术后谵妄：围手术期评估、风险降低及管理
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术后谵妄：围手术期评估、风险降低及管理
翻译：佟睿 编辑：冯玉蓉 审校：曹莹
背景：术后谵妄是一种比较常见和严重的并发症，会导致住院天数增加2~3天，7~10%术后谵妄与30天死亡率相关。术后谵妄在神经认知障碍、接受复杂或紧急手术的老年患者中最为常见。近年来的临床前及临床研究揭示了更多关于术后谵妄的病理生理学表现，并可能为临床提供更多潜在的治疗选择。
方法：利用风险分层、风险降低和抢救治疗的改良康复路径框架，我们回顾了当前的临床证据，这些证据表明了对于手术人群而言，谵妄预测评分的有效性，围手术期降低谵妄风险干预措施的有效性，以及对已确诊谵妄患者的处理方案。有效的围术期干预措施包括麻醉深度监测、术中右美托咪啶输注和多模式镇痛。
结果：全身麻醉剂的选择可能对谵妄风险的显著增加的影响无明显差异。其他几个因素，如术前禁食、体温控制和血压管理，与术后谵妄的风险是否存在关系，这些还需要进一步研究。
结论：由于可供选择的治疗方法有限，我们认为风险评估和围术期风险降低可能是管理术后谵妄的最有效的方法。
原始文献来源：Jin ZS, Hua J, Ma DQ, et al. Postoperative delirium: perioperative assessment, risk reduction, and management.[J].Br J Anaesth, 2020, Aug 11;[Epub ahead of print].
Postoperative delirium: perioperative assessment, risk reduction, and management
Abstract
Postoperative delirium is a relatively common and serious complication. It increases hospital stay by 2-3 days and is associated with a 30-day mortality of 7-10%. It is most prevalent in older patients, those with existing neurocognitive disorders, and those undergoing complex or emergency procedures. Preclinical and clinical research in recent years has uncovered more about the pathophysiology of postoperative delirium and may yield more potential therapeutic options. Using the enhanced recovery pathway framework of risk stratification, risk reduction, and rescue treatment, we have reviewed the current clinical evidence on the validity of delirium prediction scores for the surgical population, the effectiveness of perioperative delirium risk reduction interventions, and management options for established delirium. Effective perioperative interventions include depth of anaesthesia monitoring, intraoperative dexmedetomidine infusion, and multimodal analgesia. Choice of general anaesthetic agent may not be associated with significant difference in delirium risk. Several other factors, such as preoperative fasting, temperature control, and blood pressure management have some association with the risk of postoperative delirium; these will require further studies. Because of the limited treatment options available for established delirium, we propose that risk assessment and perioperative risk reduction may be the most effective approaches in managing postoperative delirium.
贵州医科大学高鸿教授课题组
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