ICU谵妄患者临床脑功能监测指标的探索：一项前瞻性病例对照研究

Explore objective clinical variables for detecting delirium in ICU patients： a prospective case-control study

目的 探讨诊断重症加强治疗病房（ICU）患者谵妄的临床客观指标.方法 采用前瞻性病例对照研究方法,选择2015年10月至2016年5月北京大学人民医院收治的因病情危重转入ICU、需要呼吸机辅助通气治疗的术后成人患者.首先对患者进行Richmond躁动-镇静评分（RASS）,若RASS≥-2分则依据ICU意识模糊评估法（CAM-ICU）将患者分为谵妄组和对照组.入ICU当日用多功能监护仪连续监测患者脑电参数（左右脑偏侧、脑内敛、脑活性、脑耗能、内专注、外专注、脑抑制、疲劳、睡眠轻重、镇静指数、疼痛指数、焦虑指数、烦躁指数、紧张指数和谵妄指数）和脑血流参数（灌注指数）,记录患者既往史,测定血常规、血气分析、血生化指标以及预后指标.用二元逻辑回归方法进行谵妄的多因素分析.结果 共纳入43例患者,谵妄组18例,对照组25例.谵妄组除外伤比例显著高于对照组外（33.3%比4.0%,P=0.031）,两组患者性别、年龄、体温、心率、呼吸频率、平均动脉压和急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分以及器官衰竭、痴呆、急诊手术等与谵妄相关的指标差异均无统计学意义.与对照组比较,谵妄组脑电、脑血流参数除脑活性显著升高外〔122.47（88.62,154.21）比89.40（86.27,115.97）,P=0.034〕,其余指标差异均无统计学意义;在血气分析指标中,除pH值显著降低（7.43±0.42比7.47±0.31,P=0.003）,Cl^-浓度（mmol/L：114.66±4.32比111.90±3.08,P=0.019）、Mg2＋浓度（mmol/L：0.60±0.10比0.54±0.06,P=0.035）及血渗透浓度〔mmol/L：290.10（284.15,306.35）比282.70（280.20,286.75）,P=0.014〕显著升高外,其余指标差异均无统计学意义.与对照组比较,谵妄组机械通气时间〔d：125.0（49.0,293.0）比149.5（32.0,251.3）〕、ICU住院时间〔d：216.5（50.5,360.8）比190.0（72.0,330.5）〕和病死率（22.2%比24.0%）差异均无统计学意义（均P〉0.05）.多因素逻辑回归分析显示,pH值〔优势比（OR）=1.446,95%可信区间（95%CI）=1.116-1.875,P=0.005〕、Cl^-浓度（OR=0.708,95%CI=0.531-0.945,P=0.019）是谵妄的潜在危险因素.结论 脑活性指标有助于谵妄的临床诊断,但仍需进一步验证;pH值、Cl^-浓度可能是谵妄发生的潜在危险因素.

Objective The aim of this case-control study is to explore clinical objective variables for diagnosing delirium of intensive care unit （ICU） patients.Methods According to the method of prospective case-control study, critical adult postoperative patients who were transferred to ICU of Peking University People＇s Hospital from October 2015 to May 2016 and needed mechanical ventilation were included. After evaluating the Richmond agitation sedation scale score （RASS）, the patients whose score were -2 or greater were sorted into two groups, delirium and non-delirium, according to the confusion assessment method for the ICU （CAM-ICU）. Then these patients were observed by domestic multifunctional detector for electroencephalographic （EEG） variables such as brain lateralization, brain introvert, brain activity, brain energy consumption, focus inward, focus outward, cerebral inhibition, fatigue, sleep severity, sedation index, pain index, anxiety index, fidgety index, stress index and the cerebral blood flow （CBF） index which was named of perfusion index. Other variables including indexes of ICU blood gas analysis, which was consisted of variables of blood gas analysis, routine blood test and biochemistry, previous history and prognostic outcome was recorded. Binary logistic regression was used for multivariate analysis.Results Forty-three postoperative patients, who needed intensive care, were included. Eighteen were in delirium group and twenty-five in control group. Excluding the trauma, variables like gender, age, temperature, heart rate, respiratory rate, mean arterial pressure, acute physiology and chronic health evaluationⅡ（APACHEⅡ） score, organ failure, dementia and emergency surgery didn＇t show any statistical significance between two groups. The trauma in delirious patients increased obviously compared with the control group （33.3% vs. 4.0%,P = 0.031）. Except for the brain activity [122.47 （88.62, 154.21） vs. 89.40 （86.27, 115.97）,P = 0.034], there were no statistical differences in any other EEG and CBF variables. In ICU blood gas analysis, only pH value （7.43±0.42 vs. 7.47±0.31,P =0.003）, chloride concentration [Cl^- （mmol/L）： 114.66±4.32 vs. 111.90±3.08,P = 0.019], magnesium concentration [Mg2＋ （mmol/L）： 0.60±0.10 vs. 0.54±0.06,P = 0.035] and blood osmolality [mmol/L： 290.10 （284.15, 306.35） vs. 282.70 （280.20, 286.75）,P = 0.014] were statistically significant. Compared with control group, the prognostic variables in delirium group such as duration of mechanical ventilation [days： 125.0 （49.0, 293.0） vs. 149.5 （32.0, 251.3）], length of stay in ICU [days： 216.5 （50.5, 360.8） vs. 190.0 （72.0, 330.5）] and mortality rate （22.2% vs. 24.0%） didn＇t appear to be statistically significant either （allP 〉 0.05）. It was shown by multivariate logistic regression analysis that pH [odds ratio （OR） = 1.446, 95% confidence interval （95%CI） = 1.116-1.875,P = 0.005] and Cl^- （OR= 0.708, 95%CI =0.531-0.945,P = 0.019） were potential risk factors of delirium.Conclusions The brain activity of HXD_Ⅰ may contribute to the clinical diagnose of delirium, but it still remained to be proved further. The pH and Cl^- are potential risk factors of delirium.