瑞马唑仑和丙泊酚麻醉对脑血管内手术的老年患者术后谵妄的影响

doi:10.3969/j.issn.1006-7795.2024.06.012

摘要/Abstract

摘要： 目的比较瑞马唑仑与丙泊酚两种麻醉药对脑血管内手术的老年患者术后谵妄的发生是否存在差别。方法选取2023年6月至2024年4月，在首都医科大学附属北京朝阳医院择期行脑血管内手术的老年患者，采用随机数字表法将患者分为瑞马唑仑麻醉组（R组）和丙泊酚麻醉组（P组），共纳入106例患者，每组53例。主要研究指标为拔管后30 min至术后7d谵妄（postoperative delirium，POD）发生率。次要研究指标为麻醉时低血压、心动过缓发生率、血管活性药物使用率、拮抗药氟马西尼使用剂量、麻醉苏醒时间、延迟拔管发生率及术后48 h患者恢复质量［采用术后康复质量15条（Quality of Recovery-15，QoR-15)问卷评估］。结果共有103例患者（R组51例，P组52例）完成研究。R组和P组术后7d内POD发生率分别为5.88% 和3.85%，两组比较差异均无统计学意义（P>0.05）。R组术中低血压和心动过缓发生率（19.60%, 9.80%）较P组（53.85%, 25.00%）显著降低，两组比较差异有统计学意义（P=0.001 3，P=0.042）。R组术中去甲肾上腺素和麻黄素使用率明显低于P组，两组比较差异有统计学意义（P=0.020, P=0.033, ）。两组患者麻醉苏醒时间、拔管时间和氟马西尼使用剂量的差异均无统计学意义（P>0.05）。两组术后48 h QoR-15评分比较差异无统计学意义（P>0.05）。结论对接受脑血管内手术的老年患者，与丙泊酚相比，瑞马唑仑不增加术后谵妄发生率，不增加麻醉苏醒和拔管时间，血流动力学更稳定，也不影响患者恢复质量。

关键词: 瑞马唑仑, 脑血管内手术, 术后谵妄

Abstract: Objective To compare the effects of remimazolam and propofol on postoperative delirium （POD） in elderly patients undergoing cerebral endovascular surgery. Methods A controlled clinical trial was conducted on patients who underwent cerebral endovascular surgery in Beijing Chaoyang Hospital, Capital Medical University from June 2023 to April 2024. The patients were divided into remimazolam group (group R) and propofol group (group P). A total of 106 patients were included, with 53 in each group. The primary outcome was the incidence of POD from 30 min to 7 days after extubation between the two groups. The secondary outcomes included the time to recovery from anesthesia, the incidence of delayed extubation, the incidence of cardiovascular adverse events, the use of vasoactive drugs and the antagonist flumazenil, and the Quality of Recovery-15 (QoR-15) questionnaire at 48 h after surgery. Results A total of 103 patients (51 in group R and 52 in group P) finally completed in the study. There was no statistical difference in the incidence of POD (5.88% vs 3.85%) between the two groups within 7 days after surgery (P >0.05). The incidence of intraoperative hypotension and bradycardia was significantly lower in group R (19.60%, 9.80%) than in group P (53.85%, 25.00%) (P =0.001 3，P =0.042). Compared with that in group P, the number of cases using norepinephrine and ephedrine, in group R was significantly lower (P =0.020, P =0.033). There was no statistical difference in the time to recovery from anesthesia and dose not increase the dosage of flumazenil antagonists between the two groups (P >0.05). There was no statistical difference in QoR-15 at 48 h after surgery between the two groups (P >0.05). Conclusions The anesthetization with remimazolam show more stable hemodynamics dose not prolong the time to recovery from anesthesia and does not increase the incidence of POD in elderly patients undergoing cerebral endovascular surgery.

Key words: remimazolam, cerebral endovascular surgery, postoperative delirium (POD)

中图分类号:

R743.3

刘扬, 高超, 王小杰, 张梁, 吴安石. 瑞马唑仑和丙泊酚麻醉对脑血管内手术的老年患者术后谵妄的影响[J]. 首都医科大学学报, 2024, 45(6): 1023-1028.

Liu Yang, Gao Chao, Wang Xiaojie, Zhang Liang, Wu Anshi. Effect of remimazolam and propofol on postoperative delirium in elderly patients undergoing cerebral endovascular surgery[J]. Journal of Capital Medical University, 2024, 45(6): 1023-1028.

