Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults.
Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults.
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DOI：
10.1001/jamasurg.2015.2606
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发表时间：
2015-12
期刊：
影响因子：
16.9
通讯作者：
Inouye SK
中科院分区：
文献类型：
--
作者：
Gleason LJ;Schmitt EM;Kosar CM;Tabloski P;Saczynski JS;Robinson T;Cooper Z;Rogers SO Jr;Jones RN;Marcantonio ER;Inouye SK
重大术后并发症和谵妄独立地导致接受大手术的患者的不良结局和高资源利用;然而，它们之间的相互关系尚未得到充分研究。评价主要术后并发症和谵妄（单独或联合）与术后不良结局的相关性。前瞻性队列研究。两大学术医疗中心。无公认的痴呆或谵妄病史，年龄70岁及以上，接受择期大骨科、血管和腹部手术，住院至少3天的患者。由专家小组裁定确定重大术后并发症，定义为改变或威胁生命的事件（Accordion严重度≥ 2级）。每天使用意识模糊评估方法和经验证的病历审查方法测量谵妄。分析了四个亚组：（1）无并发症，无谵妄;（2）仅并发症;（3）仅谵妄;（4）并发症和谵妄。不良结局包括住院时间（LOS）> 5天、出院和出院后30天内再次住院。在566名参与者中，平均年龄（±SD）为76.7± 5.2岁，42%为男性，92%为白色。47例（8%）出现严重并发症，135例（24%）出现谵妄。与无并发症、无谵妄的对照组相比，仅严重并发症仅导致LOS延长（RR 2.8，95% CI 1.9-4.0）;相反，单独的谵妄显著增加了所有不良结局，包括延长的LOS（RR 1.9，95% CI 1.4-2.7）、出院（RR 1.5，95% CI 1.3-1.7）和30天再入院（RR 2.3，95% CI 1.4-3.7）。并发症和谵妄的亚组的所有不良结局发生率最高，包括延长LOS（RR 3.4，95% CI 2.3-4.8），出院（RR 1.8，95% CI 1.4-2.5）和30天再入院（RR 3.0，95% CI 1.3-6.8）。与所有其他不良事件（延长LOS、出院或再入院）相比，谵妄在人群水平上具有最高的归因风险（5.8%，95%CI 4.7-6.8）。主要术后并发症和谵妄分别与不良事件相关，并表现出强烈的联合效应。谵妄发生更频繁，在人群水平上的影响比其他主要并发症更大。
Major postoperative complications and delirium contribute independently to adverse outcomes and high resource utilization in patients undergoing major surgery; however, their inter-relationship is not well-examined. To evaluate the association of major postoperative complications and delirium, alone and in combination, with adverse outcomes after surgery. Prospective cohort study. Two large academic medical centers. Patients without recognized dementia or history of delirium, age 70 and older who underwent elective major orthopedic, vascular, and abdominal surgeries with a minimum 3-day hospitalization. Major postoperative complications, defined as life altering or threatening events (Accordion Severity ≥ grade 2), were identified by expert panel adjudication. Delirium was measured daily with the Confusion Assessment Method and a validated chart review method. Four subgroups were analyzed: (1) no complications, no delirium; (2) complications alone; (3) delirium alone; and (4) both complications and delirium. Adverse outcomes included length of stay (LOS) > 5 days, institutional discharge, and rehospitalization within 30 days of discharge. Of 566 participants, mean age (±SD) was 76.7± 5.2 years, 42% male and 92% white. Forty-seven (8%) developed major complications, and 135 (24%) developed delirium. When compared to no complications, no delirium as the reference group, major complications alone contributed only to prolonged LOS (RR 2.8, 95% CI 1.9–4.0); by contrast, delirium alone significantly increased all adverse outcomes, including prolonged LOS (RR 1.9, 95% CI 1.4–2.7), institutional discharge (RR 1.5, 95% CI 1.3–1.7), and 30-day readmission (RR 2.3, 95% CI 1.4–3.7). The subgroup with both complications and delirium had the highest rates of all adverse outcomes, including prolonged LOS (RR 3.4, 95% CI 2.3–4.8), institutional discharge (RR 1.8, 95% CI 1.4–2.5) and 30-day readmission (RR 3.0, 95% CI 1.3–6.8). Delirium exerted the highest attributable risk at a population level (5.8%, 95% CI 4.7–6.8) compared with all other adverse events (prolonged LOS, institutional discharge, or readmission). Major postoperative complications and delirium are separately associated with adverse events and demonstrate a strong combined effect. Delirium occurs more frequently, and has greater impact at the population level than other major complications.