心臟手術後病人譫妄發生率、類型和嚴重度之探討

Abstract

手術後老人發生譫妄的機會比一般住院病人要來的高。人口老化的問題日益嚴重，未來幾十年裡，術後病患發生譫妄的議題將會越來越重要。除此之外，手術的預定與否，造成譫妄的發生情形也不盡相同。 本研究共完成62位術後十天譫妄評估。其中預定手術者52位，非預定手術者10位。術後第1天至術後第10天，使用CAM和CAM-ICU作譫妄評估；若有譫妄者，進一步使用DMSS作譫妄類型評估和DRS-R-98作譫妄嚴重度評估，同時也收集人口學和手術相關資訊 進行分析。 研究結果顯示：術後十天內譫妄發生率為25.8 %。譫妄好發時間主要為術後第1~2天，佔75%；其次為術後第6~7天，佔25%。譫妄類型以低活動型和混合型譫妄為主，50%為低活動型譫妄，31.3%為混合型譫妄。譫妄時嚴重度分數平均為13.5+/-3.1分，不同類型譫妄和嚴重度間在統計上無顯著差異。 預定手術譫妄發生率為23.1 %，有低於非預定手術之譫妄發生率40 %的趨勢。當進一步使用邏輯斯迴歸作危險因子分析，建議模型選項包括年齡、男性、術前MMSE低者（≦23分）和EurosocreⅡ總分（%），並透過ROC進行檢定有92.9%的預測力（p<0.01）。 從本研究可知，心臟手術後每4人就有1人出現譫妄的問題。其中發生譫妄的高峰期為術後第1~2天和術後第6~7天。臨床上應加強術後譫妄的評估，尤其當面對老年人、男性、術前MMSE分數較低者和EuroscoreⅡ總分較高者更應特別留意。

Postoperative delirium (POD) is a common and serious adverse event in hospitalized patients, participarly for patients undergoing cardiac surgery. Understandings of incidence, subtype, and sverity of delirium in patients undergoing cardiac surgery, however, are limited. Whether the surgery is elective or non-elective might also affect the incidence of delirium. We enrolled 62 patients (aged 20 years and older) who were undergoing cardiac surgery with 52 scheduled for elective surgery and 10 were non-elective. The POD was assessed daily by a trained nurse practitioner using the confusion assessment method (CAM) or ICU-CAM up to 10 days following cardiac surgery. The delirium motor subtypes (DMSS) and Delirium Rating Scale Revised-98 (DRS-R98) were used to assess the subtype and severity. Demographics and clinical factors were also collected as coveriates. The results shown that POD occurred in 25.8% (n=16) of the sample. Majority of participants (12/16; 75%) experienced POD on 1st day or 2nd day after surgery. Another peak for POD was observed on 6th or 7th days after surgery with 4 participants being screened positive (4/16, 25%). Overall, hypoactive subtype was most common (50%) and followed by the mix motor subtypes (31.3%). The mean severity score of delirium was 13.5+/-3.1 points, but there was no significant correlation between the delirium subtype and severity scores. For elective v.s. non-elective surgery, the rate of POD was slightly higher for non-elective surgery (23.1% vs. 40%, respectively). To identify risk factors, the logistic regression model indicated that older age, male gender, per-surgical mini-mental state examination scores≦23, and higher Euroscore II (%) were predictive of POD. The power of the model's predicted values to discriminate between positive and negative cases was 92.9%, which was quantified by the Area under the ROC curve and suggestive of a high discriminating power (p<0.01). The findings suggested that POD occurred frequently, one in four patients undergoing cardiac surgery experienced POD. The POD occurred at two peak time points and could occurr as late as on the 7th day after surgery. Attention should be paid to rountinly screen for POD, participarly for patients who are older, male gender, had lower MMSE at baseline, and scored higher in the Euroscore II system.