 的患者被随机分为两组接受椎管内麻醉，DLSA 研究组（接受 8 毫克地塞米松和 12.5 毫克 0.5%左旋布比卡因）或 LSA 对照组（接受 12.5 毫克 0.5%左旋布比卡因）。术后认知障碍采用简化的意识混乱评估方法（CAM）量表进行评估，疼痛强度采用视觉模拟评分（VAS）进行评估，手术前后采集血样以测定皮质醇浓度。主要结局是鞘内给予地塞米松对影响认知障碍的血浆皮质醇的影响。次要结局包括疼痛评分和住院时间。DLSA 组术后认知功能障碍（POCD）发生率降低，p=0.043，镇痛持续时间延长，p<0.001，皮质醇水平降低，住院时间缩短，p=0.045。鞘内给予地塞米松是术后谵妄的唯一显著预测因素，OR 7.76，p=0.019。
单次鞘内给予地塞米松联合左旋布比卡因用于股骨近端骨折的麻醉可通过降低血浆皮质醇浓度来减轻应激反应，延长镇痛时间。谵妄和 POCD 等并发症的发生频率显著降低，从而促进术后康复和缩短住院时间。
