中图分类号:R614
文献标志码:A
文章编号:1671-167X(2017)06-1008-06
Effect of different anesthetic methods on postoperative outcomes in elderly patients undergoing hip fracture surgery
Abstract
Objective: To investigate the effect of general or regional anesthesia on postoperative cardiopulmonary complications and inpatient mortality after hip fracture surgery in elderly patients. Me-thods: A retrospective analysis was conducted according to the medical records of 572 elderly patients with hip fractures admitted to our hospital from January 1, 2005 to December 31, 2014. The age, gender, preoperative comorbidities, length of preoperative bedridden time, mechanism of injury, surgical types, anesthetic methods, major postoperative complications and inpatient mortality were recorded. Multivariate Logistic regression analysis was applied to analyze the impact of different anesthetic methods on inpatient mortality in these patients. Results: Of the 572 patients, 392 (68.5%) received regional anesthesia. Inpatient death occurred in 8 (8/572, mortality: 1.4%), including 5 cases of RA group (5/392, mortality: 1.3%) and 3 cases of GA group (3/180, mortality: 1.7%). There was no statistically significant difference between the two groups in inpatient mortality (P> 0.05). Multiple Logistic regression analysis showed that gender (odds ratio: 0.18, 95% CI: 0.03-1.05, P=0.057), age (odds ratio: 1.22, 95% CI: 1.07-1.38, P=0.002), preoperative pulmonary comorbidities (odds ratio: 12.09, 95% CI: 2.28-64.12, P=0.003) and surgical types (odds ratio: 9.36, 95% CI: 1.34-64.26, P=0.024) were risk factors for inpatient mortality. Postoperative cardiovascular complications occurred in 36 patients (36/572, morbidity: 6.3%), with 19 patients in RA group (19/392, morbidity: 4.8%), and 17 patients in GA group (17/180, morbidity: 9.4%). Multiple Logistic regression analysis showed that age (odds ratio: 1.13, 95% CI: 1.07-1.19, P< 0.001), hypertension (odds ratio: 2.72, 95% CI: 1.24-5.96, P=0.012) and preoperative cerebral comorbidities (odds ratio: 2.11, 95% CI: 0.99-4.52, P=0.054) were risk factors for postoperative cardiovascular complications. Postoperative pulmonary complications occurred in 56 patients (56/572, morbidity: 9.8%), with 19 patients in RA group (19/392, morbidity: 4.8%), and 37 patients in GA group (37/180, morbidity: 20.6%). Multiple Logistic regression analysis showed that age (odds ratio: 1.13, 95% CI: 1.07-1.19, P< 0.001), preoperative pulmonary comorbidities (odds ratio: 2.89, 95% CI: 1.28-7.05, P=0.020), length of preoperative bedridden time (odds ratio: 1.11, 95% CI: 1.04-1.18, P=0.003) and anesthetic methods (odds ratio: 5.86, 95% CI: 2.98-11.53, P< 0.001) were risk factors for postoperative pulmonary complications. Conclusion: General anesthesia may not affect the inpatient mortality after hip fracture surgery in elderly patients. Regional anesthesia is associated with a lower risk of pulmonary complications after surgical procedure compared with general anesthesia.
