术后谵妄危险因素的研究进展
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摘要
术后谵妄(POD)好发于老年人,是一种发病原因多、致病机制并不明确的中枢神经系统疾病,常发生在术后时期,通常出现在术后当天并持续到第6天。如及时诊断、发现并治疗,会大大提高患者的生活质量;如发现不及时,有极大可能转化为长期认知障碍,后果严重。本文从导致POD发生的术前、术中、术后的原因,探讨发生POD的危险因素及机制,为有效预防、及时发现、尽量避免发生POD提供可能。
Postoperative delirium(POD) is a kind of central nervous system disease with multiple causes and unclear pathogenesis, which often occurs on day 0 after surgery and lasts until the 6 thday after surgery. If diagnosed, discovered and treated in time, the quality of life of patients will be greatly improved, otherwise it is likely to be transformed into long-term cognitive impairment with serious consequences. This review analyzes the risk factors and mechanism of POD from preoperative, intraoperative and postoperative causes, which provides the possibility for effective prevention, timely detection, and avoiding POD.
Postoperative delirium(POD) is a kind of central nervous system disease with multiple causes and unclear pathogenesis, which often occurs on day 0 after surgery and lasts until the 6 thday after surgery. If diagnosed, discovered and treated in time, the quality of life of patients will be greatly improved, otherwise it is likely to be transformed into long-term cognitive impairment with serious consequences. This review analyzes the risk factors and mechanism of POD from preoperative, intraoperative and postoperative causes, which provides the possibility for effective prevention, timely detection, and avoiding POD.
引文
[1]RENGEL KF,PANDHARIPANDE PP,HUGHES CG.Postoperative delirium[J].Indian Journal of Critical Care Medicine,2018,10(4):448-456.
[2]NEUNER B,HADZIDIAKOS D,BETTELLI G.Pre-and postoperative management of risk factors for postoperative delirium:who is in charge and what is its essence?[J].Aging Clinical&Experimental Research,2018,30(3):1-4.
[3]PETERSEN PB,J?RGENSEN CC,KEHLET H.Delirium after fast-track hip and knee arthroplasty-a cohort study of 6331 elderly patients[J].Acta Anaesthesiol Scand,2017,61(7):767-772.
[4]HAMILTON GM,WHEELER K,DI MJ,et al.A systematic review and meta-analysis examining the impact of incident postoperative delirium on mortality[J].Anesthesiology,2017,127(1):1.
[5]WITLOX J,EURELINGS LS,DE JONGHE JF,et al.Delirium in elderly patients and the risk of postdischarge mortality,institutionalization,and dementia:a meta-analysis[J].JAMA,2010,304(4):443-451.
[6]JANKOWSKI CJ,TRENERRY MR,COOK DJ,et al.Cognitive and functional predictors and sequelae of postoperative delirium in elderly patients undergoing elective joint arthroplasty[J].Anesthesia&Analgesia,2011,112(5):1186-1193.
[7]ALDECOA C,BETTELLI G,BILOTTA F,et al.European Society of Anaesthesiology evidence-based and consensus-based guidelines on postoperative delirium[J].European Journal of Anaesthesiology,2017,34(4):192.
[8]CHUNG KS,LEE JK,PARK JS,et al.Risk factors of delirium in patients undergoing total knee arthroplasty[J].Arch Gerontol Geriatr,2015,60(3):443-447.
[9]MALDONADO JR.Neuropathogenesis of delirium:review of current etiologic theories and common pathways[J].Am J Geriatr Psychiatry,2013,21(12):1190-1222.
[10]CLEGG A,YOUNG J,ILIFFE S,et al.Frailty in elderly people[J].Lancet,2013,381(9868):752-762.
[11]王薇,王东信.外科重症老年非心脏手术患者术后谵妄的发生率及危险因素分析[J].解放军医学杂志,2011,6:653-656.
[12]BAGRI AS,RICO A,RUIZ JG.Evaluation and management of the elderly patient at risk for postoperative delirium[J].Clinics in Geriatric Medicine,2008,24(4):667-686.
[13]JUNG P,PEREIRA M A,HIEBERT B,et al.The impact of frailty on postoperative delirium in cardiac surgery patients[J].Journal of Thoracic&Cardiovascular Surgery,2015,149(3):869-875.e2.
[14]WANG SH,WANG JY,LIN PY,et al.Predisposing risk factors for delirium in living donor liver transplantation patients in intensive care units[J].PLoS One,2014,9(5):e96676.
