Stanford A型主动脉夹层患者术后谵妄风险预测评分模型的构建与效果验证

doi:10.3761/j.issn.0254-1769.2022.08.009

摘要/Abstract

摘要：

目的构建Stanford A型主动脉夹层患者术后谵妄风险预测评分模型,并验证其预测效果。方法选取2014年1月—2020年6月温州市某三级甲等综合性医院心脏外科收治的Stanford 245例A型主动脉夹层术后住院患者作为研究对象,回顾性收集相关资料。按术后是否发生谵妄分为谵妄组（n=51）和非谵妄组（n=194）,对两组资料进行比较,根据多因素Logistic回归分析结果建立风险预测评分模型。采用Hosmer-Lemeshow检验判断模型的拟合优度,受试者工作特征曲线下面积检验模型区分度。前瞻性纳入2020年10月—2021年4月心脏外科收治的51例Stanford A型主动脉夹层术后住院患者对模型进行验证。结果 Stanford A型主动脉夹层患者术后谵妄风险预测评分模型纳入年龄>55.50岁（1分）、男性（1分）、术前血乳酸值>1.85 mmol/L（1分）、深低温停循环时间>36.50 min（1分）、心脏重症监护室住院时间>8.50 d （2分）、术后合并其他并发症（1分）6个因素。该风险预测评分模型的Hosmer-Lemeshow检验结果显示P=0.393;受试者工作特征曲线下面积为0.926。当评分≤4分时,Stanford A型主动脉夹层患者术后谵妄发生率≤15.63%;当评为≥5分时,其发生率≥50.00%。该风险预测评分模型的灵敏度为76.47%,特异度为93.30%,准确率89.80%。模型验证结果显示,受试者工作特征曲线下面积为0.896,Hosmer-Lemeshow检验P=0.359,灵敏度为75.00%,特异度为92.31%,准确率为88.24%。结论 Stanford A型主动脉夹层患者术后谵妄风险预测评分模型的预测效果良好,且临床使用便捷,可为医护人员采取预防性治疗和护理提供参考。

关键词: A型主动脉夹层, 术后谵妄, 风险评分, 预测模型, 围手术期护理

Abstract:

Objective To construct a risk prediction model of the postoperative delirium for patients with acute type A aortic dissection（ATAAD）,and to verify the prediction effect of the model. Methods A retrospective study was conducted among 245 adult patients undergoing aortic dissection surgery in the cardiac surgery department of a tertiary A hospital in Wenzhou from October 2020 to April 2021. According to the occurrence of postoperative delirium,the patients were divided into a delirium group （n=51） and a non-delirium group （n=194）,and the data of the 2 groups were compared. The risk prediction scoring model was constructed based on the multivariate logistic regression analysis of ATAAD postoperative delirium risk factors. The Hosmer-Lemeshow test was used to determine the model’s goodness of fit of the model,and the receiver operator characteristic curve （ROC） was used to test the model differentiation. The risk prediction model was validated by the prospective study with inclusion of 51 ATAAD patients admitted to the cardiac surgery department from July,2020 to June,2021. Results There were 6 factors included in the risk prediction model of patients with postoperative delirium,namely age over than 55.50 years（1 point）,male（1 point）,preoperative blood lactic acid value more than 1.85 mmol/L（1 point）,hypothermia cycle arrest time more than 36.50 minutes（1 point）,length of stay in CCU（cardiovascular intensive care unit）more than 8.50 days（2 points）,and other postoperative complications（1 point）. The Hosmer-Lemeshow test of the prediction scoring model showed that when P=0.393,the area under the ROC was 0.926. When the patient’s score was ≤4,the incidence of postoperative delirium in patients with ATAAD was≤15.63%;while it was≥5,the incidence was ≥50.00%. The sensitivity,specificity and accuracy of the risk stratification model were 76.47%,93.30% and 89.80%,respectively. The result of model verification shows that when the area under the ROC was 0.896,the Hosmer-Lemeshow test P=0.359. The sensitivity,specificity and accuracy of the risk stratification model were 75.00%,92.31% and 88.24%,respectively. Conclusion This risk prediction model provides an effective prediction effect,and it is simple and convenient to use in clinical application,which could be a reference for medical staff to take preventive treatment and nursing care.

Key words: Type A Aortic Dissection, Postoperative Delirium, Risk Score, Prediction Model, Perioperative Nursing

李雪苹, 王磊, 张淮, 邢爱珍, 陈朝红, 尹志勤. Stanford A型主动脉夹层患者术后谵妄风险预测评分模型的构建与效果验证[J]. 中华护理杂志, 2022, 57(8): 950-957.

