【摘要】：目的：圍手術(shù)期全身麻醉手術(shù)，，術(shù)前及術(shù)后隨訪，觀察在老年病人中首次手術(shù)病人與多次手術(shù)病人術(shù)前焦慮程度的差異及術(shù)前焦慮與術(shù)后譫妄發(fā)生率的相關(guān)性；探討改善老年病人術(shù)前焦慮和減少術(shù)后譫妄發(fā)生的可行方法。 方法：選擇122例患者接受全身麻醉骨科，婦科、普外科手術(shù)患者中，性別不限，年齡超過65歲，體重指數(shù)小于25， ASA分級1-2級。所有患者按照首次手術(shù)或多次手術(shù)進入不同的研究隊列。組1為首次手術(shù)，組2為多次手術(shù)。術(shù)前一日于病房內(nèi)進行術(shù)前訪視,術(shù)前焦慮問卷評分。術(shù)后第一天和第二天進行術(shù)后隨訪，對所有患者進行術(shù)后譫妄的測試。麻醉前靜脈注射阿托品0.3mg。應(yīng)用依托咪酯0.3mg/kg，舒芬太尼0.4ug/kg，咪達唑侖0.5mg/kg，順式苯磺酸阿曲庫銨0.15mg/kg靜脈迅速誘導，手術(shù)過程中使用異丙酚和瑞芬太尼維持麻醉，用量分別為4-6mg/kg*h和0.5-1ug/kg*min，間斷注射苯磺酸阿曲庫銨。監(jiān)測腦電雙頻指數(shù)（BIS）保持在40-60之間。在手術(shù)結(jié)束即刻、手術(shù)結(jié)束后6小時后、手術(shù)結(jié)束24小時后、手術(shù)結(jié)束48小時后，對所有患者進行譫妄評估的測試，依據(jù)評估結(jié)果對患者進行是否發(fā)生術(shù)后譫妄的判斷，如果發(fā)生譫妄則每日隨訪至恢復或出院。 結(jié)果：共122例患者參與本研究，其中組1有62例，組2有60例。兩組患者的一般情況無顯著差異。各組中各手術(shù)類型比較無顯著差異。組1患者，有26例發(fā)生術(shù)前焦慮的發(fā)生率為42%，有14例發(fā)生術(shù)后譫妄，術(shù)前焦慮的病人中術(shù)后譫妄的發(fā)病危險是不存在術(shù)前焦慮的病人的1.726倍（RR值等于1.726）總體相對危險度的95%的可信區(qū)間為（1.023-2.203）。組2患者，有18例發(fā)生術(shù)前焦慮的發(fā)生率為30%，有8例發(fā)生術(shù)后譫妄，術(shù)后譫妄的發(fā)生率為13%。存在術(shù)前焦慮的病人中術(shù)后譫妄的發(fā)病危險是不存在術(shù)前焦慮的病人的2.312倍。（RR值等于2.312），總體相對危險度的95%的可信區(qū)間為（1.512-4.361）。 結(jié)論：老年擇期全身麻醉的患者中，首次手術(shù)和多次手術(shù)的患者術(shù)前焦慮程度是不同的，與既往有手術(shù)麻醉史的病人相比，首次接受麻醉手術(shù)的病人的術(shù)前焦慮程度更高。術(shù)前焦慮是術(shù)后譫妄的發(fā)病危險因素，首次手術(shù)的患者，術(shù)前焦慮的病人術(shù)后譫妄的發(fā)病危險是普通患者的1.726倍，（相對危險度RR值等于1.726）；多次手術(shù)的患者，術(shù)前焦慮的病人術(shù)后譫妄的發(fā)病危險是普通患者的2.312倍，（相對危險度RR值等于2.312）。通過耐心細致的術(shù)前訪視，減輕患者的術(shù)前焦慮可能降低術(shù)后譫妄的發(fā)生，提高麻醉質(zhì)量，改善患者預后。
[Abstract]:Objective: to observe the degree of preoperative anxiety and the correlation between preoperative anxiety and postoperative delirium in elderly patients during perioperative general anesthesia, preoperative and postoperative follow-up. To explore the feasible methods to improve anxiety and reduce postoperative delirium in elderly patients. Methods: one hundred and twenty-two patients undergoing general anesthesia orthopaedics gynecology and general surgery were selected. The patients were of no gender age over 65 years old body mass index (BMI) less than 25 and ASA grade 1-2. All patients were enrolled in different study cohorts according to first or multiple operations. Group 1 was operated on for the first time and group 2 for multiple operations. The preoperative interview was conducted in the ward on the first day before operation, and the preoperative anxiety questionnaire was scored. All patients were followed up on the first and second day after operation for postoperative delirium testing. Atropine was injected intravenously at 0.3 mg before anesthesia. Etomidate 0.3 mg / kg, sufentanil 0.4 mg / kg, midazolam 0.5 mg / kg, cisbenzenesulfonic acid atracurium 0.15mg/kg were used for intravenous induction, propofol and remifentanil were used to maintain anesthesia during the operation. The dosage was 4-6mg/kg*h and 0.5-1 ugr / kg 路min, respectively, with intermittent injection of atracurium benzenesulfonate. The bispectral index (BIS) of EEG was kept between 40 and 60. Immediately after surgery, 6 hours after surgery, 24 hours after surgery, 48 hours after surgery, all patients were tested for delirium evaluation, and the results were used to judge whether postoperative delirium occurred. If delirium occurs, follow up daily until recovery or discharge. Results: a total of 122 patients participated in this study, including 62 cases in group 1 and 60 cases in group 2. There was no significant difference in general conditions between the two groups. There was no significant difference in the types of operation in each group. In group 1, there were 26 cases of preoperative anxiety and 14 cases of postoperative delirium. The risk of postoperative delirium in patients with preoperative anxiety was 1.726 times (RR = 1.726) and 95% of the total relative risk (1.023-2.203). In group 2, there were 18 cases of preoperative anxiety, 8 cases of postoperative delirium and 13 cases of postoperative delirium. The risk of postoperative delirium in patients with preoperative anxiety was 2.312 times that of patients without preoperative anxiety (. (RR = 2.312), and the confidence interval of 95% of the total relative risk was (1.512-4.361). Conclusion: among the elderly patients undergoing elective general anesthesia, the degree of preoperative anxiety is different between the first operation and the multiple operation. Compared with the patients with previous history of anesthesia, the preoperative anxiety of the patients undergoing the first anesthesia is higher than that of the patients with previous anesthesia. Preoperative anxiety was the risk factor of postoperative delirium. The risk of postoperative delirium was 1.726 times higher in patients with preoperative anxiety than in common patients (RR = 1.726). The risk of postoperative delirium in patients with multiple surgeries was 2.312 times higher than that in normal patients (RR = 2.312). By patient and meticulous preoperative visit, reducing preoperative anxiety may reduce postoperative delirium, improve anaesthesia quality and improve prognosis of patients.
【學位授予單位】：大連醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R614

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