心脏术后 ICU患者继发谵妄的研究进展

Progress in the study of secondary delirium in ICU patients after cardiac surgery

我国人口日益老龄化,心血管疾病的发病率呈现出了逐年上升的趋势,越来越多的患者需要接受针对心脏的手术治疗。谵妄是心脏术后重症监护病房(ICU)患者常见的一种有着严重精神症状的临床综合征,心脏术后ICU患者继发谵妄会延长患者的机械通气时间,导致患者陷入长期认知缺陷,延长其住院时间,增加病死率,影响患者预后。目前,谵妄发生的病理生理机制仍不明确,但已经有一些研究揭示了心脏术后ICU患者继发谵妄的影响因素。这些因素包括术前已经存在的高危因素,如高龄、高血压、糖尿病、房颤等;术中改变的影响因素,如心功能障碍、手术和体外循环的时间长、微栓子的形成等;以及术后的影响因素,如ICU特殊环境刺激、体内电解质紊乱、疼痛控制不良等。本文对心脏术后ICU患者继发谵妄的影响因素、诊断评估工具、预防和护理措施进行了总结,希望临床医务人员通过掌握诊断和评估谵妄的工具,有效识别和管理诱发谵妄的影响因素,并在常规治疗及护理基础上,采取药物或非药物预防措施,实施ABCDEF集束化护理方案(A:评估、预防和管理疼痛;B:每日自发觉醒试验和自主呼吸试验;C:镇痛剂及镇静剂的选择;D:评估、预防和管理谵妄;E:早期活动和锻炼;F:家庭成员参与),预防心脏术后ICU患者谵妄的发生,减少谵妄的持续时间,改善患者的预后。

Objective Our population is increasingly ageing,the incidence of cardiovascular diseases has shown a rising trend year by year,more and more patients need to receive the heart surgical treatments.Delirium is a common clinical syndrome with severe psychiatric symptoms in postoperative cardiac intensive care unit(ICU)patients.Secondary delirium in postoperative cardiac ICU patients prolongs the duration of mechanical ventilation,leads to long-term cognitive defi cits,prolongs hospitalization,increases the mortality rate,aff ects the prognosis of patients.At present,the pathophysiologic mechanisms underlying the development of delirium are still unclear,but a number of studies have revealed the factors infl uencing secondary delirium in postoperative cardiac ICU patients.These factors include high-risk factors that already existed preoperatively,such as advanced age,hypertension,diabetes mellitus,and atrial fi brillation;intraoperative altered infl uencing factors,such as cardiac dysfunction,prolonged duration of surgery and extracorporeal circulation,and microembolism;and postoperative influencing factors,such as special environmental stimuli in the ICU,electrolyte disorders in the body,and bad pain control.This article summarizes the influencing factors,diagnostic and assessment tools,preventive and nursing measures of secondary delirium in ICU patients after cardiac surgery,hoping that clinical medical staff can eff ectively identify and manage the infl uencing factors that induce delirium by mastering the tools for diagnosing and assessing delirium,and take pharmacological or non-pharmacological preventive measures based on conventional treatment and nursing care,and implement the ABCDEF cluster nursing program(A:Assessment,prevention and management of pain.B:Daily spontaneous awakening test and autonomous breathing test.C:Choice of analgesic and sedative.D:Assessment,prevention and management of delirium.E:Early activity and exercise.F:Participation of family members),to prevent the occurrence of delirium in post-cardiac surgery ICU patients,to reduce the duration of delirium,and to improve the prognosis of patients.