髋部骨折多见于老年人, 伴随人口老龄化, 越来越多的老年人正遭受这一疾病的困扰[1]。髋部骨折的老年患者术后住院期间死亡率约5%, 术后30天死亡率约10%, 髋部骨折不仅严重危害老年人的身心健康, 还给家庭和社会带来沉重的负担, 正在成为一个全球性的医疗卫生难题[2, 3, 4, 5, 6]。髋部骨折采取保守治疗的并发症和死亡率高, 而早期外科手术治疗已成为公认的首选方法[7, 8]。
全身麻醉(general anesthesia, GA)和区域阻滞麻醉(regional anesthesia, RA)是髋部骨折手术通常采用的麻醉方法。GA的优点是舒适度高, 有利于呼吸循环的管理, 但全身麻醉药物和机械通气的使用会增加术后麻醉相关不良事件, 相比之下, RA可避免气管内插管及机械通气, 提供更完善的术后镇痛, 降低术后肺部感染的发生风险。尽管如此, 目前国内外对两种麻醉方法的优劣性尚未达成共识[9, 10, 11]。本研究通过回顾性收集我院收治的老年髋部骨折患者的资料, 探讨不同麻醉方法对其术后心肺并发症和住院死亡率的影响, 以期为改善患者转归提供依据。
1 资料与方法1.1 研究对象本研究为回顾性队列研究, 分析2005年1月1日至2014年12月31日我院收治的髋部骨折患者的临床资料。入选标准:年龄≥ 65岁; 影像学检查确诊为髋部骨折, 未合并其他部位骨折; 接受内固定手术治疗; 受伤机制为低能量损伤。排除标准:临床资料不完整, 病理性骨折, 晚期肿瘤患者。1 256例患者中有572例患者符合入选标准。
对于符合入选和排除标准的患者分别记录性别、年龄、术前主要内科合并症、术前卧床时间、受伤机制、手术方式、麻醉方式、术后心肺并发症以及住院期间的死亡率, 详细资料见表1。
表1
Table 1
表1(Table 1)
表1 患者的临床资料 Table 1 Clinical data of the patientsVariables | GA (n=180) | RA (n=392) | χ 2/t/Z | P |
---|
Age/years, ± s | 79.1± 6.3 | 78.4± 7.1 | 1.332 | 0.184 | Gender, n (%) | | | | | Male | 60 (33.3) | 145 (37.0) | 0.717 | 0.397 | Female | 120 (66.7) | 247 (63.0) | | | Bedridden time/d, median (min-max) | 3 (1-23) | 4 (1-31) | 0.883 | 0.377 | Comorbidities, n (%) | | | | | Cardiac | 56 (31.1) | 93 (23.7) | 3.494 | 0.062 | Pulmonary | 15 (8.3) | 40 (10.2) | 0.497 | 0.481 | Cerebral | 58 (32.2) | 61 (15.6) | 20.783 | < 0.001 | Hypertention | 92 (51.1) | 195 (49.7) | 0.092 | 0.762 | Diabetes | 50 (27.8) | 84 (21.4) | 2.772 | 0.096 | Surgical type, n (%) | | | | | Extramedullary | 11 (6.1) | 52 (13.3) | 6.442 | 0.011 | Intramedullary | 169 (93.9) | 340 (86.7) | | |
GA, general anesthesia; RA, regional anesthesia. | 表1 患者的临床资料 Table 1 Clinical data of the patients |
1.2 病例收集及麻醉方法收集我院骨科2005年1月1日至2014年12月31日间收治的髋部骨折患者的临床资料, 由2名工作人员依据入选标准和排除标准共同完成病例的收集工作。入选患者572例, RA组选择椎管内麻醉和外周神经阻滞的患者, 共392例; GA组选择采用气管插管全身麻醉的患者, 剔除采用喉罩全身麻醉的患者, GA组共180例。
1.3 观察指标患者住院期间死亡率是主要观察指标, 住院期间死亡病例指自接受内固定手术至出院前发生的院内死亡病例。术后新发的心血管系统并发症和呼吸系统并发症是次要观察指标。
1.4 统计学分析所有数据采用SPSS 18.0统计软件包进行分析, 应用Kolmogorov-Smirnov检验分析数据的分布是否符合正态分布, 计量资料符合正态分布的用均值± 标准差描述, 采用独立样本t检验比较其均值; 不符合正态分布的用中位数(最小值~最大值)描述, 采用非参数检验(Mann-Whitney检验)比较其分布; 计数资料采用卡方检验; 采用多重Logistic回归(后退法)分析患者术后并发症和住院死亡率的影响因素, P< 0.05为差异有统计学意义。
