Qin Yunjian, Li Ying, Chen Jianqin, Zeng Fenghua, Zhang Hongxia
Department of Intensive Care Unit, the First People's Hospital of Changde, Changde 415000, Hunan, China. Corresponding author: Li Ying, Email:
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2021 Jan;33(1):84-88. doi: 10.3760/cma.j.cn121430-20200828-00600.
To study the optimal pain control goal for preventing delirium in critical patients.
A prospective cohort study were conducted. The patients admitted to general departments and transferred to the intensive care unit (ICU) due to critical illness in the First People's Hospital of Changde from January 2017 to November 2019 were enrolled. The General data of the patients were collected within 48 hours after admission. All patients admitted to the ICU were evaluated for pain level using the critical care pain observation tool (CPOT) every 8 hours by nurses, and confusion assessment method of ICU (CAM-ICU) was used to screen delirium patient every 8 hours by the leader of nursing team without knowing the pain level of the patients, until the subjects were transferred out of ICU. The receiver operating characteristic (ROC) curve was drawn, the area under ROC curve (AUC) and the optimal threshold were analyzed with delirium as the reference standard; according to the optimal threshold, multivariate Logistic regression analysis was used to evaluate the correlation between CPOT score and delirium.
During the study period, 575 patients were admitted to the participating departments and passed the preliminary screening according to the inclusion and exclusion criteria. During the study period, 34 patients were excluded due to incomplete data. Finally, a total of 541 patients were enrolled in the analysis, including 149 patients in delirium group and 392 patients in non-delirium group. There was no significant difference in gender, age, source of patients, education level, smoking history, drinking history, family mental history, acute physiology and chronic health evaluation II (APACHE II) score or other general information between the two groups. There were 10.1% (15/149) of patients in the delirium group used opioids, which was significantly higher than 4.3% (17/392) in the non-delirium group, and the difference was statistically significant (P < 0.05). The CPOT score in the delirium group was significantly higher than that in the non-delirium group (4.24±1.78 vs. 2.75±1.95, P < 0.01). The patients were subdivided into young group (< 40 years old), middle-aged group (40-65 years old) and old group (> 65 years old) according to age. The analysis results were consistent with the overall analysis results. ROC curve analysis showed that the AUC of CPOT score predicting delirium was 0.719; when the best threshold value of CPOT score was 2.5, the sensitivity was 91.3%, the specificity was 49.0%, the positive predictive value was 40.5% and the negative predictive value was 93.7%. Multivariate Logistic regression analysis showed that the risk of delirium in ICU patients with CPOT score ≥ 3 was 10.043 times higher than that in patients with CPOT score < 3 [odds ratio (OR) = 10.043, 95% confidence interval (95%CI) was 5.498-18.345, P < 0.001]. When the gender, age, APACHE II score, smoking history, drinking history, opioids usage were adjusted, the risk of delirium in patients with CPOT score ≥ 3 was 10.719 times higher than that in patients with CPOT score < 3 (OR = 10.719, 95%CI was 5.689-20.196, P < 0.001).
The best pain control goal for preventing the occurrence of delirium in ICU patients is a CPOT score of 3 or less.
研究预防危重症患者谵妄的最佳疼痛控制目标。
进行一项前瞻性队列研究。纳入2017年1月至2019年11月在常德市第一人民医院因危重症入住普通科室后转入重症监护病房（ICU）的患者。在入院后48小时内收集患者的一般资料。ICU所有患者由护士每8小时使用重症监护疼痛观察工具（CPOT）评估疼痛程度，护理团队组长在不知道患者疼痛程度的情况下每8小时使用ICU意识模糊评估法（CAM-ICU）筛查谵妄患者，直至患者转出ICU。绘制受试者工作特征（ROC）曲线，以谵妄为参考标准分析ROC曲线下面积（AUC）及最佳阈值；根据最佳阈值，采用多因素Logistic回归分析评估CPOT评分与谵妄的相关性。
研究期间，575例患者入住参与研究科室并根据纳入和排除标准通过初步筛查。研究期间，34例患者因数据不完整被排除。最终，共541例患者纳入分析，其中谵妄组149例，非谵妄组392例。两组在性别、年龄、患者来源、教育程度、吸烟史、饮酒史、家族精神病史、急性生理与慢性健康状况评分II（APACHE II）或其他一般资料方面无显著差异。谵妄组使用阿片类药物的患者占10.1%（15/149），显著高于非谵妄组的4.3%（17/392），差异有统计学意义（P<0.05）。谵妄组CPOT评分显著高于非谵妄组（4.24±1.78 vs. 2.75±1.95，P<0.01）。根据年龄将患者分为青年组（<40岁）、中年组（40-65岁）和老年组（>65岁），分析结果与总体分析结果一致。ROC曲线分析显示，CPOT评分预测谵妄的AUC为0.719；当CPOT评分最佳阈值为2.5时，灵敏度为91.3%，特异度为49.0%，阳性预测值为40.5%，阴性预测值为93.7%。多因素Logistic回归分析显示，CPOT评分≥3的ICU患者发生谵妄的风险比CPOT评分<3的患者高10.043倍[比值比（OR）=10.043，95%置信区间（95%CI）为5.498-18.345，P<0.001]。调整性别、年龄、APACHE II评分、吸烟史、饮酒史、阿片类药物使用情况后，CPOT评分≥3的患者发生谵妄的风险比CPOT评分<3的患者高10.719倍（OR=10.719，95%CI为5.689-20.196，P<0.001）。
预防ICU患者发生谵妄的最佳疼痛控制目标是CPOT评分为3分及以下。
