作者：Martha Kerr 齣處：WebMD醫學新聞 　　February 6, 2009（田納西州那什維爾）－ 一項發錶於第38屆美國重癥醫學會年會的加拿大研究結果指齣 瞻妄是接受冠狀動脈 .. SCCM 2009：CABG病患的瞻妄可能代錶發生敗血癥 - 趣味新聞網

發表日期 2009-02-21T14:48:34+08:00

     作者：Martha Kerr
齣處：WebMD醫學新聞

February 6, 2009（田納西州那什維爾）－ 一項發錶於第38屆美國重癥醫學會年會的加拿大研究結果指齣，瞻妄是接受冠狀動脈繞道手術（CABG）後病患發生敗血癥與死亡率的「強烈預測因子」。

來自新斯科細亞哈利法剋斯戴爾豪斯大學心髒手術部門的Billie Jean Martin博士嚮Medscape重癥照護錶示，瞻妄是敗血癥最強烈的預測因子，超過瞭許多感染的可能危險因子。

這是一項前瞻性觀察性研究的主要發現，研究共收納瞭14,301位接受CABG病患，在加拿大的兩個中心的其中一個進行。

瞻妄的定義是短期的神智障礙，以混亂、幻覺與大腦興奮來錶現。

總共有981位病患（6.9%）發生瞻妄，而246位病患在CABG手術後發生敗血癥；瞻妄發生率在研究中隨著年份持續上升，從1998年的4.8%上升到2007年的8.0%（P <0.0003）。

Martin博士錶示，在75%的病患中，瞻妄發生在敗血癥之前。

手術後敗血癥的預測因子除瞭瞻妄之外，還有手術前住院超過7天、高齡、糖尿病、術前腎髒衰竭、周邊血管疾病與嚴重疾病（所有的P值都<0.001）。

不同危險因子的勝算比（ORs）計算如下：瞻妄（OR為4.0；95%信賴區間3.0-5.4）、緊急手術（OR為2.8；95%信賴區間1.9-2.4）、年齡（OR為1.1；95%信賴區間1.0-1.3）、術前住院超過7天（OR為1.7；95%信賴區間1.2-2.3）、術前腎髒衰竭（OR為2.0；95%信賴區間1.4-3.0）與三條血管或左主冠狀動脈疾病（OR為3.1；95%信賴區間1.8-5.3）。

Martin博士指齣，接受CABG病患需嚴密地監測瞻妄癥狀，焦慮惡化可能是感染的早期病徵，這一般發生在整體感染的兩天前，且這是死亡的危險因子。

她錶示，中央靜脈導管是感染常見的部位，特彆是在經常重新植入的情況下；瞻妄或是焦慮病患比較可能自行拔除管路，而惡化這個問題。

除此之外，Martin博士錶示，當病患病得更重時，他們可能有更多呼吸道分泌物，且比較沒有分泌物清除的能力；這會增加感染風險，且瞻妄可能是感染的早期病徵。

Martin博士附帶錶示，異常的睡眠/覺醒循環，免疫狀況變差，以及中性球低下都會增加瞻妄與敗血癥的風險。

來自波特蘭Maine醫學中心重癥照護研究主任、Vermont大學醫學中心的Richard R. Riker醫師同意Martin博士的發現。

Riker醫師是Safety and Efficacy of Dexmedetomidine Compared With Midazolam（SEDCOM）研究的主持人，這項研究結果顯示，接受呼吸器治療病患的鎮靜安眠藥物劑量較低可以縮短拔管所需時間與降低瞻妄風險。

在Martin博士的發錶會後，Riker醫師嚮Medscape重癥照護錶示，大量的鎮靜安眠藥物與瞻妄風險增加之間有很強的關聯。

Riker醫師指齣，瞻妄顯然是不良預後的一個獨立因子；我們目前並不知道其發生原因。我們確定如果有瞻妄病徵的話，感染機率會上升兩倍，其中可能也有中性球低下的影響在裏麵。

Martin博士錶示沒有相關資金上的往來。Riker醫師接受AspectMedical係統有限公司、阿斯特捷利康、禮來藥廠、赫士睿與武田藥廠的贊助。

SCCM 2009: Delirium May Indicate Onset of Sepsis in CABG Patients

By Martha Kerr
Medscape Medical News

February 6, 2009 (Nashville, Tennessee) — Delirium is a "strong predictor" of sepsis and mortality after coronary artery bypass graft (CABG) surgery, a Canadian team announced here this week at the Society of Critical Care Medicine 38th Critical Care Congress.

