咪达唑仑和谵妄:你能两者兼得吗?

R. Greengrass
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摘要

我饶有兴趣地阅读了Mentsoudis等人最近发表的一篇关于咪达唑仑在全关节置换术人群术前的风险/收益的文章。他们报告咪达唑仑与谵妄没有关联,心脏和肺部并发症的发生率显著降低,跌倒的发生率增加。在先前发表的一篇综述中,使用相同的Premier Healthcare数据库检查了与当前文章相同的关节人群,作者确定接受短效苯二氮卓类药物的患者术后谵妄的风险显着降低。谵妄的发生率较低可能是由于在关节置换术引起的血管栓塞期间咪达唑仑给予神经保护。事实上,咪达唑仑对大脑的保护作用已经被Michenfelder等人报道过。在当前的数据库分析中,作者证实咪达唑仑不会增加谵妄的风险(并引用附带调查),因此长期以来认为咪达唑仑导致谵妄发生率增加的观点可能是没有根据的。美国标准协会的一些成员引用了一篇关于老年人不当用药的文章,其中提到“所有苯二氮卓类药物都会增加谵妄的风险”;然而,咪达唑仑并没有在这篇文章中提到,也没有列出任何引用来证实这一说法。在当前的文章中,作者还确定了服用咪达唑仑的患者肺部和心脏并发症的风险显著降低,这导致了对这部分患者的心脏和肺保护作用的推测。摔倒增加的可能联系很难理解,特别是在术前给予咪达唑仑后谵妄减少和咪达唑仑作用迅速溶解的情况下。作者还确定加巴喷丁类药物与咪达唑仑联合使用会增加镇静相关的并发症,这在添加任何镇静剂时都是可以预料到的。我同意作者的观点,即不鼓励滥用任何药物,包括咪达唑仑;然而,文献记载的减少谵妄和减少肺部和心脏并发症的益处不应排除在有指征的这类患者中使用它。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Midazolam and delirium: can you have it both ways?
I read with interest the recent article by Mentsoudis et al regarding the risk/benefits of midazolam preoperatively in a total joint arthroplasty population. They reported no association of midazolam with delirium, a significantly decreased incidence of cardiac and pulmonary complications and an increased incidence of falls. In a previously published review using the same Premier Healthcare Database examining the same total joint population as the current article, the authors determined that patients receiving shortacting benzodiazepines had significantly lower risks of postoperative delirium. The lesser incidences of delirium may have been because of neuroprotection accorded by midazolam during periods of vascular embolization incurred by arthroplasty surgery. Indeed, cerebral protective effects from midazolam have been previously reported by Michenfelder and others. 4 In the current database analysis, the authors confirm that there is no increased risk of delirium from midazolam (and cite collateral investigations thus the long held view that midazolam results in increased incidences of delirium may be unfounded. Of interest in an article cited by some members of the ASA regarding inappropriate medication use in older adults, it is stated “all benzodiazepines increase risk of delirium”; however, midazolam is not mentioned in this article and no citations are listed to substantiate this statement. In the current article, the authors also determined a significantly decreased risk of pulmonary and cardiac complications in patients who received midazolam which leads to speculation of additive cardiac and pulmonary protective effects in this subset of patients. The possible association of increased falls is difficult to understand particularly with the knowledge of decreased delirium associated with midazolam administration and rapid dissolution of midazolam effect if only given preoperatively. The authors also determined that gabapentinoids when combined with midazolam increased sedationrelated complications which would be expected when adding any sedative agent. I concur with the authors that indiscriminate use of any drug, including midazolam, should be discouraged; however, the documented benefits of decreased delirium, and lesser pulmonary and cardiac complications in a total joint population should not preclude its use in this population of patients when indicated.
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