60岁以上结直肠癌患者术后谵妄的危险因素和临床结局

Risk factors and outcomes of postoperative delirium in colorectal cancer patients over 60 years

目的探讨60岁以上结直肠癌患者术后谵妄的发生率、高危因素及临床结局。方法前瞻性纳入2013年6月至2016年6月间深圳市第二人民医院连续收治的382例≥60岁结直肠癌手术患者，采用意识模糊评估量表对术后谵妄进行筛查，每日评估1次，持续7 d。比较术后谵妄与非谵妄患者的并发症发生率、术后住院时间和术后30 d病死率。并采用Logistic回归模型对术后谵妄的危险因素进行多因素分析。结果全组382例结直肠癌患者中男230例，女152例，中位年龄67（60-92）岁；结肠癌213例，直肠癌169例。术后46例（12.0%）出现谵妄，其中78.3%（36/46）出现在术后3 d以内。谵妄患者较无谵妄者术后并发症发生率升高[30.4%（14/46）比17.3%（58/336），P = 0.032]，病死率升高[6.5%（3/46）比1.8%（6/336），P = 0.047]，术后住院时间延长（中位数：14 d比9 d，P = 0.008）。单因素分析结果显示，高龄、男性、合并症较多、手术风险较大、术前白蛋白较低、有精神病史、有脑血管病史、酗酒、围手术期输血、术后转ICU者术后谵妄风险增加（均P 〈 0.05）。多因素分析证实，高龄（OR = 1.06，95%CI：1.01-1.13）、有精神疾病史（OR = 10.89，95%CI：2.73-41.59）和围手术期输血（OR = 2.37，95%CI：1.11-7.32）是术后谵妄的独立危险因素。结论术后谵妄在结直肠癌手术后较为常见，且术后谵妄具有较高的并发症发生率和病死率。有必要将谵妄的术前风险评估和术后筛查工具纳入临床常规。对于高龄、既往有精神病史、接受围手术期输血等术后谵妄高危患者，应予以积极的综合性干预措施。

Objective To determine the incidence, risk factors and clinical outcomes of postoperative delirium in eolorectal cancer patients over 60 years. Methods Consecutive 382 patients older than 60 years undergoing colorectal cancer surgery at Shenzhen Second People＇s Hospital from June 2013 to June 2016 were recruited prospectively in this study. These patients were evaluated daily after surgery for 7 days by confusion assessment method. Clinical outcomes were compared between patients with and without postoperative delirium, including postoperative complications, length of hospital stay, and mortality within 30 days. Logistic regression analysis was used to identify independent predictors of postoperative delirium. Results There were 230 male and 152 female patients with median age of 67 （range 60 to 92） years. Among them, 213 had colon cancer and 169 had rectal cancer. Postoperative delirium developed in 46 （12.0%） patients, and most deliriums （78.3%） were diagnosed within 3 days after surgery. Patients with postoperative delirium had more complications [30.4%（14/46） vs. 17.3%（58/336）, P=0.032], higher mortality [6.5% （3/46） vs. 1.8% （6/336）, P = 0.047 ], and longer postoperative hospital stay （median 14 days vs. 9 days, P = 0.008）. Univariate analysis revealed that advanced age, male, higher Charlson comorbidity index, higher American Society of Anesthesiologists Classification, lower preoperative blood albumin concentration, history of psychiatric disease, history of cerebrovascular disease, alcohol abuse, emergent operation, and perioperative blood transfusion were significantly related to the development of postoperative delirium. Logistic regression analysis identified that advanced age （OR = 1.06, 95%CI： 1.01 to 1.13）, history of psychiatric disease （OR = 10.89, 95%CI： 2.73 to 41.59） and perioperative blood transfusion （OR -- 2.37, 95%CI： 1.11 to 7.32） were independent risk factors of postoperative delirium. Conclusions Postoperative delirium is relatively common in elderly patients over 60 years undergoing colorectal cancer surgery. The high morbidity of postoperative complication and mortality associated with postoperative delirium warrant implementation of preoperative risk assessment and postoperative screening protocol for postoperative delirium. Comprehensively preventive strategies should be carried out for high-risk patients, e.g. advanced age, history of psychiatric disease, and perioperative blood transfusion.