Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients?
Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients?
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DOI：
10.1097/aln.0b013e3181acf7e6
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发表时间：
2009-09
期刊：
影响因子：
8.8
通讯作者：
Tsai T
中科院分区：
文献类型：
--
作者：
Leung JM;Sands LP;Paul S;Joseph T;Kinjo S;Tsai T
术后疼痛是术后谵妄的独立预测因素。术后谵妄是否限制患者自控镇痛 (PCA) 的使用尚未确定。我们对接受非心脏手术的老年患者进行了一项巢式队列研究，并使用 PCA 进行术后镇痛。使用混乱评估方法来测量谵妄。我们计算了结构方程模型，以确定疼痛和阿片类药物消耗对谵妄状态的影响以及谵妄对阿片类药物使用的影响。在 335 名患者中，108 名（32.2%）在术后第 1 天（POD）出现谵妄，120 名（35.8%）在术后第 2 天出现谵妄。术后谵妄并没有限制 PCA 的使用。与无谵妄患者相比，术后谵妄患者在 24 小时内 (POD 2) 使用更多 PCA（氢吗啡酮 ± SE 的平均剂量经协变量调整后分别为 2.24 ± 0.71 mg 与 1.25 ± 0.67 mg，P = 0.02）。尽管阿片类药物使用较多，谵妄患者报告的 VAS 评分高于非谵妄患者（POD 1：静息时平均视觉模拟量表 ± SE 4.2 ± 0.23 与 3.3 ± 0.22，P = 0.0051；POD 2：3.3 ± 0.23 与 2.5 ± 0.19，P = 0.004）。结构方程模型的路径系数显示，疼痛和阿片类药物的使用会影响谵妄状态，但谵妄不会影响随后的阿片类药物剂量。术后谵妄并没有限制 PCA 的使用。尽管阿片类药物使用较多，但谵妄患者的视觉模拟量表得分较高。未来对谵妄的研究应考虑疼痛和疼痛管理作为潜在病因的作用。
Postoperative pain was an independent predictor of postoperative delirium. Whether postoperative delirium limits patient controlled analgesia (PCA) use has not been determined. We conducted a nested cohort study in older patients undergoing noncardiac surgery and used PCA for postoperative analgesia. Delirium was measured using the Confusion Assessment Method. We computed a structural equation model to determine the effects of pain and opioid consumption on delirium status and the effect of delirium on opioid use. Of 335 patients, 108 (32.2%) developed delirium on postoperative day (POD) 1, and 120 (35.8%) on POD 2. Postoperative delirium did not limit the use of PCA. Patients with postoperative delirium used more PCA in a 24-hour period (POD 2) compared to those and without delirium (mean dose of hydromorphone ± SE adjusted for co-variates was 2.24 ± 0.71 mg vs. 1.25 ± 0.67 mg, P = 0.02). Despite more opioid use, patients with delirium reported higher VAS scores than those without delirium (POD 1: mean Visual Analog Scale ± SE at rest 4.2 ± 0.23 vs. 3.3 ± 0.22, P = 0.0051; POD 2: 3.3 ± 0.23 vs. 2.5 ± 0.19, P = 0.004). Path coefficients from structural equation model revealed that pain and opioid use affect delirium status, but delirium does not affect subsequent opioid dose. Postoperative delirium did not limit PCA use. Despite more opioids use, Visual Analog Scale scores were higher in patients with delirium. Future studies on delirium should consider the role of pain and pain management as potential etiologic factors.