股骨头坏死全髋置换术后谵妄综合征情况调查及影响因素分析

徐云云; 鲁娟; 黄聪聪; 潘孝云; 薛星河; 王谊

doi:10.16766/j.cnki.issn.1674-4152.003137

股骨头坏死全髋置换术后谵妄综合征情况调查及影响因素分析

doi: 10.16766/j.cnki.issn.1674-4152.003137

温州医科大学附属第二医院骨科，浙江温州 325000

基金项目:

浙江省医药卫生科技计划项目 2020KY187

详细信息

通讯作者:
王谊，E-mail: wangyi5588992@126.com

中图分类号: R681.8 R749
计量
- 文章访问数: 123
- HTML全文浏览量: 33
- PDF下载量: 4
- 被引次数: 0
出版历程
- 收稿日期: 2023-02-06
- 网络出版日期: 2023-09-13

Investigation of delirium syndrome after total hip arthroplasty for femoral head necrosis and analysis of influencing factors

Department of Orthopedics, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China

摘要

摘要: 目的探究老年患者股骨头坏死全髋置换术后谵妄综合征及其影响因素，为临床制定针对性预防干预措施提供理论参考。方法选择2020年1月—2022年5月于温州医科大学附属第二医院骨科行全髋置换术治疗的194例老年股骨头坏死患者为观察对象，通过自制调查量表采集患者临床资料，并经意识模糊评估量表(CAM)调查患者是否发生谵妄综合征，调查谵妄综合征发生率，采用多因素logistic回归法分析老年患者股骨头坏死全髋置换术后并发谵妄综合征的影响因素。结果 194例老年股骨头坏死患者全髋置换术后发生谵妄综合征者有26例，发生率为13.40%；有谵妄综合征组、无谵妄综合征组患者在年龄、肺部疾病、夜间睡眠障碍、营养障碍、麻醉方式、手术操作时间、术中机体出血量、术后机体VAS评分、术后血清CRP水平、术后低氧血症发生率方面对比，差异均有统计学意义(均P＜0.05)；多因素logistic分析显示，高龄、肺部疾病、夜间睡眠障碍、营养障碍、麻醉方式(全麻)、手术操作时间长、术中机体出血量多、术后机体VAS评分≥7分、术后血清CRP水平增高、术后低氧血症是老年股骨头坏死患者全髋置换术后谵妄综合征发生的影响因素(均P＜0.05)。结论老年股骨头坏死患者受年龄、肺部疾病、睡眠障碍、机体营养水平等因素影响，全髋置换术后存在较高的谵妄风险，临床应提供针对性预防干预，以降低患者术后并发谵妄综合征的风险。
- 老年 /
- 股骨头坏死 /
- 全髋置换术 /
- 谵妄综合征 /
- 影响因素 /
- 预防干预措施
Abstract: Objective To explore the delirium syndrome after total hip replacement in elderly patients with femoral head necrosis and its influencing factors, and to provide theoretical reference for clinical development of targeted preventive interventions. Methods A total of 194 cases of elderly patients with femoral head necrosis who underwent total hip replacement in the Department of Orthopedics, the Second Affiliated Hospital of Wenzhou Medical University from January 2020 to May 2022 were selected as the observation subjects. The clinical data of patients were collected by self-made survey scale, and the occurrence of delirium syndrome was investigated by the Fuzzy consciousness assessment method (CAM) and the incidence of delirium syndrome was investigated. Multivariate logistic regression was used to analyze the influencing factors of delirium syndrome after total hip replacement in elderly patients with femoral head necrosis. Results There were 26 cases of delirium syndrome after total hip replacement in 194 elderly patients with femoral head necrosis, the incidence was 13.40%. There were differences in age, pulmonary disease, nocturnal sleep disorder, nutritional disorder, anesthesia method, operation time, intraoperative blood loss, postoperative VAS score, postoperative serum CRP level, and postoperative hypoxemia incidence between patients with and without delirium syndrome (all P < 0.05). Multivariate logistic analysis found that advanced age, pulmonary diseases, nocturnal sleep disorders, nutritional disorders, anesthesia method (general anesthesia), long operation time, large amount of intraoperative blood loss, postoperative VAS score ≥7, postoperative serum CRP level increased, and postoperative hypoxemia were the influencing factors for the occurrence of delirium syndrome after total hip replacement in elderly patients with femoral head necrosis (all P < 0.05). Conclusion Elderly patients with femoral head necrosis are affected by age, lung disease, sleep disorder, nutritional level and other factors, and there is a high risk of delirium after total hip replacement. Clinical preventive interventions should be provided to reduce the risk of postoperative delirium syndrome.
- The aged /
- Femoral head necrosis /
- Total hip replacement /
- Delirium syndrome /
- Influencing factors /
- Preventive interventions