[15]HONDA S,FURUKAWA K,NISHIWAKI N,et al.Risk factors for postoperative delirium after gastrectomy in gastric cancer patients[J].World Journal of Surgery,2018:1-7.
[16]ANSALONI,L,CATENA,F,CHATTAT,R,et al.Risk factors and incidence of postoperative delirium in elderly patients after elective and emergency surgery[J].British Journal of Surgery,2010,97(2):273-280.
[17]KYEONG S,SHIN JE,YANG KH,et al.Neural predisposing factors of postoperative delirium in elderly patients with femoral neck fracture[J].Scientific Reports,2018,8(1):7602.
[18]LEUNG JM,SANDS LP,MULLEN EA,et al.Are preoperative depressive symptoms associated with postoperative delirium in geriatric surgical patients?[J].Journals of Gerontology,2005,60(12):1563.
[19]James L,RUDOLPHAHI,RICHARD N,et al.Independent vascular and cognitive risk factors for postoperative delirium[J].American Journal of Medicine,2007,120(9):807-813.
[20]ENDO Y,AHARONOFF GB,ZUCKERMAN JD,et al.Gender differences in patients with hip fracture:a greater risk of morbidity and mortality in men[J].Journal of Orthopaedic Trauma,2005,19(1):29-35.
[21]VAURIO LE,SANDS LP,WANG Y,et al.Postoperative delirium:the importance of pain and pain management[J].Anesthesia&Analgesia,2006,102(4):1267-1273.
[22]TAGARAKIS GI,TSOLAKI-TAGARAKI F,TSOLAKI M,et al.The role of apolipoprotein E in cognitive decline and delirium after bypass heart operations[J].Am J Alzheimers Dis Other Demen,2007,22(3):223-228.
[23]LEUNG JM,SANDS LP,VAURIO LE,et al.Nitrous oxide does not change the incidence of postoperative delirium or cognitive decline in elderly surgical patients[J].British Journal of Anaesthesia,2006,96(6):754-760.
[24]SIEBER FE,MEARS S,LEE H,et al.Postoperative opioid consumption and its relationship to cognitive function in older adults with hip fracture[J].Journal of the American Geriatrics Society,2011,59(12):2256-2262.
[25]VAN RB,SCHUURMANS MJ,SHORTRIDGE-BAGGETT LM,et al.Risk factors for intensive care delirium:a systematic review[J].Critical Care,2009,24(2):98-107.
[26]VASILEVSKIS EE,HAN JH,HUGHES CG,et al.Epidemiology and risk factors for delirium across hospital settings[J].Best Pract Res Clin Anaesthesiol,2012,26(3):277-287.
[27]SALALLONCH R,BARTRéSFAZ D,JUNQUéC.Reorganization of brain networks in aging:a review of functional connectivity studies[J].Frontiers in Psychology,2015,6(663):663.
[28]STAM CJ,JONES BF,NOLTE G,et al.Small-world networks and functional connectivity in Alzheimer's disease[J].Cerebral Cortex,2007,17(1):92-99.
[29]RADTKE FM,FRANCK M,LENDNER J,et al.Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction[J].British Journal of Anaesthesia,2013,110(3):98-105.
[30]MASON SE,NOEL-STORR A,RITCHIE CW.The impact of general and regional anesthesia on the incidence of post-operative cognitive dysfunction and post-operative delirium:a systematic review with meta-analysis[J].Journal of Alzheimers Disease Jad,2010,22Suppl 3(3):67.
[31]ILANGO S,PULLE R C,BELL J,ET AL.General versus spinal anaesthesia and postoperative delirium in an orthogeriatric population[J].Australasian Journal on Ageing,2015,35(1):42-47.
[32]ROYSE CF,ANDREWS DT,NEWMAN SN,et al.The influence of propofol or desflurane on postoperative cognitive dysfunction in patients undergoing coronary artery bypass surgery[J].Anaesthesia,2011,66(6):455-464.
[33]HUDETZ JA,PATTERSON KM,IQBAL Z,et al.Ketamine attenuates delirium after cardiac surgery with cardiopulmonary bypass[J].Journal of Cardiothoracic&Vascular Anesthesia,2009,23(5):651-657.
[34]YANG L,YAN J,JIN X,et al.Screening for dementia in older adults:comparison of mini-mental state examination,mini-cog,clock drawing test and AD8[J].PLoS One,2016,11(12):e0168949.
