老年患者髋膝关节置换术后谵妄风险评估表的构建及效果评价

Establishment and assessment of a postoperative delirium risk scale for elderly patients undergoing hip and knee replacement

中文关键词: 术后谵妄  老年  髋膝关节置换术  风险评估表

英文关键词: Postoperative delirium  Aged  Hip and knee replacement  Risk assessment scale

中文摘要:

      
目的：构建老年患者髋膝关节置换术后谵妄（POD）的风险评估表并评价效果。
方法：选择2021年3月至2022年5月行髋膝关节置换术的老年患者474例和2022年1—5月的同质患者153例，分别作为训练集和验证集。根据是否发生POD将患者分成两组：非POD组和POD组。采用单因素和多因素Logistic回归分析训练集并确定发生POD的独立危险因素。采用Homser-Lemeshow拟合优度检验评价模型的一致性。根据OR值对所选变量进行赋值后建立POD风险评估表，通过受试者工作特征（ROC）曲线评价风险评估表的预测效能。将训练集和验证集根据截断值进行风险分层分为：低危和高危。计算不同风险分层的POD发病率，评估风险评估表的适用性。
结果：训练集中有58例（12.2%）发生POD，验证集中有19例（12.4%）发生POD。多因素Logistic回归分析结果显示，年龄≥85岁、ASA Ⅲ或Ⅳ级、简易智力状态检查量表（MMSE）评分≤24分、术前睡眠障碍、合并神经系统疾病、全麻、术中未使用右美托咪定为POD的独立危险因素。风险评估表以截断值44.5分进行危险分层，其预测POD的ROC曲线下面积（AUC）为0.956（95%CI 0.937～0.975）。训练集和验证集使用风险预测评估表将患者分为低危和高危，与低危患者比较，高危患者POD发病率均明显升高（P<0.001）。
结论：采用年龄≥85岁、ASA Ⅲ或Ⅳ级、MMSE评分≤24分、术前睡眠障碍、合并神经系统疾病、全麻、术中未使用右美托咪定构建的POD风险评估表，对行髋膝关节置换术的老年患者进行危险分层，能有效识别发生POD的高危患者。

英文摘要:

      
Objective: To construct a risk assessment scale for postoperative delirium (POD) in elderly patients undergoing hip and knee joint replacement and evaluate the effect.
Methods: A total of 474 elderly patients undergoing hip and knee arthroplasty from March 2021 to May 2022 were collected as the training set, and a total of 153 the homogeneous patients from January 2022 to May 2022 were collected as the validation set. The patients were divided into two groups based on whether or not POD occurred: non-POD group and POD group. Risk factors of POD in the training set were analyzed by univariate analysis and multifactorial logistic regression. The consistency of the model was evaluated by Homser-Lemeshow goodness of fit test. The postoperative delirium risk assessment scale was established after the selected variables assigned value according to OR value, and the predictive efficacy of the scale was evaluated by receiver operating characteristic (ROC) curve. The patients in the training set and the validation set were divided into two groups according to the cut-off value: high-risk and low-risk. The incidence rate of POD with different risk stratification was calculated and the applicability of the risk assessment scale was evaluated.
Results: Fifty-eight patients (12.2%) with POD in the training set, and nineteen patients (12.4%) with POD in the validation set. Multifactor logistic regression showed that age ≥ 85 years, ASA physical status Ⅲ or Ⅳ, the mini-mental state examination (MMSE) score ≤ 24 points, preoperative sleep disorder, comorbid neurological disorders, use of general anesthesia, and non-use of dexmedetomidine were independent risk factors of POD. The POD risk assessment scale was then published based the seven risk factors. The ROC curve showed that the area under the curve (AUC) for this scale to predict the risk of POD was 0.956 (95% CI 0.937-0.975), and the risk stratification was performed with a cut-off value of 44.5 points, which divided the patients into low-risk and high-risk. Compared with low-risk, the incidence rate of POD in high-risk patients group was significantly increased (P < 0.001).
Conclusion: A risk assessment scale based on the seven risk factors: age ≥ 85 years, ASA physical status Ⅲ or Ⅳ, MMSE score ≤ 24 points, preoperative sleep disorder, combined neurological disease, use of general anesthetic modality, and non-use of dexmedetomidine, can effectively identify elderly patients undergoing hip and knee replacement who are at high risk of developing POD.