摘要
背景谵妄是重症监护病房常见并发症,可增加死亡风险,影响预后,其防控重要性大于治疗。国内外尚未见通过风险分层模型联合优化的评估措施筛查中高风险及亚综合型谵妄并进行早期干预的报道。目的探讨基于E-PRE-DELIRIC早期风险分层模型的谵妄管理模式对重症监护病房(intensive care unit,ICU)患者谵妄发生率的影响,并对该风险预测模型进行效能验证研究。方法以常州市第四人民医院ICU病区2019年6月-2021年12月收治的患者为研究对象,干预组采用E-PRE-DELIRIC风险分层模型对入组患者进行风险分层,并建立基于logistic回归的多指标风险预测模型,通过ROC分析评估其预测效能。临床药师加入ICU谵妄管理团队,对中高风险患者实施重点药学监护,实施早期干预。对照组按常规谵妄管理模式执行。比较两组患者谵妄发生率、谵妄持续时间、疼痛评分、ICU住院时间和药物不良反应发生率。结果共纳入212例患者,干预组107例,对照组105例。两组年龄、性别、认知障碍史、酗酒史、既往病史、紧急入院、入院APACHEⅡ评分、尿素氮(blood urea nitrogen,BUN)、平均动脉压(mean arterial pressure,MAP)、糖皮质激素使用率和主要合并疾病等方面的差异均无统计学意义(P>0.05)。与对照组比较,干预组谵妄发生率显著降低[8.41%(9/98)vs 26.67%(28/77),P<0.01],疼痛评分较低[Md(IQR):0(0,0)vs 0.5(0,0.5)],ICU住院时间较短[(10.21±8.21)d vs(13.32±9.74)d],药物不良反应发生率显著降低[3.74%(4/103)vs 11.43%(12/93)],差异均有统计学意义(P<0.05)。以本研究样本所建风险预测模型:Log(P/1-P)(联合虚拟指标/概率)=-1.317+0.018×年龄+0.712×认知功能障碍史+0.215×酗酒史+0.592×治疗经历+0.008×入ICU时的MAP值+0.416×呼吸衰竭+0.011×入ICU时的BUN值。ROC分析显示,7指标联合应用对ICU患者发生谵妄的风险预测效能较高,ROC-AUC(95%CI)、敏感度、特异度、准确度分别为0.882(0.834~0.931)、0.892、0.869、0.873。结论基于E-PRE-DELIRIC早期风险预估分层模型的谵妄管理模式(药学监护及早期干预等措施)可降低ICU患者谵妄发生率,降低药物不良反应发生率,并能缩短患者的ICU住院时间。
Background Delirium is a common complication in intensive care unit,which can increase the mortality and affect the prognosis.Prevention and control are more important than treatment.However,there is no assessment or early intervention to screen medium high risk and sub comprehensive delirium by joint optimization of risk stratification model at home and abroad.Objective To explore the effect of delirium management mode based on E-PRE-DELIRIC early risk stratification model on the incidence of delirium in intensive care unit(ICU),and verify the effectiveness of the risk prediction model.Methods Taking the patients admitted to the ICU ward of Changzhou Fourth People's Hospital from June 2019 to December 2021 as the research objects,the intervention group adopted the delirium management and control mode based on the early risk stratification model,the multi-index risk prediction model based on logistic regression was established and its prediction performance was evaluated by ROC analysis.The control group performed the conventional delirium management mode.The incidence of delirium,duration of delirium,pain score,length of stay in ICU and incidence of adverse drug reactions were compared between the two groups.Results A total of 212 patients were included,107 cases were in the intervention group and 105 cases in the control group.There was no significant difference between the two groups in terms of age,gender,history of cognitive impairment,history of alcoholism,past medical history,emergency admission,admission APACHE II score,BUN and MAP,glucocorticoid use rate and major combined diseases(P>0.05).Compared with the control group,the incidence of delirium in the clinical pharmacist intervention group was significantly lower(8.41%[9/98]vs 26.67%[28/77],P<0.01),the pain score was lower([0,0]vs[0,0.5],P<0.01),the length of stay in ICU was shorter([10.21±8.21]d vs[13.32±9.74]d,P<0.05),and the incidence of adverse drug reactions was significantly lower(3.74%[4/103]vs 11.43%[12/93],P<0.05).The risk prediction model based on the sample of this study was Log(P/1-P)(Joint virtual indicator/probability)=-1.317+0.018×Age+0.712×History of cognitive impairment+0.215×History of alcoholism+0.592×Treatment experience+0.008×MAP value when entering ICU+0.416×Respiratory failure+0.011×BUN value when entering ICU.According to ROC analysis,the combined application of these seven indicators had high prediction efficiency for the risk of delirium in ICU patients,with ROC-AUC(95%CI),sensitivity,specificity and accuracy of 0.882(0.834-0.931),0.892,0.869 and 0.873,respectively.Conclusion Delirium management model based on early risk prediction hierarchical model can reduce the incidence of delirium in ICU patients and adverse drug reactions,and shorten the length of stay in ICU.
作者
曹烨君
张明珠
潘国俊
范秀丽
祖元元
杨剑税
CAO Yejun;ZHANG Mingzhu;PAN Guojun;FAN Xiuli;ZU Yuanyuan;YANG Jianshui(Department of Pharmacy,the Fourth People's Hospital of Changzhou,Changzhou 213000,Jiangsu Province,China;Department of Pharmacy,Shandong Provincial Third Hospital,Jinan 250031,Shandong Province,China;Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy,Xuzhou Medical University,Xuzhou 221005,Jiangsu Province,China;Intensive Care Unit,the Fourth People's Hospital of Changzhou,Changzhou 213000,Jiangsu Province,China;Administration Department of Nosocomial Infection,the Fourth People's Hospital of Changzhou,Changzhou 213000,Jiangsu Province,China)
出处
《解放军医学院学报》
CAS
北大核心
2023年第5期501-507,524,共8页
Academic Journal of Chinese PLA Medical School
基金
江苏高校优势学科建设工程资助项目(苏政办发[2018]87号)
江苏省药学会基金(Q202033)
常州市科技局应用基础研究指导项目(CJ20189002)
山东省医药卫生科技发展计划项目(2019WS456)。
