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Postoperative Delirium in Patients on Cardiopulmonary Bypass for Cardiovascular Surgeries: Incidence and Influencing Factors
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摘要:
目的 探索体外循环下心血管手术患者的术后谵妄（postoperative delirium, POD）与亚谵妄综合征（subsyndromal delirium, SSD）发生情况及影响因素。 方法 收集2022年5–9月湖北省某三甲医院体外循环下心血管手术患者的一般资料、围手术期血常规及生理生化指标、手术及治疗情况等，采用护理谵妄筛查量表评估结局指标即POD和SSD发生情况，不同组别的影响因素分析采用无序多分类logistic回归。 结果 202例患者中，SSD、SSD进展为POD、直接发生POD的发生率为13.4%、6.4%、34.2%。回归分析显示，以无POD或SSD组为对照，术前血糖〔比值比（odds ratio, OR）=0.38，95%置信区间（CI）：0.19～0.76）〕、术中输注血小板（OR=0.37，95%CI：0.15～0.92）、术中依托咪酯剂量（OR=0.93，95%CI：0.87～0.98）、术后总胆红素水平（OR=1.04，95%CI：1.01～1.07）是SSD的影响因素；年龄（OR=1.09，95%CI：1.01～1.17）、ASA分级为Ⅳ级及以上（OR=10.72，95%CI：1.85～62.08）、术中右美托咪定剂量（OR=1.01，95%CI：1.003～1.02）、机械通气时长（OR=1.04，95%CI：1.01～1.07）是SSD进展为POD的影响因素；年龄（OR=1.06，95%CI：1.02～1.10）、初中或高中学历（OR=0.35，95%CI：0.15～0.83）、机械通气时长（OR=1.04，95%CI：1.01～1.07）是直接发生POD的影响因素。 结论 年龄、受教育程度、ASA分级、术前血糖、术中输注血小板、术中依托咪酯剂量、术中右美托咪定剂量、术后总胆红素和机械通气时长是体外循环下心血管手术患者POD和SSD发生情况的影响因素，且不同组别的影响因素存在差异，应精准评估和干预不同组别的危险因素，预防或遏制POD或SSD的发生和发展，促进患者加速康复。 Abstract:Objective To investigate the incidence and influencing factors of postoperative delirium (POD) and subsyndromal delirium (SSD) in patients connected to cardiopulmonary bypass during cardiovascular surgeries. Methods We collected the general data and the data for the perioperative hematological, physiological, and biochemical indicators and the surgical and therapeutic conditions of patients connected to cardiopulmonary bypass during the course of cardiovascular surgeries conducted at a tertiary-care hospital in Hubei province between May 2022 and September 2022. The outcome indicators, including the incidence of POD and SSD, were assessed with the Nursing Delirium Screening Scale (Nu-DESC). Multinomial logistic regression was performed to analyze the influencing factors of patients with different statuses of POD and SSD. Results Among the 202 patients, the incidence of SSD, SSD progressing to POD, and no POD or SSD (ND) progressing to POD were 13.4%, 6.4%, and 34.2%, respectively. Regression analysis showed that, with ND patients as the controls, the influencing factors for SSD were preoperative blood glucose (odds ratio [OR]=0.38, 95% confidence interval [CI]: 0.19-0.76), intraoperative platelet transfusion (OR=0.37, 95% CI: 0.15-0.92), intraoperative etomidate (OR=0.93, 95% CI: 0.87-0.98), and postoperative total bilirubin level (OR=1.04, 95% CI: 1.01-1.07). For the progression of SSD to POD, the influencing factors were age (OR=1.09, 95% CI: 1.01-1.17), ASA classification of IV and above (OR=10.72, 95% CI: 1.85-62.08), intraoperative dexmedetomidine (OR=1.01, 95% CI: 1.003-1.02), and the duration of mechanical ventilation (OR=1.04, 95% CI: 1.01-1.07). For the progression of ND to POD, the influencing factors were age (OR=1.06, 95% CI: 1.02-1.10), middle or high school education (OR=0.35, 95% CI: 0.15-0.83), and the duration of mechanical ventilation (OR=1.04, 95% CI: 1.01-1.07). Conclusion Age, education, ASA classification, preoperative blood glucose, intraoperative platelet transfusion, intraoperative etomidate, intraoperative dexmedetomidine, postoperative total bilirubin, and the duration of mechanical ventilation are influencing factors for different statuses of POD and SSD among patients connected to cardiopulmonary bypass when they are undergoing cardiovascular surgeries. The influencing factors vary across groups of patients with different statuses of POD and SSD. Therefore, we should accurately assess the risk factors of patients with different statuses of POD and SSD and carry out corresponding interventions, thereby preventing or reducing the occurrence of POD and SSD, and ultimately promoting enhanced recovery after surgery. -
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表 1 不同分组患者的一般资料比较（n=202）
Table 1. Comparison of the general data of patients with different statuses of POD and SSD (n=202)
Variable Different statuses of POD and SSD F/H/χ2 P ND (n=93) SSD (n=27) SSD→POD
(n=13)ND→POD
(n=69)Male/case (%) 58 (62.4) 14 (51.9) 10 (76.9) 36 (52.2) 4.016 0.260 Age/yr., M (IQR) 32.00 (20.00-38.00) 36.00 (27.50-41.50) 39.00 (32.00-42.00) 35.00 (29.00-43.00) 9.970 0.019 Highest education attained/case (%) 16.132 0.013 Primary school or below 17 (18.3) 9 (33.3) 1 (7.7) 28 (40.6) Junior or senior high school 54 (58.1) 11 (40.7) 10 (76.9) 33 (47.8) College or bachelor's degree or above 22 (23.7) 7 (25.9) 2 (15.4) 8 (11.6) Smoking/case (%) 13 (14) 6 (22.2) 2 (15.4) 10 (14.5) 1.363 0.726 Drinking/case (%) 10 (10.8) 3 (11.1) 4 (30.8) 7 (10.1) 4.174 0.225 BMI/(kg/m2), M (IQR) 23.44 (21.05-25.65) 22.49 (21.34-25.84) 23.44 (21.05-26.30) 23.05 (20.99-25.59) 0.254 0.968 Chronic diseases/case (%) 42 (45.2) 15 (55.6) 10 (76.9) 35 (50.7) 4.969 0.174 Cerebrovascular disease 4 (4.3) 2 (7.4) 1 (7.7) 0 (0) 5.790 0.075 Diabetes 6 (6.5) 0 (0) 1 (7.7) 1 (1.4) 3.916 0.237 Hypertension 18 (19.4) 5 (18.5) 3 (23.1) 19 (27.5) 1.786 0.618 Heart diseases 26 (27.9) 11 (40.7) 8 (61.5) 20 (28.9) 7.124 0.068 Others 8 (8.6) 1 (3.7) 2 (15.4) 7 (10.1) 1.850 0.559 History of cardiovascular surgery/case (%) 5 (5.4) 1 (3.7) 0 (0) 7 (10.1) 1.996 0.564 ASA classification/case (%) 28.707 <0.001 Ⅱ or Ⅲ 84 (90.3) 24 (88.9) 5 (38.5) 45 (65.2) Ⅳ or above 9 (9.7) 3 (11.1) 8 (61.5) 24 (34.8) NYHA classification/case (%) 6.627 0.357 Ⅰ 30 (32.3) 13 (48.1) 4 (30.8) 29 (42.0) Ⅱ 25 (26.9) 4 (14.8) 1 (7.7) 14 (20.3) Ⅲ or above 38 (40.9) 10 (37.0) 8 (61.5) 26 (37.7) POD: postoperative delirium; SSD: subsyndromal delirium; ND: no subsyndromal delirium or postoperative delirium; M: median; IQR: interquartile range; BMI: body mass index; ASA classification: American Society of Anesthesiologists (ASA) Physical Status Classification System; NYHA: New York Heart Association Functional Classification. 
