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Article(id=1198202432682553915, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198202427301265552, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.1535.2024.0304, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1700496000000, receivedDateStr=2023-11-21, revisedDate=null, revisedDateStr=null, acceptedDate=1704124800000, acceptedDateStr=2024-01-02, onlineDate=1763603321476, onlineDateStr=2025-11-20, pubDate=1730044800000, pubDateStr=2024-10-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1763603321476, onlineIssueDateStr=2025-11-20, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1763603321476, creator=13701087609, updateTime=1763603321476, updator=13701087609, issue=Issue{id=1198202427301265552, tenantId=1146029695717560320, journalId=1189873630562394117, year='2024', volume='49', issue='10', pageStart='1099', pageEnd='1220', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1763603320193, creator=13701087609, updateTime=1763603941762, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1198205034396746241, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198202427301265552, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1198205034396746242, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198202427301265552, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1110, endPage=1116, ext={EN=ArticleExt(id=1198202432917434948, articleId=1198202432682553915, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Incidence and modifiable risk factors of postoperative delirium in patients undergoing cardiac surgery: a prospective observational study based on propensity score matching, columnId=1198202428035268754, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Special Issue on Mechanisms and Protective Strategies of Perioperative Organ Injury Ⅱ, runingTitle=null, highlight=null, articleAbstract=

Objective To investigate incidence and modifiable risk factors of postoperative delirium (POD) in patients undergoing cardiac surgery. Methods A prospective observational research method was conducted on 880 cardiac surgery patients admitted to the Department of Cardiovascular Surgery, at the First Affiliated Hospital of Chongqing Medical University from January 2022 to June 2023. Patients' general and clinical data were collected. POD was assessed twice daily from the second day in the ICU using the Confusion Assessment Method of Intensive Care Unit(CAM-ICU) until discharge or transfer from ICU. The patients were divided into two groups based on the presence of POD, and the incidence rate was calculated. Subsequently, a 1:1 propensity score matching (PSM) was applied between the two groups. The differences in general information and clinical characteristics between the two groups of patients before and after PSM were compared. Logistic regression analysis was used to evaluate the modifiable risk factors for POD in patients undergoing cardiac surgery after PSM. Results Of the 880 patients, 278 experienced POD during their stay in the ICU, with an incidence rate of 31.6%. POD occurred between the 2nd and 12th day following ICU admission, with 91.4%(254 patients) experiencing it between the 2nd and 6th day. Univariate analysis identified preoperative factors of POD including gender, age, history of hypertension, history of diabetes, and smoking history; Intraoperative factors were ASA anesthesia grade, operation duration, extracorporeal circulation time, and aortic occlusion time; Postoperative factors included ICU length of stay, mechanical ventilation duration, and VAS score, all of which were statistically significant (P<0.05). After PSM, the distribution of three immutable demographic factors including gender, age, and blood type tended to be consistent among groups (P>0.05). Further multivariate logistic regression analysis showed that surgical time, ICU stay time, mechanical ventilation time, and VAS score were independent modifiable risk factors for POD in cardiac surgery patients (P<0.05), with corresponding OR values of 1.003, 3.117, 1.385, and 1.590, respectively. Conclusions Surgical time, ICU stay time, mechanical ventilation time, and VAS score are independent modifiable risk factors for the occurrence of POD in patients undergoing cardiac surgery. In clinical work, early intervention should be carried out based on the characteristics of the patient's condition and risk factors to further reduce the occurrence of POD.

, correspAuthors=Qing-Chen Wu, authorNote=null, correspAuthorsNote=
E-mail:
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目的 探讨心脏外科手术患者术后谵妄(POD)的发生率及可干预危险因素。方法 采用前瞻性观察方法，连续纳入重庆医科大学附属第一医院心脏大血管外科2022年1月－2023年6月收治的880例心脏外科手术患者作为研究对象。记录所有患者的一般资料及临床特征，采用重症监护病房(ICU)意识模糊评分法(CAM-ICU)于患者入住ICU的第2天起进行2次/d的POD评估，转出ICU后停止随访观察。按照是否发生POD分为两组，计算POD的发生率，对两组患者进行1∶1倾向性评分匹配(PSM)，比较两组患者PSM前后一般资料及临床特征的差异，采用logistic回归模型分析经PSM后心脏外科手术患者发生POD的可干预危险因素。结果 880例心脏外科手术患者中，有278例入住ICU期间发生了POD，发生率为31.6%，发生时间在入住ICU后的第2~12天，其中，254例(91.4%)发生于入住ICU的第2~6天。单因素分析显示，与POD相关的术前因素有性别、年龄、高血压、糖尿病、吸烟史，与POD相关的术中因素有ASA麻醉分级、手术时间、体外循环时间、主动脉阻断时间，与POD相关的术后因素有ICU入住时间、机械通气时间、VAS评分(P<0.05)。经PSM后，性别、年龄、血型3个人口学因素，在组间分布趋于一致(P>0.05)；进一步多因素logistics回归分析显示，手术时间、ICU入住时间、机械通气时间、VAS评分是心脏外科手术患者发生POD的独立可干预危险因素(OR值分别为1.003、3.117、1.385、1.590，P<0.05)。结论 手术时间、ICU入住时间、机械通气时间、VAS评分是心脏外科手术后患者POD发生的可干预独立危险因素。因此，应根据病情特点结合危险因素进行早期干预，以进一步减少POD的发生。