HTML全文

表 1 老年股骨头坏死患者全髋置换术后谵妄综合征发生影响因素的单因素分析[例(%)]

Table 1. Univariate analysis of influencing factors of delirium syndrome after total hip replacement in elderly patients with femoral head necrosis[cases(%)]

因素	有谵妄综合征组 (n=26)	无谵妄综合征组 (n=168)	χ²值	P值	因素	有谵妄综合征组 (n=26)	无谵妄综合征组 (n=168)	χ²值	P值
性别			0.255	0.614	营养障碍			6.947	0.008
女性	11(42.31)	80(47.62)			有	10(38.46)	25(14.88)
男性	15(57.69)	88(52.38)			无	16(61.54)	143(85.12)
年龄(岁)			21.041	< 0.001	麻醉方式			5.965	0.015
≥65	20(76.92)	51(30.36)			全身麻醉	17(65.38)	67(39.88)
＜65	6(23.08)	117(69.64)			非全身麻醉	9(34.62)	101(60.12)
疾病类型			2.136	0.545	手术操作时间(min)			4.586	0.032
药物性股骨头坏死	12(46.15)	77(45.83)			≥60	15(57.69)	60(35.71)
放射术后股骨头坏死	0	2(1.19)			＜60	11(42.31)	108(64.29)
酒精性股骨头坏死	13(50.00)	88(52.38)			术中机体出血量(mL)			4.264	0.039
减压病	1(3.85)	1(0.60)			≥250	10(38.46)	34(20.24)
Ficat分期			0.967	0.326	＜250	16(61.54)	134(79.76)
Ⅲ期	8(30.77)	37(22.02)			术后VAS评分≥7分			15.280	< 0.001
Ⅳ期	18(69.23)	131(77.98)			是	15(57.69)	36(21.43)
酗酒			0.289	0.592	否	11(42.31)	132(78.57)
是	5(19.23)	22(13.10)			术后全血Hb水平(g/L)			0.286	0.593
否	21(80.77)	146(86.90)			＜110	14(53.85)	81(48.21)
基础疾病					≥110	12(46.15)	87(51.79)
肺部疾病	14(53.85)	54(32.14)	4.659	0.031	术后血清CRP水平(mg/L)			5.448	0.020
高血压	15(57.69)	101(60.12)	0.055	0.814	＞10	15(57.69)	57(33.93)
糖尿病	7(26.92)	37(22.02)	0.308	0.579	≤10	11(42.31)	111(66.07)
冠心病	14(53.85)	96(57.14)	0.100	0.652	术后全血红细胞比容(%)			1.577	0.209
焦虑			0.134	0.714	＜37	7(26.92)	25(14.88)
是	6(23.08)	30(17.86)			≥37	19(73.08)	143(85.12)
否	20(76.92)	138(82.14)			术后低氧血症			6.812	0.009
抑郁			0.265	0.607	有	8(30.77)	17(10.12)
是	5(19.23)	40(23.81)			无	18(69.23)	151(89.88)
否	21(80.77)	128(76.19)
夜间睡眠障碍			5.934	0.015
有	10(38.46)	27(16.07)
无	16(61.54)	141(83.93)

