老年髖部骨折患者術(shù)后譫妄危險因素的相關(guān)性分析
發(fā)布時間：2018-07-23 20:16
【摘要】：目的:譫妄又稱急性腦綜合征,主要表現(xiàn)為意識障礙、行為無章、注意力無法集中、認知功能下降、覺醒度改變、感知覺異常、日夜顛倒等,通常起病急,病情波動明顯,常見于老年人。早在2000年前,希波克拉底即將譫妄描述為急性的精神混亂狀態(tài)和明顯的認知功能與注意力的全面損害。但時至今日,譫妄的危險因素尚不完全明確、發(fā)病機制亦不清楚、預(yù)防及治療措施因較多的副反應(yīng)而并未得到廣泛應(yīng)用,且老年髖部骨折譫妄發(fā)病率高、危害大,因此設(shè)計本實驗以探討老年髖部骨折患者術(shù)后發(fā)生譫妄的危險因素,并評估RD譫妄風(fēng)險評分表用于國人髖部骨折譫妄風(fēng)險評估的有效性,為臨床預(yù)防譫妄的發(fā)生提供理論指導(dǎo)。方法:收集西南醫(yī)科大學(xué)附屬醫(yī)院2014年9月至2016年12月髖部骨折并接受手術(shù)治療的患者239例,年齡60-100歲,平均74.0歲,其中男105例,女134例;股骨頸骨折129例,轉(zhuǎn)子間骨折110例;全髖關(guān)節(jié)置換術(shù)(Total Hip Arthroplasty,THA)82例,人工股骨頭置換術(shù)41例,空心螺釘內(nèi)固定術(shù)6例,股骨近端防旋轉(zhuǎn)螺釘內(nèi)固定術(shù)(Proximal Femoral Nail Antirotation,PFNA)110例;入院即以意識錯亂評估方法(The Confusion Assessment Method,CAM)評估并排除已處于譫妄狀態(tài)的患者;以簡易精神評估量表(The Minimum Mental State Examination,MMSE)評估患者的基礎(chǔ)認知功能情況;以RD譫妄風(fēng)險評分表(The Risk Model For Delirium,RD)評估患者發(fā)生譫妄的風(fēng)險大小;入院后除手術(shù)日外,每日早晨及下午以CAM評估患者是否處于譫妄狀態(tài),及時排除術(shù)前出現(xiàn)譫妄的患者;收集非譫妄狀態(tài)患者的骨折部位、手術(shù)方式、年齡、性別、入院至結(jié)束觀察期間夜間睡眠時間的平均值(夜間平均睡眠時間)、受傷至手術(shù)的間隔時間(間隔時間)、心臟射血分數(shù)、入院后第一次抽血化驗的肝腎功能結(jié)果,如谷丙轉(zhuǎn)氨酶(Alanine Aminotransferase,ALT)、谷草轉(zhuǎn)氨酶(Aspartate Transaminase,AST)、肌酐(Creatinine,Cr)、胱抑素C(Cystatin C,CYC)、腎小球濾過率(Glomerular Filtration Rate,GFR),高血壓及糖尿病病史、麻醉方式、麻醉時間、術(shù)中失血量以及RD評分等資料并進行卡方檢驗,將卡方檢驗結(jié)果中P≤0.1的因素行非條件Logistic回歸統(tǒng)計學(xué)分析;結(jié)果:1.對上述資料以卡方檢驗分析,結(jié)果提示年齡、手術(shù)方式、受傷至手術(shù)的間隔時間、夜間平均睡眠時間、射血分數(shù)、麻醉方式、麻醉時間、術(shù)中失血量及RD評分為老年患者髖部骨折術(shù)后譫妄的影響因素;2.非條件Logistic回歸分析結(jié)果顯示年齡≥75歲的患者發(fā)生譫妄風(fēng)險是75歲患者的7.672倍;受傷至手術(shù)的間隔時間3天的患者發(fā)生譫妄的風(fēng)險是≤3天患者的7.820倍;夜間平均睡眠時間≤5h的患者發(fā)生譫妄的風(fēng)險是5h患者的4.132倍;麻醉方式為全身麻醉的患者發(fā)生譫妄風(fēng)險是蛛網(wǎng)膜下腔麻醉患者的4.804倍;麻醉時間≥120min的患者發(fā)生譫妄風(fēng)險是120min患者的5.955倍;術(shù)中失血量≥300ml的患者發(fā)生譫妄風(fēng)險是300ml患者的5.462倍;RD評分≥5分的患者發(fā)生譫妄的風(fēng)險是5分患者的12.777倍。手術(shù)方式為全髖關(guān)節(jié)置換者相較于人工股骨頭置換、空心螺釘內(nèi)固定及股骨近端防旋轉(zhuǎn)螺釘內(nèi)固定更容易發(fā)生譫妄,OR分別為0.385、0.000及0.086。非條件Logistic回歸分析結(jié)果提示年齡≥75歲、手術(shù)方式為全髖關(guān)節(jié)置換、受傷至手術(shù)間隔時間3天、夜間平均睡眠時間≤5h、全麻、麻醉時間≥120min、失血量≥300ml、RD≥5分為影響術(shù)后譫妄發(fā)生的獨立危險因素。結(jié)論:1.老年髖部骨折術(shù)后譫妄的發(fā)生是多因素綜合作用的結(jié)果;2.術(shù)前肝腎功能指標(ALT、AST、Cr、Cyc、GFR)異常不影響術(shù)后譫妄的發(fā)生;3.年齡、手術(shù)方式、受傷至手術(shù)的間隔時間、夜間平均睡眠時間、射血分數(shù)、麻醉方式、麻醉時間、術(shù)中失血量及RD評分為老年患者髖部骨折術(shù)后譫妄的影響因素;4.年齡≥75歲、手術(shù)方式為全髖關(guān)節(jié)置換、受傷至手術(shù)間隔時間3天、夜間平均睡眠時間≤5h、全麻、麻醉時間≥120min、失血量≥300ml、RD≥5分為影響術(shù)后譫妄發(fā)生的獨立危險因素;5.年齡越大、夜間平均睡眠時間越少、受傷至手術(shù)間隔時間越長、麻醉時間越長、術(shù)中失血量越大,譫妄的發(fā)生風(fēng)險越大。6.RD譫妄風(fēng)險評分表能有效用于國人老年髖部骨折譫妄風(fēng)險的評估;7.夜間平均睡眠時間作為一簡易指標能有效評估夜間睡眠狀態(tài)用于譫妄風(fēng)險評估。
