重新思考老年手术患者围手术期神经认知风险降低：保留活动能力的镇痛、早期活动与多学科护理

摘要(中文译文)

老年手术患者的围手术期神经认知风险不仅可能受术中麻醉管理的影响，还可能受术后可干预因素的影响，包括疼痛、阿片类药物暴露、制动和康复延迟。比较全身麻醉与椎管内麻醉用于老年髋部骨折手术的大型随机试验发现，术后谵妄（POD）发生率或功能结局均无显著差异。这些发现被广泛解读为所用麻醉方式对围手术期神经认知障碍（PND）影响甚微的证据；然而，这些研究并未对椎管内技术和外周神经阻滞（PNB）分别进行评估，术后镇痛策略和早期活动也未标准化。在这篇叙述性综述中，我们重新审视当前证据，并提出将重点从传统的“全身麻醉与区域麻醉”二元对立转向术后镇痛、阿片类药物最小化和早期活动。我们发现，尽管神经炎症与术后认知下降的生物学背景相关，但表明PNB通过该机制减轻人体全身炎症反应或改善神经认知结局的直接证据仍然有限。保留运动功能的PNB可被视为在多学科围手术期路径中实现有效镇痛、减少阿片类药物暴露和早期活动的潜在促进手段，而非具有明确直接抗炎或神经保护作用的干预措施。我们回顾了PROSPECT指南中针对具体术式的推荐意见，讨论了PNB在脑健康加速康复外科（Brain-ERAS）框架中的作用，并确定了在老年手术患者中前瞻性评估神经认知结局的优先事项。

Abstract

Perioperative neurocognitive risk in older surgical patients may be influenced not only by intraoperative anesthetic management, but also by postoperative factors that are modifiable, including pain, opioid exposure, immobility, and delayed rehabilitation. Large randomized trials that compared general anesthesia with neuraxial anesthesia in older patients undergoing hip fracture surgery found no significant differences in the incidence of postoperative delirium (POD) or functional outcomes. These findings have been widely interpreted as evidence that the anesthetic modality used has little impact on perioperative neurocognitive disorders (PND); however, neuraxial techniques and peripheral nerve blocks (PNBs) were not evaluated separately and postoperative analgesic strategies and early mobilization were not standardized in these studies. In this narrative review, we re-examine the current evidence and propose a shift in emphasis from the traditional dichotomy of "general versus regional anesthesia" toward postoperative analgesia, opioid minimization, and early mobilization. We found that, although neuroinflammation is relevant to the biological context of postoperative cognitive decline, direct evidence indicating that PNBs attenuate systemic inflammatory responses or improve neurocognitive outcomes via this mechanism in humans remains limited. Motor-sparing PNBs may be considered potential enablers of effective analgesia, reduced opioid exposure, and early mobilization within a multidisciplinary perioperative pathway, rather than as interventions with an established direct anti-inflammatory or neuroprotective effect. We review procedure-specific recommendations from the PROSPECT guidelines, discuss the role of PNBs within a Brain-Enhanced Recovery After Surgery (Brain-ERAS) framework, and identify priorities for the prospective evaluation of neurocognitive outcomes in older surgical patients.

如何引用

Korean journal of anesthesiology 的其他文献

• 现代皮肤病药物的围手术期管理：以麻醉为重点的叙述性综述