参考文献

［1］ Zhang J B, Zhang J X, Wang Y Y, et al. Effect of remimazolam vs propofol on emergence from general anesthesia in patients undergoing cerebral endovascular procedures: A randomized controlled, non-inferiority trial［J］. J Clin Anesth, 2024, 93: 111356.
［2］ Oliveira J E Silva L, Berning M J, Stanich J A, et al. Risk factors for delirium in older adults in the emergency department: a systematic review and Meta-Analysis［J］. Ann Emerg Med, 2021, 78(4): 549－565.
［3］ Futier E, Lefrant J Y, Guinot P G, et al. Effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction among High-Risk patients undergoing major surgery: a randomized clinical trial［J］. JAMA, 2017, 318(14): 1346－1357.
［4］ Kappen P R, Kakar E, Dirven C M F, et al. Delirium in neurosurgery: a systematic review and meta-analysis［J］. Neurosurg Rev, 2022, 45(1): 329－341.
［5］ Lee S, Okoro U E, Swanson M B, et al. Opioid and benzodiazepine use in the emergency department and the recognition of delirium within the first 24 hours of hospitalization［J］. J Psychosom Res, 2022, 153: 110704.
［6］ Taipale P G, Ratner P A, Galdas P M, et al. The association between nurse-administered midazolam following cardiac surgery and incident delirium: an observational study［J］. Int J Nurs Stud, 2012, 49(9): 1064－1073.
［7］ Vasilevskis E E, Han J H, Hughes C G, et al. Epidemiology and risk factors for delirium across hospital settings［J］. Best Pract Res Clin Anaesthesiol, 2012, 26(3): 277－287.
［8］ Casault C, Soo A, Lee C H, et al. Sedation strategy and ICU delirium: a multicentre, population-based propensity score-matched cohort study［J］. BMJ Open, 2021, 11(7): e045087.
［9］ By the 2023 American Geriatrics Society Beers Criteria^® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria^® for potentially inappropriate medication use in older adults［J］. J Am Geriatr Soc, 2023, 71(7): 2052－2081.
［10］ Zhou J, Leonowens C, Ivaturi V D, et al. Population pharmacokinetic/pharmacodynamic modeling for remimazolam in the induction and maintenance of general anesthesia in healthy subjects and in surgical subjects［J］. J Clin Anesth, 2020, 66: 109899.
［11］ Hu Q X, Liu X, Wen C L, et al. Remimazolam: an updated review of a new sedative and anaesthetic［J］. Drug Des Devel Ther, 2022, 16: 3957－3974.
［12］ Wesolowski A M, Zaccagnino M P, Malapero R J, et al. Remimazolam: pharmacologic considerations and clinical role in anesthesiology［J］. Pharmacotherapy, 2016, 36(9): 1021－1027.
［13］ Yang J J, Lei L, Qiu D, et al. Effect of remimazolam on postoperative delirium in older adult patients undergoing orthopedic surgery: a prospective randomized controlled clinical trial［J］. Drug Des Devel Ther, 2023, 17: 143－153.
［14］ Doi M, Morita K, Takeda J, et al. Efficacy and safety of remimazolam versus propofol for general anesthesia: a multicenter, single-blind, randomized, parallel-group, phase IIb/III trial［J］. J Anesth, 2020, 34(4): 543－553.
［15］ Nilsson J, Östling S, Waern M, et al. The 1-month prevalence of generalized anxiety disorder according to DSM-IV, DSM-V, and ICD-10 among nondemented 75-year-olds in Gothenburg, Sweden［J］. Am J Geriatr Psychiatry, 2012, 20(11): 963－972.
［16］ Association A P. Practice guideline for the treatment of patients with delirium［J］. Am J Psychiatry, 1999, 156(Suppl5): 1－20.
［17］ Stark P A, Myles P S, Burke J A. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15［J］. Anesthesiology, 2013, 118(6): 1332－1340.
［18］ Bu X S, Zhang J, Zuo Y X. Validation of the Chinese version of the quality of recovery-15 score and its comparison with the post-operative quality recovery scale［J］. Patient, 2016, 9(3): 251－259.
［19］ Wang J, Ji Y Y, Wang N, et al. Risk factors for the incidence of delirium in cerebrovascular patients in a Neurosurgery Intensive Care Unit: a prospective study［J］. J Clin Nurs, 2018, 27(1/2): 407－415.
［20］ Kaneko S, Morimoto T, Ichinomiya T, et al. Effect of remimazolam on the incidence of delirium after transcatheter aortic valve implantation under general anesthesia: a retrospective exploratory study［J］. J Anesth, 2023, 37(2): 210－218.
［21］穆珊珊, 吴延, 吴安石, 等. 非心脏手术老年患者术后谵妄及术后认知功能障碍相关危险因素研究［J］. 首都医科大学学报, 2018, 39(3): 366－372.
［22］ Yang X, Huang X W, Li M, et al. Identification of individuals at risk for postoperative cognitive dysfunction (POCD)［J］. Ther Adv Neurol Disord, 2022, 15: 17562864221114356.
［23］ Huang Y Q, Yan T, Zhang L C, et al. Efficacy and safety of remimazolam compared with propofol in hypertensive patients undergoing breast cancer surgery: a single-center, randomized, controlled study［J］. BMC Anesthesiol, 2023, 23(1): 409.