下载: 导出CSV

表 2 自变量赋值情况

Table 2. Assignment of independent variables

自变量	赋值方法
年龄	≥65岁=0，＜65岁=1
肺部疾病	有=0，无=1
夜间睡眠障碍	有=0，无=1
营养障碍	有=0，无=1
麻醉方式	全身麻醉=0，非全身麻醉=1
手术操作时间	≥60 min=0，＜60 min=1
术中机体出血量	≥250 mL=0，＜250 mL=1
术后机体VAS评分≥7分	是=0，否=1
术后血清CRP水平	＞10 mg/L=0，≤10 mg/L=1
术后低氧血症	有=0，无=1

下载: 导出CSV

表 3 老年股骨头坏死全髋置换术后谵妄综合征发生影响因素的多因素logistic分析

Table 3. Multivariate logistic analysis of influencing factors of delirium syndrome after total hip replacement in elderly patients with femoral head necrosis

因素	B	SE	Wald χ²	P值	OR(95% CI)
年龄	2.034	0.495	16.904	< 0.001	7.647(2.900~20.168)
肺部疾病	0.901	0.427	4.463	0.035	2.463(1.067~5.684)
夜间睡眠障碍	1.183	0.455	6.772	0.009	3.264(1.339~7.955)
营养障碍	1.274	0.458	7.747	0.005	3.565(1.458~8.767)
麻醉方式	1.046	0.441	5.622	0.018	2.847(1.199~6.762)
手术操作时间	0.898	0.428	4.394	0.036	2.455(1.060~5.683)
术中机体出血量	0.901	0.447	4.076	0.043	2.463(1.027~5.910)
术后机体VAS评分≥7分	1.609	0.439	13.426	< 0.001	5.000(2.114~11.826)
术后血清CRP水平	0.977	0.429	5.180	0.023	2.656(1.145~6.157)
术后低氧血症	1.373	0.496	7.665	0.006	3.948(1.493~10.436)

下载: 导出CSV

参考文献(20)

