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护理学报 ›› 2020, Vol. 27 ›› Issue (1): 56-61.doi: 10.16460/j.issn1008-9969.2020.01.056

• 临床护理 • 上一篇    下一篇

心脏外科ICU患者术后谵妄的危险因素研究

祝利花a, 周敏b, 翟晓媛a   

  1. 山东大学齐鲁医院 a.心脏外科重症监护病房; b.重症医学科,山东 济南 250012
  • 收稿日期:2019-07-17 出版日期:2020-01-10 发布日期:2020-07-20
  • 通讯作者: 周敏（1969-）,女,山东济南人,硕士,主任护师,E-mail: 13791122359@126.com。
  • 作者简介:祝利花（1986-）,女,山东济南人,本科学历,硕士研究生在读,护师。

Risk Factors of Postoperative Delirium in Patients in Cardiac Surgery Intensive Care Unit

ZHU Li-huaa, ZHOU Minb, ZHAI Xiao-yuana   

  1. 1. Intensive Care Unit of Dept. of Cardiac Surgery;
    2. Dept. of Intensive Care Unit, Qilu Hospital of Shandong University, Jinan 250012, China
  • Received:2019-07-17 Online:2020-01-10 Published:2020-07-20

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摘要： 目的 评估心脏外科重症监护病房（CSICU）患者术后谵妄的发生率,分析其危险因素及各危险因素预测术后谵妄发生的效能。方法 采用横断面调查研究法,选取2019年1—5月于某三级甲等综合医院CSICU住院的心脏手术后患者为研究对象。谵妄评估采用ICU患者意识模糊评估法,采用一般资料调查问卷、急性生理和慢性健康评分（Acute Physiology and Chronic Health Evaluation,APACHEⅡ）、中文版重症监护疼痛观察工具、匹兹堡睡眠质量指数量表和ICU环境压力源量表收集资料。采用单因素分析及多因素Logistic回归分析患者术后谵妄的危险因素,利用受试者工作特征曲线（ROC曲线）描述各危险因素的曲线下面积及最佳临界值。结果 （1）共纳入316例患者,发生谵妄81例（25.6%）, Logistic回归分析结果显示,术后谵妄的独立危险因素包括：APACHEⅡ评分（OR=1.257,95%CI为1.018~1.553）,停循环时间>15 min（OR=6.943,95%CI为1.288~37.429）,术后疼痛平均得分（OR=2.918,95%CI为1.749~4.867）,睡眠质量得分（OR=1.147,95%CI为1.038~1.267）,ICU环境压力源得分（OR=1.161,95%CI为1.110~1.214）。（2）ROC曲线结果显示：APACHEⅡ评分、停循环时间>15 min、术后疼痛平均得分、睡眠质量得分、ICU环境压力源得分的曲线下面积分别为0.745、0.617、0.758、0.837、0.910,APACHEⅡ评分、术后疼痛平均得分、睡眠质量得分、ICU环境压力源得分的最佳截断值分别为9分、3分、14分、72分。结论 CSICU患者术后谵妄的发病率处于一个较高水平,APACHEⅡ评分>9分、停循环时间>15 min、术后疼痛平均得分>3分、睡眠质量得分>14分、ICU环境压力源得分>72分的患者更容易发生术后谵妄。本研究为完善CSICU患者术后谵妄的管理提供参考依据。

