【罂粟摘要】接受大型骨科手术的老年患者术前糖尿病与术后谵妄的关联

术后谵妄（POD）是一种常见的术后脑功能障碍，尤其是在老年人中。然而，其风险因素在很大程度上仍有待确定。本研究旨在探讨：(1)术前糖尿病是否与择期骨科手术后的POD相关；(2)术中额叶α功率是否是术前糖尿病与POD相关性的中介因素。

这是一项前瞻性配对队列研究，研究对象是年龄在60岁或以上术前患有糖尿病并接受择期骨科手术的患者。在年龄、性别和手术类型方面，非糖尿病患者与糖尿病患者的配对比例为1:1。主要结果是POD的发生率，在术后第1-7天或出院前，每天下午6点到晚上8点使用3分钟诊断性混淆评估法（3D-CAM）评估一次。次要结果是POD的严重程度，使用CAM-Severity简表对所有参与者进行评估。从麻醉诱导前开始记录额叶脑电图（EEG），直至出手术室。术中α功率是通过多锥体频谱分析计算得出的。中介分析用于估计术前糖尿病和POD之间的关联比例。

共有138对符合条件的患者以1：1成功匹配。入组后，由于缺乏原始的脑电图数据，糖尿病组6例患者被排除，非糖尿病组4例患者被排除。最终的分析包括132名术前糖尿病患者和134名非术前糖尿病患者，中位年龄为68岁，72.6%的患者为女性。术前有糖尿病的患者的POD发生率为16.7%（22/132），而术前无糖尿病的患者的发生率为6.0%（8/134）。术前调整年龄、性别、体重指数、教育程度、高血压、心律失常、冠心病和卒中史后，术前糖尿病与POD几率增加相关（优势比，3.2；95%可信区间[CI]，1.4-8.0；P=0.009)。术中α功率估计占糖尿病和POD之间关联的20%（95%CI，2.6-60%；P=0.021）。

本研究表明，术前糖尿病与接受重大骨科手术的老年患者的POD风险增加相关，术中α功率低在一定程度上介导了这种关联。

原始文献来源：Shang Z,Jiang Y,Fang P, et al. The Association of Preoperative Diabetes With Postoperative Delirium in Older Patients Undergoing Major Orthopedic Surgery: A Prospective Matched Cohort Study. Anesth Analg. 2024;138 (5):1031-1042.

The Association of Preoperative Diabetes With Postoperative Delirium in Older Patients Undergoing Major Orthopedic Surgery: A Prospective Matched Cohort Study

Abstract

BACKGROUND

Postoperative delirium (POD) is a common form of postoperative brain dysfunction, especially in the elderly. However, its risk factors remain largely to be determined. This study aimed to investigate whether (1) preoperative diabetes is associated with POD after elective orthopedic surgery and (2) intraoperative frontal alpha power is a mediator of the association between preoperative diabetes and POD.

METHODS

This was a prospective matched cohort study of patients aged 60 years or more, with a preoperative diabetes who underwent elective orthopedic surgery. Nondiabetic patients were matched 1:1 to diabetic patients in terms of age, sex, and type of surgery. Primary outcome was occurrence of POD, assessed using the 3-minute Diagnostic Confusion Assessment Method (3D-CAM) once daily from 6 pm to 8 pm during the postoperative days 1–7 or until discharge. Secondary outcome was the severity of POD which was assessed for all participants using the short form of the CAM-Severity. Frontal electroencephalogram (EEG) was recorded starting before induction of anesthesia and lasting until discharge from the operating room. Intraoperative alpha power was calculated using multitaper spectral analyses. Mediation analysis was used to estimate the proportion of the association between preoperative diabetes and POD that could be explained by intraoperative alpha power.

RESULTS

A total of 138 pairs of eligible patients successfully matched 1:1. After enrollment, 6 patients in the diabetes group and 4 patients in the nondiabetes group were excluded due to unavailability of raw EEG data. The final analysis included 132 participants with preoperative diabetes and 134 participants without preoperative diabetes, with a median age of 68 years and 72.6% of patients were female. The incidence of POD was 16.7% (22/132) in patients with preoperative diabetes vs 6.0% (8/134) in patients without preoperative diabetes. Preoperative diabetes was associated with increased odds of POD after adjustment of age, sex, body mass index, education level, hypertension, arrhythmia, coronary heart disease, and history of stroke (odds ratio, 3.2; 95% confidence interval [CI], 1.4–8.0; P = .009). The intraoperative alpha power accounted for an estimated 20% (95% CI, 2.6–60%; P = .021) of the association between diabetes and POD.

CONCLUSIONS

This study suggests that preoperative diabetes is associated with an increased risk of POD in older patients undergoing major orthopedic surgery, and that low intraoperative alpha power partially mediates such association.