Intensive Care Unit, Azienda Ospedaliera Luigi Sacco, University of Milan, Italy.
Minerva Anestesiol. 2012 Sep;78(9):1026-33. Epub 2012 Jul 6.
A wide variability in the approach towards delirium prevention and treatment in the critically ill results from the dearth of prospective randomised studies.
We launched a two-stage prospective observational study to assess delirium epidemiology, risk factors and impact on patient outcome, by enrolling all patients admitted to our Intensive Care Unit (ICU) over a year. The first step - from January to June 2008 was the observational phase, whereas the second one from July to December 2008 was interventional. All the patients admitted to our ICU were recruited but those with pre-existing cognitive disorders, dementia, psychosis and disability after stroke were excluded from the data analysis. Delirium assessment was performed according with Confusion Assessment Method for the ICU twice per day after sedation interruption. During phase 2, patients underwent both a re-orientation strategy and environmental, acoustic and visual stimulation.
We admitted a total of respectively 170 (I-ph) and 144 patients (II-ph). The delirium occurrence was significantly lower in (II-ph) 22% vs. 35% in (I-ph) (P=0.020). A Cox's Proportional Hazard model found the applied reorientation strategy as the strongest protective predictors of delirium: (HR 0.504, 95% C.I. 0.313-0.890, P=0.034), whereas age (HR 1.034, 95% CI: 1.013-1.056, P=0.001) and sedation with midazolam plus opiate (HR 2.145, 95% CI: 2.247-4.032, P=0.018) were negative predictors.
A timely reorientation strategy seems to be correlated with significantly lower occurrence of delirium.
由于缺乏前瞻性随机研究，导致重症患者预防和治疗谵妄的方法存在很大差异。
我们开展了一项两阶段前瞻性观察性研究，通过对一年内入住我们重症监护病房（ICU）的所有患者进行评估，以了解谵妄的流行病学、危险因素以及对患者预后的影响。第一阶段（2008 年 1 月至 6 月）为观察阶段，第二阶段（2008 年 7 月至 12 月）为干预阶段。所有入住 ICU 的患者均被纳入研究，但那些有预先存在的认知障碍、痴呆、精神病和中风后残疾的患者被排除在数据分析之外。根据 ICU 意识混乱评估方法（CAM-ICU），在镇静中断后每天进行两次谵妄评估。在第二阶段，患者接受了定向策略和环境、声学和视觉刺激。
我们分别收治了 170 例（I 期）和 144 例患者（II 期）。在 II 期，谵妄发生率显著降低（22% vs. 35%，P=0.020）。Cox 比例风险模型发现，应用定向策略是预防谵妄的最强保护因素：（HR 0.504，95%CI 0.313-0.890，P=0.034），而年龄（HR 1.034，95%CI：1.013-1.056，P=0.001）和咪达唑仑加阿片类药物镇静（HR 2.145，95%CI：2.247-4.032，P=0.018）是负预测因素。
及时的定向策略似乎与谵妄发生率显著降低相关。