关键词: 心脏外科重症监护病房, 术后谵妄, 危险因素, ROC曲线

Abstract: Objective To evaluate the incidence of postoperative delirium in patients in cardiac surgery intensive care unit (CSICU), and to analyze the risk factors and the efficiency of each risk factor in predicting postoperative delirium. Methods In this cross-section survey, patients hospitalized in CSICU after cardiac surgery of one tertiary grade A hospital from January to May 2019 were selected as research objects. Confusion Assessment Methodfor the Intensive Care Unit, general information questionnaire, Acute Physiology and Chronic Health Evaluation (APACHEⅡ), Critical-care Pain Observation Tool, Pittsburgh sleep quality index and intensive care unit environmental stressor scale were used to collect the data. Risk factors of postoperative delirium in CSICU patients were analyzed by using single factor analysis and multivariate logistic regression. ROC curve was used to describe the predictive effectiveness of the risk factors and the best threshold. Results Of the 316 patients included, 81 cases of delirium were found, with an incidence of 25.6%. Logistic regression showed that APACHEⅡscore(OR=1.257,95%CI=1.018~1.553), circulatory arrest time more than 15 minutes (OR=6.943, 95%CI=1.288~37.429), average postoperative pain score (OR=2.918, 95%CI=1.749~4.867), sleep quality score (OR=1.147,95%CI=1.038~1.267),and ICU environment pressure source score(OR=1.161,95%CI=1.110~1.214) were independent risk factors of postoperative delirium. ROC curve results showed that the area under the curve of APACHEⅡ,circulatory arrest time longer than 15 minutes, mean score of postoperative pain, sleep quality score and ICU environmental pressure source score were 0.745, 0.617, 0.758, 0.837 and 0.910 respectively, and their optimal cut-off value was 9, 3, 14 and 72 respectively. Conclusion The incidence of postoperative delirium CSICU patients is high. Postoperative delirium is more likely to occur in patients with APACHEⅡscore>9, circulatory arrest time longer than 15min, mean score of postoperative pain>3, score of sleep quality>14,and score of ICU environment pressure source>72 are risk factors of postoperative delirium. This study provides reference for improving the management of postoperative delirium in CSICU patients.

Key words: cardiac surgical intensive care unit, postoperative delirium, risk factor, ROC curve

中图分类号: 

