脓毒症患者远期认知功能影响因素的临床研究

Clinical study on the factors associated with long-term cognitive function in patients with sepsis

目的探讨脓毒症患者远期认知功能障碍的发生情况及影响因素。方法选择2014年7月至2017年9月天津市第三中心医院重症医学科(ICU)收治的脓毒症患者,采用蒙特利尔认知评估量表(MoCA)对其出院后3、12、24个月认知功能进行随访,根据12个月MoCA评分将患者分为认知功能障碍组(MoCA评分<26分)及认知功能正常组(MoCA评分≥26分)。记录两组患者一般情况及相关临床资料,将单因素分析中差异有统计学意义的变量纳入二元Logistic回归分析,筛选脓毒症患者发生远期认知功能障碍的影响因素。结果研究期间共收治脓毒症患者1 748例,210例存活出院,最终125例患者参与随访。在出院后3、12、24个月时分别有61.6%(77/125)、54.4%(56/103)以及54.2%(39/72)的患者发生认知功能障碍。103例完成12个月随访患者MoCA评分较3个月时明显升高(分:23.4±5.7比23.0±6.0,P<0.01);72例完成24个月随访患者MoCA评分较12个月时略有下降(分:23.6±5.4比23.7±5.0,P>0.05)。随访12个月时认知功能正常组47例,认知功能障碍组56例。与认知功能正常组比较,认知功能障碍组女性患者更多〔51.8%(29/56)比31.9%(15/47)〕,年龄更大(岁:66.1±15.9比52.4±18.9),接受教育时间更短(年:7.6±4.0比11.2±3.1),谵妄持续时间更长〔d:2(0,3)比0(0,1)〕,差异均有统计学意义(均P<0.05);而两组患者婚姻状况、感染严重程度、基础疾病、转入途径、总住院时间、ICU住院时间、入ICU 24 h内急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA)、查尔森合并症指数(CCI)评分以及低氧血症、低血压、机械通气、血液滤过、药物使用情况等差异均无统计学意义。二元Logistic回归分析显示:接受教育时间为脓毒症患者随访12个月时发生认知功能障碍的保护因素〔优势比(OR)=0.791,95%可信区间(95%CI)=0.678~0.923,P=0.003〕,年龄和谵妄持续时间为危险因素(年龄:OR=1.038,95%CI=1.009~1.068,P=0.010;谵妄持续时间:OR=1.314,95%CI=1.002~1.724,P=0.048)。结论超过半数的脓毒症患者在出院后发生远期认知功能障碍,随时间推移有所改善;接受教育时间为脓毒症患者发生远期认知功能障碍的保护因素,而年龄及谵妄持续时间为危险因素。

Objective To investigate the occurrence and influencing factors of long-term cognitive impairment in patients with sepsis.Methods The septic patients admitted to intensive care unit(ICU)of Tianjin Third Central Hospital from July 2014 to September 2017 were enrolled.Montreal cognitive assessment scale(MoCA)was used to assess the cognitive function of patients at 3,12 and 24 months after discharge from hospital.The patients were divided into cognitive impairment group(MoCA score<26)and normal cognitive function group(MoCA score≥26)according to the MoCA scores at 12 months after discharge from hospital.The basic characteristics and clinical data were recorded in both groups,the variables with statistical significance in univariate analysis were enrolled in bivariate Logistic regression analysis,and the influencing factors of cognitive impairment in patients with sepsis were screened.Results During the study period,1 748 patients with sepsis were admitted,210 survived and discharged,and 125 patients participated in the follow-up.Cognitive impairment occurred in 61.6%(77/125),54.4%(56/103)and 54.2%(39/72)of the septic patients at 3,12 and 24 months after discharge,respectively.The MoCA score of 103 patients who completed 12-month follow-up was significantly higher than that of 3-month follow-up(23.4±5.7 vs.23.0±6.0,P<0.01);the MoCA score of 72 patients who completed 24-month follow-up was only slightly lower than that of 12-month follow-up(23.6±5.4 vs.23.7±5.0,P>0.05).Following up for 12 months,47 patients were enrolled in the normal cognitive function group and 56 in the cognitive impairment group.Compared with the normal cognitive function group,the cognitive dysfunction group had more female[51.8%(29/56)vs.31.9%(15/47)]and older patients(years old:66.1±15.9 vs.52.4±18.9),also had shorter time to receive education(years:7.6±4.0 vs.11.2±3.1),longer duration of delirium[days:2(0,3)vs.0(0,1)],with significant differences(all P<0.05).There was no significant difference in the marital status,severity of infection,underlying diseases,routes of transfer,total length of hospital stay,the length of ICU stay,acute physiology and chronic health evaluationⅡ(APACHEⅡ)score,sequential organ failure assessment(SOFA)score,Charlson comorbidity index(CCI)score within 24 hours of admission to ICU,hypoxemia,hypotension,mechanical ventilation,hemofiltration,or drug use between the two groups.Bivariate Logistic regression analysis showed that the duration of education was a protective factor for cognitive impairment in patients with sepsis who were followed up for 12 months[odds ratio(OR)=0.791,95%confidence interval(95%CI)=0.678-0.923,P=0.003],and age and duration of delirium were risk factors(age:OR=1.038,95%CI=1.009-1.068,P=0.010;duration of delirium:OR=1.314,95%CI=1.002-1.724,P=0.048).Conclusions Long-term cognitive impairment occurs in many septic patients after discharge and improves over time.Duration of education is a protective factor for cognitive impairment in patients with sepsis,while age and delirium duration are risk factors.