危重病人术后低血压与谵妄的关系：回顾性队列分析
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Association Between Perioperative Hypotension and Delirium in Postoperative Critically Ill Patients: A Retrospective Cohort Analysis
背景与目的
术后谵妄在危重病人中很常见，报告的发病率为11%-43%，其与显著的发病率和费用有关。术后谵妄可能由术后低血压以及脑的低灌注压导致。因此，我们验证术中和术后低血压与危重护理相关的谵妄的假设。
方 法
我们纳入了1083名直接从手术室进入外科重症监护室的术后病人。意识模糊评估法对重症监护病房的患者每隔12小时进行一次谵妄评估。我们使用Cox比例风险生存模型来评估术中低血压（测量为平均动脉压<65mmHg的时间加权平均值）与危重病人谵妄之间的关系。此后，我们使用Cox模型，以每个重症监护日平均动脉压最低作为一个时变的协变量，评估重症监护室低血压与谵妄之间的关系，并根据混杂因素和术中低血压量进行调整。
结 果
在外科重症监护病房术后5天内有377名（35%）患者出现谵妄。术中低血压与术后谵妄发生率较高有关。调整后的危险比与1mm Hg增加的平均动脉压<65mmHg的时间加权平均值为1.11(95%可信区间[CI]，1.03-1.20；P=。008)。术后重症监护室每天最低平均压力降低10mmHg与谵妄危险性增高显著相关，调整后危险比为1.12 （95%CI，1.04-1.20；P=0.003）。
结 论
术中和术后低血压与术后危重病人的谵妄有关。这些关系在多大程度上是因果关系尚不清楚，但在一定程度上，预防低血压可有助于减少谵妄，因此应在前瞻性临床试验中加以研究。
原始文献摘要
Kamal Maheshwari, Sanchit Ahuja, Ashish K. Khanna,et al.Association Between Perioperative Hypotension and Delirium in Postoperative Critically Ill Patients: A Retrospective Cohort Analysis.Anesth Analg 2020;130:636–43.
BACKGROUND: Postoperative delirium is common in critically ill patients, with a reported incidence of 11%–43%, and is associated with significant morbidity and cost. Perioperative hypotension and consequent brain hypoperfusion may contribute. We, therefore, tested the hypotheses that intraoperative and postoperative hypotension are associated with critical care delirium.
METHODS: We included 1083 postoperative patients who were admitted directly from an operating room to the surgical intensive care unit. Delirium was assessed with the Confusion Assessment Method for Intensive Care Unit patients at 12-hour intervals. We used a confounder-adjusted Cox proportional hazard survival model to assess the association between the amount of intraoperative hypotension, which was measured as the time-weighted average of mean arterial pressure <65 mm Hg, and delirium while in critical care. Thereafter, we used a Cox model with the lowest mean arterial pressure on each intensive care day as a time-varying covariate to assess the relationship between critical care hypotension and delirium, adjusted for confounders and amount of intraoperative hypotension.
RESULTS: Three hundred seventy-seven (35%) patients had delirium within the first 5 postoperative days in the surgical intensive care unit. Intraoperative hypotension was moderately associated with higher odds of postoperative delirium. The adjusted hazard ratio associated with 1 mm Hg increase in time-weighted average of mean arterial pressure <65 mm Hg was 1.11 (95% confidence interval [CI], 1.03–1.20; P = .008). Postoperatively, a 10 mm Hg reduction in the lowest mean pressure on each day in the critical care unit was significantly associated with a higher hazard of delirium, with an adjusted hazard ratio 1.12 (95% CI, 1.04–1.20; P = .003).
CONCLUSIONS: Both intraoperative and postoperative hypotension are associated with delirium in postoperative critical care patients. The extent to which these relationships are causal remains unknown, but to the extent that they are, hypotension prevention may help reduce delirium and should be studied in prospective clinical trials.
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翻译：任文鑫 编辑：冯玉蓉 审校：王贵龙