譫妄與重症系統性乏力對於加護病房病人三個月死亡率與住院天數之影響

Abstract

背景 譫妄和重症系統性乏力是加護病房病人常見的併發症。本研究旨在調查譫妄和重症系統性乏力的發生率，以及它們對三個月死亡率和住院時間的影響。 方法 本研究為一項單中心前瞻性隊列研究，使用來自「加護病房出院後一年的生理活動功能恢復」研究計畫案之數據。於北部某醫學中心的六個加護病房，以連續取樣之方式，收集年齡≥20歲之病人。在病人加護病房住院期間每日評估譫妄持續14天（或直至死亡或出院），使用的工具為CAM-ICU-7，並分析譫妄的嚴重程度。根據病人在14天內的平均CAM-ICU-7分數分為三組：無譫妄（CAM-ICU-7分數0-2），輕度譫妄（CAM-ICU-7分數3-5），和重度譫妄（CAM-ICU-7分數6-7）。之後，在病人轉出加護病房的48小時內評估有無重症系統性乏力，使用的工具為MRC量表。該量表對六個肌群進行評估（MRC得分範圍為0到60）。根據MRC總分，病人被進一步分類為無重症系統性乏力（MRC得分>48）、輕度重症系統性乏力（MRC得分36-48），和重度重症系統性乏力（MRC得分<36）。這些病人在轉出加護病房三個月後再次評估三個月死亡率和住院時間。 結果 在248名病人中，平均年齡為65.7歲，55.2%為65歲以上的病人，41.5%使用呼吸器，平均使用呼吸器的時間為7.4天。在加護病房住院期間的14天內，107名病人（43.1%）為譫妄，55位病人（22%）在轉出加護病房後出現了重症系統性乏力。雖然加護病房譫妄與三個月死亡率無顯著相關，但重度譫妄與三個月內死亡風險增加2.09倍有關（aHR= 2.09，95% CI= [1.06, 4.14]，p= 0.033），以及住院天數增加19.24天（adjusted β= 19.24，95% CI= [9.78, 28.7]，p< 0.001）。患有重症系統性乏力的病人，在三個月內死亡的風險是沒有重症系統性乏力的2.86倍（aHR=2.86；95% CI=[1.51,5.42]），重度重症系統性乏力與三個月內死亡風險增加7.32倍有關（aHR=7.32，95% CI=[3.15, 17.03]，p<0.001），且和更長的住院天數有關（adjusted β=19.88；95% CI=[10.54,29.21], p< 0.001）。然而，重度的重症系統性乏力與住院天數之間沒有顯著相關。 結論 重度譫妄和加護病房出院後三個月內較高死亡率以及更長的住院天數有關。此外，重症系統性乏力與三個月內較高的死亡風險及更長的住院天數有關，然而其嚴重程度對住院天數的影響各異。輕度的重症系統性乏力顯著增加住院天數，而重度重症系統性乏力則和更長的住院天數彼此沒有顯著相關。未來的研究需進一步探討有效的預防或介入方法，以減少這些加護病房病人發生譫妄和重症系統性乏力。

BACKGROUND＆OBJECTIVES: Delirium and weakness are both common complications of critical illness acquired in intensive care units (ICUs). This study aims to investigate the incidence of ICU delirium and ICU-acquired weakness (ICUAW) as well as their effects on 3-month mortality and hospital length of stay (LOS) in critically ill patients. METHODS: This is a single-center prospective cohort study using data from a Functional Improvement for ICU Survivors project. Consecutive patients (aged ≥20 years) admitted to six medical ICUs of a university-affiliated tertiary hospital were recruited. ICU delirium was measured using the Confusion Assessment Method (CAM-ICU-7) daily for 14 days (or until death or ICU discharge). Delirium severity were further analyzed, participants were categorized into three groups based on their average CAM-ICU-7 scores in 14 days: no delirium (CAM-ICU-7 scores 0-2), mild delirium (CAM-ICU-7 scores 3-5), and severe delirium (CAM-ICU-7 scores 6-7). Lastly, participants who survived and discharged from the ICUs were assessed for weakness using the Medical Research Council (MRC) scale for Muscle Strength at six parallel muscle group (summed MRC score range from 0 to 60) within 48 hours of ICU discharge. ICUAW severity were also further analyzed, participants were categorized into no ICUAW, mild ICUAW (MRC scores 36-48), and severe ICUAW (MRC scores <36), based on their summed MRC scores. These survivors were evaluated again for 3-month mortality and hospital LOS after their ICU discharge. RESULTS: With a total of 248 survivors, participants had a mean (SD) age of 65.7 years, 55.2% were ≥65 years old, and 41.5% receiving mechanical ventilation with an average 7.4 day of ventilation duration. During the first 14 days of their ICU stay, 107 participants (43.1%) experienced delirium, and ICUAW was present in 55 of the participants (22%) after ICU discharge. While ICU delirium was not significant associated with three-month mortality, severe delirium was associated with a 2.09-fold higher risk of death in three months (adjusted hazard ratio (aHR)= 2.09, 95% CI= [1.06, 4.14], p= 0.033), as well as a 19.24-days longer hospital LOS (adjusted β= 19.24, 95% CI= [9.78, 28.7], p< 0.001). Participants who developed ICUAW had a 2.86-fold higher risk of death in three months (aHR=2.86; 95% CI=[1.51,5.42]), and severe ICUAW was associated with a 7.32-fold higher risk of death in three months (aHR=7.32, 95% CI=[3.15, 17.03], p<0.001). Also, incident ICUAW was associated with longer hospital LOS (adjusted β=19.88; 95% CI=[10.54,29.21], p<0.001). However, there were no significant findings between severe ICUAW with prolonged hospital LOS. CONCLUSION: Severe delirium in critically ill patients is a strong predictor of higher mortality within three months after ICU discharge and contributes to prolonged hospitalization. Additionally, weakness in critical illness is associated with a higher risk of 3-month mortality and prolonged hospital LOS following ICU discharge. Our findings indicate that while ICUAW is associated with prolonged hospital LOS, its severity shows varying impacts. Mild ICUAW significantly extends hospital stays, whereas severe ICUAW does not. Further research is required to investigate adequate prevention or intervention methods to mitigate the development of delirium and weakness among these survivors.