2 结果8例患者发生住院期间死亡(8/572, 死亡率1.4%), 其中RA组5例(5/392, 死亡率1.3%), GA组3例(3/180, 死亡率1.7%), 两组患者术后死亡率的差异无统计学意义。髋部骨折老年患者发生术后死亡的单因素分析显示, 年龄、性别和术前肺部合并症是患者发生术后死亡的相关危险因素, 术前卧床时间、麻醉方式、手术方式、心脑血管合并症、高血压及糖尿病等内科合并症不是发生术后死亡的相关危险因素(表2); 多重Logistic回归分析显示, 性别、年龄、术前肺部合并症和手术方式是患者发生住院期间死亡的独立危险因素(表3)。
表2
Table 2
表2(Table 2)
表2 髋部骨折老年患者发生住院死亡危险的单因素分析 Table 2 Univariate analysis of factors affecting inpatient mortality after hip fracture surgery in elderly patientsVariables | Deaths | Discharges | χ 2/t/Z | P |
---|
Age/years, ± s | 86.0± 9.2 | 78.6± 6.8 | 3.055 | 0.002 | Gender, n (%) | | | | | Male | 6 (75.0) | 199 (35.3) | 5.411 | 0.020 | Female | 2 (25.0) | 365 (64.7) | | | Bedridden time/d, median (min-max) | 4 (2-8) | 4 (1-31) | 0.648 | 0.517 | Comorbidities, n (%) | | | | | Cardiac | 2 (25.0) | 147 (26.1) | 0.005 | 0.946 | Pulmonary | 4 (50.0) | 51 (9.0) | 15.226 | < 0.001 | Cerebral | 3 (37.5) | 116 (20.6) | 1.373 | 0.241 | Hypertention | 5 (62.5) | 282 (50.0) | 0.493 | 0.483 | Diabetes | 3 (37.5) | 131 (23.2) | 0.896 | 0.344 | Surgical type, n (%) | | | | | Extramedullary | 2 (25.0) | 61 (10.8) | 1.619 | 0.203 | Intramedullary | 6 (75.0) | 503 (89.2) | | | Anesthetic methods, n (%) | | | | | GA | 3 (37.5) | 177 (31.4) | 0.137 | 0.711 | RA | 5 (62.5) | 387 (68.6) | | |
GA, general anesthesia; RA, regional anesthesia. | 表2 髋部骨折老年患者发生住院死亡危险的单因素分析 Table 2 Univariate analysis of factors affecting inpatient mortality after hip fracture surgery in elderly patients |
表3
Table 3
表3(Table 3)
表3 髋部骨折患者发生住院死亡危险相关因素的多重Logistic回归分析 Table 3 Multivariate Logistic regression analysis of factors affecting inpatient mortality after hip fracture surgery in elderly patientsVariables | β | SE | Wald | OR | 95% CI | P |
---|
Gender | -1.700 | 0.890 | 3.632 | 0.18 | 0.03-1.05 | 0.057 | Age | 0.197 | 0.065 | 9.191 | 1.22 | 1.07-1.38 | 0.002 | Pulmonary comorbidities | 2.492 | 0.851 | 8.568 | 12.09 | 2.28-64.12 | 0.003 | Surgical type | 2.236 | 0.991 | 5.094 | 9.36 | 1.34-65.26 | 0.024 |
SE, standard error; OR, odds ratio; CI, confidence interval. | 表3 髋部骨折患者发生住院死亡危险相关因素的多重Logistic回归分析 Table 3 Multivariate Logistic regression analysis of factors affecting inpatient mortality after hip fracture surgery in elderly patients |