, correspAuthors=吴庆琛, authorNote=null, correspAuthorsNote=
吴庆琛，E-mail：
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王宇，硕士研究生，主治医师，主要从事心脏大血管外科临床方面的研究

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Surg Clin North Am, 2022, 102(1): 139-148., articleTitle=Management of delirium in the intensive care unit, refAbstract=null)], funds=[Fund(id=1198319033297760670, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, awardId=CSTB2022NSCQ-MSX0817, language=EN, fundingSource=Natural Science Foundation of Chongqing(CSTB2022NSCQ-MSX0817), fundOrder=null, country=null), Fund(id=1198319033402618273, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, awardId=CSTB2022NSCQ-MSX0817, language=CN, fundingSource=重庆市自然科学基金项目(CSTB2022NSCQ-MSX0817), fundOrder=null, country=null), Fund(id=1198319033486504358, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, awardId=CYB21171, language=EN, fundingSource=Innovation Fund for Graduate Students of Chongqing Universities(CYB21171), fundOrder=null, country=null), Fund(id=1198319033587167657, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, awardId=CYB21171, language=CN, fundingSource=重庆市高等学校研究生创新基金项目(CYB21171), fundOrder=null, country=null), Fund(id=1198319033775911343, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, awardId=CYYY-YJSJXCX-202318, language=EN, fundingSource=Project of Innovation Team for Graduate Teaching(CYYY-YJSJXCX-202318), fundOrder=null, country=null), Fund(id=1198319033977237940, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, awardId=CYYY-YJSJXCX-202318, language=CN, fundingSource=重庆市高等学校研究生教学创新团队项目(CYYY-YJSJXCX-202318), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1198319028797272309, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, xref=null, ext=[AuthorCompanyExt(id=1198319028805660918, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, companyId=1198319028797272309, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=Department of Thoracic Surgery/Cardiovascular and Large Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China), AuthorCompanyExt(id=1198319028809855223, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, companyId=1198319028797272309, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=重庆医科大学附属第一医院胸外科/心脏大血管外科，重庆 400016)])], figs=[ArticleFig(id=1198319030802149732, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=EN, label=Tab.1, caption=

Time distribution of POD occurrence in patients under-going cardiac surgery

, figureFileSmall=null, figureFileBig=null, tableContent=
发生时间例数发生率(%)构成比(%)
合计27831.6100.0
第2天445.015.8
第3天8810.031.7
第4天546.119.4
第5天424.815.1
第6天263.09.4
第7天101.13.6
第8~12天141.65.0
), ArticleFig(id=1198319030890230119, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=CN, label=表1, caption=

心脏外科手术患者POD发生时间分布

, figureFileSmall=null, figureFileBig=null, tableContent=
发生时间例数发生率(%)构成比(%)
合计27831.6100.0
第2天445.015.8
第3天8810.031.7
第4天546.119.4
第5天424.815.1
第6天263.09.4
第7天101.13.6
第8~12天141.65.0
), ArticleFig(id=1198319031011864941, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=EN, label=Tab.2, caption=

Univariate analysis of preoperative factors and POD occurrence in patients undergoing cardiac surgery

, figureFileSmall=null, figureFileBig=null, tableContent=
变量非POD组(n=602)POD组(n=278)χ2/tP
性别[例(%)]8.1060.004
男280(46.5)158(56.8)
女322(53.5)120(43.2)
年龄(岁, $\bar{x}±s$)51.0±11.455.7±10.9-5.813<0.001
年龄[例(%)]35.820<0.001
<40岁92(15.3)20(7.2)
40~50岁146(24.3)40(14.4)
50~60岁244(40.5)130(46.8)
60~70岁94(15.6)58(20.7)
≥70岁26(4.3)30(10.8)
文化程度[例(%)]6.4690.091
小学及以下228(37.9)126(45.3)
初中204(33.9)92(33.1)
高中/中专86(14.3)34(12.2)
大专及以上84(14.0)26(9.4)
血型[例(%)]4.7690.190
A型228(37.8)88(31.7)
B型140(23.3)74(26.6)
AB型62(10.3)24(8.6)
O型172(28.6)92(33.1)
高血压[例(%)]7.1980.007
无482(80.1)200(71.9)
有120(19.9)78(28.1)
糖尿病[例(%)]9.5820.002
无562(93.4)242(87.1)
有40(6.6)36(12.9)
房颤[例(%)]2.5900.108
无578(96.0)260(93.5)
有24(4.0)18(6.5)
脑血管事件病史[例(%)]3.1820.074
无574(95.3)272(97.8)
有28(4.7)6(2.2)
吸烟史[例(%)]4.5560.033
无362(60.1)188(67.6)
有240(39.9)90(32.4)
饮酒史[例(%)]1.8530.173
无330(54.8)166(59.7)
有272(45.2)112(40.3)
ICU住院史[例(%)]3.7770.052
无574(95.3)256(92.1)
有28(4.7)22(7.9)
NYHA心功能分级[例(%)]4.3750.112
Ⅰ级118(19.6)42(15.1)
Ⅱ级120(19.9)48(17.3)
Ⅲ-Ⅳ级364(60.5)188(67.6)
), ArticleFig(id=1198319031171248499, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=CN, label=表2, caption=

