外科重症监护病房的谵妄预防计划改善了老年患者的结局。

Delirium prevention program in the surgical intensive care unit improved the outcomes of older adults.

机构信息

Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ.

出版信息

J Surg Res. 2014 Jul;190(1):280-8. doi: 10.1016/j.jss.2014.02.044. Epub 2014 Feb 28.

DOI:10.1016/j.jss.2014.02.044

PMID:24666988

Abstract

BACKGROUND

Hospital-acquired delirium is a known risk factor for negative outcomes in patients admitted to the surgical intensive care unit (SICU). Outcomes worsen as the duration of delirium increases. The purpose of this study was to evaluate the efficacy of a delirium prevention program and determine whether it decreased the incidence and duration of hospital-acquired delirium in older adults (age>50 y) admitted to the SICU.

METHODS

A prospective pre- or post-intervention cohort study was done at an academic level I trauma center. Older adults admitted to the SICU were enrolled in a delirium prevention program. Those with traumatic brain injury, dementia, or 0 d of obtainable delirium status were excluded from analysis. The intervention consisted of multidisciplinary education, a pharmacologic protocol to limit medications associated with delirium, and a nonpharmacologic sleep enhancement protocol. Primary outcomes were incidence of delirium and delirium-free days/30. Secondary outcomes were ventilator-free days/30, SICU length of stay (LOS), daily and cumulative doses of opioids (milligram, morphine equivalents) and benzodiazepines (milligram, lorazepam equivalents), and time spent in severe pain (greater than or equal to 6 on a scale of 1-10). Delirium was measured using the Confusion Assessment Method for the ICU. Data were analyzed using Chi-squared and Wilcoxon rank sum analysis.

RESULTS

Of 624 patients admitted to the SICU, 123 met inclusion criteria: 57 preintervention (3/12-6/12) and 66 postintervention (7/12-3/13). Cohorts were similar in age, gender, ratio of trauma patients, and Injury Severity Score. Postintervention, older adults experienced delirium at the same incidence (pre 47% versus 58%, P=0.26), but for a significantly decreased duration as indicated by an increase in delirium-free days/30 (pre 24 versus 27, P=0.002). After intervention, older adults with delirium had more vent-free days (pre 21 versus 25, P=0.03), shorter SICU LOS (pre 13 [median 12] versus 7 [median 6], P=0.01) and were less likely to be treated with benzodiazepines (pre 85% versus 63%, P=0.05) with a lower daily dose when prescribed (pre 5.7 versus 3.6 mg, P=0.04). After intervention, all older adults spent less time in pain (pre 4.7 versus 3.1 h, P=0.02), received less total opioids (pre 401 versus 260 mg, P=0.01), and had shorter SICU LOS (pre 9 [median 5] versus 6 [median 4], P=0.04).

CONCLUSIONS

Although delirium prevention continues to be a challenge, this study successfully decreased the duration of delirium for older adults admitted to the SICU. Our simple, cost-effective program led to improved pain and sedation outcomes. Older adults with delirium spent less time on the ventilator and all patients spent less time in the SICU.

摘要

背景

医院获得性谵妄是入住外科重症监护病房（SICU）患者发生不良结局的已知危险因素。谵妄持续时间越长，预后越差。本研究旨在评估谵妄预防计划的疗效，确定其是否降低了入住 SICU 的老年患者（年龄>50 岁）发生医院获得性谵妄的发生率和持续时间。

方法

在一家学术水平为 I 级的创伤中心进行了前瞻性的预干预或后干预队列研究。将入住 SICU 的老年患者纳入谵妄预防计划。排除有创伤性脑损伤、痴呆或无法获得 0 天谵妄状态的患者。干预措施包括多学科教育、限制与谵妄相关的药物的药物方案，以及非药物睡眠增强方案。主要结局是谵妄的发生率和无谵妄天数/30 天。次要结局是无呼吸机天数/30 天、SICU 住院时间（LOS）、每日和累积剂量的阿片类药物（毫克，吗啡当量）和苯二氮䓬类药物（毫克，劳拉西泮当量）以及严重疼痛时间（评分 1-10 时大于或等于 6）。使用 ICU 意识混乱评估方法测量谵妄。使用卡方检验和 Wilcoxon 秩和检验进行数据分析。

结果

在入住 SICU 的 624 名患者中，有 123 名符合纳入标准：57 名患者在干预前（3/12-6/12），66 名患者在干预后（7/12-3/13）。队列在年龄、性别、创伤患者比例和损伤严重程度评分方面相似。干预后，老年患者的谵妄发生率相同（干预前为 47%，干预后为 58%，P=0.26），但由于无谵妄天数/30 增加，谵妄持续时间明显缩短（干预前为 24 天，干预后为 27 天，P=0.002）。干预后，有谵妄的老年患者有更多的无呼吸机天数（干预前为 21 天，干预后为 25 天，P=0.03），SICU LOS 更短（干预前为 13 [中位数 12]天，干预后为 7 [中位数 6]天，P=0.01），并且不太可能使用苯二氮䓬类药物（干预前为 85%，干预后为 63%，P=0.05），当开处方时，每日剂量较低（干预前为 5.7 毫克，干预后为 3.6 毫克，P=0.04）。干预后，所有老年患者疼痛时间更短（干预前为 4.7 小时，干预后为 3.1 小时，P=0.02），接受的阿片类药物总量更少（干预前为 401 毫克，干预后为 260 毫克，P=0.01），SICU LOS 更短（干预前为 9 [中位数 5]天，干预后为 6 [中位数 4]天，P=0.04）。