[Abstract]:Objective: delirium, also known as acute brain syndrome, is mainly manifested in disturbance of consciousness, lack of behavior, concentration of attention, decline of cognitive function, change of awakening, abnormal perception and reversal of day and night, usually in the elderly. Before 2000, F Pokela Di's delirium is described as an acute mental disorder before 2000. But today, the risk factors of delirium are not completely clear, the pathogenesis is not clear, the prevention and treatment measures are not widely used because of many side effects, and the incidence of delirium in the elderly hip fracture is high and the harm is great. Therefore, this experiment is designed to explore the elderly hip. The risk factors for postoperative delirium in patients with fracture, and evaluate the effectiveness of the RD delirium risk rating scale for the assessment of the risk of delirium in Chinese hip fractures, provide theoretical guidance for the occurrence of clinical delirium prevention. Methods: 239 cases of hip fractures in the Southwest Medical University Affiliated Hospital from September 2014 to December 2016 and the patients received surgical treatment were collected. The age was 60-100 years old, with an average of 74 years of age, including 105 males and 134 females, 129 femoral neck fractures, 110 intertrochanteric fractures, 82 Total Hip Arthroplasty, THA, 41 artificial femoral head replacement, 6 hollow screw internal fixation, and proximal femoral screw fixation (Proximal Femoral Nail Antirotation, PFNA) 110 The Confusion Assessment Method (CAM) was used to assess and exclude patients in delirium; a simple mental assessment scale (The Minimum Mental State Examination, MMSE) was used to evaluate the patient's basic cognitive function. The size of the risk of delirium in the patient; to evaluate the patient's delirium by CAM every morning and afternoon except for the operation day, and to exclude patients with delirium in time, and to collect the fracture sites, surgical methods, age, sex, and the mean night sleep time during the admission to the end of the observation period (night). Mean sleep time), interval time of injury to operation (interval time), cardiac ejection fraction, liver and kidney function results of Alanine Aminotransferase, ALT, Aspartate Transaminase, AST, creatinine (Cr), Cystatin C (Cystatin C, CYC), glomerular filtration rate. Omerular Filtration Rate, GFR), history of hypertension and diabetes, anesthesia, anesthesia time, intraoperative blood loss and RD scores and other data and chi square test, the factors of P < 0.1 in the result of chi square test were analyzed by non conditional Logistic regression analysis. Results: 1. of the above data were analyzed by chi square test, and the results prompted age, operation. Methods, the interval