貂皮大衣,【文献速递】脑电引导的麻醉药物办理对晚年患者大手术后谵妄的效果——JAMA临床研讨,曾黎

脑电引导的麻醉药物处理对晚年患者大手术后谵妄的作用

ENGAGES随机对照临床试验

TRIALREGISTRATION ClinicalTrials.govIdentifier:NCT02241655

JAMA.2019;321(5):473-483. doi:10.1001/jama.2018.22005

研讨布景及意图

围手术期脑电图(electroencephalogram,EEG )显现脑电波按捺一般预示麻醉深度过深june,并和术后谵妄发作相关。最近一项依据随机对照研讨(randomized clinical trial,RCT的荟萃剖析成果显现,脑电引导的麻醉处理可使术后谵妄发病率下降1/3~1/2。晚年患者术后谵妄发病率高,延伸重症监护室停留时刻和住院时刻的一起,也增加了住院费用的开销。因而,本研讨旨在调查晚年人全麻下承受大手术时采纳EEG引导麻醉处理战略是否能够下降术后谵妄的发病率。

图1 脑电图和对应状态及BIS值

研讨办法

该研讨为单中心、随机对照、双盲临床研讨。

归入规范:60岁及以上于全麻下承受大手术(包含心脏手术)的患者。

扫除规范:未签署知情同意书,精力紊乱,聋哑人,文盲,无法流利运用英语沟通及发作术中知晓、术后5天内承受二次手术的患者。

分组:患者1:1随机分为两组(并依据患者是否承受心脏手术和近期是否有跌倒的病史进行分层),EEG引导麻醉处理组(n=614)和传统麻醉处理组(n=618)。本研讨脑电选用运用脑电双频仪器将探头置于前额调查脑电改变,全身麻醉药物运用吸入麻醉气体。参加研讨的麻醉医生在发现呈现脑电按捺时被鼓舞下降吸入麻醉药浓度。

首要调查目标:术后第1至5天谵妄的发病率(运用CAM和CAM-ICU量表来评价谵妄)。

其他调查目标包含:

术中相关目标包含,麻醉药物浓度、EEG按捺和低血压的时刻等;

不良事情包含,术中非意向性运动,术中知晓,术后厌恶吐逆,医疗相关并发症以及死亡率。

图2 研讨流程图

研讨成果

自2015年1月至2018年6月,共1232名60岁及以上在圣路易斯Barnes-Jewish医院于全麻下承受大手术(包含心脏手术)的患者,归入了该项随机对照研讨,其均匀年龄为69岁(60~95),其间563名为女人(45.7%)。EEG引导麻醉处理组有10名患者因为术中脑电信号差,传统麻醉处理组中有9名患者因为术中特殊状况需求调查脑电状况终究没有进行术后谵妄的评价,因而终究有1213 (98.5%) 名患者进行了首要调查目标的评价。

表1 患者术前一般状况

术后第1天到第5天谵妄的发病率,实验组为157/604 (26.0%),对照组中为140/609 (23.0%) (差值为,3.0% [95% CI,−2.0% ~8.0%];P = 0.22) 。

图3 两组患者谵妄发病率、脑电按捺及BIS值低于40的总时刻

实验组中,呼气末麻醉气体浓度均匀值明显低于对照组(最低肺泡浓度分别为0.69 vs 0.80;差值为,−0.11 [95% CI, −0.13 ~0.10]),EEG按捺的总时刻均匀实验组也明显低于对照组(7 vs 13 min; 差值为,−6.0 [95% CI, −9.9 to −2.1])。两组间均匀动脉压低于60 mm Hg 的总时刻均匀值没有统计学差异(7 vs 7 min;差值为,0.0 [95% CI, −1.7 to 1.7])。非意向性运动在实验组中有137(22.3%)名患者呈现,对照组中有95(15.4%)名患者呈现,两组患者均未发作术中知晓 。术后厌恶吐逆在对照组中有48(7.8%)名患者发作,实验组中有55(8.9%)名发作。实验组中有124(20.2%)患者发作了严峻不良事情的,对照组中有130(21.0%)名患者。术后30天内死亡率在对照组中为3.07%(19例),实验组仅为0.65%(4例)。研讨者一起将19名未进行谵妄评貂皮大衣,【文献速递】脑电引导的麻醉药物处理对晚年患者大手术后谵妄的作用——JAMA临床研讨,曾黎估的患者,悉数视为发作谵妄或悉数没有发作谵妄再次进行统计剖析,对成果并无影响。

表2 围手术期监护丈量目标

表3 首要调查目标、非必须调查目标和不良事情状况

评论与定论

研讨者指出,这一成果和现有荟萃剖析的成果不一致或许和以往随机对照研讨的质量良莠不齐有关。本研讨的办法学是谨慎且强有力的,但一起研讨者也指出谵妄较难确诊且存在波动性因而距离时段的评价办法或许会有遗失。及几画本研讨成果仅针对吸入麻醉,中的针对EEG引导组的患者死亡率的明显下降这一成果,研讨者指出还将进行进一步的研讨进行验证。

承受大手术的晚年患者,术中运用EEG引导麻醉处理相较传统麻醉处理其术后谵妄发作率。

注:EgugoolNGAGESElectroencephalographyGuidance of Anesthesia to Alleviate Geriatric Syndromes,脑电图引导的麻醉减轻晚年综合症随机对照临床试验。

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

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编译 姚婧鑫

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