术前因素与心脏外科手术后发生POD的单因素分析

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变量非POD组(n=602)POD组(n=278)χ2/tP
性别[例(%)]8.1060.004
男280(46.5)158(56.8)
女322(53.5)120(43.2)
年龄(岁, $\bar{x}±s$)51.0±11.455.7±10.9-5.813<0.001
年龄[例(%)]35.820<0.001
<40岁92(15.3)20(7.2)
40~50岁146(24.3)40(14.4)
50~60岁244(40.5)130(46.8)
60~70岁94(15.6)58(20.7)
≥70岁26(4.3)30(10.8)
文化程度[例(%)]6.4690.091
小学及以下228(37.9)126(45.3)
初中204(33.9)92(33.1)
高中/中专86(14.3)34(12.2)
大专及以上84(14.0)26(9.4)
血型[例(%)]4.7690.190
A型228(37.8)88(31.7)
B型140(23.3)74(26.6)
AB型62(10.3)24(8.6)
O型172(28.6)92(33.1)
高血压[例(%)]7.1980.007
无482(80.1)200(71.9)
有120(19.9)78(28.1)
糖尿病[例(%)]9.5820.002
无562(93.4)242(87.1)
有40(6.6)36(12.9)
房颤[例(%)]2.5900.108
无578(96.0)260(93.5)
有24(4.0)18(6.5)
脑血管事件病史[例(%)]3.1820.074
无574(95.3)272(97.8)
有28(4.7)6(2.2)
吸烟史[例(%)]4.5560.033
无362(60.1)188(67.6)
有240(39.9)90(32.4)
饮酒史[例(%)]1.8530.173
无330(54.8)166(59.7)
有272(45.2)112(40.3)
ICU住院史[例(%)]3.7770.052
无574(95.3)256(92.1)
有28(4.7)22(7.9)
NYHA心功能分级[例(%)]4.3750.112
Ⅰ级118(19.6)42(15.1)
Ⅱ级120(19.9)48(17.3)
Ⅲ-Ⅳ级364(60.5)188(67.6)
), ArticleFig(id=1198319031334826363, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=EN, label=Tab.3, caption=

Univariate analysis of intraoperative factors and POD occurrence in patients undergoing cardiac surgery

, figureFileSmall=null, figureFileBig=null, tableContent=
变量非POD组(n=602)POD组(n=278)χ2/ZP
ASA麻醉分级[例(%)]25.418<0.001
Ⅱ级74(12.3)6(2.1)
Ⅲ级432(71.8)212(76.3)
Ⅳ级96(15.9)60(21.6)
手术时间[min, M(Q1, Q3)]240(200, 305)300(240, 385)-7.228<0.001
体外循环时间[min, M(Q1, Q3)]105(52, 143)128(78, 185)-5.169<0.001
主动脉阻断时间[min, M(Q1, Q3)]63(0, 94)77(41, 118)-3.773<0.001
术中出血量[ml, M(Q1, Q3)]300(220, 400)310(240, 450)-1.9500.051
输血量[ml, M(Q1, Q3)]400(226, 800)400(200, 800)-0.6210.534
), ArticleFig(id=1198319032454705533, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=CN, label=表3, caption=

术中因素与心脏外科手术后发生POD的单因素分析

, figureFileSmall=null, figureFileBig=null, tableContent=
变量非POD组(n=602)POD组(n=278)χ2/ZP
ASA麻醉分级[例(%)]25.418<0.001
Ⅱ级74(12.3)6(2.1)
Ⅲ级432(71.8)212(76.3)
Ⅳ级96(15.9)60(21.6)
手术时间[min, M(Q1, Q3)]240(200, 305)300(240, 385)-7.228<0.001
体外循环时间[min, M(Q1, Q3)]105(52, 143)128(78, 185)-5.169<0.001
主动脉阻断时间[min, M(Q1, Q3)]63(0, 94)77(41, 118)-3.773<0.001
术中出血量[ml, M(Q1, Q3)]300(220, 400)310(240, 450)-1.9500.051
输血量[ml, M(Q1, Q3)]400(226, 800)400(200, 800)-0.6210.534
), ArticleFig(id=1198319032551174529, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=EN, label=Tab.4, caption=

Univariate analysis of postoperative factors and POD occurrence in patients undergoing cardiac surgery

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变量非POD组(n=602)POD组(n=278)χ2/ZP
右美托咪定使用[例(%)]1.9560.376
未用右美托咪定412(68.4)186(66.9)
单用右美托咪定184(30.6)86(30.9)
右美托咪定联合其他药物6(1.0)6(2.2)
ICU入住时间[d, M(Q1, Q3)]3.0(2.0, 3.0)4.0(3.0, 5.0)-13.918<0.001
机械通气时间[min, M(Q1, Q3)]966.0(483.0, 1219.0)1441.0(898.0, 2735.0)-9.779<0.001
APACHE Ⅱ评分[分, M(Q1, Q3)]7.0(5.0, 15.0)8.0(6.0, 10.0)-1.2110.226
VAS评分[min, M(Q1, Q3)]1.0(0.0, 2.0)2.0(0.0, 6.0)-4.490<0.001
), ArticleFig(id=1198319032626672005, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=CN, label=表4, caption=

