加護病房病人第一次發生譫妄前後的鎮靜負荷變化及其與無譫妄及昏迷天數之關聯

Abstract

研究背景與目的：譫妄是加護病房病人常見症狀，與轉出後的認知障礙和較長的住院天數相關。過去社區的研究發現較高的鎮靜負荷和譫妄的發生率相關，但尚未有研究探討加護病房病人發生譫妄後鎮靜負荷的變化以及其對於譫妄恢復的影響。此研究欲探討(1)加護病房病人初發譫妄前後24小時的鎮靜負荷變化以及(2)譫妄發生後的鎮靜負荷與其後七天無譫妄及昏迷天數之關聯。 研究方法：本研究採回溯性世代設計，使用2022年1月至12月間某醫學中心醫療整合資料庫的病歷資料進行分析。納入對象為在入加護病房後24小時之後發生譫妄，且接受機械通氣的成年病人。鎮靜負荷的計算採用修改版的 Sloane Model，根據病人的鎮靜藥物劑量及其鎮靜等級計算，並以加護病房常用鎮靜藥物的建議平均日維持劑量（rADMD）進行標準化。統計方面使用Wilcoxon 符號排序檢定分析譫妄前後鎮靜負荷的變化，並以Spearman等級相關性分析及負二項回歸分析檢視譫妄後鎮靜負荷與接下來七天內「無譫妄與昏迷天數」（DCFDs）之關聯。 研究結果：加護病房病人在第一次發生譫妄後的鎮靜負荷未顯著上升（n = 61），但在高活動力譫妄個案中，鎮靜負荷呈現一致上升的趨勢。譫妄發生後 24 小時內鎮靜負荷與其後無譫妄與昏迷天數（DCFDs）呈弱負相關；在有完整DCFDs資料的 48 位個案中，控制年齡、疾病嚴重程度與共病指數後，鎮靜負荷每增加一單位，DCFDs 平均減少約 37%。 結論：加護病房病人在初次發生譫妄後，整體鎮靜負荷並未顯著增加，可能與低活動力譫妄個案比例較高、RASS 持續波動及譫妄的多樣性表現有關。然譫妄發生後 24 小時內的鎮靜負荷與後續無譫妄及昏迷天數（DCFDs）呈負相關，顯示 較高的鎮靜負荷可能會影響短期認知功能的恢復。回歸分析發現，鎮靜負荷對 DCFDs 的影響顯著，而年齡與 APACHE II 等變項則未達統計顯著，顯示鎮靜負荷可能是譫妄恢復過程中較具調整潛力的介入目標。鎮靜負荷可作為加護病房病人實施 RASS 導引鎮靜策略時的輔助參考，未來研究可進一步探討在譫妄發生後適度控制鎮靜負荷是否能促進譫妄的恢復。

Background and Objectives: Delirium is a common complication among ICU patients, associated with post-ICU cognitive decline and prolonged hospitalization. While increased sedative load was found to be associated with incident delirium in community-dwelling older adults, little is known about how sedative load changes after ICU delirium onset and its association with short-term recovery. This study aimed to (1) assess changes in sedative load within 24 hours before and after the first delirium episode, and (2) examine the relationship between post-delirium sedative load and delirium- and coma-free days (DCFDs) over the subsequent 7 days. Methods: A retrospective cohort study was conducted using ICU data extracted from the integrative medical data center of a tertiary medical center, covering admissions between January and December 2022. Adult patients who developed delirium after the first 24 hours of ICU admission and received invasive mechanical ventilation were included. Sedative load was calculated using a modified Sloane Model, based on 24-hour sedative doses and sedation ratings, standardized to the recommended average daily maintenance dose (rADMD) for commonly used ICU sedatives. Wilcoxon signed-rank test were used to evaluate changes in sedative load before and after delirium onset. Spearman rank correlation and negative binomial regression were applied to examine associations between post-delirium sedative load and delirium- and coma-free days (DCFDs). Results: Among 61 patients, sedative load did not significantly increase after delirium onset overall but tended to rise in hyperactive cases. In the 48 patients with complete follow-up data, post-delirium sedative load demonstrated a weak negative correlation with delirium- and coma-free days (DCFDs), with each additional unit associated with a 37% decrease in DCFDs. Conclusion: Post-delirium sedative load did not significantly increase in this ICU cohort, likely due to the predominance of hypoactive delirium, the fluctuation of RASS levels, and the heterogeneous clinical presentations of delirium. However, higher sedative load within 24 hours after delirium onset was negatively associated with subsequent delirium- and coma-free days (DCFDs), suggesting a potential impact on short-term recovery. In multivariable analysis, sedative load remained a statistically significant predictor of DCFDs, whereas age and APACHE II score did not show significant associations. These findings suggest that sedative load may represent a modifiable target for intervention during the delirium recovery process. It may also serve as a useful adjunct when implementing RASS-based sedation strategies in ICU practice. Further research is needed to explore whether reducing sedative load after delirium onset can help facilitate recovery.