老年患者髋部骨折修复术后谵妄的危险因素_王洁.pdf

临床研究老年患者髋部骨折修复术后谵妄的危险因素王洁双鹏展赵龙彪李昭王秀丽刘朋DOI:1012089/jca202303002基金项目:河北省重点研发计划项目(22377732D)作者单位:050051石家庄市，河北医科大学第三医院麻醉科通信作者:刘朋，Email:liupeng2010aa 126com【摘要】目的探讨老年患者髋部骨折术后谵妄(POD)的危险因素。方法选择 2022 年 1 月至 6 月择期在蛛网膜下腔阻滞联合髂筋膜阻滞麻醉下行髋部骨折修复术的患者 110 例，男 41 例，女69 例，年龄6585 岁，BMI 1828 kg/m2，ASA或级。麻醉诱导前留取静脉血 35 ml，采用 ELISA法测定血清胰岛素(INS)浓度，采用全自动生化分析仪测定空腹血糖(Glu)和糖化血红蛋白(HbA1c)浓度，依据胰岛素稳态模型计算胰岛素抵抗指数(HOMA-I)。蛛网膜下腔阻滞穿刺成功后抽取脑脊液(CSF)23 ml，测定 CSF INS、-淀粉样蛋白(A)42、总 tau 蛋白(t-tau)和磷酸化 tau 蛋白(p-tau)。根据术后 15 d 内是否发生 POD，将患者分为两组:谵妄组和非谵妄组。采用单因素和多因素 Logistic 回归分析 POD 的影响因素，根据多因素 Logistic 回归分析结果建立预测模型，计算联合预测因子。绘制受试者工作特征(OC)曲线，计算 OC 曲线下面积(AUC)和 95%可信区间(CI)以评估诊断价值。结果本研究有 41 例(37.3%)患者发生 POD。多因素 Logistic 回归分析结果显示，血清 INS(O=1.742，95%CI 1.5581.986，P=0.039)和 HOMA-I(O=3.103，95%CI 1.0669.034，P=0.038)升高是 POD 的危险因素，CSF INS(O=0.026，95%CI 0.003 0.193，P0.001)和 CSFA42/p-tau 比值(O=0.312，95%CI 0.1080.896，P=0.027)升高是 POD 的保护因素。血清 INS预测 POD 的 AUC 为 0.718(95%CI 0.617 0.818，P0.001)，CSF INS 的 AUC 为 0.911(95%CI0.8490.973，P0.001)，CSF A42/p-tau 比值的 AUC 为 0.797(95%CI 0.714 0.880，P0.001)，HOMA-I 的 AUC 为 0.811(95%CI 0.7320.891，P0.001)。预测模型为 Logit(P)=5.118+0.097血清 INS+1.129HOMA-I 3.729CSF INS1.123CSF A42/p-tau 比值，该模型 AUC 为 0.965(95%CI 0.9271.000，P0.001)，敏感性 90.2%，特异性 94.2%。结论血清 INS 和 HOMA-I 升高是老年髋部骨折患者 POD 的危险因素，CSF INS 和 CSF A42/p-tau 比值升高是其保护因素。【关键词】胰岛素抵抗;-淀粉样蛋白 42;磷酸化 tau 蛋白;术后谵妄;髋部骨折;危险因素isk factors of postoperative delirium in elderly patients undergoing hip fracture repair surgeryWANG Jie，SHUANG Pengzhan，ZHAO Longbiao，LI Zhao，WANG Xiuli，LIU Peng Department of An-esthesiology，the Third Hospital of Hebei Medical University，Shijiazhuang 050051，ChinaCorresponding author:LIU Peng，Email:liupeng2010aa 126com【Abstract】ObjectiveTo investigate the risk factors of postoperative delirium(POD)in elderlypatients with hip fracture MethodsA total of 110 patients，41 males and 69 females，aged 6585 years，ASA physical status or，underwent elective hip fracture repair under subarachnoid block combinedwith fascia iliaca block anesthesia from January to July 2022 were selected Venous blood 35 ml was col-lected before anesthesia induction，and serum insulin(INS)concentrations were detected by ELISA，andfasting blood-glucose(Glu)and glycosylated hemoglobin(HbA1c)concentrations were measured by auto-matic biochemical analyzer Insulin resistance index(HOMA-I)was calculated based on insulin homeosta-sis model After successful subarachnoid puncture，cerebrospinal fluid(CSF)23 ml was extracted todetect the concentrations of CSF