LI Xueping, WANG Lei, ZHANG Huai, XING Aizhen, CHEN Chaohong, YIN Zhiqin. Construction and evaluation of a risk prediction model of postoperative delirium in patients with Stanford type A aortic dissection[J]. Chinese Journal of Nursing, 2022, 57(8): 950-957.

图/表 4

表1 Stanford A型主动脉夹层患者术后谵妄危险因素的单因素分析结果

Table 1 Univariate analysis of risk factors for postoperative delirium in patients with Stanford type A aortic dissection

表2 连续变量的最佳界值

Table 2 Optimal bounds for continuous variables

表3 Stanford A型主动脉夹层患者术后谵妄危险因素的Logistic回归分析结果

Table 3 Logistic regression analysis results of risk factors for postoperative delirium in patients with Stanford type A aortic dissection

图1 Stanford A型主动夹层患者术后谵妄风险预测评分模型的ROC曲线

Figure 1 ROC curve of risk factor prediction model of postoperative delirium in patients with Stanford type A aortic dissection

参考文献 29

[1]	龙明, 张松峰. 外科学[M]. 8版. 北京:人民卫生出版社, 2016. Long M, Zhang SF. Surgery[M]. 8th ed. People’s Medical Publishing House,2016.
[2]	李乐之, 路潜. 外科护理学[M]. 6版. 北京:人民卫生出版社, 2017. Li LZ, Lu Q. Surgical nursing[M]. 6th ed. Beijing: People’s Medical Publishing House,2017.
[3]	Oderich GS, Panneton JM, Bower TC, et al. Aortic dissection with aortic side branch compromise:impact of malperfusion on patient outcome[J]. Perspect Vasc Surg Endovasc Ther, 2008, 20(2):190-200. DOI URL
[4]	郝伟, 于欣. 精神病学[M]. 7版. 北京:人民卫生出版社, 2013. Hao W, Yu X, Psychiatry[M]. 7th ed. Beijing: People’s Medical Publishing House,2013.
[5]	周楚芝, 杨建安, 温隽珉, 等.急性A型主动脉夹层患者术后谵妄发生的危险因素分析[J]. 中国动脉硬化杂志, 2016, 24(12):1253-1257.
	Zhou CZ, Yang JA, Wen JM, et al. Analysis of risk factors for postoperative delirium in patients with acute type A aortic dissection[J]. Chin J Arterioscler, 2016, 24(12):1253-1257.
[6]	李晓晴, 马闻建, 毕齐, 等.A型主动脉夹层术后谵妄的发生率和危险因素研究[J]. 安徽医药, 2014, 18(6):1065-1069.
	Li XQ, Ma WJ, Bi Q, et al. Morbidity and related risk factors of postoperative delirium after aortic dissection surgery[J]. An-hui Med Pharm J, 2014, 18(6):1065-1069.
[7]	闫晓英, 刘哲, 宋艳, 等.A型主动脉夹层术患者术后谵妄的影响因素分析[J]. 护理实践与研究, 2020, 17(1):7-10.
	Yan XY, Liu Z, Song Y, et al. Analysis of influencing factors of postoperative delirium in patients with type A aortic dissection[J]. Nurs Pract Res, 2020, 17(1):7-10.
[8]	Bucerius J, Gummert JF, Borger MA, et al. Predictors of delirium after cardiac surgery delirium:effect of beating-heart (off-pump) surgery[J]. J Thorac Cardiovasc Surg, 2004, 127(1):57-64. DOI URL
[9]	Rudolph JL, Jones RN, Levkoff SE, et al. Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery[J]. Circulation, 2009, 119(2):229-236. DOI PMID
[10]	洪亮, 孙加奎, 沈骁, 等.心脏手术后谵妄的危险因素分析及预测模型构建[J]. 临床麻醉学杂志, 2020, 36(12):1195-1200.
	Hong L, Sun JK, Shen X, et al. Risk factors analysis and prediction model construction of postoperative delirium after cardiac surgery[J]. J Clin Anesthesiol, 2020, 36(12):1195-1200.
[11]	谈莉萍, 段霞, 庄英, 等.冠状动脉旁路移植术后患者谵妄独立预测因子的现况分析[J]. 护理学杂志, 2017, 32(14):1-5.
	Tan LP, Duan X, Zhuang Y, et al. Predictors of delirium after coronary artery bypass graft surgery[J]. J Nurs Sci, 2017, 32(14):1-5.
[12]	美国精神医学学会. 精神障碍诊断与统计手册[M]. 5版. 北京: 北京大学出版社, 2015.
	American Psychiatric Association. Diagnostic and statistical ma-nual of mental disorders[M]. 5th ed. Beijing: Peking University Press, 2015.