[35]OLIN K,ERIKSDOTTER-J?NHAGEN M,JANSSON A,et al.Postoperative delirium in elderly patients after major abdominal surgery[J].British Journal of Surgery,2010,92(12):1559-1564.
[36]LESCOT T,KARVELLAS CJ,CHAUDHURY P,et al.Postoperative delirium in the intensive care unit predicts worse outcomes in liver transplant recipients[J].Canadian Journal of Gastroenterology,2016,27(4):207.
[37]KLEINSCHMIDT A,VUILLEUMIER P.Disconnecting cognition[J].Current Opinion in Neurology,2013,26(4):333-338.
[38]SANDERS RD.Hypothesis for the pathophysiology of delirium:role of baseline brain network connectivity and changes in inhibitory tone[J].Medical Hypotheses,2011,77(1):140-143.
[39]RAPAZZINI P.Functional interrelationship of brain aging and delirium[J].Aging Clinical&Experimental Research,2016,28(1):1-4.
[40]MARCHI N,CAVAGLIA M,FAZIO V,et al.Peripheral markers of blood-brain barrier damage[J].Clinica Chimica Acta,2004,342(1):1-12.
[41]TRZEPACZ PT.Is there a final common neural pathway in delirium?Focus on acetylcholine and dopamine[J].Semin Clin Neuropsychiatry,2000,5(2):132-148.
[42]BERNARDO SR,DUTRA MF,FELIPE S,et al.Delirium in postoperative nonventilated intensive care patients:risk factors and outcomes[J].Annals of Intensive Care,2012,2(1):51-51.
[43]BHATTACHARYA B,MAUNG A,BARRE K,et al.Postoperative delirium is associated with increased intensive care unit and hospital length of stays after liver transplantation[J].Journal of Surgical Research,2017,207:223-228.
[44]LEE H,OH SY,YU JH,et al.Risk factors of postoperative delirium in the intensive care unit after liver transplantation[J].World Journal of Surgery,2018:1-8.
[45]BAJAJ S,ALKOZEI A,DAILEY NS,et al.Brain aging:uncovering cortical characteristics of healthy aging in young adults[J].Frontiers in Aging Neuroscience,2017,9:412..
[46]RADTKE FM,FRANCK M,HAGEMANN L,et al.Risk factors for inadequate emergence after anesthesia:emergence delirium and hypoactive emergence[J].Minerva Anestesiologica,2010,76(6):394-403.
[47]BURKE SN,BARNES CA.Neural plasticity in the ageing brain[J].Nature Reiview Neuroscience,2006,7(1):30-40.
[48]HAYHURST CJ,PANDHARIPANDE PP,HUGHES CG.Intensive Care Unit Delirium:a review of diagnosis,prevention,and treatment[J].Anesthesiology,2016,125(6):1229.
[49]VASUNILASHORN SM,NGO L,INOUYE SK,et al.Cytokines and postoperative delirium in older patients undergoing major elective surgery[J].J Gerontol A Biol Sci Med Sci,2015,11(7):P211-P211.
[50]OLIVER N,BOHORQUEZ H,ANDERS S,et al.Post-liver transplant delirium increases mortality and length of stay[J].Ochsner Journal,2017,17(1):25.
[2]NEUNER B,HADZIDIAKOS D,BETTELLI G.Pre-and postoperative management of risk factors for postoperative delirium:who is in charge and what is its essence?[J].Aging Clinical&Experimental Research,2018,30(3):1-4.
[3]PETERSEN PB,J?RGENSEN CC,KEHLET H.Delirium after fast-track hip and knee arthroplasty-a cohort study of 6331 elderly patients[J].Acta Anaesthesiol Scand,2017,61(7):767-772.
[4]HAMILTON GM,WHEELER K,DI MJ,et al.A systematic review and meta-analysis examining the impact of incident postoperative delirium on mortality[J].Anesthesiology,2017,127(1):1.
[5]WITLOX J,EURELINGS LS,DE JONGHE JF,et al.Delirium in elderly patients and the risk of postdischarge mortality,institutionalization,and dementia:a meta-analysis[J].JAMA,2010,304(4):443-451.
[6]JANKOWSKI CJ,TRENERRY MR,COOK DJ,et al.Cognitive and functional predictors and sequelae of postoperative delirium in elderly patients undergoing elective joint arthroplasty[J].Anesthesia&Analgesia,2011,112(5):1186-1193.
[7]ALDECOA C,BETTELLI G,BILOTTA F,et al.European Society of Anaesthesiology evidence-based and consensus-based guidelines on postoperative delirium[J].European Journal of Anaesthesiology,2017,34(4):192.