36例患者术后发生心血管系统并发症(36/572, 发生率6.3%), 其中RA组19例(19/392, 发生率4.8%), GA组17例(17/180, 发生率9.4%), 两组患者术后心血管系统并发症发生率的差异有统计学意义。髋部骨折老年患者术后发生心血管系统并发症的单因素分析显示, 两组患者间的年龄、术前合并高血压和麻醉方法是发生心血管系统并发症的相关危险因素(表4); 多重Logistic回归分析显示, 年龄、术前合并高血压和脑血管合并症是发生术后心血管系统并发症的独立危险因素(表5)。
表4
Table 4
表4(Table 4)
表4 髋部骨折老年患者发生术后心血管并发症危险的单因素分析 Table 4 Univariate analysis of factors affecting cardiovascular complications after hip fracture surgery in elderly patientsVariables | Cardiovascular complications | χ 2/t/Z | P |
---|
Yes | | No |
---|
Age/years, ± s | 82.8± 6.5 | 78.4± 6.8 | 3.788 | < 0.001 | Bedridden time/d, median (min-max) | 4 (2-8) | 4 (1-31) | 1.244 | 0.214 | Gender, n (%) | | | | | Male | 12 (33.3) | 193 (36.0) | 0.105 | 0.746 | Female | 24 (66.7) | 343 (64.0) | | | Comorbidities, n (%) | | | | | Cardiac | 14 (38.9) | 135 (25.2) | 3.288 | 0.070 | Pulmonary | 4 (11.1) | 51 (9.5) | 0.099 | 0.753 | Cerebral | 12 (33.3) | 107 (20.0) | 3.660 | 0.056 | Hypertention | 26 (61.1) | 281 (49.4) | 5.317 | 0.021 | Diabetes | 9 (25.0) | 125 (23.3) | 0.053 | 0.818 | Surgical type, n (%) | | | | | Extramedullary | 2 (5.6) | 61 (11.4) | 1.392 | 0.214 | Intramedullary | 34 (94.4) | 475 (88.6) | | | Anesthetic methods, n (%) | | | | | GA | 17 (47.2) | 163 (30.4) | 4.421 | 0.035 | RA | 19 (52.8) | 373 (69.6) | | |
GA, general anesthesia; RA, regional anesthesia. | 表4 髋部骨折老年患者发生术后心血管并发症危险的单因素分析 Table 4 Univariate analysis of factors affecting cardiovascular complications after hip fracture surgery in elderly patients |
表5
Table 5
表5(Table 5)
表5 髋部骨折患者发生术后心血管并发症危险的多重Logistic回归分析 Table 5 Multivariate Logistic regression analysis of factors affecting cardiovascular complications after hip fracture surgery in elderly patientsVariables | β | SE | Wald | OR | 95% CI | P |
---|
Age | 0.121 | 0.028 | 18.013 | 1.13 | 1.07-1.19 | < 0.001 | Hypertention | 1.001 | 0.400 | 6.266 | 2.72 | 1.24-5.96 | 0.012 | Cerebral comorbidities | 0.748 | 0.388 | 3.717 | 2.11 | 0.99-4.52 | 0.054 |
SE, standard error; OR, odds ratio; CI, confidence interval. | 表5 髋部骨折患者发生术后心血管并发症危险的多重Logistic回归分析 Table 5 Multivariate Logistic regression analysis of factors affecting cardiovascular complications after hip fracture surgery in elderly patients |
