2020 年第 11 期 第 15 卷

累积液体平衡水平对脓毒性休克患者发生谵妄的影响

Effect of cumulative fluid balance on delirium in patients with septic shock

作者：陈钰霖邢柏

英文作者：Chen Yulin Xing Bo

单位：海南医学院第二附属医院急诊科，海口570311

英文单位：Department of Emergency， the Second Affiliated Hospital of Hainan Medical University Haikou 570311 China

关键词：脓毒性休克；累积液体平衡；谵妄；相关性

英文关键词：Septicshock；Cumulatedfluidbalance；Delirium；Correlation

• 摘要：

• 目的 探讨累积液体平衡（CFB）水平对脓毒性休克患者发生谵妄的影响。方法 选取2018年1月至2020年1月在海南医学院第二附属医院重症监护病房（ICU）住院治疗的脓毒性休克患者248例，入ICU后第3天发生谵妄181例（谵妄组），其中持续性谵妄128例，进展性谵妄53例，入ICU后第3天未发生谵妄67例（无谵妄组），其中好转性谵妄27例，始终无谵妄40例。比较谵妄组和无谵妄组患者的一般资料和临床特征，入ICU 24、48、72 h的CFB水平以及入ICU 72 h CFB>中位数水平者比例，不同谵妄状态脓毒性休克患者入ICU不同时间的CFB水平，分析脓毒性休克患者72 h CFB与第3天序贯器官衰竭评估（SOFA）评分的相关性，采用多因素Logistic回归方法分析脓毒性休克患者发生谵妄的危险因素。结果 谵妄组年龄、有脑血管疾病者比例、第1天急性生理学与慢性健康状况评分系统Ⅱ评分、第1天SOFA评分、第3天SOFA评分、28 d病死率均高于无谵妄组，ICU停留时间长于无谵妄组，而氧合指数、血红蛋白、血细胞比容、第1天格拉斯哥昏迷量表评分均低于无谵妄组(均P<0.05)。谵妄组患者入ICU 24、48、72 h CFB水平均高于无谵妄组（均P＜0.001），且入ICU 72 h CFB>6.6 L者比例高于无谵妄组［60.8%(110/181)比22.4%（15/67）］（χ2=28.822，P＜0.001）。持续性谵妄组和进展性谵妄组患者入ICU 24、48、72 h CFB水平逐渐增加（均P<0.001），而始终无谵妄组及好转性谵妄组患者入ICU 24、48、72 h CFB水平比较差异均无统计学意义（均P>0.05）。Pearson相关分析结果显示脓毒性休克患者72 h CFB与第3天SOFA评分呈显著正相关（r=0.344，P<0.001）。多因素Logistic回归分析结果显示，年龄、第1天SOFA评分和72 h CFB>6.6 L均为脓毒性休克患者第3天存在谵妄的独立危险因素（比值比=1.060、1.187、6.006，95%置信区间:1.034~1.088、1.047~1.347、2.832~12.734，均P<0.05）。结论 72 h CFB水平与脓毒性休克患者谵妄的发生相关，早期CFB水平的持续增加可能提示谵妄持续存在而影响患者预后。

• Objective To investigate the effect of cumulative fluid balance (CFB) on delirium in patients with septic shock. Methods A total of 248 patients with septic shock admitted to the intensive care unit(ICU) of the Second Affiliated Hospital of Hainan Medical University from January 2018 to January 2020 were selected. There were 181 cases of delirium on the third day after admission (delirium group), including 128 cases of persistent delirium, 53 cases of progressive delirium; there were 67 cases without delirium on the third day after admission (non-delirium group), including 27 cases of improved delirium, and 40 cases of never delirium. The general data and clinical characteristics, CFB level at 24, 48, 72 h after entering ICU, and the proportion of CFB > median level at 72 h after entering ICU were compared between the two groups. The CFB levels of patients with septic shock in different delirium states were recorded. The correlation between 72h CFB and sequential organ failure assessment (SOFA) score on the third day in patients with septic shock was analyzed. Risk factors for delirium in septic shock patients were analyzed by multivariate Logistic regression. Results Age, the proportion of cerebrovascular diseases， the Acute Physiology and Chronic Health Evaluation Ⅱ（APACHE Ⅱ）score on 1st day, the SOFA score on 1st day and 3rd day, 28 d mortality in the delirium group were significantly higher than those in non-delirium group. The ICU length of stay in the delirium group was significantly longer than that in non-delirium group. While oxygenation index， hemoglobin， hematocrit and the Glasgow Coma Scale score on 1st day were significantly lower than those in non-delirium group (all P<0.05). CFB level at 24, 48 and 72 h after entering ICU in the delirium group were significantly higher than those in non-delirium group（all P<0.001）, and the proportion of 72 h CFB>6.6 L in the delirium group was significantly higher than that in non-delirium group［60.8%(110/181) vs 22.4%（15/67）］（χ2=28.822， P＜0.001）. The level of CFB increased gradually at ICU 24, 48 and 72 h after entering ICU in persistent delirium group and progressive delirium group.（all P<0.001）, there was no significant difference in the levels of ICU 24, 48 and 72 h CFB between never delirium or improved delirium (all P>0.05). Pearson correlation analysis showed that 72 h CFB of patients with septic shock was significantly positively correlated with SOFA score on 3rd day (r=0.344， P<0.001). Multivariate Logistic regression analysis showed that age, the SOFA score on 1st day and 72 h CFB>6.6 L were independent risk factors for achieving delirium on 3rd day in patients with septic shock after adjusted other risk factors (odds ratio=1.060, 1.187, 6.006， 95% confidence interval： 1.034-1.088, 1.047-1.347, 2.832-12.734， all P<0.05). Conclusion72 h CFB level is associated with delirium in patients with septic shock. The continuous increase of CFB level in the early stage may indicate the persistence of delirium and affect the prognosis.【