蛛网膜下腔注射地塞米松对髋关节手术后认知障碍的影响

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蛛网膜下腔注射地塞米松对髋关节手术后认知障碍的影响

贵州医科大学 麻醉与心脏电生理课题组

翻译：柏雪   编辑：柏雪   审校：曹莹

背景 股骨近端骨折 (PrFF) 是老年人急诊入院的最常见原因之一。大多数患者都有基础疾病，这些疾病会因急诊手术而恶化。

目的 本文的目的是评估单次地塞米松联合左旋布比卡因蛛网膜下腔注射是否能减少近端股骨骨折患者的术后疼痛和术后认知并发症。

方法 这项研究是在一家二级创伤中心进行的，该中心是教学医院的一部分，该医院的服务区人口约有 300,000 名患者，第一作者隶属于该医院。该中心每年进行约 500 次 PrFF。所有参与者在随机分组之前都口头告知并签署知情同意书。

结果 纳入60 名ASA II-III级的 PrFF 患者，随机分为两组进行腰麻：DLSA 研究组（给予8 mg 地塞米松和 0.5 % 左旋布比卡因12.5 mg）， LSA 对照组（给予0.5 % 左旋布比卡因12.5 mg）。术后认知障碍采用简化混淆评估法(CAM)量表评估，使用视觉模拟量表 (VAS) 测量疼痛强度，并在手术前后采集血样以确定皮质醇浓度。主要结果是蛛网膜下腔注射地塞米松后血浆皮质醇改变及其对术后认知障碍的影响。次要结果包括疼痛评分和住院时间。DLSA 组术后认知功能障碍 (POCD) 的发生率降低（p=0.043），镇痛持续时间更长（p<0.001），皮质醇水平降低和住院时间缩短（p=0.045）。蛛网膜下腔注射地塞米松是术后谵妄的唯一显著预测因子（OR 7.76，p=0.019）。

结论 地塞米松联合左旋布比卡因单次蛛网膜下腔注射用于股骨近端骨折的麻醉，通过降低血浆皮质醇浓度来降低应激反应，延长镇痛时间。谵妄和 POCD 等并发症的发生频率明显降低，有利于术后康复并缩短住院时间。

原始文献来源：Livija Sakic, Dinko Tonkovicc, Zlatko Hrgovic, Antonio Klasan. Spinal Dexamethasone Effect on Cognitive Disorders After Hip Surgery. MED ARCH. FEB; 77(1): 18-23, doi: 10.5455/medarh.2023.77.18-23

英文原文：

Spinal Dexamethasone Effect on Cognitive Disorders After Hip Surgery

ABSTRACT

Background: Proximal femoral fractures (PrFF) are one of the most common causes of emergency admission in the elderly population. The majority of patients have pre-existing conditions that get worsened by unplanned surgery. 

Objective: Purpose of this article was to evaluate if a is single shot of dexamethasone with levobupivacaine administered intrathecally reduces postoperative pain and cognitive complications in patients with proximal femoral fractures. 

Methods: The study was performed at a level II trauma center which is a part of a teaching hospital with a catchment population of around 300,000 patients, the first author’s affiliation. Around 500 PrFF are performed yearly in the center. All participants gave oral and written informed consent before randomization. 

Results: In total, 60 patients with a PrFF, ASA status 2 or 3 were randomized into two groups for spinal anaesthesia as DLSA study group (received 8 mg of dexamethasone and 12.5 mg of 0.5 % levobupivacaine) or LSA control group (received 12.5 mg of 0,5 % levobupivacaine). Postoperative cognitive disturbance was evaluated using simplified Confusion Assessment Method (CAM) scale, pain intensity was measured using Visual Analogue Scale (VAS) and blood samples for defining cortisol concentrations were taken before and after the surgical procedure. The primary outcomes were effects of intrathecal dexamethasone on plasma cortisol affecting cognitive disturbances. Secondary outcomes included pain scores and length of hospital stay. The DLSA group demonstrated a reduced incidence of postoperative cognitive dysfunction (POCD), p=0.043, longer analgesia duration, p<0.001, decreased cortisol levels and shorter hospitalization p=0.045. Intrathecal dexamethasone was the only significant predictor of postoperative delirium, OR 7.76, p=0.019. 

Conclusion: Single shot intrathecal administration of dexamethasone with levobupivacaine used in anaesthesia for proximal femoral fractures reduces the stress response by decreasing plasma cortisol concentrations prolonging analgesia. Complications such as delirium and POCD occurred with significantly lower frequency allowing better postoperative rehabilitation and shortening the hospitalization.

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免责声明：

文中所涉及药物使用、疾病诊疗等内容仅供医学专业人士参考。

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编辑：MiLu.米鹭

校对：Michel.米萱  

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