56例患者术后发生呼吸系统并发症(56/572, 发生率9.8%), 其中RA组19例(19/392, 发生率4.8%), GA组37例(37/180, 发生率20.6%), 两组患者间呼吸系统并发症发生率的差异有统计学意义。髋部骨折老年患者术后发生呼吸系统并发症的单因素分析显示, 年龄、术前卧床时间和麻醉方法是发生呼吸系统并发症的相关危险因素(表6); 多重Logistic回归分析显示, 年龄、术前肺部合并症、术前卧床时间和麻醉方式是发生术后肺部并发症的独立危险因素(表7)。
表6
Table 6
表6(Table 6)
表6 髋部骨折患者发生术后呼吸系统并发症危险的单因素分析 Table 6 Univariate analysis of factors affecting pulmonary complications after hip fracture surgery in elderly patientsVariables | Pulmonary complications | χ 2/t/Z | P |
---|
Yes | | No |
---|
Age/years, ± s | 82.3± 7.1 | 78.3± 6.7 | 4.191 | < 0.001 | Bedridden time/d, median (min-max) | 4 (1-23) | 3 (1-31) | 2.926 | 0.003 | Gender, n (%) | | | | | Male | 24 (42.9) | 181 (35.1) | 1.330 | 0.249 | Female | 32 (57.1) | 335 (64.9) | | | Comorbidities, n (%) | | | | | Cardiac | 15 (26.8) | 134 (26.0) | 0.017 | 0.895 | Pulmonary | 9 (16.1) | 46 (8.9) | 2.977 | 0.084 | Cerebral | 13 (23.2) | 106 (20.5) | 0.219 | 0.640 | Hypertention | 30 (53.6) | 257 (49.8) | 0.071 | 0.790 | Diabetes | 13 (23.2) | 121 (23.4) | 0.002 | 0.968 | Surgical type, n (%) | | | | | Extramedullatary | 8 (14.3) | 55 (10.7) | 0.678 | 0.410 | Intramedullatary | 48 (85.7) | 461 (89.3) | | | Anesthetic methods, n (%) | | | | | GA | 35 (62.5) | 145 (28.1) | 27.719 | < 0.001 | RA | 21 (37.5) | 371 (71.9) | | |
GA, general anesthesia; RA, regional anesthesia. | 表6 髋部骨折患者发生术后呼吸系统并发症危险的单因素分析 Table 6 Univariate analysis of factors affecting pulmonary complications after hip fracture surgery in elderly patients |
表7
Table 7
表7(Table 7)
表7 髋部骨折患者术后发生呼吸系统并发症危险的多重Logistic回归分析 Table 7 Multivariate Logistic regression analysis of factors affecting pulmonary complications after hip fracture surgery in elderly patientsVariables | β | SE | Wald | OR | 95% CI | P |
---|
Age | 0.119 | 0.026 | 21.507 | 1.13 | 1.07-1.19 | < 0.001 | Pulmonary comorbidities | 1.060 | 0.456 | 5.410 | 2.89 | 1.18-7.05 | 0.020 | Bedridden time | 0.102 | 0.034 | 9.108 | 1.11 | 1.04-1.18 | 0.003 | Anesthetic methods | 1.767 | 0.346 | 26.103 | 5.85 | 2.97-11.53 | < 0.001 |
