Psychological sequelae of surgery in a prospective cohort of patients from three intraoperative awareness prevention trials.
Psychological sequelae of surgery in a prospective cohort of patients from three intraoperative awareness prevention trials.
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DOI：
10.1213/ane.0000000000000498
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发表时间：
2015-01
影响因子：
5.7
通讯作者：
Avidan MS
中科院分区：
文献类型：
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作者：
Whitlock EL;Rodebaugh TL;Hassett AL;Shanks AM;Kolarik E;Houghtby J;West HM;Burnside BA;Shumaker E;Villafranca A;Edwards WA;Levinson CA;Langer JK;Fernandez KC;El-Gabalawy R;Zhou EY;Sareen J;Jacobsohn E;Mashour GA;Avidan MS
择期手术可能有长期的心理后遗症，尤其是那些术中意识不清的患者。然而，除了对手术后创伤后应激障碍（PTSD）症状的认识外，其他危险因素的定义并不明确，实用的筛查方法尚未广泛应用于手术患者。手术心理后遗症（Psych SOS）研究是一项前瞻性队列研究，纳入了先前在美国和加拿大进行的预防术中意识的3项试验的患者。根据年龄、性别、手术类型和意识风险，68例明确或可能意识到的患者与418例否认意识到的患者相匹配。参与者完成PTSD检查表-特异性（PCL-S）和/或修改的迷你国际神经精神病学访谈电话评估，以确定PTSD症状和与PTSD诊断一致的症状复合体。然后，我们使用结构方程模型生成复合PTSD评分，并检查潜在的危险因素。140名患者无法联系上；在这些接触者中，303人（88%）在术后中位数2年内参加了治疗。219例完成PCL-S的患者中有44例（20.1%）超过了手术引起的PTSD症状的平民筛查临界值（35例中有15例（43%）有意识，184例中有29例（16%）没有意识）。19名患者（8.7%；35名患者中有5名[14%]意识到，184名患者中有14名[7.6%]没有意识到）都超过了临界值，并且证实了与DSM-IV诊断的创伤后应激障碍相一致的症状广度，可归因于他们的手术。与PTSD症状独立相关的因素有社会支持不良、既往PTSD症状、既往心理健康治疗、手术相关解离、术中生命威胁感知、术中意识（p均≤0.017）。围手术期分离被认为是围手术期PTSD症状的潜在中介。围手术期的事件可诱发与亚综合征和综合征型PTSD一致的心理症状。我们证实了清醒患者术后PTSD的高发生率，但也发现了匹配的非清醒对照组的显著发生率。用PCL-S筛查手术患者，特别是那些存在术中意识或围术期游离等潜在危险因素的患者，其术后PTSD症状具有实用性，并可促进早期转诊、评估和治疗。
Elective surgery can have long-term psychological sequelae, especially for patients who experience intraoperative awareness. However, risk factors other than awareness for symptoms of posttraumatic stress disorder (PTSD) after surgery are poorly defined, and practical screening methods have not been applied to a broad population of surgical patients. The Psychological Sequelae of Surgery (Psych SOS) study was a prospective cohort study of patients previously enrolled in the United States and Canada in 3 trials for the prevention of intraoperative awareness. The 68 patients who experienced definite or possible awareness were matched, based on age, sex, surgery type, and awareness risk, with 418 patients who denied awareness. Participants completed the PTSD Checklist–Specific (PCL-S) and/or a modified Mini International Neuropsychiatric Interview telephone assessment to identify symptoms of PTSD and symptom complexes consistent with a PTSD diagnosis. We then used structural equation modeling to produce a composite PTSD score and examined potential risk factors. One hundred forty patients were unreachable; of those contacted, 303 (88%) participated a median of 2 years postoperatively. Forty-four of the 219 patients (20.1%) who completed the PCL-S exceeded the civilian screening cutoff score for PTSD symptoms resulting from their surgery (15 of 35 [43%] with awareness and 29 of 184 [16%] without). Nineteen patients (8.7%; 5 of 35 [14%] with awareness and 14 of 184 [7.6%] without) both exceeded the cutoff and endorsed a breadth of symptoms consistent with the DSM-IV diagnosis of PTSD attributable to their surgery. Factors independently associated with PTSD symptoms were poor social support, prior PTSD symptoms, prior mental health treatment, dissociation related to surgery, perceiving that one's life was threatened during surgery, and intraoperative awareness(all p ≤ 0.017). Perioperative dissociation was identified as a potential mediator for perioperative PTSD symptoms. Events in the perioperative period can precipitate psychological symptoms consistent with subsyndromal and syndromal PTSD. We confirmed the high rate of postoperative PTSD in awareness patients, but also identified a significant rate in matched nonawareness controls. Screening surgical patients, especially those with potentially mediating risk factors such as intraoperative awareness or perioperative dissociation, for postoperative PTSD symptoms with the PCL-S is practical and could promote early referral, evaluation and treatment.