[8]CHUNG KS,LEE JK,PARK JS,et al.Risk factors of delirium in patients undergoing total knee arthroplasty[J].Arch Gerontol Geriatr,2015,60(3):443-447.
[9]MALDONADO JR.Neuropathogenesis of delirium:review of current etiologic theories and common pathways[J].Am J Geriatr Psychiatry,2013,21(12):1190-1222.
[10]CLEGG A,YOUNG J,ILIFFE S,et al.Frailty in elderly people[J].Lancet,2013,381(9868):752-762.
[11]王薇,王东信.外科重症老年非心脏手术患者术后谵妄的发生率及危险因素分析[J].解放军医学杂志,2011,6:653-656.
[12]BAGRI AS,RICO A,RUIZ JG.Evaluation and management of the elderly patient at risk for postoperative delirium[J].Clinics in Geriatric Medicine,2008,24(4):667-686.
[13]JUNG P,PEREIRA M A,HIEBERT B,et al.The impact of frailty on postoperative delirium in cardiac surgery patients[J].Journal of Thoracic&Cardiovascular Surgery,2015,149(3):869-875.e2.
[14]WANG SH,WANG JY,LIN PY,et al.Predisposing risk factors for delirium in living donor liver transplantation patients in intensive care units[J].PLoS One,2014,9(5):e96676.
[15]HONDA S,FURUKAWA K,NISHIWAKI N,et al.Risk factors for postoperative delirium after gastrectomy in gastric cancer patients[J].World Journal of Surgery,2018:1-7.
[16]ANSALONI,L,CATENA,F,CHATTAT,R,et al.Risk factors and incidence of postoperative delirium in elderly patients after elective and emergency surgery[J].British Journal of Surgery,2010,97(2):273-280.
[17]KYEONG S,SHIN JE,YANG KH,et al.Neural predisposing factors of postoperative delirium in elderly patients with femoral neck fracture[J].Scientific Reports,2018,8(1):7602.
[18]LEUNG JM,SANDS LP,MULLEN EA,et al.Are preoperative depressive symptoms associated with postoperative delirium in geriatric surgical patients?[J].Journals of Gerontology,2005,60(12):1563.
[19]James L,RUDOLPHAHI,RICHARD N,et al.Independent vascular and cognitive risk factors for postoperative delirium[J].American Journal of Medicine,2007,120(9):807-813.
[20]ENDO Y,AHARONOFF GB,ZUCKERMAN JD,et al.Gender differences in patients with hip fracture:a greater risk of morbidity and mortality in men[J].Journal of Orthopaedic Trauma,2005,19(1):29-35.
[21]VAURIO LE,SANDS LP,WANG Y,et al.Postoperative delirium:the importance of pain and pain management[J].Anesthesia&Analgesia,2006,102(4):1267-1273.
[22]TAGARAKIS GI,TSOLAKI-TAGARAKI F,TSOLAKI M,et al.The role of apolipoprotein E in cognitive decline and delirium after bypass heart operations[J].Am J Alzheimers Dis Other Demen,2007,22(3):223-228.
[23]LEUNG JM,SANDS LP,VAURIO LE,et al.Nitrous oxide does not change the incidence of postoperative delirium or cognitive decline in elderly surgical patients[J].British Journal of Anaesthesia,2006,96(6):754-760.
[24]SIEBER FE,MEARS S,LEE H,et al.Postoperative opioid consumption and its relationship to cognitive function in older adults with hip fracture[J].Journal of the American Geriatrics Society,2011,59(12):2256-2262.
[25]VAN RB,SCHUURMANS MJ,SHORTRIDGE-BAGGETT LM,et al.Risk factors for intensive care delirium:a systematic review[J].Critical Care,2009,24(2):98-107.
[26]VASILEVSKIS EE,HAN JH,HUGHES CG,et al.Epidemiology and risk factors for delirium across hospital settings[J].Best Pract Res Clin Anaesthesiol,2012,26(3):277-287.
[27]SALALLONCH R,BARTRéSFAZ D,JUNQUéC.Reorganization of brain networks in aging:a review of functional connectivity studies[J].Frontiers in Psychology,2015,6(663):663.
[28]STAM CJ,JONES BF,NOLTE G,et al.Small-world networks and functional connectivity in Alzheimer's disease[J].Cerebral Cortex,2007,17(1):92-99.
[29]RADTKE FM,FRANCK M,LENDNER J,et al.Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction[J].British Journal of Anaesthesia,2013,110(3):98-105.
