脑电图指导的麻醉管理对老年患者大手术后谵妄的影响
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Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial
背景与目的
老年患者是大手术后发生谵妄的高危人群。术后谵妄不仅延长住院时间和ICU停留时间，占用更多的医疗资源，而且还消耗患者家属以及医护人员大量精力。预防谵妄已成为公共卫生问题中的当务之急。本研究旨在探讨在脑电图指导下减少麻醉药量以及避免脑电抑制，是否可降低老年患者大手术后谵妄的发生率。
方 法
该试验是一项单中心、基于临床实效、对患者和评估者施盲的随机研究，研究时间从2015年1月至2018年5月。入组的1232例患者年龄均超过60周岁，在全麻下接受大手术，分为EEG监测组614例，对照组618例。排除标准包括不愿意参加者、精神病患者、盲人、耳聋、文盲、不懂英语、曾经历过术中知晓、以及5天内接受第二次手术的患者。主要观察指标是术后1至5d谵妄的发生率。术中监测麻醉药浓度、EEG抑制发生情况、低血压。记录的不良事件包括未预测到的体动、术中知晓、术后恶心呕吐、内科并发症以及死亡。
结 果
术后1至5d谵妄发生率如下：EEG监测组为26%（157/604），常规监测组为23%（140/609）（差异为3%，[95%CI，-2.0%至8.0%]，P=0.22）；EEG监测组呼气末吸入药浓度中位数显著低于对照组（0.69 vs 0.80MAC，差异为-0.11[95%CI，-0.13至-0.10]），EEG监测组EEG抑制的平均累计时间短于对照组（7 vs 13分钟，差异为-6.0[95%CI，-9.9至-2.1]）,平均动脉血压低于60mmHg的累计时间两组没有差别（7 vs 7分钟，差异为0.0[95%CI，-1.7至-1.7]）。未预计的体动反应发生率EEG监测组为22.3%（137例），对照组为15.4%（95例）。两组均未出现术中知晓。术后恶心呕吐发生率EEG监测组为7.8%（48例），对照组为8.9%（55例）。严重不良事件发生率EEG监测组为20.2%（124例），对照组为21.0%（130例）。术后30天死亡率EEG监测组为0.65%（4例），对照组为3.07%（19例）。
结 论
与常规监护相比，EEG指导下的麻醉管理不会降低接受大手术的老年患者术后谵妄的发生率。本研究不支持EEG指导麻醉管理用于降低术后谵妄。
原始文献摘要
Wildes TS, Mickle AM, Ben Abdallah A, et al. Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial. JAMA. 2019 Feb 5;321(5):473-483. doi: 10.1001/jama.2018.22005.
IMPORTANCE Intraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium.
OBJECTIVE To assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium.
DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 1232 adults aged60years and older undergoing major surgery and receiving general anesthesia at Barnes-Jewish Hospital in St Louis. Recruitmentwas from January 2015 toMay 2018, with follow-up until July 2018.
INTERVENTIONS Patients were randomized 1:1 (stratified by cardiac vs noncardiac surgery and positive vs negative recent fall history) to receive EEG-guided anesthetic administration
(n = 614) or usual anesthetic care (n = 618).
MAIN OUTCOMES AND MEASURES The primary outcomewas incident delirium during ostoperative days 1 through 5. Intraoperative measures included anesthetic concentration, EEG suppression, and hypotension. Adverse events included undesirable intraoperative movement, intraoperative awareness with recall, postoperative nausea and vomiting, medical complications, and death.
RESULTS Of the 1232 randomized patients (median age, 69 years [range, 60to 95]; 563women [45.7%]), 1213 (98.5%)were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 157 of 604patients (26.0%)in the guided group and 140 of 609 patients (23.0%)in the usual care group (difference, 3.0%[95%CI, −2.0%to 8.0%]; P = .22). Median end-tidal volatile anesthetic concentrationwas significantly lower in the guided group than the usual care group (0.69 vs0.80minimum alveolar concentration; difference, −0.11 [95%CI, −0.13 to −0.10), and median cumulative time with EEGsuppressionwas significantly less (7 vs 13 minutes; difference, −6.0[95%CI, −9.9 to −2.1]). Therewas no significant difference between groups in the median cumulative time with mean arterial pressure below60mmHg (7 vs 7 minutes; difference,0.0[95%CI, −1.7 to 1.7]). Undesirablemovement occurred in 137 patients 22.3%) in the guided and 95 (15.4%) in the usual care group.No patients reported intraoperative awareness. Postoperative nausea and vomitingwas reported in 48 patients (7.8%) in the guided and 55 patients (8.9%) in the usual care group. Serious adverse eventswere reported in 124 patients (20.2%) in the guided and 130 (21.0%)in the usual care group. Within 30 days of surgery, patients (0.65%) in the guided group and 19 (3.07%) in the usual care group died.
CONCLUSIONS AND RELEVANCE Among older adults undergoing major surgery, EEG-guided anesthetic administration, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support the use of EEG-guided anesthetic administration for this indication.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：王贵龙 编辑：余晓旭 审校：王贵龙
