Toxic Metabolic Encephalopathy in Hospitalized Patients with COVID-19.
Toxic Metabolic Encephalopathy in Hospitalized Patients with COVID-19.
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DOI：
10.1007/s12028-021-01220-5
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发表时间：
2021-12
影响因子：
3.5
通讯作者：
Galetta S
中科院分区：
文献类型：
--
作者：
Frontera JA;Melmed K;Fang T;Granger A;Lin J;Yaghi S;Zhou T;Lewis A;Kurz S;Kahn DE;de Havenon A;Huang J;Czeisler BM;Lord A;Meropol SB;Troxel AB;Wisniewski T;Balcer L;Galetta S
在7-31%的2019冠状病毒病（COVID-19）住院患者中报告了中毒性代谢性脑病（TME）；然而，一些报道包括镇静相关的谵妄，很少有关于TME病因的资料。我们旨在确定严重急性呼吸综合征冠状病毒2 （SARS-CoV-2）阳性患者中与TME相关的患病率、病因和死亡率。我们对2020年3月1日至2020年5月20日期间在同一卫生网络的四家纽约市医院住院的逆转录聚合酶链反应确诊的SARS-CoV-2感染患者进行了一项回顾性、多中心、观察性队列研究。TME被诊断为精神状态改变的患者停用镇静或在充分的镇静冲洗后。排除患有结构性脑疾病、癫痫发作或原发性神经学诊断的患者。主要结局是按病因和住院死亡率（不包括舒适护理患者）分层的TME患病率，采用多变量时间相关Cox比例风险模型，调整年龄、种族、性别、插管、重症监护病房要求、序贯器官衰竭评估评分、医院位置和入院日期。在4491例COVID-19患者中，559例（12%）被诊断为TME，其中559例中有435例（78%）在入院前立即发生脑病。最常见的病因是感染性脑病（559例中有247例[62%]）、缺氧缺血性脑病（559例中有331例[59%]）和尿毒症（559例中有156例[28%]）。435例（78%）患者存在多种病因。与没有TME的患者（n = 3932）相比，TME患者年龄较大（76岁vs. 62岁），有痴呆（27% vs. 3%）或精神病史（20% vs. 10%），插管次数较多（37% vs. 20%），住院时间较长（7.9 vs. 6.0天），出院次数较少（25% vs. 66%[均P < 0.001]）。排除舒适护理患者（4491例[6%]中n = 267例），调整混杂因素后，TME仍与院内死亡风险增加相关(425例[30%]TME患者中n = 128例死亡，而3799例[16%]非TME患者中n = 600例死亡；校正风险比[aHR] 1.24, 95%可信区间[CI] 1.02-1.52, P = 0.031)，低氧血症引起的TME风险最高（233例[42%]HIE患者中n = 97例死亡，而3991例[16%]非HIE患者中n = 631例死亡；aHR 1.56, 95% CI 1.21-2.00, P = 0.001）。TME发生在八分之一的COVID-19住院患者中，通常是多因素的，最常见的原因是低氧血症、败血症和尿毒症。在我们对混杂因素进行调整后，TME与住院死亡率增加24%的风险相关。在线版本包含补充材料，可在10.1007/s12028-021-01220-5获得。
Toxic metabolic encephalopathy (TME) has been reported in 7–31% of hospitalized patients with coronavirus disease 2019 (COVID-19); however, some reports include sedation-related delirium and few data exist on the etiology of TME. We aimed to identify the prevalence, etiologies, and mortality rates associated with TME in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients. We conducted a retrospective, multicenter, observational cohort study among patients with reverse transcriptase–polymerase chain reaction-confirmed SARS-CoV-2 infection hospitalized at four New York City hospitals in the same health network between March 1, 2020, and May 20, 2020. TME was diagnosed in patients with altered mental status off sedation or after an adequate sedation washout. Patients with structural brain disease, seizures, or primary neurological diagnoses were excluded. The coprimary outcomes were the prevalence of TME stratified by etiology and in-hospital mortality (excluding comfort care only patients) assessed by using a multivariable time-dependent Cox proportional hazards models with adjustment for age, race, sex, intubation, intensive care unit requirement, Sequential Organ Failure Assessment scores, hospital location, and date of admission. Among 4491 patients with COVID-19, 559 (12%) were diagnosed with TME, of whom 435 of 559 (78%) developed encephalopathy immediately prior to hospital admission. The most common etiologies were septic encephalopathy (n = 247 of 559 [62%]), hypoxic-ischemic encephalopathy (HIE) (n = 331 of 559 [59%]), and uremia (n = 156 of 559 [28%]). Multiple etiologies were present in 435 (78%) patients. Compared with those without TME (n = 3932), patients with TME were older (76 vs. 62 years), had dementia (27% vs. 3%) or psychiatric history (20% vs. 10%), were more often intubated (37% vs. 20%), had a longer hospital length of stay (7.9 vs. 6.0 days), and were less often discharged home (25% vs. 66% [all P < 0.001]). Excluding comfort care patients (n = 267 of 4491 [6%]) and after adjustment for confounders, TME remained associated with increased risk of in-hospital death (n = 128 of 425 [30%] patients with TME died, compared with n = 600 of 3799 [16%] patients without TME; adjusted hazard ratio [aHR] 1.24, 95% confidence interval [CI] 1.02–1.52, P = 0.031), and TME due to hypoxemia conferred the highest risk (n = 97 of 233 [42%] patients with HIE died, compared with n = 631 of 3991 [16%] patients without HIE; aHR 1.56, 95% CI 1.21–2.00, P = 0.001). TME occurred in one in eight hospitalized patients with COVID-19, was typically multifactorial, and was most often due to hypoxemia, sepsis, and uremia. After we adjustment for confounding factors, TME was associated with a 24% increased risk of in-hospital mortality. The online version contains supplementary material available at 10.1007/s12028-021-01220-5.
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