  • R473.54
[1] 罗爱林,张杰.2017版欧洲麻醉学会《基于循证和专家共识的术后谵妄指南》解读[J].临床外科杂志,2018,1(1):29-33. DOI:10.3969/j.issn.1005-6483. 2018.01.009.
[2] Salluh JI, Wang H, Schneider EB, et al.Outcome of Delirium in Critically Ill Patients: Systematic Review and Meta-analysis[J]. BMJ, 2015,350(5):2538. DOI:10.1136/bmj.h2538.
[3] Th BC, Laflam A, Max L, et al.The Impact of Delirium after Cardiac Surgical Procedures on Postoperative Resource Use[J]. Ann Thorac Surg, 2016, 101(5):1663-1669. DOI:10.1016/j.athoracsur.2015.12.074.
[4] Saczynski JS, Marcantonio ER, Quach L, et al.Cognitive Trajectories after Postoperative Delirium[J]. N Engl J Med,2012,367(1):30-39.DOI:10.1056/NEJMc1209366#SA2.
[5] Ely EW, Shintani A, Truman B, et al.Delirium as a Predictor of Mortality in Mechanically Ventilated Patients in the Intensive Care Unit[J]. JAMA,2004, 291(14):1753-1762. DOI:10.1001/jama.291.14.1753.
[6] Tse L, Schwarz SK, Bowering JB, et al.Incidence of and Risk Factors for Delirium after Cardiac Surgery at a Quaternary Care Center: A Retrospective Cohort Study[J]. J Cardiothor Vasc An,2015,29(6):1472-1479. DOI:10.10 53/j.jvca.2015.06.018.
[7] Andrejaitiene J, Benetis R, Sirvinskas E.Postoperative Delirium Following Cardiac Surgery: The Incidence, Risk Factors and Outcome[J]. J Cardiothorac Surg, 2015,10(1):A298. DOI:10.1186/1749-8090-10-S1-A298.
[8] 郭海凌,孙丹丹,梁涛.ICU意识模糊评估法使用中常见问题解读[J].中国临床医生杂志,2017,45(1):108-110. DOI: 10.3969/j.issn.2095-8552.2017.01.040.
[9] 李钰,金献冠,胡明磊,等.急性生理和慢性健康评分Ⅱ、急性肾小管坏死个体病情严重性指数评分在急性肾损伤中的应用价值[J].中国基层医药,2015,31(5):685-688. DOI:10.3760/cma.j.issn.1008-6706.2015.05.016.
[10] Gelinas C, Fillion L, Puntillo KA, et al.Validation of the Critical-care Pain Observation Tool in Adult Patients[J]. Am J Crit Care, 2006,15(4):420-427. DOI:10.1164/rccm.200601-027OC.
[11] 陈杰,杨晓红,路潜,等.中文版重症监护疼痛观察工具在非气管插管患者中应用的信效度研究[J]. 中华护理杂志,2015,50(9):1132-1136.DOI:10.376 1,j.issn.0254-1769.2015.09.025.
[12] Buysse DJ, Reynolds III, Monk TH, et al.The Pittsburgh Sleep Quality Index: A New Instrument for Psychiatric Practice and Research[J]. Psychiatry Res,1989, 28(2):193-213. DOI:10.1016/0165-1781(89)90047-4.
[13] 刘贤臣,唐茂芹. 匹兹堡睡眠质量指数的信度与效度研究[J].中华精神科杂志,1996,29(2):103-107. DOI:10.1007/BF02951625.
[14] Ballard, Karen S.Identification of Environmental Stressors for Patients in a Surgical Intensive Care Unit[J]. Issues Ment Health Nurs,1981,3(1-2):89-108.DOI:10.3109/01612848109140863.
[15] 苏丽静,颜艺鹭,黄文娟,等.中文版ICU环境压力源量表的修订和信效度评价[J].中华护理杂志,2018,53(4):126-130. DOI:CNKI:SUN:ZHHL.0.2018 -04-035.
[16] 吴琼,江智霞,潘燕彬,等.机械通气患者发生谵妄的影响因素分析[J].中华护理杂志, 2018, 53(5):543-548. DOI:10.3761/j.issn.0254-1769.2018.05.006.
[17] Guenther U, Theuerkauf N,Frommann I, et al.Predisposing and Precipitating Factors of Delirium after Cardiac Surgery: A Prospective Observational Cohort Study[J]. Ann Surg,2013, 57(6):1160-1167. DOI:10.1097/SLA.0b013e318281b01c.
[18] McPherson JA, Wagner CE, Boehm LM, et al. Delirium in the Cardiovascular ICU: Exploring Modifiable Risk Factors[J]. Crit Care Med,2013,41(2):405-413.DOI:10.1097/CCM.0b013e31826ab49b.
[19] Su L, Yan Y, Huang W, et al.Risk Factors For Intensive Care Unit Delirium after Cardiac Operation[J]. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue,2019, 31(2):165-171. DOI:10.3760/cma.j.issn.2095-4352.2019.02.009.
[20] 黄洁,肖倩,吴瑛. ICU谵妄危险因素的Meta分析[J]. 中华护理杂志, 2010, 45(1):6-9. DOI:10.3761/j.issn.0254-1769.2010.01.002.
[21] Zaal IJ, Devlin JW, Peelen LM, et al.A Systematic Review of Risk Factors for Delirium in the ICU[J]. Crit Care Med,2015, 43(1):40-47.DOI:10.1097/CCM.0000000000000625.
[22] Tang B, Wang XT, Chen WJ, et al.Experts Consensus on the Management of Delirium Incritically Ill Patients[J]. Zhonghua Nei Ke Za Zhi,2019, 58(2):108-118.DOI:10.3760/cma.j.issn.0578-1426.2019.02.007.
[23] Brummel NE, Girard TD.Preventing Delirium in the Intensive Care Unit[J]. Crit Care Clin,2013, 29(1):51-65. DOI:10.1016/j.ccc.2012.10.007.
[24] Subramaniam B, Shankar P, Shaefi S, et al.Effect of Intravenous Acetaminophen vs Placebo Combined with Propofol or Dexmedeto Midine on Postoperative Delirium among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial[J]. JAMA,2019,321(7):686-696. DOI:10.1001/ jama.2019.0234.
[25] Oh ES, Fong TG, Hshieh TT, et al.Delirium in Older Persons: Advances in Diagnosis and Treatment[J]. JAMA,2017,318(12):1161. DOI:10. 1001/jam a.2017.12067.
[26] Van Rompaey B, Elseviers MM, Van Drom W, et al.The Effect of Earplugs During the Night on the Onset of Delirium and Sleep Perception: A Randomized Controlled Trial in Intensive Care Patients[J]. Crit Care,May 4,2012,16(3):R73. DOI:10.1186/cc11330.
[27] Caruso P, Guardian L, Tiengo T, et al.ICU Architectural Design Affects The Delirium Prevalence: A Comparison Between Single-bed and Multibed Rooms[J]. Crit Care Med,2014, 42(10):2204-2210.DOI:10.1097/CCM.0000000000000502.
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