Risk factors of delirium and outcomes in senile critical patients undergoing mechanical ventilation

目的：探讨影响机械通气老年危重症患者谵妄及预后的危险因素。方法采用回顾性研究方法，连续选择2014年9月至2015年1月北京大学人民医院外科重症加强治疗病房（ICU）患者的临床资料，纳入机械通气时间＞24h、接受镇静或镇痛治疗、年龄50～85岁的危重症患者。记录性别、年龄、体重、疾病严重程度、肝肾功能、镇痛镇静治疗、谵妄及死亡等情况，根据是否发生谵妄或28d预后分为谵妄组和非谵妄组以及死亡组和存活组，采用Logistic回归分析患者发生谵妄及死亡的危险因素。结果最终纳入105例患者，42例发生谵妄，发生率为40.0%；28d死亡15例，病死率为14.3%。①与非谵妄组相比，谵妄组患者急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分更高（分：22.2±5.6比18.8±4.8），肝功能Child-Pugh分级A级比例更低（57.1%比79.4%），镇痛镇静联合治疗率明显降低（52.4%比76.2%），镇静前平均动脉压（MAP）明显降低〔mmHg（1mmHg＝0.133kPa）：75.5（67.0～94.0）比86.0（77.0～95.0）〕，镇静前疼痛行为量表（BPS）评分及ICU疼痛观察工具表（CPOT）评分明显升高〔分：4.0（4.0～5.0）比4.0（3.0～4.0），4.0（3.0～4.2）比2.0（2.2～4.0）〕，苏醒时间（h：2.65±0.99比2.29±0.87）、撤机时间〔h：25.5（8.4～50.8）比10.0（6.4～28.8）〕、机械通气时间〔h：157.0（100.8～353.5）比86.0（59.0～143.0）〕和ICU住院时间〔d：8.5（5.0～24.2）比6.0（5.0～8.0）〕明显延长；28d病死率明显增加（33.3%比1.6%，均P＜0.05）。Logistic回归分析发现，瑞芬太尼联合咪达唑仑是谵妄的独立保护因素〔优势比（OR）＝0.122，95%可信区间（95%CI）＝0.029～0.510，P＝0.004〕。②与存活组比较，死亡组患者APACHEⅡ评分明显增高（分：23.2±6.1比19.7±5.1），镇静前MAP明显降低〔mmHg：70.0（66.0～81.0）比85.0（74.0～96.2）〕，镇静前BPS评分明显增高〔分：4.0（4.0～5.0）比4.0（3.8～4.0）〕，镇痛镇静联合治疗率明显降低（40.0%比68.9%），谵妄发生率明显升高（93.3%比31.1%，均P＜0.05）。Logistic回归分析发现，谵妄（OR＝1249.000，95%CI＝25.690～6077.000，P＝0.000）和高APACHEⅡ评分（OR＝1.251，95%CI＝1.019～1.535，P＝0.032）是患者死亡的独立危险因素，镇痛镇静联合治疗是死亡的独立保护因素（OR＝0.026，95%CI＝0.001～0.535，P＝0.018）。结论高APACHEⅡ评分和谵妄是机械通气老年危重症患者死亡的独立危险因素；镇痛镇静联合治疗是机械通气老年危重症患者谵妄和死亡的独立保护因素。Objective To investigate the risk factors of delirium and outcomes in senile critical patients undergoing mechanical ventilation. Methods A retrospective study was conducted. The clinical data of patients admitted to surgical intensive care unit (ICU) of Peking University People's Hospital from September 2014 to January 2015 were enrolled, including gender, age, severity of the disease, liver and renal function, analgesic and sedative treatment, delirium and mortality rate. According to whether with delirium or not and whether died or not, the patients were divided into delirium and non-delirium groups as well as non-survival and survival groups. The risk factors of delirium and outcomes of the patients were analyzed by Logistic regression analysis. Results A total of 105 patients were enrolled, and 42 patients suffered from delirium with an incidence of 40.0%. Fifteen patients died within 28 days with a mortality rate of 14.3%. ① Compared with those without delirium, the patients with delirium had higher acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score (22.2±5.6 vs. 18.8±4.8), lower incidence of Child-Pugh grade A (57.1% vs. 79.4%), lower rate of analgesic and sedative combination therapy (52.4% vs. 76.2%), lower mean arterial pressure [MAP (mmHg, 1 mmHg = 0.133 kPa): 75.5 (67.0-94.0) vs. 86.0 (77.0-95.0)] and higher behavior pain scale (BPS) score and critical-care pain observation tool (CPOT) score [4.0 (4.0-5.0) vs. 4.0 (3.0-4.0), 4.0 (3.0-4.2) vs. 2.0 (2.2-4.0)] before sedation, as well as a longer recovery time (hours: 2.65±0.99 vs. 2.29±0.87), weaning time [hours: 25.5 (8.4-50.8) vs. 10.0 (6.4-28.8)], duration of mechanical ventilation [hours: 157.0 (100.8-353.5) vs. 86.0 (59.0-143.0)], and length of ICU stay [days: 8.5 (5.0-24.2) vs. 6.0 (5.0-8.0)], and higher 28-day mortality rate (33.3% vs. 1.6%, all P < 0.05). It was shown by Logistic regression analysis that remifentanil combined with midazolam was the independent protective factor of delirium [odds ratio (OR) = 0.122, 95% confidence interval (95%CI) = 0.029-0.510, P = 0.004]. ② Compared with survival group, the patients in the non-survival group had significant higher APACHE Ⅱ score (23.2±6.1 vs. 19.7±5.1), lower MAP [mmHg: 70.0 (66.0-81.0) vs. 85.0 (74.0-96.2)] and higher BPS score [4.0 (4.0-5.0) vs. 4.0 (3.8-4.0)] before sedation, lower rate of analgesic and sedative combination therapy (40.0% vs. 68.9%) and higher rate of delirium (93.3% vs. 31.1%, all P < 0.05). It was shown by Logistic regression analysis that delirium (OR = 1 249.000, 95%CI = 25.690-6 077.000, P = 0.000) and higher APACHEⅡ score (OR = 1.251, 95%CI = 1.019-1.535, P = 0.032) were independent risk factors of death, the analgesic and sedative combination therapy was the independent protective factor of death (OR = 0.026, 95%CI = 0.001-0.535, P = 0.018). Conclusions High APACHEⅡ score and delirium are independent risk factors of death in senile patients on mechanical ventilation. The analgesic and sedative combination therapy is the independent protective factor of delirium and death in senile patients on mechanical ventilation.首都临床特色应用研究项目中国科技核心期刊(ISTIC)中国科学引文数据库(CSCD)111003-10082