术后因素与心脏外科手术后发生POD的单因素分析

, figureFileSmall=null, figureFileBig=null, tableContent=
变量非POD组(n=602)POD组(n=278)χ2/ZP
右美托咪定使用[例(%)]1.9560.376
未用右美托咪定412(68.4)186(66.9)
单用右美托咪定184(30.6)86(30.9)
右美托咪定联合其他药物6(1.0)6(2.2)
ICU入住时间[d, M(Q1, Q3)]3.0(2.0, 3.0)4.0(3.0, 5.0)-13.918<0.001
机械通气时间[min, M(Q1, Q3)]966.0(483.0, 1219.0)1441.0(898.0, 2735.0)-9.779<0.001
APACHE Ⅱ评分[分, M(Q1, Q3)]7.0(5.0, 15.0)8.0(6.0, 10.0)-1.2110.226
VAS评分[min, M(Q1, Q3)]1.0(0.0, 2.0)2.0(0.0, 6.0)-4.490<0.001
), ArticleFig(id=1198319032744112524, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=EN, label=Tab.5, caption=

Comparison of non-interference risk factors between POD group and non-POD group before and after PSM [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
因素PSM前PSM后
非POD组(n=602)POD组(n=278)χ2P非POD组(n=275)POD组(n=275)χ2P
性别8.1060.0040.0300.863
男280(46.5)158(56.8)158(57.4)156(56.7)
女322(53.5)120(43.2)117(42.6)119(43.3)
年龄35.820<0.0010.0790.999
<40岁92(15.3)20(7.2)19(6.9)20(7.3)
40~50岁146(24.3)40(14.4)41(14.9)40(14.6)
50~60岁244(40.5)130(46.8)130(47.3)128(46.6)
60~70岁94(15.6)58(20.7)56(20.4)57(20.7)
≥70岁26(4.3)30(10.8)29(10.6)30(10.9)
血型4.7690.1900.1220.989
A型228(37.9)88(31.7)89(32.4)87(31.6)
B型140(23.2)74(26.6)74(26.9)73(26.6)
AB型62(10.3)24(8.6)22(8.0)24(8.7)
O型172(28.6)92(33.1)90(32.7)91(33.1)
), ArticleFig(id=1198319032853164430, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=CN, label=表5, caption=

PSM前后POD组与非POD组不可干预危险因素比较[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
因素PSM前PSM后
非POD组(n=602)POD组(n=278)χ2P非POD组(n=275)POD组(n=275)χ2P
性别8.1060.0040.0300.863
男280(46.5)158(56.8)158(57.4)156(56.7)
女322(53.5)120(43.2)117(42.6)119(43.3)
年龄35.820<0.0010.0790.999
<40岁92(15.3)20(7.2)19(6.9)20(7.3)
40~50岁146(24.3)40(14.4)41(14.9)40(14.6)
50~60岁244(40.5)130(46.8)130(47.3)128(46.6)
60~70岁94(15.6)58(20.7)56(20.4)57(20.7)
≥70岁26(4.3)30(10.8)29(10.6)30(10.9)
血型4.7690.1900.1220.989
A型228(37.9)88(31.7)89(32.4)87(31.6)
B型140(23.2)74(26.6)74(26.9)73(26.6)
AB型62(10.3)24(8.6)22(8.0)24(8.7)
O型172(28.6)92(33.1)90(32.7)91(33.1)
), ArticleFig(id=1198319032983187861, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=EN, label=Tab.6, caption=

Multivariate logistic analysis of modifiable risk factors for POD in patients undergoing cardiac surgery

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危险因素βSEOR(95%CI)χ2P
高血压0.0040.3251.004(0.531~1.898)0.0000.990
糖尿病0.7850.4602.193(0.890~5.404)2.9130.088
吸烟史-0.4540.2380.635(0.398~1.014)3.6210.057
ASA麻醉分级0.3760.2341.456(0.920~2.305)2.5680.109
手术时间0.0040.0021.004(1.000~1.007)4.8680.027
体外循环时间0.0060.0041.006(0.999~1.013)2.8380.092
主动脉阻断时间-0.0080.0050.992(0.983~1.002)2.2950.130
ICU入住时间1.2190.1443.383(2.552~4.484)71.843<0.001
机械通气时间0.0390.0131.039(1.013~1.066)8.8840.003
VAS评分0.4530.0541.573(1.415~1.748)70.423<0.001
), ArticleFig(id=1198319033088045465, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432682553915, language=CN, label=表6, caption=

