Opioid Use Increases the Risk of Delirium in Critically Ill Adults Independently of Pain
Opioid Use Increases the Risk of Delirium in Critically Ill Adults Independently of Pain
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DOI：
10.1164/rccm.202010-3794oc
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发表时间：
2021-09-01
影响因子：
24.7
通讯作者：
Slooter, Arjen J. C.
中科院分区：
文献类型：
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作者：
Duprey, Matthew S.;Dijkstra-Kersten, Sandra M. A.;Slooter, Arjen J. C.
理由：目前尚不清楚阿片类药物的使用是否会增加ICU精神错乱的风险。以前的研究还没有考虑混杂因素，包括日常疾病的严重程度、疼痛和可能阻止检测到精神错乱的相互竞争的事件。目的：评估ICU阿片类药物暴露、阿片类药物剂量和精神错乱发生之间的关系。方法：在连续入院超过24小时的成年人中，日常精神状态被归类为清醒而没有精神错乱、精神错乱或无法唤醒。采用多项Logistic回归分析的一阶马尔可夫模型考虑了四种可能的第二天结果(即清醒而没有精神错乱、精神错乱、清醒和ICU出院或死亡)和11个与精神错乱相关的协变量(基线：入院类型、年龄、性别、急性生理学和慢性健康评估IV评分和Charlson共病评分；每日：ICU天数、改良序贯器官衰竭评估、呼吸机使用、苯二氮卓类药物使用和严重疼痛)。这一模型被用来量化阿片类药物使用、阿片类药物剂量和第二天精神错乱发生之间的关系。测量和主要结果：4,075名成人ICU天数为26,250天，57.0%(n=14,975)使用阿片类药物，7.0%(n=1,829)出现剧烈疼痛，23.5%(n=6,176)出现妄想。剧烈疼痛与转化为精神错乱呈负相关(优势比[OR]0.72；95%可信区间[CI]，0.53-0.97)。清醒而无精神错乱的患者服用任何阿片类药物都与第二天精神错乱的风险增加相关[OR，1.45；95%CI，1.24-1.69]。每天静脉注射相当于10毫克吗啡的剂量与第二天精神错乱的风险增加2.4%相关。结论：在ICU接受阿片类药物增加了转化为精神错乱的几率，并呈剂量依赖关系。
Rationale: It is unclear whether opioid use increases the risk of ICU delirium. Prior studies have not accounted for confounding, including daily severity of illness, pain, and competing events that may preclude delirium detection.Objectives: To evaluate the association between ICU opioid exposure, opioid dose, and delirium occurrence.Methods: In consecutive adults admitted for more than 24 hours to the ICU, daily mental status was classified as awake without delirium, delirium, or unarousable. A first-order Markov model with multinomial logistic regression analysis considered four possible next-day outcomes (i.e., awake without delirium, delirium, unarousable, and ICU discharge or death) and 11 delirium-related covariables (baseline: admission type, age, sex, Acute Physiology and Chronic Health Evaluation IV score, and Charlson comorbidity score; daily: ICU day, modified Sequential Organ Failure Assessment, ventilation use, benzodiazepine use, and severe pain). This model was used to quantify the association between opioid use, opioid dose, and delirium occurrence the next day. Measurements and MainResults: The 4,075 adults had 26,250 ICU days; an opioid was administered on 57.0% (n = 14,975), severe pain occurred on 7.0% (n = 1,829), and delirium occurred on 23.5% (n = 6,176). Severe pain was inversely associated with a transition to delirium (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.53-0.97). Any opioid administration in awake patients without delirium was associated with an increased risk for delirium the next day [OR, 1.45; 95% CI, 1.24-1.69]. Each daily 10-mg intravenous morphine-equivalent dose was associated with a 2.4% increased risk for delirium the next day.Conclusions: The receipt of an opioid in the ICU increases the odds of transitioning to delirium in a dose-dependent fashion.