Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan.
Department of Anaesthesiology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan.
JAMA Netw Open. 2022 Oct 3;5(10):e2235339. doi: 10.1001/jamanetworkopen.2022.35339.
Intensive care unit (ICU)-acquired delirium and/or coma have consequences for patient outcomes. However, contradictory findings exist, especially when considering short-term (ie, in-hospital) mortality and length of stay (LOS).
To assess whether incident delirium, days of delirium, days of coma, and delirium- and coma-free days (DCFDs) are associated with 14-day mortality, in-hospital mortality, and hospital LOS among patients with critical illness receiving mechanical ventilation.
DESIGN, SETTING, AND PARTICIPANTS: This single-center prospective cohort study was conducted in 6 ICUs of a university-affiliated tertiary hospital in Taiwan. A total of 267 delirium-free patients (aged ≥20 years) with critical illness receiving mechanical ventilation were consecutively enrolled from August 14, 2018, to October 1, 2020.
Participants were assessed daily for the development of delirium and coma status over 14 days (or until death or ICU discharge) using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively.
Mortality rates (14-day and in-hospital) and hospital LOS using electronic health records.
Of 267 participants (median [IQR] age, 65.9 [57.4-75.1] years; 171 men [64.0%]; all of Taiwanese ethnicity), 149 patients (55.8%) developed delirium for a median (IQR) of 3.0 (1.0-5.0) days at some point during their first 14 days of ICU stay, and 105 patients (39.3%) had coma episodes also lasting for a median (IQR) of 3.0 (1.0-5.0) days. The 14-day and in-hospital mortality rates were 18.0% (48 patients) and 42.1% (112 of 266 patients [1 patient withdrew from the study]), respectively. The incidence and days of delirium were not associated with either 14-day mortality (incident delirium: adjusted hazard ratio [aHR], 1.37; 95% CI, 0.69-2.72; delirium by day: aHR, 1.00; 95% CI, 0.91-1.10) or in-hospital mortality (incident delirium: aHR, 1.00; 95% CI, 0.64-1.55; delirium by day: aHR, 1.02; 95% CI, 0.97-1.07), whereas days spent in coma were associated with an increased hazard of dying during a given 14-day period (aHR, 1.16; 95% CI, 1.10-1.22) and during hospitalization (aHR, 1.10; 95% CI, 1.06-1.14). The number of DCFDs was a protective factor; for each additional DCFD, the risk of dying during the 14-day period was reduced by 11% (aHR, 0.89; 95% CI, 0.84-0.94), and the risk of dying during hospitalization was reduced by 7% (aHR, 0.93; 95% CI, 0.90-0.97). Incident delirium was associated with longer hospital stays (adjusted β = 10.80; 95% CI, 0.53-21.08) when compared with no incident delirium.
In this study, despite prolonged LOS, ICU delirium was not associated with short-term mortality. However, DCFDs were associated with a lower risk of dying, suggesting that future research and intervention implementation should refocus on maximizing DCFDs to potentially improve the survival of patients receiving mechanical ventilation.
重症监护病房（ICU）获得性谵妄和/或昏迷对患者预后有影响。然而，目前的研究结果存在矛盾，尤其是在考虑短期（即住院期间）死亡率和住院时间（LOS）时。
评估在接受机械通气的危重病患者中，新发谵妄、谵妄天数、昏迷天数、谵妄和昏迷无天数（DCFDs）与 14 天死亡率、住院死亡率和医院 LOS 的关系。
设计、地点和参与者：这项单中心前瞻性队列研究在台湾一家大学附属医院的 6 个 ICU 进行。从 2018 年 8 月 14 日至 2020 年 10 月 1 日，连续纳入 267 名无谵妄（年龄≥20 岁）、接受机械通气的危重病患者。
使用重症监护室谵妄评估方法和 Richmond 镇静-躁动量表，分别在 14 天（或直至死亡或 ICU 出院）期间每天评估患者发生谵妄和昏迷的情况。
使用电子健康记录评估死亡率（14 天和住院期间）和 LOS。
在 267 名患者中（中位数[IQR]年龄，65.9[57.4-75.1]岁；171 名男性[64.0%]；均为台湾人），149 名患者（55.8%）在 ICU 入住的前 14 天内出现了谵妄，中位（IQR）持续时间为 3.0（1.0-5.0）天，105 名患者（39.3%）出现了昏迷，中位（IQR）持续时间也为 3.0（1.0-5.0）天。14 天和住院期间的死亡率分别为 18.0%（48 例）和 42.1%（266 例患者中的 112 例[1 例患者退出研究]）。谵妄的发生率和天数与 14 天死亡率（新发谵妄：调整后的危险比[aHR]，1.37；95%CI，0.69-2.72；谵妄天数：aHR，1.00；95%CI，0.91-1.10）或住院期间死亡率（新发谵妄：aHR，1.00；95%CI，0.64-1.55；谵妄天数：aHR，1.02；95%CI，0.97-1.07）均无相关性，而昏迷天数与给定 14 天期间死亡风险增加相关（aHR，1.16；95%CI，1.10-1.22）和住院期间（aHR，1.10；95%CI，1.06-1.14）。DCFD 数是一个保护因素；每增加一个 DCFD，14 天期间的死亡风险降低 11%（aHR，0.89；95%CI，0.84-0.94），住院期间的死亡风险降低 7%（aHR，0.93；95%CI，0.90-0.97）。与无新发谵妄相比，新发谵妄与较长的住院时间相关（调整后β=10.80；95%CI，0.53-21.08）。
在这项研究中，尽管 LOS 延长，但 ICU 谵妄与短期死亡率无关。然而，DCFD 与较低的死亡风险相关，这表明未来的研究和干预实施应重新聚焦于最大限度地延长 DCFD，以潜在改善接受机械通气的患者的生存率。
