术后谵妄与认知功能障碍  

Postoperative delirium and cognitive dysfunction

作　　者：王多友[1] 

机构地区：[1]吉林大学白求恩第一医院麻醉科,吉林长春130003

出　　处：《大连医科大学学报》2013年第5期409-415,共7页Journal of Dalian Medical University

摘　　要：术后谵妄和认知功能障碍是一种临床常见的急性脑功能障碍综合征,外科病人手术后的发病率可高达70%。术后谵妄和认知功能障碍对病人近期和远期康复均会产生不良影响。除增加术后并发症和病死率外,还可导致住院时间延长,并增加病人出院后需要长期医疗护理的潜在风险。虽然谵妄的临床分型主要分为反应过激型和反应迟钝型,但其临床表现的实质是病人认知能力下降。尽管目前尚不清楚其特异性发病原因,现已知其发病与诸多因素有关。脑组织对外周炎性介质变化所产生的应答反应是各类谵妄病理生理改变所致的临床表现的主要原因,老年病人的脑组织对外周炎性剌激所产生的反应较年轻人脑组织所产生的反应尤为严重。谵妄的发病风险因素可分为病人自身因素和外界诱发因素。前者主要包括病人年龄、并存症、认知功能和机体功能下降、视觉和听觉功能障碍以及术前长期需要医疗护理等。后者主要为术后转入ICU进行重症监护治疗、应用抗胆碱能药物、酒精与药物戒断、感染、医源性并发症、代谢紊乱以及术后应用镇痛药(阿片类)和镇静药(苯二氮卓类)。尽管临床工作中已有数种评分方法可供用于判断病人的谵妄程度,但意识紊乱测试法(confusion assessment method,CAM)和危重症病人意识紊乱测试法(confusion assessment method for ICU patient,CAM-ICU)是目前应用较为普遍的标准方法。非药物性多模式预防方案和药物性预防方法均有助于降低术后谵妄的发生率。围手术期应用氟哌啶醇可明显降低其发生率并减轻其临床症状,多模式预防和治疗手段是降低其发病率、缓解发病程度的有效措施。Postoperative delirium and cognitive dysfunction are common manifestations of acute brain dysfunction, occurring in up to 70% of post - surgical patients. The development of postoperative delirium and postoperative cognitive dysfunction have long -term consequences, such as higher morbidity and mortality and increased hospital stay, and it increases the risk of dependency and institutionalisation. Delirium presents clinically with differing subtypes ranging from hyperactive to hypoactive. Despite the relevance of these cognitive disorders, the specific aetiology is still unknown, and there are many factors that have been associated with its development. In many forms of delirium, the brain＇s reaction to a peripheral inflammatory process is considered to be a pathophysiological key element and the aged brain seems to react more markedly to a peripheral inflammatory stimulus than a younger brain. The risk factors for delirium are categorised as predisposing or precipitating factors. In the presence of many predisposing factors, well documented predisposing factors are age, medical comorbidities, cognitive, functional, visual and hearing impairment and institutional residence. Important precipitating factors apart from surgery are admission to an ICU, anticholinergic drugs, alcohol or drug withdrawal, infections, iatrogenic complications, metabolic derangements, pain and the exposure to analgesics （opioids）and hypnotics （benzodiaz- epines）. Several bedside instruments are available for the routine ward and ICU setting. The Confusion Assessment Method （CAM） and a version specifically developed for the intensive care setting （ CAM - ICU） have emerged as a standard. Non -pharmacological multicomponent strategies and pharmacological prophylaxis may be useful to reduce the incidence of postoperative delirium. Perioperative administration of haloperidol has been shown to reduce the severity and the incidence of delirium. The multicomponent interventions for prevention and treatment have been shown to red

关 键 词：谵妄 认知功能障碍 围手术期管理 急性脑功能障碍 

分 类 号：R619[医药卫生—外科学]