非体外循环冠状动脉搭桥患者术前糖化血红蛋白水平与术后谵妄的关系

Relationship between preoperative glycosylated hemoglobin and postoperative delirium in patients following off-pump coronary artery bypass grafting

目的·研究非体外循环冠状动脉搭桥(off-pump coronary artery bypass surgery,OPCAB)患者术前糖化血红蛋白(hemoglobin A1c,HbA1c)水平与术后谵妄的关系,为进一步实施干预提供参考依据。方法·采用前瞻性研究,纳入上海交通大学医学院附属瑞金医院心脏外科收治的OPCAB手术患者364例,通过一般资料问卷、简易智力状态评估量表收集资料,通过ICU意识模糊评估量表、中文版3D-CAM谵妄量表评估术后谵妄。采用单因素分析,筛选出P<0.05的谵妄的危险因素后,再进行多因素Logistic回归分析。利用广义相加模型观察HbA1c水平与术后谵妄发生率的动态变化,并绘制受试者操作特征曲线(receiver operating characteristic curve,ROC curve),明确其界值。结果·OPCAB患者术后谵妄的影响因素有年龄、饮酒史、糖尿病、贫血、周围血管疾病、术前心功能分级、左室射血分数、白蛋白、HbA1c、术中输血、酸碱失衡、电解质紊乱。通过广义相加模型和多因素Logistic回归分析,结果显示术前HbA1c值越高,OPCAB患者术后谵妄的发生率越高。通过ROC曲线分析,确定当HbA1c值>6.45%时,OPCAB术后谵妄发生的风险随之增高。结论·对于接受OPCAB手术的患者,HbA1c值是术后谵妄的独立危险因素;随着HbA1c值的升高,谵妄的发生率也逐渐增高。提示OPCAB患者术前HbA1c值应尽量维持在正常水平。

Objective·To investigate the relationship between postoperative delirium and preoperative HbA1 c in patients with offpump coronary artery bypass grafting(OPCAB), so as to provide reference for further intervention. Methods·A prospective study was used to collect 364 surgical patients admitted to the Department of Cardiac Surgery in Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. The data were collected through the general information questionnaire and the simple mental status assessment scale, and the Confusion Assessment Method of Intensive Care Unit, and Chinese Version of 3-minute Diagnostic Confusion Assessment Method were used to assess postoperative delirium. Univariate analysis was used to screen out the risk factors for delirium with P<0.05, and then a multi-factor Logistic regression analysis was used. The generalized additive model was used to observe the dynamic changes of HbA1 c and the incidence of postoperative delirium, and the receiver operating characteristic(ROC) curve was drawn to clarify the boundary value. Results·The influencing factors of postoperative delirium in OPCAB patients were age, alcohol use, peripheral vascular disease, NYHA function classification, LVEF, albumin, HbA1 c, intraoperative blood transfusion, acid-base imbalance, and electrolyte imbalance. The generalized additive model and multivariate Logistic regression analysis showed that the higher the preoperative HbA1 c, the higher the incidence of postoperative delirium in OPCAB patients.Through ROC curve analysis, it was determined that when the HbA1 c>6.45%, the risk of delirium after OPCAB increased accordingly. Conclusion·For patients undergoing OPCAB surgery, HbA1 c is an independent risk factor for postoperative delirium.With the increase of HbA1 c, the incidence of delirium gradually increases, suggesting that the preoperative HbA1 c of OPCAB patients should be maintained at a normal level.