接受静脉-静脉体外膜肺氧合治疗的COVID-19患者谵妄的特征及其与镇静和院内死亡率的关系
Characteristics of delirium and its association with sedation and in-hospital mortality in patients with COVID-19 on veno-venous extracorporeal membrane oxygenation.
作者信息
Sun Philip Young-Woo, Fanning Jonathon, Peeler Anna, Shou Benjamin, Lindsley John, Caturegli Giorgio, Whitman Glenn, Cha Stephanie, Kim Bo Soo, Cho Sung-Min
机构信息
Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, United States.
出版信息
Front Med (Lausanne). 2023 May 25;10:1172063. doi: 10.3389/fmed.2023.1172063. eCollection 2023.
BACKGROUND
Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been used in patients with COVID-19 acute respiratory distress syndrome (ARDS). We aim to assess the characteristics of delirium and describe its association with sedation and in-hospital mortality.
METHODS
We retrospectively reviewed adult patients on VV-ECMO for severe COVID-19 ARDS in the Johns Hopkins Hospital ECMO registry in 2020-2021. Delirium was assessed by the Confusion Assessment Method for the ICU (CAM-ICU) when patients scored-3 or above on the Richmond Agitation-Sedation Scale (RASS). Primary outcomes were delirium prevalence and duration in the proportion of days on VV-ECMO.
RESULTS
Of 47 patients (median age = 51), 6 were in a persistent coma and 40 of the remaining 41 patients (98%) had ICU delirium. Delirium in the survivors ( = 21) and non-survivors ( = 26) was first detected at a similar time point (VV-ECMO day 9.5(5,14) vs. 8.5(5,21), = 0.56) with similar total delirium days on VV-ECMO (9.5[3.3, 16.8] vs. 9.0[4.3, 28.3] days, = 0.43). Non-survivors had numerically lower RASS scores on VV-ECMO days (-3.72[-4.42, -2.96] vs. -3.10[-3.91, -2.21], = 0.06) and significantly prolonged delirium-unassessable days on VV-ECMO with a RASS of -4/-5 (23.0[16.3, 38.3] vs. 17.0(6,23), = 0.03), and total VV-ECMO days (44.5[20.5, 74.3] vs. 27.0[21, 38], = 0.04). The proportion of delirium-present days correlated with RASS (r = 0.64, < 0.001), the proportions of days on VV-ECMO with a neuromuscular blocker (r = -0.59, = 0.001), and with delirium-unassessable exams (r = -0.69, < 0.001) but not with overall ECMO duration (r = 0.01, = 0.96). The average daily dosage of delirium-related medications on ECMO days did not differ significantly. On an exploratory multivariable logistic regression, the proportion of delirium days was not associated with mortality.
CONCLUSION
Longer duration of delirium was associated with lighter sedation and shorter paralysis, but it did not discern in-hospital mortality. Future studies should evaluate analgosedation and paralytic strategies to optimize delirium, sedation level, and outcomes.
背景
静脉-静脉体外膜肺氧合（VV-ECMO）已用于新型冠状病毒肺炎急性呼吸窘迫综合征（ARDS）患者。我们旨在评估谵妄的特征，并描述其与镇静及住院死亡率的关联。
方法
我们回顾性分析了2020 - 2021年约翰霍普金斯医院ECMO登记处接受VV-ECMO治疗的重症新型冠状病毒肺炎ARDS成年患者。当患者在里士满躁动-镇静量表（RASS）上得分-3或更高时，采用重症监护病房意识模糊评估法（CAM-ICU）评估谵妄。主要结局为谵妄患病率及在VV-ECMO治疗天数中所占的持续时间。
结果
47例患者（中位年龄 = 51岁）中，6例处于持续性昏迷，其余41例中的40例（98%）发生了重症监护病房谵妄。幸存者（n = 21）和非幸存者（n = 26）的谵妄首次在相似的时间点被检测到（VV-ECMO第9.5天（5,14）对8.5天（5,21），P = 0.56），在VV-ECMO上总的谵妄天数相似（9.5[3.3, 16.8]对9.0[4.3, 28.3]天，P = 0.43）。非幸存者在VV-ECMO日的RASS评分在数值上较低（-3.72[-4.42, -2.96]对-3.10[-3.91, -2.21]，P = 0.06），并且在RASS为-4/-5时，在VV-ECMO上谵妄无法评估的天数显著延长（23.0[16.3, 38.3]对17.0（6,23），P = 0.03），以及总的VV-ECMO天数（44.5[20.5, 74.3]对27.0[21, 38]，P = 0.04）。存在谵妄的天数比例与RASS相关（r = 0.64，P < 0.001），与使用神经肌肉阻滞剂的VV-ECMO天数比例相关（r = -0.59，P = 0.001），以及与谵妄无法评估的检查相关（r = -0.69，P < 0.001），但与总的ECMO持续时间无关（r = 0.01，P = 0.96）。在ECMO日与谵妄相关药物的平均每日剂量无显著差异。在探索性多变量逻辑回归分析中，谵妄天数比例与死亡率无关。
结论
谵妄持续时间较长与镇静较轻和麻痹时间较短相关，但与住院死亡率无关。未来研究应评估镇痛镇静和麻痹策略以优化谵妄、镇静水平及结局。
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