老年脊柱结核患者术后发生认知功能障碍的影响因素分

doi:10.3969/j.issn.1000-6621.2021.05.006

摘要/Abstract

摘要：

目的分析老年脊柱结核患者术后认知功能障碍影响因素,为有效预防围手术期神经认知障碍(perioperative neurocognitive disorders,PND)提供科学依据。方法采用前瞻性观察研究方法,选取2019年1月至2020年6月在杭州市红十字会医院接受脊柱手术治疗的102例老年脊柱结核患者作为研究对象。收集研究对象临床资料,术中连续测量局部脑氧饱和度(regional cerebral oxygen saturation, rSO₂),手术前后采用简易智能精神状态检查(mini-mental state examination, MMSE)评估患者认知功能;分析影响老年脊柱结核患者术后发生PND的因素。结果 102例研究对象中,10例退出,92例完成研究。完成研究者中,74例(80.43%)未发生PND,18例(19.57%)于术后7d发生PND,其中10例于术后30d恢复。单因素分析显示,发生PND者rSO₂低于60%持续时间[41.5(33.5,64.7)min]明显长于未发生者[0.0(0.0,5.8)min],差异有统计学意义(Z=-6.454,P=0.001)。多因素logistic回归分析显示,rSO₂低于60%持续时间处于31~59min者发生PND的风险是持续时间低于30min者的5.903(95%CI:1.228~28.385)倍;rSO₂低于持续时间≥60min者发生PND的风险是持续时间低于30min者的10.168(95%CI:1.177~87.857)倍。结论 rSO₂低于60%持续时间长是影响老年脊柱结核手术患者发生PND的危险因素,术中应关注患者脑氧饱和度变化,及时干预,避免患者脑氧饱和度过低。

关键词: 结核,脊柱, 老年人, 手术后并发症, 认知障碍, 前瞻性研究

Abstract:

Objective To analyze the influencing factors of the postoperative cognitive dysfunction in elderly spinal tuberculosis patients undergoing the surgery, and to provide scientific evidence for the effective prevention of the perioperative neurocognitive disorders (PND). Methods A prospective observational research was conducted with 102 elderly spinal tuberculosis patients undergoing spinal surgery from Hangzhou Red Cross Hospital between January 2019 and June 2020. Clinical data of the patients were collected. Regional oxygen saturation (rSO₂) was continuously measured during the operation, the cognitive function was also assessed by mini-mental state examination (MMSE) before and after the operation to analyze the influential factors of PND in elderly spinal tuberculosis patients after surgery. Results Among the 102 patients, 10 withdrawn and the other 92 completed the study. Of these 92 patients, 74 (80.43%) did not occur PND, and 18 (19.57%) occurred PND 7 days after operation, and 10 cases recovered 30 days postoperative. A univariate analysis revealed that the duration of rSO₂ <60% intraoperative was 41.5 (33.5, 64.7) minutes in patients with PND, which was significantly longer than that in patients without PND (0.0 (0.0, 5.8) minutes, Z=-6.454, P=0.001). The multivariate logistic regression analysis showed that the risk of PND in patients with the duration of rSO₂ <60% during 31-59 minutes was 5.903 (95%CI: 1.228-28.385) times as high as that in patients with the duration ≤30 minutes; the risk of PND in patients with the duration ≥60 minutes was 10.168 (95%CI: 1.177-87.857) times as high as that in patients with the duration ≤30 minutes. Conclusion The long duration of rSO₂ <60% in the spinal tuberculosis surgery was a risk factor of PND. During the operation, attention should be paid to the change of cerebral oxygen saturation, and the timely intervention would help to avoid low cerebral oxygen saturation in patients.