心脏外科手术后POD可干预危险因素的多因素logistics分析

, figureFileSmall=null, figureFileBig=null, tableContent=
危险因素βSEOR(95%CI)χ2P
高血压0.0040.3251.004(0.531~1.898)0.0000.990
糖尿病0.7850.4602.193(0.890~5.404)2.9130.088
吸烟史-0.4540.2380.635(0.398~1.014)3.6210.057
ASA麻醉分级0.3760.2341.456(0.920~2.305)2.5680.109
手术时间0.0040.0021.004(1.000~1.007)4.8680.027
体外循环时间0.0060.0041.006(0.999~1.013)2.8380.092
主动脉阻断时间-0.0080.0050.992(0.983~1.002)2.2950.130
ICU入住时间1.2190.1443.383(2.552~4.484)71.843<0.001
机械通气时间0.0390.0131.039(1.013~1.066)8.8840.003
VAS评分0.4530.0541.573(1.415~1.748)70.423<0.001
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心脏外科手术患者术后谵妄的发生率及其可干预危险因素：一项基于倾向性评分匹配的前瞻性观察研究
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王宇 , 张诚 , 吴庆琛 *
解放军医学杂志 | 围手术期器官损伤机制及保护策略专题Ⅱ 2024,49(10): 1110-1116
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解放军医学杂志 | 围手术期器官损伤机制及保护策略专题Ⅱ 2024, 49(10): 1110-1116
心脏外科手术患者术后谵妄的发生率及其可干预危险因素：一项基于倾向性评分匹配的前瞻性观察研究
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王宇, 张诚, 吴庆琛*
作者信息
  • 重庆医科大学附属第一医院胸外科/心脏大血管外科，重庆 400016

    • 王宇，硕士研究生，主治医师，主要从事心脏大血管外科临床方面的研究

通讯作者:

吴庆琛，E-mail：
Incidence and modifiable risk factors of postoperative delirium in patients undergoing cardiac surgery: a prospective observational study based on propensity score matching
Yu Wang, Cheng Zhang, Qing-Chen Wu*
Affiliations
  • Department of Thoracic Surgery/Cardiovascular and Large Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
出版时间: 2024-10-28 doi: 10.11855/j.issn.0577-7402.1535.2024.0304
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摘要
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目的 探讨心脏外科手术患者术后谵妄(POD)的发生率及可干预危险因素。方法 采用前瞻性观察方法，连续纳入重庆医科大学附属第一医院心脏大血管外科2022年1月－2023年6月收治的880例心脏外科手术患者作为研究对象。记录所有患者的一般资料及临床特征，采用重症监护病房(ICU)意识模糊评分法(CAM-ICU)于患者入住ICU的第2天起进行2次/d的POD评估，转出ICU后停止随访观察。按照是否发生POD分为两组，计算POD的发生率，对两组患者进行1∶1倾向性评分匹配(PSM)，比较两组患者PSM前后一般资料及临床特征的差异，采用logistic回归模型分析经PSM后心脏外科手术患者发生POD的可干预危险因素。结果 880例心脏外科手术患者中，有278例入住ICU期间发生了POD，发生率为31.6%，发生时间在入住ICU后的第2~12天，其中，254例(91.4%)发生于入住ICU的第2~6天。单因素分析显示，与POD相关的术前因素有性别、年龄、高血压、糖尿病、吸烟史，与POD相关的术中因素有ASA麻醉分级、手术时间、体外循环时间、主动脉阻断时间，与POD相关的术后因素有ICU入住时间、机械通气时间、VAS评分(P<0.05)。经PSM后，性别、年龄、血型3个人口学因素，在组间分布趋于一致(P>0.05)；进一步多因素logistics回归分析显示，手术时间、ICU入住时间、机械通气时间、VAS评分是心脏外科手术患者发生POD的独立可干预危险因素(OR值分别为1.003、3.117、1.385、1.590，P<0.05)。结论 手术时间、ICU入住时间、机械通气时间、VAS评分是心脏外科手术后患者POD发生的可干预独立危险因素。因此，应根据病情特点结合危险因素进行早期干预，以进一步减少POD的发生。

心脏外科手术  /  术后谵妄  /  可干预危险因素  /  倾向性评分匹配

Objective To investigate incidence and modifiable risk factors of postoperative delirium (POD) in patients undergoing cardiac surgery. Methods A prospective observational research method was conducted on 880 cardiac surgery patients admitted to the Department of Cardiovascular Surgery, at the First Affiliated Hospital of Chongqing Medical University from January 2022 to June 2023. Patients' general and clinical data were collected. POD was assessed twice daily from the second day in the ICU using the Confusion Assessment Method of Intensive Care Unit(CAM-ICU) until discharge or transfer from ICU. The patients were divided into two groups based on the presence of POD, and the incidence rate was calculated. Subsequently, a 1:1 propensity score matching (PSM) was applied between the two groups. The differences in general information and clinical characteristics between the two groups of patients before and after PSM were compared. Logistic regression analysis was used to evaluate the modifiable risk factors for POD in patients undergoing cardiac surgery after PSM. Results Of the 880 patients, 278 experienced POD during their stay in the ICU, with an incidence rate of 31.6%. POD occurred between the 2nd and 12th day following ICU admission, with 91.4%(254 patients) experiencing it between the 2nd and 6th day. Univariate analysis identified preoperative factors of POD including gender, age, history of hypertension, history of diabetes, and smoking history; Intraoperative factors were ASA anesthesia grade, operation duration, extracorporeal circulation time, and aortic occlusion time; Postoperative factors included ICU length of stay, mechanical ventilation duration, and VAS score, all of which were statistically significant (P<0.05). After PSM, the distribution of three immutable demographic factors including gender, age, and blood type tended to be consistent among groups (P>0.05). Further multivariate logistic regression analysis showed that surgical time, ICU stay time, mechanical ventilation time, and VAS score were independent modifiable risk factors for POD in cardiac surgery patients (P<0.05), with corresponding OR values of 1.003, 3.117, 1.385, and 1.590, respectively. Conclusions Surgical time, ICU stay time, mechanical ventilation time, and VAS score are independent modifiable risk factors for the occurrence of POD in patients undergoing cardiac surgery. In clinical work, early intervention should be carried out based on the characteristics of the patient's condition and risk factors to further reduce the occurrence of POD.

