癌症患者重症期间的谵妄及后续治疗变化：一项中介分析

Delirium During Critical Illness and Subsequent Change of Treatment in Patients With Cancer: A Mediation Analysis.

作者信息

Vizzacchi Bárbara A, Dettino Aldo L A, Besen Bruno A M P, Caruso Pedro, Nassar Antonio P

机构信息

Rehabilitation and Palliative Care Supervision, A.C. Camargo Cancer Center, São Paulo, Brazil.

Department of Clinical Oncology. A.C. Camargo Cancer Center, São Paulo, Brazil.

出版信息

Crit Care Med. 2024 Jan 1;52(1):102-111. doi: 10.1097/CCM.0000000000006070. Epub 2023 Oct 19.

DOI:10.1097/CCM.0000000000006070

PMID:37855674

Abstract

OBJECTIVES

To assess whether delirium during ICU stay is associated with subsequent change in treatment of cancer after discharge.

DESIGN

Retrospective cohort study.

SETTING

A 50-bed ICU in a dedicated cancer center.

PATIENTS

Patients greater than or equal to 18 years old with a previous proposal of cancer treatment (chemotherapy, target therapy, hormone therapy, immunotherapy, radiotherapy, oncologic surgery, and bone marrow transplantation).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We considered delirium present if Confusion Assessment Method for the ICU was positive. We assessed the association between delirium and modification of the treatment after discharge. We also performed a mediation analysis to assess both the direct and indirect (i.e., mediated by the development of functional dependence after discharge) of delirium on modification of cancer treatment and whether the modification of cancer treatment was associated with mortality at 1 year. We included 1,134 patients, of whom, 189 (16.7%) had delirium. Delirium was associated with the change in cancer treatment (adjusted odds ratio [OR], 3.80; 95% CI, 2.72-5.35). The association between delirium in ICU and change of treatment was both direct and mediated by the development of functional dependence after discharge. The proportion of the total effect of delirium on change of treatment mediated by the development of functional dependence after discharge was 33.0% (95% CI, 21.7-46.0%). Change in treatment was associated with increased mortality at 1 year (adjusted OR, 2.68; 95% CI, 2.01-3.60).

CONCLUSIONS

Patients who had delirium during ICU stay had a higher rate of modification of cancer treatment after discharge. The effect of delirium on change in cancer treatment was only partially mediated by the development of functional dependence after discharge. Change in cancer treatment was associated with increased 1-year mortality.

摘要

目的

评估重症监护病房（ICU）住院期间出现的谵妄是否与出院后癌症治疗的后续变化相关。

设计

回顾性队列研究。

地点

一家拥有50张床位的专门癌症中心的ICU。

患者

年龄大于或等于18岁且先前有癌症治疗方案（化疗、靶向治疗、激素治疗、免疫治疗、放疗、肿瘤手术和骨髓移植）的患者。

干预措施

无。

测量指标及主要结果

如果ICU意识模糊评估方法呈阳性，则认为存在谵妄。我们评估了谵妄与出院后治疗改变之间的关联。我们还进行了中介分析，以评估谵妄对癌症治疗改变的直接和间接影响（即由出院后功能依赖的发展介导），以及癌症治疗的改变是否与1年死亡率相关。我们纳入了1134例患者，其中189例（16.7%）出现谵妄。谵妄与癌症治疗的改变相关（校正比值比[OR]为3.80；95%可信区间[CI]为2.72 - 5.35）。ICU中的谵妄与治疗改变之间的关联既是直接的，也由出院后功能依赖的发展介导。出院后功能依赖的发展介导的谵妄对治疗改变的总效应比例为33.0%（95%CI为21.7 - 46.0%）。治疗改变与1年死亡率增加相关（校正OR为2.68；95%CI为2.01 - 3.60）。