硬膜外-全身联合麻醉或全身麻醉行大手术的老年患者术后谵妄的一项随机试验

谵妄是一种常见且严重的术后并发症，尤其是在老年人中。硬膜外麻醉可以通过改善镇痛、减少阿片类药物的消耗和减弱对手术的应激反应来减少谵妄。因此，本试验验证了硬膜外-全身联合麻醉降低老年非心脏手术康复患者术后谵妄发生率的假设。

研究纳入了年龄在60岁至90岁之间，计划进行为期2小时或以上的非心脏手术、胸科手术或腹部手术的患者。参与者按1:1的比例随机分为硬膜外-全麻联合术后硬膜外镇痛或全麻联合术后静脉镇痛。主要结果是谵妄的发生率，在术后最初的7天内，用重症监护室的混乱评估法每天评估两次。

2011年11月至2015年5月，1802例患者随机接受硬膜外-全身联合麻醉(n=901)或单独全身麻醉(n=901)。其中，1720例患者（平均年龄，70岁，35%的女性）完成了研究，并被纳入意向治疗分析。硬膜外-全麻联合麻醉组（857例患者中有15例[1.8%]）的谵妄发生率明显低于全麻组（863例患者中有43例[5.0%]）；相对危险度0.351；95%可信区间为0.197～0.627；P<0.001；需要治疗的人数（31人）。术中低血压（收缩压低于80 mmHg）在硬膜外麻醉患者中更为常见（421例[49%]对288例[33%]；相对危险度为1.47，95%可信区间为1.31-1.65；P<0.001），更多的硬膜外患者使用血管升压药（495[58%]比387[45%]；相对危险度1.29；95%可信区间为1.17～1.41；P<0.001）。

老年患者在胸腹部手术中随机接受硬膜外-全身联合麻醉，其谵妄发生率为三分之一，低血压发生率高出50%。临床医生应考虑在有术后谵妄风险的病人中用硬膜外-全身联合麻醉，而在有低血压风险的病人中避免联合使用。

Ya-Wei Li, Huai-Jin Li, Hui-Juan Li,et al.Delirium in Older Patients after Combined Epidural–General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial.ANESTHESIOLOGY 2021; 135:218–32.

Delirium in Older Patientsafter Combined Epidural–General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial

Abstract

Background: Delirium is a common and serious postoperative complication, especially in the elderly. Epidural anesthesia may reduce delirium by improving analgesia, reducing opioid consumption, and blunting stress response to surgery. This trial therefore tested the hypothesis that combined epidural–general anesthesia reduces the incidence of postoperative delirium in elderly patients recovering from major noncardiac surgery.

Methods: Patients aged 60 to 90 yr scheduled for major noncardiac thoracic or abdominal surgeries expected to last 2 h or more were enrolled. Participants were randomized 1:1 to either combined epidural–general anesthesia with postoperative epidural analgesia or general anesthesiawith postoperative intravenous analgesia. The primary outcome was the incidence of delirium, which was assessed with the Confusion Assessment Method for the Intensive Care Unit twice daily during the initial 7 postoperative days.

Results: Between November 2011 and May 2015, 1,802 patients were randomized to combined epidural–general anesthesia (n = 901) or general anesthesia alone (n = 901). Among these, 1,720 patients (mean age, 70 yr; 35% women) completed the study and were included in the intention-to-treat analysis. Delirium was significantly less common in the combined epidural–general anesthesia group (15 [1.8%] of 857 patients) than in the general anesthesia group (43 [5.0%] of 863 patients; relative risk, 0.351; 95% CI, 0.197 to 0.627; P < 0.001; number needed to treat 31). Intraoperative hypotension (systolic blood pressure less than 80 mmHg) was more common in patients assigned to epidural anesthesia (421 [49%] vs. 288 [33%]; relative risk, 1.47, 95% CI, 1.31 to 1.65; P < 0.001), and more epidural patients were given vasopressors (495 [58%] vs. 387 [45%]; relative risk, 1.29; 95% CI, 1.17 to 1.41; P < 0.001).

Conclusions: Older patients randomized to combined epidural-general anesthesia for major thoracic and abdominal surgeries had one third as much delirium but 50% more hypotension. Clinicians should consider combining epidural and general anesthesia in patients at risk of postoperative delirium, and avoiding the combination in patients at risk of hypotension.