of the injury to the operation, the average night time, the ejection fraction, the way of anaesthesia, the time of anesthesia, the amount of blood loss and the RD score were the factors affecting the delirium after the operation of the hip fracture in the elderly; the 2. unconditional Logistic regression analysis showed that the risk of delirium in the patients aged over 75 years was 7.672 times as much as 75 years old. The risk of delirium in patients with 3 days of surgery was 7.820 times more than those in 3 days; the risk of delirium in patients with average sleep time less than 5h at night was 4.132 times as high as that of 5h patients; the risk of delirium in general anesthesia patients was 4.804 times as high as those in subarachnoid anesthesia; patients with anesthesia time more than 120min The risk of delirium was 5.955 times as high as that of 120min patients; the risk of delirium in patients with intraoperative blood loss more than 300ml was 5.462 times as high as that of 300ml patients; the risk of delirium in patients with RD score more than 5 was 12.777 times more than that of 5 patients. OR 0.385,0.000 and 0.086. non conditional Logistic regression analysis showed that age was more than 75 years old, total hip replacement, injury to operation interval 3 days, night average sleep time less than 5h, general anesthesia, anesthesia time more than 120min, blood loss more than 300ml, RD more than 5 to affect postoperative delirium. Conclusion: 1. the occurrence of postoperative delirium in 1. elderly hip fractures is the result of multiple factors; 2. abnormal liver and kidney function indexes (ALT, AST, Cr, Cyc, GFR) have no effect on postoperative delirium; 3. age, operation mode, interval time of injury to operation, night mean sleep time, ejection fraction, anaesthesia Anesthesia time, intraoperative blood loss and RD score were the influencing factors of postoperative delirium in the elderly patients with hip fracture; 4. age or more than 75 years old, total hip replacement, 3 days of operation interval, average sleep time less than 5h at night, general anesthesia, anesthesia time more than 120min, blood loss of more than 300ml, RD more than 5 to affect postoperative delirium only only The higher the 5. age, the less the night average sleep time, the longer the injury to the operation interval, the longer the anesthesia time, the greater the amount of blood loss in the operation, the greater the risk of delirium, the.6.RD delirium risk score table can be effectively used to assess the risk of delirium in the elderly hip fracture, and 7. night average sleep time as a simple indicator. It can effectively assess nocturnal sleep state and assess delirium risk.