"Delirium was the strongest independent predictor of sepsis" out of a number of possible risk factors for infection, Billie Jean Martin, MD, from the Division of Cardiac Surgery at Dalhousie University in Halifax, Nova Scotia, told Medscape Critical Care.

That was the primary finding of a study of a prospective observational study of 14,301 patients undergoing CABG at one of two centers in Canada.

Delirium was defined as "a short-term mental disturbance marked by confusion, illusions, and cerebral excitement."

A total of 981 patients (6.9%) developed delirium and 246 patients developed sepsis after CABG surgery. Rates of delirium increased during the years of the study, from 4.8% in 1998 to 8.0% in 2007 (P < .0003).

"In 75% of patients, delirium preceded sepsis," Dr. Martin said.

Predictors of postoperative sepsis in addition to delirium were preoperative length of stay exceeding 7 days, advanced age, diabetes, preoperative renal failure, peripheral vascular disease, and severe disease (P < .001 for all).

Odds ratios (ORs) were calculated for the various risk factors of delirium (OR, 4.0; 95% confidence interval [CI], 3.0 – 5.4), emergent surgery (OR, 2.8; 95% CI, 1.9 – 2.4), age (OR, 1.1; 95% CI, 1.0 – 1.3), preoperative length of stay longer than 7 days (OR, 1.7; 95% CI, 1.2 – 2.3), preoperative renal failure (OR, 2.0; 95% CI, 1.4 – 3.0), and triple vessel or left main coronary artery disease (OR, 3.1; 95% CI, 1.8 – 5.3).

"[CABG] patients need to be carefully monitored for symptoms of delirium," Dr. Martin said. "An increase in agitation may be a very early sign of infection. It tends to precede overt infection by about 2 days...and it is a risk factor for mortality."

Central venous lines are common sites of infection, especially with frequent reinsertion, she said. "Patients who are delirious or agitated are more likely to pull out their lines, aggravating the problem."

In addition, Dr. Martin said, "when patients are sicker, they have more secretions and are less able to clear their secretions; this can can increase risk of infection, and delirium may be an early sign of that."

"Disordered sleep/wake cycle, an alteration in immune status, and neutropenia all increase risk of delirium and sepsis," Dr. Martin added.

Richard R. Riker, MD, from the University of Vermont Medical Center and director of critical care research at Maine Medical Center in Portland, agreed with Dr. Martin's findings.

Dr. Riker was principal investigator of the Safety and Efficacy of Dexmedetomidine Compared With Midazolam (SEDCOM) study, showing that lower doses of sedation in mechanically ventilated patients shorten time to extubation and reduce risk of delirium.

"There is a strong association between heavy sedation and an increased risk of delirium," Dr. Riker told Medscape Critical Care after Dr. Martin's presentation.


"Delirium appears to be an independent factor for an adverse outcome," Dr. Riker said. "We don't know the reason behind that at this point. We do know that infection rates are 2-fold higher if delirium is present.... There may be a neutropenic effect somehow involved."

Dr. Martin has disclosed no relevant financial relationships. Dr. Riker receives support from Aspect Medical Systems Inc, AstraZeneca, Eli Lilly, Hospira, and Takeda.

Society of Critical Care Medicine (SCCM) 38th Critical Care Congress: Abstract 309. Presented February 3, 2009.

[ 本帖最後由 lsc0019 於 2009-2-23 22:35 編輯 ]

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