[1]	安琪, 杨楠, 朱玥荃, 师文娟, 黄敏琪, 赵咏梅. 自噬抑制剂3-MA对脑缺血再灌注损伤大鼠脑内炎症反应的影响[J]. 首都医科大学学报, 2024, 45(6): 1008-1015.
[2]	李亚堃, 李蔚, 杨雪琦, 师文娟, 朱玥荃, 赵咏梅. 活性氧自由基清除剂EUK-134对脑缺血再灌注损伤大鼠线粒体相关蛋白PGC-1α和VDAC1的影响[J]. 首都医科大学学报, 2024, 45(6): 1016-1022.
[3]	李兴茂, 李秀, 王婷, 赵鑫, 王德杨, 商海燕, 赵咏梅, 李森. GLP-1 受体激动剂对 2 型糖尿病患者急性缺血性脑卒中后认知功能的影响[J]. 首都医科大学学报, 2024, 45(6): 1029-1037.
[4]	沈童, 李芳芳, 范俊芬, 罗玉敏. 外周血Yes相关蛋白与缺血性卒中预后影响因素及卒中后炎性反应指标的相关性分析[J]. 首都医科大学学报, 2024, 45(6): 1071-1078.
[5]	梁发, 吴侑煊, 王鑫焱, 菅敏钰, 刘海洋, 韩如泉. 全身麻醉转化对急性脑卒中患者机械取栓术后神经功能的影响[J]. 首都医科大学学报, 2023, 44(2): 237-243.
[6]	秦琳慧, 李宁, 杨宇, 杨勇, 任长虹. 肢体远隔缺血期适应联合后适应促进大鼠缺血性脑卒中模型神经发生的作用及机制[J]. 首都医科大学学报, 2023, 44(1): 54-61.
[7]	李雪, 范俊芬, 王荣亮, 马青峰, 罗玉敏, 赵海苹. HDAC2对急性缺血性卒中患者中性粒细胞TBC蛋白家族成员的表观调控[J]. 首都医科大学学报, 2023, 44(1): 62-71.
[8]	姜富城, 黄菊梅, 冯跃先, 钟红亮, 贾建文, 杨洪超, 刘赫, 刘扬. 清醒镇静在急性缺血性脑卒中血管内治疗中的应用效果及预后影响评估[J]. 首都医科大学学报, 2023, 44(1): 72-77.
[9]	李森, 郭学文, 赵鑫, 黄安琪, 林婧格, 李兴茂, 李秀, 杜怡峰, 赵咏梅, 白洁, 夏章勇. 急性缺血性脑卒中合并糖尿病人群的血糖变异性与神经功能恶化的相关性分析[J]. 首都医科大学学报, 2023, 44(1): 78-84.
[10]	赵文博, 任长虹, 李思颉, 马红蕊, 吉训明. 低氧与缺血适应防治缺血性脑卒中新技术体系的创研及推广应用——2020年度国家科学技术进步奖二等奖[J]. 首都医科大学学报, 2022, 43(1): 1-5.
[11]	杨楠, 丁锚, 黄语悠, 房亚兰, 师文娟, 赵咏梅. 一氧化氮在大鼠短暂性局灶性脑缺血损伤中对神经生长因子和脑源性神经营养因子表达的影响[J]. 首都医科大学学报, 2020, 41(6): 908-913.
[12]	国家卫生健康委脑卒中防治工程专家委员会, 国家卫生健康委脑卒中防治工程委员会医院管理委员会, 国家卫生健康委脑卒中防治工程专家委员会急诊专业委员会. 新型冠状病毒肺炎疫情时期脑卒中绿色通道管理专家共识[J]. 首都医科大学学报, 2020, 41(2): 293-297.
[13]	房亚兰, 黄语悠, 赵咏梅, 师文娟, 李锦程, 段云霞, 高利, 罗玉敏. 大黄酚对局灶性脑缺血再灌注小鼠Beclin1及Bax的作用[J]. 首都医科大学学报, 2019, 40(5): 703-708.
[14]	黄语悠, 房亚兰, 师文娟, 刘克建, 赵咏梅, 丁锚, 罗玉敏. 一氧化氮清除剂Carboxy-PTIO对短暂性局灶性脑缺血大鼠PERK/p-eIF2α通路的调节作用[J]. 首都医科大学学报, 2019, 40(5): 709-714.
[15]	李森, 黄安琪, 郭健飞, 白洁, 张光珍, 王婷, 赵咏梅. 沙格列汀对2型糖尿病患者缺血性脑卒中后认知功能的影响[J]. 首都医科大学学报, 2019, 40(5): 715-720.