[30]MASON SE,NOEL-STORR A,RITCHIE CW.The impact of general and regional anesthesia on the incidence of post-operative cognitive dysfunction and post-operative delirium:a systematic review with meta-analysis[J].Journal of Alzheimers Disease Jad,2010,22Suppl 3(3):67.
[31]ILANGO S,PULLE R C,BELL J,ET AL.General versus spinal anaesthesia and postoperative delirium in an orthogeriatric population[J].Australasian Journal on Ageing,2015,35(1):42-47.
[32]ROYSE CF,ANDREWS DT,NEWMAN SN,et al.The influence of propofol or desflurane on postoperative cognitive dysfunction in patients undergoing coronary artery bypass surgery[J].Anaesthesia,2011,66(6):455-464.
[33]HUDETZ JA,PATTERSON KM,IQBAL Z,et al.Ketamine attenuates delirium after cardiac surgery with cardiopulmonary bypass[J].Journal of Cardiothoracic&Vascular Anesthesia,2009,23(5):651-657.
[34]YANG L,YAN J,JIN X,et al.Screening for dementia in older adults:comparison of mini-mental state examination,mini-cog,clock drawing test and AD8[J].PLoS One,2016,11(12):e0168949.
[35]OLIN K,ERIKSDOTTER-J?NHAGEN M,JANSSON A,et al.Postoperative delirium in elderly patients after major abdominal surgery[J].British Journal of Surgery,2010,92(12):1559-1564.
[36]LESCOT T,KARVELLAS CJ,CHAUDHURY P,et al.Postoperative delirium in the intensive care unit predicts worse outcomes in liver transplant recipients[J].Canadian Journal of Gastroenterology,2016,27(4):207.
[37]KLEINSCHMIDT A,VUILLEUMIER P.Disconnecting cognition[J].Current Opinion in Neurology,2013,26(4):333-338.
[38]SANDERS RD.Hypothesis for the pathophysiology of delirium:role of baseline brain network connectivity and changes in inhibitory tone[J].Medical Hypotheses,2011,77(1):140-143.
[39]RAPAZZINI P.Functional interrelationship of brain aging and delirium[J].Aging Clinical&Experimental Research,2016,28(1):1-4.
[40]MARCHI N,CAVAGLIA M,FAZIO V,et al.Peripheral markers of blood-brain barrier damage[J].Clinica Chimica Acta,2004,342(1):1-12.
[41]TRZEPACZ PT.Is there a final common neural pathway in delirium?Focus on acetylcholine and dopamine[J].Semin Clin Neuropsychiatry,2000,5(2):132-148.
[42]BERNARDO SR,DUTRA MF,FELIPE S,et al.Delirium in postoperative nonventilated intensive care patients:risk factors and outcomes[J].Annals of Intensive Care,2012,2(1):51-51.
[43]BHATTACHARYA B,MAUNG A,BARRE K,et al.Postoperative delirium is associated with increased intensive care unit and hospital length of stays after liver transplantation[J].Journal of Surgical Research,2017,207:223-228.
[44]LEE H,OH SY,YU JH,et al.Risk factors of postoperative delirium in the intensive care unit after liver transplantation[J].World Journal of Surgery,2018:1-8.
[45]BAJAJ S,ALKOZEI A,DAILEY NS,et al.Brain aging:uncovering cortical characteristics of healthy aging in young adults[J].Frontiers in Aging Neuroscience,2017,9:412..
[46]RADTKE FM,FRANCK M,HAGEMANN L,et al.Risk factors for inadequate emergence after anesthesia:emergence delirium and hypoactive emergence[J].Minerva Anestesiologica,2010,76(6):394-403.
[47]BURKE SN,BARNES CA.Neural plasticity in the ageing brain[J].Nature Reiview Neuroscience,2006,7(1):30-40.
[48]HAYHURST CJ,PANDHARIPANDE PP,HUGHES CG.Intensive Care Unit Delirium:a review of diagnosis,prevention,and treatment[J].Anesthesiology,2016,125(6):1229.
[49]VASUNILASHORN SM,NGO L,INOUYE SK,et al.Cytokines and postoperative delirium in older patients undergoing major elective surgery[J].J Gerontol A Biol Sci Med Sci,2015,11(7):P211-P211.
[50]OLIVER N,BOHORQUEZ H,ANDERS S,et al.Post-liver transplant delirium increases mortality and length of stay[J].Ochsner Journal,2017,17(1):25.