INS，-amyloid protein(A)42，total tau protein(t-tau)and phospho-rylated tau protein(p-tau)Patients were divided into two groups:POD group and non-POD group accord-ing to whether POD occurred within 15 days after operation Univariate and multivariate Logistic regressionanalysis were used to analyze the influencing factors of POD A prediction model was established based onthe results of multivariate Logistic regression analysis，and the combined predictors were calculated The re-ceiver operating characteristic(OC)curve was drawn，and the area under the OC curve(AUC)and532临床麻醉学杂志 2023 年 3 月第 39 卷第 3 期J Clin Anesthesiol，March 2023，Vol39，No395%confidence interval(CI)were calculated to evaluate the diagnostic value esultsPOD occurred in41 patients(37.3%)Multivariate Logistic regression analysis showed that elevated serum INS(O=1.742，95%CI 1.5581.986，P=0.039)and HOMA-I(O=3.103，95%CI 1.0669.034，P=0.038)were risk factors for POD The elevated CSF INS(O=0.026，95%CI 0.0030.193，P 0.001)and CSF A42/p-tau(O=0.312，95%CI 0.1080.896，P=0.027)were protective factorsfor POD OC curve analysis showed that the AUC of serum INS for predicting the occurrence of POD was0.718(95%CI 0.6170.818，P 0.001)，the AUC of CSF INS was 0.911(95%CI 0.8490.973，P 0.001)，the AUC of CSF A42/p-tau was 0.797(95%CI 0.7140.880，P 0.001)，and the AUC ofHOMA-I was 0.811(95%CI 0.7320.891，P 0.001)The combined prediction model was Logit(P)=5.118+0.097 serum INS+1.129 HOMA-I 3.729 CSF INS 1.123 CSF A42/p-tau TheAUC of the model was 0.965(95%CI 0.9271.000，P 0.001)，with a sensitivity of 90.2%，and aspecificity of 94.2%ConclusionIncreased serum INS and HOMA-I are risk factors for POD，and in-creased CSF INS and CSF A42/p-tau are protective factors in elderly patients with hip fracture【Key words】Insulin resistance;Total tau protein;Phosphorylated tau protein;Postoperative deliri-um;Hip fracture;isk Factors术后谵妄(postoperative delirium，POD)被定义为一种急性精神错乱状态，常见于老年患者，其主要临床表现为注意力和意识水平的波动、记忆障碍、睡眠觉醒周期紊乱和思维混乱1。POD 可导致患者并发症增多、住院时间延长、死亡率升高，进而加重社会和经济负担2。因此，明确 POD 发生的危险因素对 POD 的防治极为重要。目前，POD 的病理生理机制尚不清楚。Chan 等3 研究表明，POD与阿尔茨海默病(Alzheimer s disease，AD)等神经退 行 性 疾 病 密 切 相 关，胰 岛 素 抵 抗(insulinresistance，I)、脑内 淀粉样蛋白(-amyloid pep-tide，A)异常聚集和 tau 蛋白过度磷酸化等在 AD中具有重要意义的发病机制，可能与老年 POD 的发生有关4。本研究收集老年髋部骨折患者的临床资料，分析此类患者 POD 发生的危险因素，为临床提供参考。资料与方法一般资料本研究已通过医院伦理委员会审核(科 2021-063-1)，并在中国临床试验注册中心完成注册(ChiCT2100050675)，患者或家属签署知情同意书。选择 2022 年 1 月至 6 月接受手术治疗的老年髋部骨折患者，性别不限，年龄 6585 岁，BMI1828 kg/m2，ASA 或级，麻醉方式均采用蛛网膜下腔阻滞联合髂筋膜阻滞。排除标准:术前存在精神性疾病或其他神经退行性疾病，长期服用抗抑郁药或镇静药，酒精依赖，视力或听力受损，无法进行认知功