cardiac surgery  /  postoperative delirium  /  modifiable risk factors  /  propensity score matching
王宇, 张诚, 吴庆琛. 心脏外科手术患者术后谵妄的发生率及其可干预危险因素：一项基于倾向性评分匹配的前瞻性观察研究. 解放军医学杂志, 2024 , 49 (10) : 1110 -1116 . DOI: 10.11855/j.issn.0577-7402.1535.2024.0304
Yu Wang, Cheng Zhang, Qing-Chen Wu. Incidence and modifiable risk factors of postoperative delirium in patients undergoing cardiac surgery: a prospective observational study based on propensity score matching[J]. Medical Journal of Chinese People’s Liberation Army, 2024 , 49 (10) : 1110 -1116 . DOI: 10.11855/j.issn.0577-7402.1535.2024.0304
正文
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术后谵妄(postoperative delirium，POD)是外科手术患者术后常见的一种急性神经精神综合征[1]，主要表现为急性发作的认知功能障碍、注意力不集中、感知力异常等[2-3]。POD不仅使住院时间延长、医疗费用增加、ICU病死率增高，还可能导致远期认知功能损害，影响术后生存率及生活质量[4-6]。近年来，随着麻醉技术、手术及体外循环技术的改进和提升，心脏手术患者的病死率明显降低[7]，但POD仍然是心脏外科难以避免的一种严重术后并发症[8]，且其病理生理学基础及发病机制目前尚不完全清楚，临床诊断仍以量表观察评估为主[9]。因此，探讨心脏外科手术患者发生POD的危险因素，针对可干预和可改变的危险因素进行预防和干预，对降低POD的发生率具有重要意义[10]。但目前国内外关于POD危险因素的相关研究差异性较大[11-12]，尚无关于可干预危险因素的相关研究。因此，本研究前瞻性观察择期行心脏外科手术患者POD的发生情况，并采用倾向性评分匹配(propensity score matching，PSM)对是否发生POD的患者进行匹配，探讨其可能相关的可干预危险因素，以期为POD的防治及缓解患者的神经系统症状提供参考。
1 资料与方法
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1.1 研究对象
前瞻性连续纳入重庆医科大学附属第一医院心脏大血管外科2022年1月－2023年6月收治的880例心脏外科手术患者作为研究对象，选择符合《赫尔辛基宣言》的相关原则。本研究通过医院伦理委员会审批(审批号K2023-635)。
1.1.1 纳入标准
(1)年龄≥18岁，不限性别；(2)择期行心脏手术(开胸体外循环下瓣膜置换术、冠状动脉旁路移植术、先天性心脏病修复手术)患者；(3)术后直接转入ICU，ICU入住时间24 h~14 d；(4)患者及家属知情同意参与本研究并签署知情同意书。
1.1.2 排除标准
(1)术中出现心脏骤停和(或)需进行心肺复苏等严重不良事件；(2)同时进行两种及以上心脏手术或行其他胸部脏器大手术，如肺癌、食管癌手术等；(3)颅脑疾病史或围手术期发生神经系统并发症，如脑梗死、脑出血等；(4)术后无法苏醒或其他原因导致的意识障碍；(5)存在精神疾病或认知功能减退；(6)有酒精依赖或存在酒精依赖戒断症状或药物滥用史；(7)临床资料缺失，影响结果评价。
1.1.3 退出、终止及脱落标准
(1)退出标准：随访观察期间发生新病情，且不宜继续观察；(2)终止标准：转科、转院或ICU发生死亡；(3)脱落标准：主动要求停止研究及各种原因失访。
1.2 研究方法
1.2.1 资料收集
由专人负责记录患者从入院、手术、入ICU、转回普通病房直至出院的全部一般资料及临床特征，并按照术前、术中、术后因素对数据进行清洗整理。(1)术前因素：性别、年龄、文化程度、血型、高血压、糖尿病、心房颤动、脑血管事件、吸烟、饮酒、ICU住院史及美国纽约心脏病协会(New York Heart Association，NYHA)心功能分级；(2)术中因素：美国麻醉医师协会(American Society of Anesthesiologists，ASA)麻醉分级、手术时间、体外循环时间、主动脉阻断时间、术中出血量、输血量、手术方式(体外循环下瓣膜置换术、冠状动脉旁路移植术、先天性心脏病修复手术)；(3)术后因素：ICU入住时间、机械通气时间、APACHE Ⅱ评分、视觉模拟疼痛(visual analogue scale，VAS)评分、镇静镇痛药物使用(单用右美托咪定、右美托咪定联合其他药物)情况。
1.2.2 研究分组及POD评估
