Visser Linda, Prent Anna, van der Laan Maarten J, van Leeuwen Barbara L, Izaks Gerbrand J, Zeebregts Clark J, Pol Robert A
Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
J Vasc Surg. 2015 Jul;62(1):183-9. doi: 10.1016/j.jvs.2015.01.041. Epub 2015 Mar 7.
The objective of this study was to determine the incidence of and specific preoperative and intraoperative risk factors for postoperative delirium (POD) in electively treated vascular surgery patients.
Between March 2010 and November 2013, all vascular surgery patients were included in a prospective database. Various preoperative, intraoperative, and postoperative risk factors were collected during hospitalization. The primary outcome variable was the incidence of POD. Secondary outcome variables were any surgical complication, hospital length of stay, and mortality.
In total, 566 patients were prospectively evaluated; 463 patients were 60 years or older at the time of surgery and formed our study cohort. The median age was 72 years (interquartile range, 66-77), and 76.9% were male. Twenty-two patients (4.8%) developed POD. Factors that differed significantly by univariate analysis included current smoking (P = .001), increased comorbidity (P = .001), hypertension (P = .003), diabetes mellitus (P = .001), cognitive impairment (P < .001), open aortic surgery or amputation surgery (P < .001), elevated C-reactive protein level (P < .001), and blood loss (P < .001). Multivariate logistic regression analysis revealed preoperative cognitive impairment (odds ratio [OR], 16.4; 95% confidence interval [CI], 4.7-57.0), open aortic surgery or amputation surgery (OR, 14.0; 95% CI, 3.9-49.8), current smoking (OR, 10.5; 95% CI, 2.8-40.2), hypertension (OR, 7.6; 95% CI, 1.9-30.5) and age ≥80 years (OR, 7.3; 95% CI, 1.8-30.1) to be independent predictors of the occurrence of POD. The combination of these parameters allows us to predict delirium with a sensitivity of 86% and a specificity of 92%. The area under the curve of the corresponding receiver operating characteristics was 0.93. Delirium was associated with longer hospital length of stay (P < .001), more frequent and increased intensive care unit stays (P = .008 and P = .003, respectively), more surgical complications (P < .001), more postdischarge institutionalization (P < .001), and higher 1-year mortality rates (P = .0026).
In vascular surgery patients, preoperative cognitive impairment and open aortic or amputation surgery were highly significant risk factors for the occurrence of POD. In addition, POD was significantly associated with a higher mortality and more institutionalization. Patients with these risk factors should be considered for high-standard delirium care to improve these outcomes.
本研究的目的是确定择期接受血管手术患者术后谵妄（POD）的发生率以及术前和术中的特定危险因素。
2010年3月至2013年11月期间，所有血管手术患者均纳入前瞻性数据库。住院期间收集了各种术前、术中和术后危险因素。主要结局变量是POD的发生率。次要结局变量是任何手术并发症、住院时间和死亡率。
总共对566例患者进行了前瞻性评估；463例患者在手术时年龄为60岁或以上，构成了我们的研究队列。中位年龄为72岁（四分位间距，66 - 77岁），76.9%为男性。22例患者（4.8%）发生了POD。单因素分析显示有显著差异的因素包括当前吸烟（P = 0.001）、合并症增加（P = 0.001）、高血压（P = 0.003）、糖尿病（P = 0.001）、认知障碍（P < 0.001）、开放性主动脉手术或截肢手术（P < 0.001）、C反应蛋白水平升高（P < 0.001）和失血（P < 0.001）。多因素逻辑回归分析显示术前认知障碍（比值比[OR]，16.4；95%置信区间[CI]，4.7 - 57.0）、开放性主动脉手术或截肢手术（OR，14.0；95% CI，3.9 - 49.8）、当前吸烟（OR，10.5；95% CI，2.8 - 40.2）、高血压（OR，7.6；95% CI，1.9 - 30.5）和年龄≥80岁（OR，7.3；95% CI，1.8 - 30.1）是POD发生的独立预测因素。这些参数的组合使我们能够以86%的敏感性和92%的特异性预测谵妄。相应的受试者工作特征曲线下面积为0.93。谵妄与更长的住院时间（P < 0.001）、更频繁和更长时间的重症监护病房住院（分别为P = 0.008和P = 0.003）、更多的手术并发症（P < 0.001）、出院后更多的机构化（P < 0.001）以及更高的1年死亡率（P = 0.0026）相关。
在血管手术患者中，术前认知障碍和开放性主动脉或截肢手术是POD发生的高度显著危险因素。此外，POD与更高的死亡率和更多的机构化显著相关。对于具有这些危险因素的患者，应考虑给予高标准的谵妄护理以改善这些结局。
