外科Apgar评分预测开腹大手术后谵妄的回顾性病例对照研究

A retrospective case-control study on surgical Apgar score in predicting delirium after major open abdominal surgery

目的:回顾性分析开腹大手术术后谵妄的危险因素,并探索外科Apgar评分(Surgical Apgar Score,SAS)对术后谵妄的预测价值。方法:收集火箭军特色医学中心2015年1月至2016年12月具有完整术后谵妄相关记录的接受开腹大手术的320例患者的术前和术中临床资料,根据术中最低平均动脉压(mean arterial pressure,MAP)、最低心率(heart rate,HR)和术中出血量计算SAS值。根据是否发生术后谵妄分为非谵妄组和谵妄组。选择两组间比较有差异的变量,通过多因素logistic回归分析探索术后谵妄的危险因素。绘制SAS评分判断术后谵妄的受试者工作特征曲线(receiver operating characteristic curve,ROC),计算曲线下面积、最佳临界值、灵敏度和特异性。结果:320例患者中有128例患者发生了术后谵妄,发生率为40.0%。多因素Logistic回归分析发现,年龄≥65岁[P=0.013,校准后OR(优势比)=1.972]、术前凝血功能障碍(P=0.002,校准后OR=2.425)、糖尿病(P=0.030,校准后OR=2.128)是术后谵妄发生的危险因素。随着SAS评分升高,谵妄发生风险下降(P<0.001,校准后OR=0.754)。SAS评分预测术后谵妄的曲线下面积为0.648,95%置信区间为0.587~0.709,临界值为6分,灵敏度为76.0%,特异度为71.1%。结论:术中SAS≤6分有助于预测开腹大手术术后谵妄的发生,但预测效能较弱。

Objective:To retrospectively analyze the risk factors for postoperative delirium in patients after major open abdominal surgery and to explore the predictive value of Surgical Apgar Score(SAS)for postoperative delirium.Methods:We retrospectively collected preoperative and intraoperative clinical data from 320 patients who had undergone major open abdominal surgery between January 2015 and December 2016 in our hospital,and calculated the SAS.SAS was calculated based on the lowest mean arterial pressure(MAP),lowest heart rate(HR)and estimated blood loss in surgery.The patients were assigned into two groups,a delirium group and a non-delirium group,depending on whether postoperative delirium developed or not.Different variables between the two groups were selected,and multi-variate Logistic regression analysis was employed to detect the independent risk factors for postoperative delirium.The area under the curve(AUC)from the receiver operating characteristic curve(ROC)was used to detect the SAS’s discriminatory power for postoperative delirium.The optimal cut-off value and corresponding sensitivity and specificity were also calculated.Results:Postoperative delirium occurred in 128 patients of 320 patients,with an incidence rate of 40%.The multi-variate Logistic regression analysis showed that ages over 65 years[P=0.013,adjusted OR(odds ratio)=1.972],preoperative coagulation dysfunction(P=0.002,adjusted OR=2.425),diabetes(P=0.030,adjusted OR=2.128)were independent risk factors for postoperative delirium.The risk of delirium was decreased as the SAS increased(P<0.001,adjusted OR=0.754).After the surgery,the area under curve was 0.648(95%confidence interval,0.587~0.709),and the optimal cut-off was 6 with a sensitivity of 76.0%and a specificity of 71.1%,according to the prediction of SAS scores.Conclusion:Surgical Apgar score≤6 has a limited predicting power for postoperative delirium in patients undergoing open abdominal surgery.