根据随访观察期间是否发生POD分为POD组与非POD组。入住ICU的第2天起进行2次/d(早9－10点、晚19－20点)的POD评估，转出ICU后停止评估，普通病房出院后停止观察。由经过专门培训的临床医师参照欧洲麻醉学会(European Society of Anesthesiology，ESA)推荐的ICU意识模糊评分量表(Confusion Assessment Method of Intensive Care Unit，CAM-ICU)进行评估，主要包括4个诊断特征：(1)意识状态急性发病或症状反复波动；(2)注意力不集中或注意力障碍；(3)思维混乱；(4)意识水平改变。满足(1)或(2)+(3)或(4)即可诊断为POD。
1.3 统计学处理
采用SPSS 24.0软件进行统计分析。对连续性计量资料采用Kolmogorov-Smirnov法进行正态性检验，符合正态分布者以$\bar{x}±s$表示，两组间比较采用t检验；非正态分布者以M(Q1，Q3)表示，组间比较采用Mann-Whitney U非参数检验。计数资料以例(%)表示，组间比较采用χ2检验或Fisher确切概率法。选用PSM模块，匹配容差设置为0.1，以不可干预的人口学特征作为协变量，进行1∶1匹配计算每个样本的PS值，以是否发生POD作为结局变量，以经PSM后的术前、术中、术后因素作为自变量，采用logistic回归模型筛选POD的独立危险因素。P<0.05为差异有统计学意义。
2 结果
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2.1 一般资料及POD发生情况
880例心脏外科手术患者中，男438例(49.8%)，女442例(50.2%)，男女性别比为0.99∶1；年龄18~76岁(52.5±11.5)岁。278例在入住ICU期间发生POD，发生率为31.6%，发生时间在入住ICU后的第2~12天，其中91.4%(254例)发生于入住ICU的第2~6天(表1)。
2.2 心脏外科手术患者发生POD危险因素的单因素分析
2.2.1 术前因素与POD
分别对POD组和非POD组患者的术前因素进行单因素分析，结果显示，POD组患者的男性多、年龄大，有高血压、糖尿病、吸烟史的患者POD发生风险高，差异有统计学意义(P<0.05，表2)。
2.2.2 术中因素与POD
分别对POD组和非POD组患者的术中因素进行单因素分析，结果显示，随着ASA麻醉分级的增高，患者发生POD的风险也逐渐增高；POD组患者的中位手术时间、中位体外循环时间、中位主动脉阻断时间均长于非POD患者，差异有统计学意义(P<0.05，表3)。
2.2.3 术后因素与POD
分别对POD组和非POD组患者的术后因素进行单因素分析，结果显示，POD组患者的中位ICU入住时间、中位机械通气时间、中位VAS评分均高于非POD患者，差异有统计学意义(P<0.05，表4)。
2.3 心脏外科手术患者发生POD可干预危险因素的多因素logistic回归分析
2.3.1 PSM分析
采用PSM对不可干预的危险因素进行1∶1匹配，匹配因素包括性别、年龄、血型3个人口学因素，共成功匹配275对患者，PSM后各人口学特征影响在组间分布趋于一致(P>0.05，表5)。
2.3.2 心脏外科手术患者发生POD可干预危险因素的多因素logistics分析
利用PSM后的275对患者数据进行分析，以心脏外科手术患者ICU期间是否发生POD作为因变量(ICU期间发生POD：Y=1，未发生POD：Y=0)，以单因素分析中差异有统计学意义的危险因素作为自变量，进行多因素logistics回归分析(变量筛选方法：Enter法)。结果显示，手术时间、ICU入住时间、机械通气时间、VAS评分是心脏手术外科患者发生POD的独立可干预危险因素(OR值分别为1.003、3.117、1.385、1.590，P<0.05，表6)。
3 讨论
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POD是一种急性发作的、暂时性的中枢神经系统综合征，是外科手术后的常见并发症[13]。POD可导致术后患者发生多种不良转归，包括住院时间延长、医疗费用上涨、30 d再入院率及相关并发症发生率增高，影响预后，甚至导致病死率增高[14-16]。但截至目前尚未发现针对POD的特效预防方法或干预手段。因此，探讨POD发生的相关可干预危险因素，并在围手术期针对性地采取预防性干预措施及综合防治，对降低POD发生率、减轻疾病的危害程度，以及改善患者预后具有重要的临床意义。
POD的发生率与手术类型相关。有研究显示，我国心脏外科手术患者POD的发生率为13.7%~54.9%[17-18]，且心脏外科手术患者POD的发生率明显高于其他非心脏外科手术患者[19-20]。本研究纳入880例心脏外科手术患者进行前瞻性观察，POD的发生率为31.6%，处于中间水平，发生率的差异可能与手术方式及病情的影响有关。POD主要发生在术后7 d内，本研究中，POD在入住ICU后的第1~12天均有发生，其中，93.5%的发生于入住ICU的第2~6天，这与POD急性起病的发病特点相关，也与文献[11]报道的结果相符。
PSM是一种针对非随机对照研究数据的统计学方法，可以均衡不同混杂因素在不同干预组间的分布，从而消除混杂因素对干预组间真实差异的影响[21]。本研究采用PSM对POD组与非POD组患者不可改变的危险因素(包括性别、年龄、血型)进行匹配，经PSM后，各混杂因素的影响在组间的分布趋于一致，在此基础上进行多因素logistics回归分析筛选影响心脏手术患者POD发生的可干预危险因素，结果显示，手术时间、ICU入住时间、机械通气时间、VAS评分是心脏手术外科患者发生POD的独立可干预危险因素。