[1]	程鹏, 杨卿, 朱波, 等. 直接前方入路与后外侧入路初次全髋关节置换术治疗股骨头坏死的早期临床疗效比较[J]. 骨科, 2020, 11(4): 281-286. https://www.cnki.com.cn/Article/CJFDTOTAL-HYXZ202004003.htm CHENG P, YANG Q, ZHU B, et al. Comparison of the early clinical effect of direct anterior approach vs. posterolateral approach for primary total hip arthroplasty in femoral head necrosis[J]. Orthopedics, 2020, 11(4): 281-286. https://www.cnki.com.cn/Article/CJFDTOTAL-HYXZ202004003.htm
[2]	王标, 王雷原, 纪木火. 老年患者髋关节置换术后谵妄的危险因素[J]. 临床麻醉学杂志, 2022, 38(7): 688-692. https://www.cnki.com.cn/Article/CJFDTOTAL-LCMZ202207003.htm WANG B, WANG L Y, JI M H. Risk factors for delirium after hip replacement in elderly patients[J]. Journal of Clinical Anesthesiology, 2022, 38(7): 688-692. https://www.cnki.com.cn/Article/CJFDTOTAL-LCMZ202207003.htm
[3]	CHOI E J, CHOI Y J, LEE S W, et al. Effect of anesthetic method on incidence of delirium after total hip replacement arthroplasty in South Korea: a population-based study using National Health Insurance claims data[J]. Korean J Anesthesiol, 2020, 73(1): 36-43. doi: 10.4097/kja.19091
[4]	徐孟婷, 凌云志, 张景俊, 等. 右美托咪定复合不同麻醉深度对老年全髋关节置换术患者术后谵妄的影响[J]. 中华全科医学, 2021, 19(10): 1646-1649. doi: 10.16766/j.cnki.issn.1674-4152.002132 XU M T, LING Y Z, ZHANG J J, et al. Effect of dexmedetomidine combined with different anaesthesia depth on postoperative delirium in elderly patients undergoing total hip replacement[J]. Chinese Journal of General Practice, 2021, 19(10): 1646-1649 doi: 10.16766/j.cnki.issn.1674-4152.002132
[5]	MOHANTY S, GILLIO A, LINDROTH H, et al. Major surgery and long term cognitive outcomes: the effect of postoperative delirium on dementia in the year following discharge[J]. J Surg Res, 2022, 270(12): 327-334.
[6]	中国医师协会骨科医师分会显微修复工作委员会, 中国修复重建外科专业委员会骨缺损及骨坏死学组, 中华医学会骨科分会显微修复学组. 成人股骨头坏死临床诊疗指南(2016)[J]. 中华骨科杂志, 2016, 36(15): 945-954. doi: 10.3760/cma.j.issn.0253-2352.2016.15.001 Microrepair Working Committee Orthopaedic Surgeons Branch of Chinese Medical Doctor Association, Bone Defect and Osteonecrosis Group of Chinese Orthopaedic Surgery Professional Committee, Microrepair Group of Orthopaedic Branch of Chinese Medical Association. Diagnosis and treatment of femoral head necrosis in adults (2016)[J]. Chinese Journal of Orthopaedics, 2016, 36(15): 945-954. doi: 10.3760/cma.j.issn.0253-2352.2016.15.001
[7]	中华医学会老年医学分会. 老年患者术后谵妄防治中国专家共识[J]. 中华老年医学杂志, 2016, 35(12): 1257-1262. doi: 10.3760/cma.j.issn.0254-9026.2016.12.001 Chinese Society of Geriatric Medicine. Chinese expert consensus on prevention and control of elderly patients with postoperative delirium[J]. Chinese Journal of Geriatrics, 2016, 35(12): 1257-1262. doi: 10.3760/cma.j.issn.0254-9026.2016.12.001
[8]	姚杰, 刘斐, 左慕妍, 等. 丙泊酚不同输注方式对老年病人髋关节置换术后谵妄的影响[J]. 实用老年医学, 2021, 35(3): 286-289. https://www.cnki.com.cn/Article/CJFDTOTAL-SYLA202103021.htm YAO J, LIU F, ZUO M Y, et al. Effects of different methods infusion of propofol on delirium in elderly patients receiving hip replacement surgery[J]. Practical Geriatrics, 2021, 35(3): 286-289. https://www.cnki.com.cn/Article/CJFDTOTAL-SYLA202103021.htm
[9]	WEINSTEIN S M, POULTSIDES L, BAAKLINI L R, et al. Postoperative delirium in total knee and hip arthroplasty patients: a study of perioperative modifiable risk factors[J]. Brit J Anaesth, 2018, 120(5): 999-1008. doi: 10.1016/j.bja.2017.12.046
[10]	戴传强, 秦磊磊, 黄伟, 等. 老年关节置换患者发生术后谵妄的影响因素分析[J]. 中国煤炭工业医学杂志, 2020, 23(2): 203-208. https://www.cnki.com.cn/Article/CJFDTOTAL-ZMGY202002021.htm DAI C Q, QIN L L, HUANG W, et al. Influence factors of postoperative delirium in elderly patients undergoing arthroplasty[J]. Chinese Journal of Coal Industry Medicine, 2020, 23(2): 203-208. https://www.cnki.com.cn/Article/CJFDTOTAL-ZMGY202002021.htm
