Association of Delirium during Critical Illness With Mortality: Multicenter Prospective Cohort Study.
Association of Delirium during Critical Illness With Mortality: Multicenter Prospective Cohort Study.
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DOI：
10.1213/ane.0000000000005544
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发表时间：
2021-11-01
影响因子：
5.7
通讯作者：
Patel MB
中科院分区：
文献类型：
--
作者：
Hughes CG;Hayhurst CJ;Pandharipande PP;Shotwell MS;Feng X;Wilson JE;Brummel NE;Girard TD;Jackson JC;Ely EW;Patel MB
危重病期间谵妄与死亡率的时间相关性尚不清楚，沿着的是谵妄的运动功能减退和过度活跃亚型与死亡率的相关性。我们的目的是评估危重病期间谵妄（包括运动功能减退和运动功能亢进亚型）与住院和出院后1年内死亡率的关系。我们分析了一项前瞻性队列研究，研究对象是在大学、社区和退伍军人事务部医院住院的呼吸衰竭和/或休克成人。我们使用里士满激动-镇静量表和ICU的意识模糊评估方法评估患者，如果存在谵妄，则根据相应的里士满激动-镇静量表定义运动亚型。我们使用考克斯比例风险模型，校正基线特征、昏迷和每日医院事件，以确定在给定日期的谵妄是否预测住院患者第二天的死亡率，并确定谵妄的存在和持续时间是否预测存活至出院患者出院后1年的死亡率。我们对谵妄的活动减退和活动过度亚型进行了类似的分析。在1,040例危重患者中，214例（21%）在1年内死于医院，204例（20%）死于院外。谵妄很常见，740例（71%）患者发生谵妄的中位[IQR]为4 [2-7]天。733例（70%）患者发生低活动性谵妄，185例（18%）患者发生高活动性谵妄，分别持续中位3 [2-7]天和1 [1-2]天。特定日期的谵妄（HR 2.87，95% CI [1.32-6.21]，P=0.008），特别是活动减退亚型（HR 3.35，95% CI [1.51-7.46]，P=0.003），与次日住院死亡风险增加独立相关。过度活跃性谵妄与院内死亡风险增加无关（HR 4.00，95% CI [0.49-32.51]，P=0.19）。在医院存活者中，无论是谵妄的存在（HR 1.01，95% CI [0.82-1.24]，P=0.95）还是持续时间（HR 0.99，95% CI [0.97-1.01]，P=0.56），无论是运动型亚型，都与出院后1年的死亡率无关。危重病期间的谵妄与住院患者次日死亡风险增加近3倍相关，但与出院后的死亡率无关。这一发现似乎主要由运动功能减退亚型驱动。谵妄和死亡率之间的独立关系发生在危重病的早期，但出院后并不持续。
The temporal association of delirium during critical illness with mortality is unclear, along with the associations of hypoactive and hyperactive motoric subtypes of delirium with mortality. We aimed to evaluate the relationship of delirium during critical illness, including hypoactive and hyperactive motoric subtypes, with mortality in the hospital and after discharge up to 1 year. We analyzed a prospective cohort study of adults with respiratory failure and/or shock admitted to university, community, and Veterans Affairs hospitals. We assessed patients’ using the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the ICU and defined the motoric subtype according to corresponding Richmond Agitation-Sedation Scale if delirium was present. We used Cox proportional hazard models, adjusted for baseline characteristics, coma, and daily hospital events, to determine whether delirium on a given day predicted mortality the following day in patients in the hospital and also to determine whether delirium presence and duration predicted mortality after discharge up to 1 year in patients who survived to hospital discharge. We performed similar analyses for hypoactive and hyperactive subtypes of delirium. Among 1,040 critically ill patients, 214 (21%) died in the hospital, and 204 (20%) died out-of-hospital by 1 year. Delirium was common, occurring in 740 (71%) patients for a median [IQR] of 4 [2-7] days. Hypoactive delirium occurred in 733 (70%) patients, and hyperactive occurred in 185 (18%) patients, lasting a median of 3 [2-7] days and 1 [1-2] days, respectively. Delirium on a given day (HR 2.87, 95% CI [1.32-6.21], P=0.008), in particular the hypoactive subtype (HR 3.35, 95% CI [1.51-7.46], P=0.003), was independently associated with increased risk of death the following day in the hospital. Hyperactive delirium was not associated with increased risk of death in the hospital (HR 4.00, 95% CI [0.49-32.51], P=0.19). Among hospital survivors, neither delirium presence (HR 1.01, 95% CI [0.82-1.24], P=0.95) nor duration (HR 0.99, 95% CI [0.97-1.01], P=0.56), regardless of motoric subtype, was associated with mortality after hospital discharge up to 1 year. Delirium during critical illness is associated with nearly a three-fold increased risk of death the following day for patients in the hospital but is not associated with mortality after hospital discharge. This finding appears primarily driven by the hypoactive motoric subtype. The independent relationship between delirium and mortality occurs early during critical illness but does not persist after hospital discharge.