心脏手术时间越长，POD的发生风险越高。心脏手术由于麻醉、失血、手术创伤和体外循环等的影响，会导致机体产生大量炎性因子，它们通过自身独特的细胞因子信号通路进入大脑，诱导大脑中的小神经胶质细胞释放过量的细胞因子促进炎性反应，对大脑炎症激活具有神经毒性，并加重脑内神经、脑细胞功能的损伤，甚至完全丧失功能，从而诱发POD[22-23]。同时，手术时间的延长还会延长体外循环时间，以及麻醉药物的用量和术中失血量等，增加POD的发生风险。因此，对于心脏手术时间过长的患者，有必要在围手术期密切评估POD的发生风险，密切观察患者的临床表现，尽早识别POD。
ICU入住时间对POD发生风险的影响主要表现在：一方面，由于ICU病房的肢体约束、留置导管插入术、封闭陌生环境等会使患者产生紧张、焦虑、烦躁等不良情绪，并影响大脑皮质醇激素的分泌，进而影响神经化学物质的传递，增加POD的发生风险[24]；另一方面，ICU入住时间与患者病情严重程度直接相关，ICU患者常用的药物(如阿片类药物和苯二氮䓬类药物)本身与POD发生有关[25]。因此，心脏手术患者入住ICU期间，治疗药物的选择、心理干预和个性化的护理措施均有助于减少POD的发生。
随着机械通气时间的延长，发生POD的风险增大。在机械通气治疗过程中，为了防止意外拔管事件的发生，对ICU患者常常使用约束带固定其肢体，这可导致不适及紧张焦虑情绪，增加了POD的发生风险[26]。同时，为了提高机械通气的舒适性和实用性，相关镇静、镇痛药物的使用明显增多。有研究显示，苯二氮䓬类镇静药物可能导致机械通气拔管延迟，这也进一步延长了ICU住院时间，增加了POD的发生风险[27]。因此，心脏手术后的ICU患者应根据病情合理采用机械通气，尽早拔管以减少机械通气时间，并鼓励患者自主呼吸，有效减少POD的发生。
术后疼痛VAS评分越高，患者发生POD的风险也越高。有研究显示，患者术后疼痛程度越高、疼痛持续时间越长，POD的发生风险也越高，尤其与静息状态下的疼痛VAS评分关系更为密切[28]。心脏外科手术后入住ICU患者存在较强烈的疼痛，疼痛所带来的不适会导致机体出现病理性改变，进而使患者出现言语不当、体动等术后躁动[29]。因此，心脏外科手术患者术后疼痛的评估及管理极为重要，早期积极主动控制并减轻患者术后的急性疼痛，包括适宜的麻醉镇痛药物缓解术后疼痛外，寻找疼痛的非语言表现并进行应对管理，有助于减少POD的发生。
综上所述，目前针对POD尚无理想的治疗方法，多以预防为主。本研究通过前瞻性观察研究结合PSM法，利用logistics回归模型筛选出了心脏外科手术患者发生POD的4个可干预的独立危险因素：手术时间、ICU入住时间、机械通气时间、VAS评分，提示在今后的临床工作中，应根据患者的病情特点结合危险因素进行早期干预，以进一步减少POD的发生。然而，本研究也存在一定的局限性：样本量有限且仅来源于一家研究中心；部分患者转回普通病房后仍有POD持续存在，但未纳入该部分患者，可能低估了POD的发生率；未涉及心脏手术的易感因素和可能的发病机制等，因此，未来需更多的前瞻性、多中心、大样本研究来进一步探索。
基金
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  • 重庆市自然科学基金项目(CSTB2022NSCQ-MSX0817)
  • 重庆市高等学校研究生创新基金项目(CYB21171)
  • 重庆市高等学校研究生教学创新团队项目(CYYY-YJSJXCX-202318)
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参考文献 引证文献
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2024年第49卷第10期
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doi: 10.11855/j.issn.0577-7402.1535.2024.0304
  • 接收时间：2023-11-21
  • 首发时间：2025-11-20
  • 出版时间：2024-10-28
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  • 收稿日期：2023-11-21
  • 录用日期：2024-01-02
基金
Natural Science Foundation of Chongqing(CSTB2022NSCQ-MSX0817)
重庆市自然科学基金项目(CSTB2022NSCQ-MSX0817)
Innovation Fund for Graduate Students of Chongqing Universities(CYB21171)
重庆市高等学校研究生创新基金项目(CYB21171)
Project of Innovation Team for Graduate Teaching(CYYY-YJSJXCX-202318)
重庆市高等学校研究生教学创新团队项目(CYYY-YJSJXCX-202318)
作者信息
    重庆医科大学附属第一医院胸外科/心脏大血管外科，重庆 400016

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