【學(xué)位授予單位】：西南醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R687.3
[Abstract]:Objective: delirium, also known as acute brain syndrome, is mainly manifested in disturbance of consciousness, lack of behavior, concentration of attention, decline of cognitive function, change of awakening, abnormal perception and reversal of day and night, usually in the elderly. Before 2000, F Pokela Di's delirium is described as an acute mental disorder before 2000. But today, the risk factors of delirium are not completely clear, the pathogenesis is not clear, the prevention and treatment measures are not widely used because of many side effects, and the incidence of delirium in the elderly hip fracture is high and the harm is great. Therefore, this experiment is designed to explore the elderly hip. The risk factors for postoperative delirium in patients with fracture, and evaluate the effectiveness of the RD delirium risk rating scale for the assessment of the risk of delirium in Chinese hip fractures, provide theoretical guidance for the occurrence of clinical delirium prevention. Methods: 239 cases of hip fractures in the Southwest Medical University Affiliated Hospital from September 2014 to December 2016 and the patients received surgical treatment were collected. The age was 60-100 years old, with an average of 74 years of age, including 105 males and 134 females, 129 femoral neck fractures, 110 intertrochanteric fractures, 82 Total Hip Arthroplasty, THA, 41 artificial femoral head replacement, 6 hollow screw internal fixation, and proximal femoral screw fixation (Proximal Femoral Nail Antirotation, PFNA) 110 The Confusion Assessment Method (CAM) was used to assess and exclude patients in delirium; a simple mental assessment scale (The Minimum Mental State Examination, MMSE) was used to evaluate the patient's basic cognitive function. The size of the risk of delirium in the patient; to evaluate the patient's delirium by CAM every morning and afternoon except for the operation day, and to exclude patients with delirium in time, and to collect the fracture sites, surgical methods, age, sex, and the mean night sleep time during the admission to the end of the observation period (night). Mean sleep time), interval time of injury to operation (interval time), cardiac ejection fraction, liver and kidney function results of Alanine Aminotransferase, ALT, Aspartate Transaminase, AST, creatinine (Cr), Cystatin C (Cystatin C, CYC), glomerular filtration rate. Omerular Filtration Rate, GFR), history of hypertension and diabetes, anesthesia, anesthesia time, intraoperative blood loss and RD scores and other data and chi square test, the factors of P < 0.1 in the result of chi square test were analyzed by non conditional Logistic regression analysis. Results: 1. of the above data were analyzed by chi square test, and the results prompted age, operation. Methods, the interval of the injury to the operation, the average night time, the ejection fraction, the way of anaesthesia, the time of anesthesia, the amount of blood loss and the RD score were the factors affecting the delirium after the operation of the hip fracture in the elderly; the 2. unconditional Logistic regression analysis showed that the risk of delirium in the patients aged over 75 years was 7.672 times as much as 75 years old. The risk of delirium in patients with 3 days of surgery was 7.820 times more than those in 3 days; the risk of delirium in patients with average sleep time less than 5h at night was 4.132 times as high as that of 5h patients; the risk of delirium in general anesthesia patients was 4.804 times as high as those in subarachnoid anesthesia; patients with anesthesia time more than 120min The risk of delirium was 5.955 times as high as that of 120min patients; the risk of delirium in patients with intraoperative blood loss more than 300ml was 5.462 times as high as that of 300ml patients; the risk of delirium in patients with RD score more than 5 was 12.777 times more than that of 5 patients. OR 0.385,0.000 and 0.086. non conditional Logistic regression analysis showed that age was more than 75 years old, total hip replacement, injury to operation interval 3 days, night average sleep time less than 5h, general anesthesia, anesthesia time more than 120min, blood loss more than 300ml, RD more than 5 to affect postoperative delirium. Conclusion: 1. the occurrence of postoperative delirium in 1. elderly hip fractures is the result of multiple factors; 2. abnormal liver and kidney function indexes (ALT, AST, Cr, Cyc, GFR) have no effect on postoperative delirium; 3. age, operation mode, interval time of injury to operation, night mean sleep time, ejection fraction, anaesthesia Anesthesia time, intraoperative blood loss and RD score were the influencing factors of postoperative delirium in the elderly patients with hip fracture; 4. age or more than 75 years old, total hip replacement, 3 days of operation interval, average sleep time less than 5h at night, general anesthesia, anesthesia time more than 120min, blood loss of more than 300ml, RD more than 5 to affect postoperative delirium only only The higher the 5. age, the less the night average sleep time, the longer the injury to the operation interval, the longer the anesthesia time, the greater the amount of blood loss in the operation, the greater the risk of delirium, the.6.RD delirium risk score table can be effectively used to assess the risk of delirium in the elderly hip fracture, and 7. night average sleep time as a simple indicator. It can effectively assess nocturnal sleep state and assess delirium risk.
【學(xué)位授予單位】：西南醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R687.3
【參考文獻】
相關(guān)期刊論文 前7條
1 鄭文迪;趙亮;王玉強;馬克;馬俊豪;王利民;;骨科手術(shù)時間與術(shù)后譫妄的相關(guān)性的Meta分析[J];河南醫(yī)學(xué)研究;2016年10期
2 喻任;陸純德;程艷;王U喨，
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