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【文獻速遞】腦電引導的麻醉藥物管理對老年患者大手術後譫妄的作用——JAMA臨床研究

圖1 腦電圖和對應狀態及BIS值

研究方法

該研究為單中心、隨機對照、雙盲臨床研究。

納入標準:60歲及以上於全麻下接受大手術(包括心臟手術)的患者。

排除標準:未簽署知情同意書,精神錯亂,聾啞人,文盲,無法流利使用英語交流及發生術中知曉、術後5天內接受二次手術的患者。

分組:患者1:1隨機分為兩組(並根據患者是否接受心臟手術和近期是否有跌倒的病史進行分層),EEG引導麻醉管理組(n=614)和傳統麻醉管理組(n=618)。本研究腦電採用使用腦電雙頻儀器將探頭置於前額觀察腦電變化,全身麻醉藥物使用吸入麻醉氣體。參與研究的麻醉醫師在發現出現腦電抑制時被鼓勵降低吸入麻醉藥濃度。

主要觀察指標:術後第1至5天譫妄的發病率(使用CAM和CAM-ICU量表來評估譫妄)。

其他觀察指標包括:

術中相關指標包括,麻醉藥物濃度、EEG抑制和低血壓的時間等;

不良事件包括,術中非意向性運動,術中知曉,術後噁心嘔吐,醫療相關併發症以及死亡率。

圖2 研究流程圖

研究結果

自2015年1月至2018年6月,共1232名60歲及以上在聖路易斯Barnes-Jewish醫院於全麻下接受大手術(包括心臟手術)的患者,納入了該項隨機對照研究,其平均年齡為69歲(60~95),其中563名為女性(45.7%)。EEG引導麻醉管理組有10名患者由於術中腦電訊號差,傳統麻醉管理組中有9名患者由於術中特殊情況需要觀察腦電情況最終沒有進行術後譫妄的評估,因此最終有1213 (98.5%) 名患者進行了主要觀察指標的評估。

表1 患者術前一般情況

術後第1天到第5天譫妄的發病率,實驗組為157/604 (26.0%),對照組中為140/609 (23.0%) (差值為,3.0% [95% CI,−2.0% ~8.0%];P = 0.22) 。

圖3 兩組患者譫妄發病率、腦電抑制及BIS值低於40的總時間

實驗組中,呼氣末麻醉氣體濃度平均值顯著低於對照組(最低肺泡濃度分別為0.69 vs 0.80;差值為,−0.11 [95% CI, −0.13 ~0.10]),EEG抑制的總時間平均實驗組也顯著低於對照組(7 vs 13 min; 差值為,−6.0 [95% CI, −9.9 to −2.1])。兩組間平均動脈壓低於60 mm Hg 的總時間平均值沒有統計學差異(7 vs 7 min;差值為,0.0 [95% CI, −1.7 to 1.7])。非意向性運動在實驗組中有137(22.3%)名患者出現,對照組中有95(15.4%)名患者出現,兩組患者均未發生術中知曉 。術後噁心嘔吐在對照組中有48(7.8%)名患者發生,實驗組中有55(8.9%)名發生。實驗組中有124(20.2%)患者發生了嚴重不良事件的,對照組中有130(21.0%)名患者。術後30天內死亡率在對照組中為3.07%(19例),實驗組僅為0.65%(4例)。研究者同時將19名未進行譫妄評估的患者,全部視為發生譫妄或全部沒有發生譫妄再次進行統計分析,對結果並無影響。

表2 圍手術期監護測量指標

表3 主要觀察指標、次要觀察指標和不良事件情況

討論與結論

研究者指出,這一結果和現有薈萃分析的結果不一致可能和以往隨機對照研究的質量參差不齊有關。本研究的方法學是嚴謹且強有力的,但同時研究者也指出譫妄較難診斷且存在波動性因此間隔時段的評估方法可能會有遺漏。本研究結果僅針對吸入麻醉,中的針對EEG引導組的患者死亡率的顯著降低這一結果,研究者指出還將進行進一步的研究進行驗證。

接受大手術的老年患者,術中使用EEG引導麻醉管理相較傳統麻醉管理其術後譫妄發生率。

注:ENGAGESElectroencephalographyGuidance of Anesthesia to Alleviate Geriatric Syndromes,腦電圖引導的麻醉減輕老年綜合症隨機對照臨床試驗。

原文連結:https://jamanetwork.com/journals/jama/article-abstract/2724026?resultClick=1PMID:30721296

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編譯 姚婧鑫