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表 2 不同分组患者的围手术期资料比较（n=202）
Table 2. Comparison of the perioperative data of patients with different statuses of POD and SSD (n=202)
Variable Different statuses of POD and SSD F/H/χ2 P ND (n=93) SSD (n=27) SSD→POD (n=13) ND→POD (n=69) Preoperative indicator/M (IQR) White blood cell/109 L−1 5.99 (4.89-7.25) 5.69 (5.14-7.13) 8.07 (7.21-11.49) 7.04 (5.18-10.04) 12.976 0.005 Red blood cell/1012 L−1 4.36 (4.04-4.82) 4.65 (4.22-5.03) 4.64 (4.24-4.94) 4.31 (4.00-4.78) 6.720 0.081 Hemoglobin/(g/L) 131.00 (120.00-145.00) 138.00 (121.00-147.00) 137.00 (128.00-142.00) 129.00 (116.00-143.00) 1.922 0.589 Glucose/(mmol/L) 5.24 (4.73-6.43) 4.97 (4.63-5.12) 5.49 (5.23-7.31) 5.38 (4.70-7.32) 9.854 0.020 Albumin/(g/L) 40.40 (37.60-43.10) 39.70 (37.55-41.30) 40.60 (38.40-41.90) 39.80 (37.00-42.90) 0.790 0.852 Total bilirubin/(μmol/L) 11.10 (7.30-15.60) 12.10 (8.45-15.45) 10.30 (7.70-16.20) 12.50 (8.60-17.60) 2.534 0.469 K/(mmol/L) 4.00 (3.77-4.22) 4.06 (3.96-4.25) 4.20 (4.09-4.36) 3.97 (3.78-4.41) 5.856 0.119 Na/(mmol/L) 140.70 (138.80-141.60) 140.70 (139.65-141.60) 138.70 (137.30-140.40) 140.10 (138.60-141.50) 4.100 0.251 Urea/(mmol/L) 5.70 (4.30-6.74) 5.80 (5.30-7.50) 7.60 (5.70-9.70) 6.01 (4.70-7.40) 8.888 0.031 Creatinine/(μmol/L) 75.00 (61.00-88.00) 73.00 (63.50-85.00) 78.00 (76.00-89.00) 80.00 (66.00-98.00) 4.490 0.213 eGFR/(mL/[min·1.73 m2]) 97.10 (80.90-107.00) 94.10 (76.20-105.05) 92.60 (71.60-97.60) 89.20 (69.50-98.30) 10.842 0.013 hs-CRP/(mg/L) 2.10 (0.80-5.60) 1.80 (1.10-7.10) 1.60 (0.80-10.40) 3.50 (0.70-27.80) 2.898 0.408 NT-proBNP/(pg/mL) 267.00 (61.00-896.00) 433.00 (81.00-1463.00) 997.00 (245.00-3691.00) 854.00 (191.00-1814.00) 12.947 0.005 Intraoperative indicator/case (%) or M (IQR) Emergency surgery 11 (11.8) 2 (7.4) 4 (30.8) 14 (20.3) 5.671 0.113 Surgery type 21.467 <0.001 Single valve or coronary artery bypass graft or others 60 (64.5) 19 (70.4) 4 (30.8) 23 (33.3) Mixed or aortic surgery 33 (35.5) 8 (29.6) 9 (69.2) 46 (66.7) Duration of surgery/h 5.67 (4.75-6.97) 5.92 (5.01-7.25) 6.63 (6.02-7.43) 6.50 (5.78-7.88) 15.119 0.002 CPB duration/min 125.00 (91.00-157.00) 128.00 (95.00-170.50) 186.00 (134.00-210.00) 170.00 (135.00-205.00) 27.262 <0.001 Duration of aortic blockade/min 73.00 (44.00-92.00) 82.00 (50.50-112.00) 109.00 (70.00-115.00) 104.00 (69.00-120.00) 19.771 <0.001 Blood transfusion Whole blood transfusion/mL 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 1.209 0.751 Red blood cell/U 0.00 (0.00-2.00) 0.00 (0.00-2.50) 0.00 (0.00-2.00) 0.00 (0.00-4.00) 2.758 0.431 Platelet/U 0.00 (0.00-1.00) 0.00 (0.00-0.00) 1.00 (1.00-2.00) 1.00 (0.00-2.00) 23.867 <0.001 Coagulation factor/U 4.75 (2.00-6.00) 5.00 (3.88-6.00) 6.00 (5.75-8.00) 6.00 (4.00-7.00) 18.695 <0.001 Plasma/mL 300.00 (150.00-500.00) 400.00 (150.00-600.00) 600.00 (200.00-600.00) 400.00 (200.00-600.00) 8.612 0.035 Blood loss/mL 600.00 (400.00-1000.00) 800.00 (500.00-1000.00) 400.00 (0.00-1000.00) 750.00 (400.00-1200.00) 3.124 0.373 Anesthetics Etomidate/mg 20.00 (0.00-20.00) 10.00 (0.00-20.00) 0.00 (0.00-16.00) 12.00 (0.00-20.00) 8.653 0.034 Dexmedetomidine/μg 200.00 (200.00-200.00) 200.00 (200.00-400.00) 400.00 (200.00-400.00) 200.00 (200.00-400.00) 12.739 0.005 Propofol/mg 1100.00 (1000.00-2000.00) 1000.00 (1000.00-2000.00) 1100.00 (1000.00-2000.00) 1500.00 (1000.00-2000.00) 2.647 0.449 Midazolam/mg 5.00 (4.00-7.00) 5.00 (4.00-5.00) 5.00 (0.00-7.00) 5.00 (2.00-7.00) 0.857 0.836 Remimazolam/mg 0.00 (0.00-16.00) 0.00 (0.00-14.50) 10.00 (0.00-50.00) 0.00 (0.00-20.00) 2.800 0.423 Postoperative indicator/M (IQR) or $ \overline x \pm s $ White blood cell/109 L−1 11.82 (9.30-13.97) 10.65 (7.63-13.23) 9.11 (8.31-11.58) 10.42 (8.24-12.69) 5.191 0.158 Red blood cell/1012 L−1 3.77±0.50 3.95±0.48 3.61±0.46 3.67±0.53 2.269 0.082 Hemoglobin/(g/L) 112.59±15.05 114.85±12.78 106.62±13.93 109.16±15.82 1.629 0.184 Albumin/(g/L) 40.10 (37.30-43.30) 39.10 (36.60-44.00) 38.50 (36.20-39.40) 39.60 (37.80-42.10) 2.338 0.505 Total bilirubin/(μmol/L) 21.80 (15.20-35.00) 32.80 (23.45-40.85) 20.20 (15.90-30.30) 30.30 (21.10-43.20) 14.916 0.002 K/(mmol/L) 4.47 (4.24-4.64) 4.53 (4.22-4.80) 4.65 (4.39-5.06) 4.63 (4.35-4.92) 6.163 0.104 Na/(mmol/L) 142.20 (139.70-144.30) 142.40 (140.90-144.45) 143.70 (141.60-148.60) 143.90 (141.20-146.80) 14.285 0.003 Urea/(mmol/L) 6.98 (5.90-8.20) 7.10 (6.40-9.70) 9.96 (9.02-11.05) 9.14 (7.10-11.93) 32.173 <0.001 Creatinine/(μmol/L) 64.00 (51.00-80.00) 62.00 (55.00-74.50) 75.00 (55.00-104.00) 60.00 (47.00-81.00) 2.178 0.536 eGFR/(mL/[min·1.73 m2]) 103.62±26.08 99.39±22.36 82.99±33.72 100.09±23.23 2.587 0.054 NT-proBNP/(pg/mL) 891.00 (506.00-1533.00) 780.00 (622.00-1911.00) 2438.00 (1020.00-4769.00) 1305.00 (891.00-3438.00) 14.043 0.003 Duration of mechanical ventilation/h 14.00 (5.00-18.00) 17.00 (6.50-19.50) 19.00 (17.00-59.00) 19.00 (16.00-26.00) 39.504 <0.001 ICU stay/d 1.84 (1.01-2.14) 2.15 (1.49-3.34) 7.10 (4.65-18.64) 3.87 (2.07-9.78) 57.884 <0.001 eGFR: estimated glomerular filtration rate; hs-CRP: high-sensitivity C-reactive protein; NT-proBNP: N-terminal pro B-type natriuretic peptide; ICU: intensive care unit.
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Table 3. ไ Results of multinomial logistic regression for influencing factors of different statuses of POD and SSD
Variable SSD SSD→POD ND→POD OR 95% CI P OR 95% CI P OR 95% CI P Age 1.04 0.99-1.08 0.117 1.09 1.01-1.17 0.022 1.06 1.02-1.10 0.004 Highest education attained Junior or senior high school 0.36 0.11-1.18 0.093 4.98 0.38-64.66 0.220 0.35 0.15-0.83 0.017 College or bachelor's degree or above 0.85 0.20-3.63 0.822 11.02 0.42-286.06 0.149 0.38 0.11-1.31 0.126 ASA classification Ⅳ or above 1.78 0.36-8.81 0.482 10.72 1.85-62.08 0.008 2.34 0.82-6.67 0.110 Preoperative glucose 0.38 0.19-0.76 0.006 0.87 0.60-1.25 0.444 0.97 0.81-1.16 0.727 Intraoperative platelet transfusion 0.37 0.15-0.92 0.033 1.23 0.57-2.65 0.597 1.50 0.98-2.31 0.065 Etomidate 0.93 0.87-0.98 0.010 0.93 0.85-1.01 0.074 0.96 0.92-1.01 0.107 Dexmedetomidine 1.00 0.99-1.004 0.786 1.01 1.003-1.02 0.007 1.00 0.99-1.004 0.449 Postoperative total bilirubin 1.04 1.01-1.07 0.012 0.99 0.95-1.04 0.735 1.02 0.99-1.05 0.106 Duration of mechanical ventilation 1.03 0.99-1.07 0.059 1.04 1.01-1.07 0.003 1.04 1.01-1.07 0.007 OR: odds ratio; CI: confidence interval.
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