文章摘要
老年患者髋部骨折修复术后谵妄的危险因素
Risk factors of postoperative delirium in elderly patients undergoing hip fracture repair surgery
  
DOI：10.12089/jca.2023.03.002
中文关键词: 胰岛素抵抗  β-淀粉样蛋白42  磷酸化tau蛋白  术后谵妄  髋部骨折  危险因素
英文关键词: Insulin resistance  Total tau protein  Phosphorylated tau protein  Postoperative delirium  Hip fracture  Risk Factors
基金项目:河北省重点研发计划项目（22377732D）
作者单位E-mail
王洁 050051,石家庄市,河北医科大学第三医院麻醉科  
双鹏展 050051,石家庄市,河北医科大学第三医院麻醉科  
赵龙彪 050051,石家庄市,河北医科大学第三医院麻醉科  
李昭 050051,石家庄市,河北医科大学第三医院麻醉科  
王秀丽 050051,石家庄市,河北医科大学第三医院麻醉科  
刘朋 050051,石家庄市,河北医科大学第三医院麻醉科 liupeng2010aa@126.com 
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中文摘要:
      
目的 探讨老年患者髋部骨折术后谵妄（POD）的危险因素。
方法 选择2022年1月至6月择期在蛛网膜下腔阻滞联合髂筋膜阻滞麻醉下行髋部骨折修复术的患者110例，男41例，女69例，年龄65～85岁，BMI 18～28 kg/m 2，ASAⅡ或Ⅲ级。麻醉诱导前留取静脉血3～5 ml，采用ELISA法测定血清胰岛素（INS）浓度，采用全自动生化分析仪测定空腹血糖（Glu）和糖化血红蛋白（HbA1c）浓度，依据胰岛素稳态模型计算胰岛素抵抗指数（HOMA-IR）。蛛网膜下腔阻滞穿刺成功后抽取脑脊液（CSF）2～3 ml，测定CSF INS、β-淀粉样蛋白（Aβ）42、总tau蛋白（t-tau）和磷酸化tau蛋白（p-tau）。根据术后1～5 d内是否发生POD，将患者分为两组：谵妄组和非谵妄组。采用单因素和多因素Logistic回归分析POD的影响因素，根据多因素Logistic回归分析结果建立预测模型，计算联合预测因子。绘制受试者工作特征（ROC）曲线，计算ROC曲线下面积（AUC）和95%可信区间（CI）以评估诊断价值。
结果 本研究有41例（37.3%）患者发生POD。多因素Logistic回归分析结果显示，血清INS（OR=1.742，95%CI 1.558～1.986，P=0.039）和HOMA-IR（OR=3.103，95%CI 1.066～9.034， P=0.038）升高是POD的危险因素，CSF INS（OR=0.026，95%CI 0.003～0.193， P＜0.001）和CSF Aβ42/p-tau比值（OR=0.312，95%CI 0.108～0.896， P=0.027）升高是POD的保护因素。血清INS预测POD的AUC为0.718（95%CI 0.617～0.818， P＜0.001），CSF INS的AUC为0.911（95%CI 0.849～0.973，P＜0.001），CSF Aβ42/p-tau比值的AUC为0.797（95%CI 0.714～0.880，P＜0.001），HOMA-IR的AUC为0.811（95%CI 0.732～0.891， P＜0.001）。预测模型为Logit（P）=5.118+0.097×血清INS+1.129×HOMA-IR-3.729×CSF INS-1.123×CSF Aβ42/p-tau比值，该模型AUC为0.965（95%CI 0.927～1.000， P＜0.001），敏感性90.2%，特异性94.2%。
结论 血清INS和HOMA-IR升高是老年髋部骨折患者POD的危险因素，CSF INS和CSF Aβ42/p-tau比值升高是其保护因素。
英文摘要:
      
Ojective To investigate the risk factors of postoperative delirium (POD) in elderly patients with hip fracture.
Methods A total of 110 patients, 41 males and 69 females, aged 65-85 years, ASA physical status Ⅱ or Ⅲ, underwent elective hip fracture repair under subarachnoid block combined with fascia iliaca block anesthesia from January to July 2022 were selected. Venous blood 3-5 ml was collected before anesthesia induction, and serum insulin (INS) concentrations were detected by ELISA, and fasting blood-glucose (Glu) and glycosylated hemoglobin (HbA1c) concentrations were measured by automatic biochemical analyzer. Insulin resistance index (HOMA-IR) was calculated based on insulin homeostasis model. After successful subarachnoid puncture, cerebrospinal fluid (CSF) 2-3 ml was extracted to detect the concentrations of CSF INS, β-amyloid protein (Aβ) 42, total tau protein (t-tau) and phosphorylated tau protein (p-tau). Patients were divided into two groups: POD group and non-POD group according to whether POD occurred within 1-5 days after operation. Univariate and multivariate Logistic regression analysis were used to analyze the influencing factors of POD. A prediction model was established based on the results of multivariate Logistic regression analysis, and the combined predictors were calculated. The receiver operating characteristic (ROC) curve was drawn, and the area under the ROC curve (AUC) and 95% confidence interval (CI) were calculated to evaluate the diagnostic value.
Results POD occurred in 41 patients (37.3%). Multivariate Logistic regression analysis showed that elevated serum INS (OR=1.742, 95% CI 1.558-1.986, P = 0.039) and HOMA-IR (OR = 3.103, 95% CI 1.066-9.034, P = 0.038) were risk factors for POD. The elevated CSF INS (OR = 0.026, 95% CI 0.003-0.193, P < 0.001) and CSF Aβ42/p-tau (OR=0.312, 95% CI 0.108-0.896, P = 0.027) were protective factors for POD. ROC curve analysis showed that the AUC of serum INS for predicting the occurrence of POD was 0.718 (95% CI 0.617-0.818, P < 0.001), the AUC of CSF INS was 0.911 (95% CI 0.849-0.973,P < 0.001), the AUC of CSF Aβ42/p-tau was 0.797 (95% CI 0.714-0.880,P < 0.001), and the AUC of HOMA-IR was 0.811 (95% CI 0.732-0.891, P < 0.001). The combined prediction model was Logit(P)=5.118 + 0.097 × serum INS + 1.129 × HOMA-IR - 3.729 × CSF INS - 1.123 × CSF Aβ42/p-tau. The AUC of the model was 0.965 (95% CI 0.927-1.000, P < 0.001), with a sensitivity of 90.2%, and a specificity of 94.2%.
Conclusion Increased serum INS and HOMA-IR are risk factors for POD, and increased CSF INS and CSF Aβ42/p-tau are protective factors in elderly patients with hip fracture.
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