[11]	熊昌军, 姜学明, 左云周, 等. 老年髋部骨折患者术后出现谵妄的危险因素分析[J]. 中国骨与关节损伤杂志, 2020, 35(2): 162-164. https://www.cnki.com.cn/Article/CJFDTOTAL-GGJS202002018.htm XIONG C J, JIANG X M, ZUO Y Z, et al. Analysis of risk factors for postoperative delirium in elderly patients with hip fracture[J]. Chinese Journal of Bone and Joint Injury, 2020, 35(2): 162-164. https://www.cnki.com.cn/Article/CJFDTOTAL-GGJS202002018.htm
[12]	AZIMARAGHI O, WONGTANGMAN K, WACHTENDORF L J, et al. Differential effects of gamma-aminobutyric acidergic sedatives on risk of post-extubation delirium in the ICU: a retrospective cohort study from a new england health care network[J]. Crit Care Med, 2022, 50(5): 434-444.
[13]	GUPTA A, JOSHI P, BHATTACHARYA G, et al. Is there evidence for using anticonvulsants in the prevention and/or treatment of delirium among older adults?[J]. Int Psychogeriatr, 2022, 34(10): 889-903.
[14]	叶杨, 淦细红, 潘璇璇, 等. 老年股骨颈骨折患者髋关节置换术后并发谵妄的危险因素分析[J]. 中国医院统计, 2020, 27(1): 47-50. https://www.cnki.com.cn/Article/CJFDTOTAL-JTYY202001009.htm YE Y, GAN X H, PAN X X, et al. Analysis of risk factors for convulsions after hip replacement in elderly patients with femoral neck fracture[J]. Chinese Journal of Hospital Statistics, 2020, 27(1): 47-50. https://www.cnki.com.cn/Article/CJFDTOTAL-JTYY202001009.htm
[15]	杨曦仑, 孙雪晨, 孔繁一, 等. 老年患者全麻下髋关节置换术后发生谵妄的危险因素及风险模型构建[J]. 中国老年学杂志, 2022, 42(8): 1866-1869. https://www.cnki.com.cn/Article/CJFDTOTAL-ZLXZ202208023.htm YANG X L, SUN X C, KONG F Y, et al. Risk factors and risk model construction of delirium after hip joint replacement under general anesthesia in elderly patients[J]. Chinese Journal of Gerontology, 2022, 42(8): 1866-1869. https://www.cnki.com.cn/Article/CJFDTOTAL-ZLXZ202208023.htm
[16]	朱向晖, 赵峰, 贾雅蕊, 等. 术中右美托咪定使用在预防全麻下全髋关节置换术后谵妄发生及认知功能障碍风险的临床研究[J]. 医药论坛杂志, 2021, 42(24): 26-31, 37. https://www.cnki.com.cn/Article/CJFDTOTAL-HYYX202124007.htm ZHU X H, ZHAO F, JIA Y R, et al. Clinical study of intraoperative dexmedetomidine application in prevention of delirium after total hip arthroplasty under general anesthesia[J]. Journal of Medical Forum, 2021, 42(24): 26-31, 37. https://www.cnki.com.cn/Article/CJFDTOTAL-HYYX202124007.htm
[17]	ZHANG G X, WANG Z W, WANG D C, et al. A systematic review and meta-analysis of the correlation between operation time and postoperative delirium in total hip arthroplasty[J]. Ann Palliat Med, 2021, 10(10): 10459-10466.
[18]	李楠, 纪玮玮, 刘伟, 等. 老年病人全麻下髋关节置换术后谵妄危险因素分析[J]. 实用老年医学, 2022, 36(8): 838-841. https://www.cnki.com.cn/Article/CJFDTOTAL-SYLA202208020.htm LI N, JI W W, LIU W, et al. Risk factors of postoperative delirium in elderly patients undergoing hip arthroplasty under general anesthesia[J]. Practical Geriatrics, 2022, 36(8): 838-841. https://www.cnki.com.cn/Article/CJFDTOTAL-SYLA202208020.htm
[19]	翟宇露, 杨玉霞, 陈艳菲. 老年髋关节置换病人术后谵妄的相关危险因素的Logistic回归分析[J]. 全科护理, 2022, 20(26): 3724-3727. https://www.cnki.com.cn/Article/CJFDTOTAL-JTHS202226032.htm ZHAI Y L, YANG Y X, CHEN Y F. Logistic regression analysis of risk factors for postoperative delirium in elderly patients with hip replacement[J]. Chinese General Practice Nursing, 2022, 20(26): 3724-3727. https://www.cnki.com.cn/Article/CJFDTOTAL-JTHS202226032.htm
[20]	王金伙, 郭建荣, 高新跃. 麻醉前应用帕瑞昔布钠对高龄髋关节置换术患者术后谵妄的预防作用及其机制[J]. 山东医药, 2023, 63(2): 64-67. https://www.cnki.com.cn/Article/CJFDTOTAL-SDYY202302014.htm WANG J H, GUO J R, GAO X Y. Preventive effect of parecoxib sodium before anesthesia on postoperative delirium in elderly patients with hip replacement and its mechanism[J]. Shandong Medical Journal, 2023, 63(2): 64-67. https://www.cnki.com.cn/Article/CJFDTOTAL-SDYY202302014.htm