基于预防重症患者谵妄发生的最佳疼痛控制目标研究  

Optimal pain control goal for preventing delirium in critical patients

作　　者：秦运俭[1] 李颖[1] 陈剑琴[1] 曾凤华[1] 张红霞[1] Qin Yunjian;Li Ying;Chen Jianqin;Zeng Fenghua;Zhang Hongxia(Department of Intensive Care Unit,the First People's Hospital of Changde,Changde 415000,Hunan,China)

机构地区：[1]常德市第一人民医院重症医学科,湖南常德415000

出　　处：《中华危重病急救医学》2021年第1期84-88,共5页Chinese Critical Care Medicine

基　　金：湖南省常德市技术研究与开发项目(2016KZ05)。

摘　　要：目的探讨预防重症患者发生谵妄的最佳疼痛控制目标。方法采用前瞻性队列研究方法,选择2017年1月至2019年12月入住常德市第一人民医院普通科室,并因病情危重转入重症监护病房(ICU)治疗的患者作为研究对象。患者入院后48 h内收集一般资料;患者入住ICU后由管床护士应用重症监护疼痛观察工具(CPOT)每8 h评估1次疼痛程度,由护理组长在不知晓患者疼痛程度的情况下应用ICU意识模糊评估法(CAM-ICU)每8 h评估1次是否发生谵妄,直至患者转出ICU。绘制受试者工作特征曲线(ROC曲线),以是否发生谵妄为参考标准分析ROC曲线下面积(AUC)和最佳阈值;根据最佳阈值,采用多因素Logistic回归分析评价CPOT评分与谵妄发生的相关性。结果研究期间入住参与研究科室且根据纳入和排除标准通过初筛者575例,因资料不完整而剔除34例,最终541例患者纳入分析,其中谵妄组149例,非谵妄组392例。两组患者性别、年龄、患者来源、文化程度、吸烟史、饮酒史、家族精神病史及急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)等一般资料比较差异均无统计学意义;谵妄组有10.1%(15/149)的患者使用过阿片类药物,明显高于非谵妄组的4.3%(17/392),差异有统计学意义(P<0.05)。谵妄组CPOT评分显著高于非谵妄组(分:4.24±1.78比2.75±1.95,P<0.01);将患者按年龄分为青年组(<40岁)、中年组(40~65岁)和老年组(>65岁),分析结果与整体分析结果一致。ROC曲线分析显示,CPOT评分预测谵妄发生的AUC为0.719;当CPOT评分最佳阈值为2.5分时,敏感度为91.3%,特异度为49.0%,阳性预测值为40.5%,阴性预测值为93.7%。多因素Logistic回归分析显示,以CPOT评分3分为界值,ICU患者CPOT评分≥3分时,其谵妄发生风险是<3分者的10.043倍〔优势比(OR)=10.043,95%可信区间(95%CI)为5.498~18.345,P<0.001〕;调整患者的性别、年龄、APACHEⅡ评分、吸烟史、饮酒史、阿片类药物使用情Objective To study the optimal pain control goal for preventing delirium in critical patients.Methods A prospective cohort study were conducted.The patients admitted to general departments and transferred to the intensive care unit(ICU)due to critical illness in the First People's Hospital of Changde from January 2017 to November 2019 were enrolled.The General data of the patients were collected within 48 hours after admission.All patients admitted to the ICU were evaluated for pain level using the critical care pain observation tool(CPOT)every 8 hours by nurses,and confusion assessment method of ICU(CAM-ICU)was used to screen delirium patient every 8 hours by the leader of nursing team without knowing the pain level of the patients,until the subjects were transferred out of ICU.The receiver operating characteristic(ROC)curve was drawn,the area under ROC curve(AUC)and the optimal threshold were analyzed with delirium as the reference standard;according to the optimal threshold,multivariate Logistic regression analysis was used to evaluate the correlation between CPOT score and delirium.Results During the study period,575 patients were admitted to the participating departments and passed the preliminary screening according to the inclusion and exclusion criteria.During the study period,34 patients were excluded due to incomplete data.Finally,a total of 541 patients were enrolled in the analysis,including 149 patients in delirium group and 392 patients in non-delirium group.There was no significant difference in gender,age,source of patients,education level,smoking history,drinking history,family mental history,acute physiology and chronic health evaluationⅡ(APACHEⅡ)score or other general information between the two groups.There were 10.1%(15/149)of patients in the delirium group used opioids,which was significantly higher than 4.3%(17/392)in the non-delirium group,and the difference was statistically significant(P<0.05).The CPOT score in the delirium group was significantly higher than that in the non-delirium

关 键 词：重症监护疼痛观察工具 谵妄 重症监护病房意识模糊评估法 受试者工作特征曲线 重症护理 

分 类 号：R459.7[医药卫生—急诊医学]