Effects Of Preventive Analgesia With Quadratus Lumbar Block On Postoperative Delirium In Elderly Patients With Hip Fracture

【Objective】To study the effects of ultrasound-guided preventive analgesia of quadratus lumbar block on postoperative delirium,perioperative analgesia,stress-inflammatory response（serum interleukin-6 and serum C-reactive protein）,cognitive-related laboratory indexes（serum NSE and cerebrospinal fluid Aβ-42）,sleep quality scores and the recovery quality score-15 of 30 days after operation in elderly patients with hip fracture,and to explore the clinical value of preventive analgesia in perioperative management of anesthesia for elderly hip fractures.【Methods】（1）Select the patients eligible for inclusion from April 1,2021 to May 31,2022.After signing the informed consent,they were randomly divided into preventive analgesia group（group Q,n=42）and blank control group（group C,n=41）.Basic information of patients were collected by nurse.（2）The anesthesiologist carried out routine preoperative interview to the patients one day before the operation,and performed single ultrasound-guided quadratus lumbar muscle block for patients in group Q.In the operating room the next day,monitor the patient’s ECG,pulse oximeter and blood pressure,evaluate cognitive function.Subarachnoid block is chosen for anesthesia regimen,maintain the anesthesia level at T₁₀during the operation,and record the intraoperative data.（3）The patient received patient-controlled intravenous analgesia（PCIA）within48 hours after operation.In the course of the study,if the NRS score of the patient’s digital scoring scale when exercising is more than 3 points or if the patient still cannot obtain satisfactory analgesia after three effective compressions of PCIA,the orthopedic doctor will use medicine for remedy,and repeat the administration if necessary.The changes of cognitive function and adverse reactions of patients were followed up within 7 days after the operation,and the recovery quality of patients will ba recorded by telephone on the 30th day after the operation.（4）Venous blood was drawn when patients with an empty stomach on the day before surgery,the day after surgery,and three days after surgery,and sent to the laboratory department to monitor the content of interleukin-6,C-reactive protein and neuron-specific enolase in serum,and the patient’s cerebrospinal fluid was extracted on the day of surgery and stored in a refrigerator at-80°C to monitor its amyloid-42content.（5）The sleep quality of patients was scored using the Athens insomnia scale 1day before surgery,on the day of surgery,1 day after surgery,and 2 days after surgery.【Results】（1）Total of 232 patients participated in the study,168 patients agreed to join the study,and finally 42 patients were included in group Q,41 were eventually included in group C.There were no significant differences between the two study groups in patient characteristics（P>0.05）,such as age,sex,ASA,BMI,preoperative GDS,preoperative MMSE,preanesthesia MMSE,type of surgery,duration of surgery,intraoperative blood loss,incidence of postoperative nausea or vomiting,salvage analgesia,length of hospital stay,and Qo R-15.（2）The total incidence of delirium 7 days after operation was 13.3%（11 of 83patients）.Through preventive analgesia,the incidence of postoperative delirium in group Q was 9.52%（4 of 42 patients）,and that in group C was 17.03%（7 of 41patients）.There was no statistical difference between the two groups（P>0.05）.There were statistical differences between the two groups in the total positive days of delirium and the duration of delirium（P<0.05）,but there was no significant difference in the first onset day on delirium.（P>0.05）.From preoperative to postoperative day 7,the difference was not statistically significant in cognitive status（P>0.05）.（3）At the baseline level,the pain scores of patients in the two groups were similar（P>0.05）.After 4 hours of nerve block and at anesthesia position on the operation day,the NRS score in group Q was lower than that in group C（P<0.05）.The significant difference were not been found in NRS scores between the two groups on the 1st and 2nd day after operation（P>0.05）.（4）Compared with group C,there was a significant difference in serum NSE test results 3 days after surgery in group Q（P<0.05）,and there was no significant difference in serum NSE between the two groups before and 1 day after surgery（P>0.05）.There was no significant difference in stress response indexes（serum interleukin-6 and serum C-reactive protein）and Aβ-42 protein in cerebrospinal fluid（P>0.05）.（5）The results of the Athens insomnia scale showed that there was no significant difference between the two groups（P>0.05）,but the difference between the groups was statistically significant（P<0.05）.The sleep quality of the two groups was significantly improved on the day of surgery,1 day after surgery and 2 days after surgery.In the Q group,the difference in sleep quality at two days after surgery compared with the day was also statistically significant（P<0.05）.【Conclusions】（1）Compared with the control group,although there was no significant difference in the incidence of delirium and the time of first onset of delirium in elderly patients with hip dysphoria,it reduced the total number of days of delirium and the number of days of delirium duration,suggesting that effective preoperative analgesia can reduce the severity of postoperative delirium,improve cognitive function in elderly patients,and accelerate postoperative recovery.（2）Compared with the traditional analgesia mode,the prophylactic analgesia of ultrasound-guided quadratus lumbar block can significantly reduce the pain score from occlusion to morning in elderly patients with hip fracture,and does not increase perioperative complications or the recovery quality score-15 of 30 days after operation.（3）In terms of laboratory indicators,NSE change results showed that changes in brain nerve damage indicators could predict changes in cognitive function.（4）In terms of sleep quality,there was no significant difference between the two groups,but the results of intra-group comparison showed that sleep quality was significantly improved after surgery compared with before surgery.In the Q group,the improvement of sleep quality 2 days after surgery compared with the day of surgery suggested that good preventive analgesia could significantly improve the sleep of patients after surgery.