长时间每小时进行神经学检查与谵妄的增加有关，而在轻度/中度老年创伤性脑损伤中没有明显获益。
Prolonged hourly neurological examinations are associated with increased delirium and no discernible benefit in mild/moderate geriatric traumatic brain injury.
机构信息
From the Department of Acute and Critical Care Surgery (R.A.F., M.C., L.D., J.A.A., H.A., D.D.T., A.D., J.M., K.S., G.V.B., G.N., L.M.K., M.R.R., M.H., J.L.), Washington University in St. Louis, St. Louis, Missouri; and Department of Surgery (A.D.F.), Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
出版信息
J Trauma Acute Care Surg. 2024 Jul 1;97(1):105-111. doi: 10.1097/TA.0000000000004296. Epub 2024 Mar 21.
BACKGROUND
Serial neurological examinations (NEs) are routinely recommended in the intensive care unit (ICU) within the first 24 hours following a traumatic brain injury (TBI). There are currently no widely accepted guidelines for the frequency of NEs. Disruptions to the sleep-wake cycles increase the delirium rate. We aimed to evaluate whether there is a correlation between prolonged hourly (Q1)-NE and development of delirium and to determine if this practice reduces the likelihood of missing the detection of a process requiring emergent intervention.
METHODS
A retrospective analysis of patients with mild/moderate TBI, admitted to the ICU with serial NEs, was performed. Cohorts were stratified by the duration of exposure to Q1-NE, into prolonged (≥24 hours) and nonprolonged (<24 hours). Our primary outcomes of interest were delirium, evaluated using the Confusion Assessment Method; radiological progression from baseline images; neurological deterioration (focal neurological deficit, abnormal pupillary examination, or Glasgow Coma Scale score decrease >2); and neurosurgical procedures.
RESULTS
A total of 522 patients were included. No significant differences were found in demographics. Patients in the prolonged Q1-NE group (26.1%) had higher Injury Severity Score with similar head Abbreviated Injury Score, significantly higher delirium rate (59% vs. 35%, p < 0.001), and a longer hospital/ICU length of stay when compared with the nonprolonged Q1-NE group. No neurosurgical interventions were found to be performed emergently as a result of findings on NEs. Multivariate analysis demonstrated that prolonged Q1-NE was the only independent risk factor associated with a 2.5-fold increase in delirium rate. The number needed to harm for prolonged Q1-NE was 4.
CONCLUSION
Geriatric patients with mild/moderate TBI exposed to Q1-NE for periods longer than 24 hours had nearly a threefold increase in ICU delirium rate. One of five patients exposed to prolonged Q1-NE is harmed by the development of delirium. No patients were found to directly benefit as a result of more frequent NEs.
LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level IV.
背景
在创伤性脑损伤（TBI）发生后的 24 小时内，重症监护病房（ICU）通常建议进行连续的神经系统检查（NEs）。目前还没有广泛接受的 NE 频率指南。睡眠-觉醒周期的中断会增加谵妄的发生率。我们旨在评估 Q1-NE 的每小时持续时间（Q1-NE）与谵妄的发展之间是否存在相关性，并确定这种做法是否降低了错过需要紧急干预的过程的检测的可能性。
方法
对 ICU 内接受连续 NE 的轻度/中度 TBI 患者进行回顾性分析。根据 Q1-NE 暴露时间的长短，将队列分为延长（≥24 小时）和非延长（<24 小时）。我们感兴趣的主要结局是使用意识混乱评估方法（CAM）评估的谵妄；从基线图像进展的放射学；神经功能恶化（局灶性神经功能缺损、异常瞳孔检查或格拉斯哥昏迷量表评分下降>2）；和神经外科手术。
结果
共纳入 522 例患者。两组患者在人口统计学上无显著差异。在 Q1-NE 延长组（26.1%）中，损伤严重程度评分较高，头部简明损伤评分相似，谵妄发生率显著较高（59% vs. 35%，p<0.001），且 ICU 住院/留院时间较长。与非延长 Q1-NE 组相比，未发现因 NE 发现而紧急进行神经外科干预。多变量分析表明，Q1-NE 延长是谵妄发生率增加 2.5 倍的唯一独立危险因素。Q1-NE 延长的危害人数需要 4 人。
结论
患有轻度/中度 TBI 的老年患者接受 Q1-NE 的时间超过 24 小时，ICU 谵妄发生率增加近三倍。每五个接受 Q1-NE 延长的患者中就有一个因谵妄而受到伤害。没有发现由于更频繁的 NE 而使患者直接受益。
证据水平
预后和流行病学；IV 级。
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