Key words: Tuberculosis, spinal, Aged, Postoperative complications, Cognition disorders, Prospective studies

万海方, 陶凡, 赵杰, 陈远辉, 黄焱明, 傅云斌. 老年脊柱结核患者术后发生认知功能障碍的影响因素分[J]. 中国防痨杂志, 2021, 43(5): 441-445. doi: 10.3969/j.issn.1000-6621.2021.05.006

WAN Hai-fang, TAO Fan, ZHAO Jie, CHEN Yuan-hui, HUANG Yan-ming, FU Yun-bin. Analysis of influencing factors of postoperative cognitive dysfunction in elderly patients with spinal tuberculosis[J]. Chinese Journal of Antituberculosis, 2021, 43(5): 441-445. doi: 10.3969/j.issn.1000-6621.2021.05.006

图/表 3

表1

老年脊柱结核手术患者术后发生PND影响因素的单因素分析结果

影响因素	对照组(74例)	发病组(18例)	统计检验值	P值
性别[例(构成比,%)]			χ²=0.053	0.466
男	44(59.46)	9(50.00)
女	30(40.54)	9(50.00)
年龄(岁, $x ˉ$ ±s)	69.69±6.99	68.17±6.52	t=0.839	0.404
BMI( $x ˉ$ ±s)	20.37±1.26	20.04±1.62	t=0.924	0.358
受累病椎数			χ²=0.027	0.870
>2	52(70.27)	13(72.22)
≤2	22(29.73)	5(27.78)
麻醉时间(min, $x ˉ$ ±s)	351.85±27.21	354.94±25.17	t=-0.439	0.662
失血量(ml, $x ˉ$ ±s)	331.00±129.90	340.14±104.15	t=-0.294	0.769
最低血球压积(%, $x ˉ$ ±s)	28.72±3.81	27.64±4.25	t=1.055	0.295
住院时间(d, $x ˉ$ ±s)	11.50±1.64	12.28±1.64	t=-1.804	0.075
VAS₁ (分, $x ˉ$ ±s)	3.81±0.87	4.17±0.86	t=-1.559	0.122
VAS₂ (分, $x ˉ$ ±s)	2.14±0.75	2.28±0.75	t=-0.726	0.470
VAS₃ [分,M(Q₁,Q₃)]	0.8(0.0,1.0)	0.5(0.0,1.0)	Z=-9.520	0.341
并发糖尿病[例(构成比,%)]			χ²=9.719	0.009
是	7(9.46)	7(38.89)
否	67(90.54)	11(61.11)
并发高血压[例(构成比,%)]			χ²=0.316	0.574
是	44(59.46)	12(66.67)
否	30(40.54)	6(33.33)
术前rSO₂(%, $x ˉ$ ±s)	70.59±2.54	71.28±3.92	t=-0.911	0.365
术中平均rSO₂(%, $x ˉ$ ±s)	66.69±2.76	64.33±3.66	t=3.037	0.003
最低rSO₂(%, $x ˉ$ ±s)	61.58±4.15	55.94±2.78	t=5.463	0.001
rSO₂低于60%的时长[min,M(Q₁,Q₃)]	0.0(0.0,5.8)	41.5(33.5,64.7)	Z=-6.454	0.001
简易智力状态检查(分, $x ˉ$ ±s)
术前	28.01±1.05	27.83±0.93	t=0.666	0.507
术后7d	27.66±0.85	24.94±1.35	t=10.763	0.001
术后30d	27.40±1.86	25.83±1.67	t=3.272	0.002

表1

表2

表3

老年脊柱结核手术患者术后发生PND影响因素的多因素logistic回归分析结果

影响因素	β值	s $x ˉ$ 值	Wald χ²值	P值	OR(95%CI)值
住院时间	0.062	0.233	0.071	0.789	1.064(0.675~1.667)
VAS₁	0.683	0.461	2.195	0.138	1.980(0.802~4.886)
并发糖尿病	1.828	0.965	3.586	0.058	6.220(0.938~41.255)
术中平均rSO₂	-0.032	0.123	0.066	0.797	0.969(0.761~1.233)
术中最低rSO₂(以≥60%为参照)
55%~59%	-0.518	1.471	0.124	0.725	0.596(0.033~10.649)
50%~54%	1.028	0.798	1.661	0.197	2.796(0.585~13.356)
rSO₂低于60%持续时间(以≤30min为参照)
31~59min	1.775	0.801	4.910	0.027	5.903(1.228~28.385)
≥60min	2.319	1.100	4.443	0.035	10.168(1.177~87.857)
常量	16.386	8.883	3.402	0.065

表3

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变量	赋值	变量	赋值
围手术期神经认知障碍	是=1,否=0	术中最低rSO₂	≥60%=1,55%~59%=2,50%~54%=3
并发糖尿病	是=1,否=0	rSO₂低于60%持续时间	≤30min=1,31~59min=2,≥60min=3