SE, standard error; OR, odds ratio; CI, confidence interval. | 表7 髋部骨折患者术后发生呼吸系统并发症危险的多重Logistic回归分析 Table 7 Multivariate Logistic regression analysis of factors affecting pulmonary complications after hip fracture surgery in elderly patients |
3 讨论老年人多伴有骨质疏松和活动能力下降, 跌倒等轻微外伤极易出现髋部骨折[12]。髋部骨折致残、致死率高, 如何有效地降低老年患者的术后并发症和死亡率是目前困扰广大医生的一大医学难题。
本研究回顾性分析我院收治的572例髋部骨折老年患者的临床资料, 结果显示患者的年龄、性别、术前肺部合并症和手术方式是发生住院死亡的独立危险因素, 麻醉方式并不影响髋部骨折老年患者的住院死亡率。老年人随着年龄增长, 器官功能日渐减退, 常伴发多种内科疾病, 增加了外科手术和麻醉的风险。髋部骨折患者通常因下肢活动受限, 被动长时间卧床, 又易并发褥疮、坠积性肺炎和下肢深静脉血栓等问题, 同时骨折本身和手术还可引起大量显性和隐性失血、脂肪栓塞等严重问题, 若再叠加高龄, 特别是在合并全身系统性疾病的基础之上, 患者手术和麻醉的风险极高[13, 14], 因此, 髋部骨折的治
疗模式也渐渐从“ 骨折” 为中心转变为以“ 高龄患者” 为中心[2]。髋部骨折患病率的性别差异与骨质疏松症在绝经后的女性患者中发病率较高相关[15]。虽然男性患者髋部骨折的患病率低, 但男性人群中普遍存在吸烟、酗酒等不良嗜好, 且治疗依从性差, 故髋部骨折术后男性患者的死亡率反而更高[11]。因此, 针对男性患者应积极纠正其不良习惯, 培养良好的治疗依从性, 以利于改善其转归。
术前肺部合并症的存在是髋部骨折老年患者发生术后死亡的高风险因素, 对于老年患者而言, 肺部并发症比心脏并发症更能预示远期的预后[16]。依据并存肺部疾病的类型进行相应的治疗(如选择理疗改善肺功能, 抗生素积极控制肺部感染等), 使得术前肺部疾病得到最大程度的缓解[16]。对于术前肺部疾病的治疗应该是一个长期而规范的过程, 而不是仅局限于围术期。髋部骨折髓外固定术具有手术创伤大、手术时间长、失血多的特点, 而髓内固定术则具有微创、手术时间短的特点[17, 18]。髋关节置换手术可能涉及骨水泥等诸多问题, 会增加患者术后早期的死亡率, 普遍认为髋关节置换手术是髋部骨折患者术后发生死亡的危险因素, 目前尚未见髋部内固定手术方式的差异与患者术后死亡相关的报道[11]。本研究纳入的病例数偏少, 可能是产生上述偏差的原因, 这也提示将来的研究需要扩大样本量, 以便探寻内固定术式的差异是否影响髋部骨折患者术后的死亡率。
不同麻醉方法是否影响患者术后的转归一直是临床中研究的热点问题[9, 11, 18]。本研究提示, 麻醉方法不是患者发生住院期间死亡的独立危险因素, 这与White等[11]的报道相一致, 但Neuman等[9]的研究结果表明, RA优于GA, RA可降低患者的住院死亡率。常规气管插管GA增加肺部感染的风险, 而髋部骨折的老年患者如果术后发生肺部感染, 有文献报道患者术后30 d的死亡率将高达近50%[16]。GA是患者发生术后肺部感染的危险因素, 而术后肺部感染又是患者发生死亡的危险因素, GA是否也是导致患者发生术后死亡的危险因素, 尚需进行深入研究。有报道, 麻醉方法与患者术后死亡率息息相关[9, 18], 但本研究并没有发现这种相关性, 推测其中可能的原因如下:首先是主要观察指标的时间窗较窄, 而导致髋部骨折患者发生术后死亡的危险因素(如肺部感染)的治疗和转归又是一个相对漫长的过程, 因此在住院期间这个较窄的时间窗内观察不到更多的死亡病例; 其次可能是病例数目不足导致研究结果偏倚; 最后, GA和RA对于患者住院期间死亡率可能确实没有影响, 这有待于进一步研究。
本研究结果显示, 年龄、术前合并高血压病和脑血管疾病是患者术后新发心血管并发症的独立危险因素, 这与以往研究结果一致[11, 19]。人口老龄化是全球面临的医疗卫生难题, 高血压是老年人最为常见的心血管疾病之一, 又与冠状动脉粥样硬化性心脏病、脑血管疾病密切相关。对于老年人应注重对其脆弱肺功能的早期预警监测和干预, 与GA相比, RA可以降低老年患者的术后呼吸系统并发症的发生风险。髋部骨折老年患者术后肺部并发症除与年龄和麻醉方式相关外, 还与术前卧床时间密切相关。有研究显示, 术前卧床时间越长, 患者的住院时间会越长, 术后心肺并发症和死亡率也会越高[20, 21], 这提示在面对这类老年患者时应权衡利弊, 不应过分强调治疗合并的内科疾病而贻误手术时机。
综上所述, RA和GA对接受手术治疗的髋部骨折老年患者的住院死亡率的影响可能没有差异, 但RA组患者术后发生呼吸系统并发症的风险低于GA组患者。基于对老年患者脆弱心、肺、脑等重要脏器功能的保护, 在能够满足外科手术的前提下, RA可能是更好的选择, 老年患者可能从中获益更多。
The authors have declared that no competing interests exist.