[13]	Chen Y, Du H, Wei BH, et al. Development and validation of risk-stratification delirium prediction model for critically ill patients:a prospective,observational,single-center study[J]. Me-dicine, 2017, 96(29):e7543.
[14]	Fu Y, Li KB, Yang XC.A risk score model for predicting cardiac rupture after acute myocardial infarction[J]. Chin Med J(Engl), 2019, 132(9):1037-1044.
[15]	林艳雅, 马飞, 叶根, 等.急性A型主动脉夹层破裂风险预测模型的构建[J]. 中华急诊医学杂志, 2019, 28(6):729-735.
	Lin YY, Ma F, Ye G, et al. Construction of risk prediction model for acute type A aortic dissection rupture[J]. Chin J emergency med, 2019, 28(6):729-735.
[16]	邢焕民, 吕冬梅, 王晓慧, 等.术后谵妄风险预测模型的构建及应用[J]. 中华护理杂志, 2019, 54(1):8-13.
	Xing HM, Lü DM, Wang XH, et al. The development and application of a risk prediction model for postoperative delirium in ICU patients[J]. Chin J Nurs, 2019, 54(1):8-13.
[17]	Hong WL, Earnest A, Sultana P, et al. How accurate are vital signs in predicting clinical outcomes in critically ill emergency department patients[J]. Eur J Emerg Med, 2013, 20(1):27-32. DOI URL
[18]	陈俊杉, 范杰梅, 余金甜, 等.神经外科ICU患者谵妄风险预测模型的构建与验证[J]. 护理学报, 2021, 28(4):1-8.
	Chen JS, Fan JM, Yu JT, et al. Development and validation of delirium prediction model for neurosurgical ICU patients[J]. J Nurs China, 2021, 28(4):1-8.
[19]	Wansrisuthon W, Ratta-Apha W, Thongchot L, et al. Accuracy of diagnosis and international classification of diseases;tenth revision coding for alcohol dependence,alcohol withdrawal,and alcohol-withdrawal delirium among inpatients at a university hospital[J]. J Addict Med, 2017, 11(3):241-242. DOI PMID
[20]	Suzuki S, Brown CM, Dela Cruz CD, et al. Timing of estrogen therapy after ovariectomy dictates the efficacy of its neuroprotective and antiinflammatory actions[J]. Proc Natl Acad Sci USA, 2007, 104(14):6013-6018. DOI URL
[21]	Hsieh SJ, Soto GJ, Hope AA, et al. The association between acute respiratory distress syndrome,delirium,and in-hospital mortality in intensive care unit patients[J]. Am J Respir Crit Care Med, 2015, 191(1):71-78. DOI URL
[22]	董飞飞.体外循环冠状动脉旁路移植术麻醉复苏期老年患者谵妄危险因素分析[J]. 护理实践与研究, 2021, 18(11):1614-1617.
	Dong FF.Risk factors of delirium in elderly patients underwent cardiopulmonary bypass grafting during anesthesia recovery[J]. Nurs Pract Res, 2021, 18(11):1614-1617.
[23]	Xing HM, Zhou WD, Fan YY, et al. Development and validation of a postoperative delirium prediction model for patients admitted to an intensive care unit in China:a prospective study[J]. BMJ Open, 2019, 9(11):e030733. DOI URL
[24]	郑哲. 成人心脏外科学[M]. 北京: 人民卫生出版社, 2016.
	Zheng Z. Cardiac surgery in the adult[M]. Beijing: People’s Medical Publishing House, 2016.
[25]	Fleck TM, Czerny M, Hutschala D, et al. The incidence of tran-sient neurologic dysfunction after ascending aortic replacement with circulatory arrest[J]. Ann Thorac Surg, 2003, 76(4):1198-1202. DOI URL
[26]	Englum BR, Andersen ND, Husain AM, et al. Degree of hypo-thermia in aortic arch surgery-optimal temperature for cerebral and spinal protection:deep hypothermia remains the gold standard in the absence of randomized data[J]. Ann Cardiothorac Surg, 2013, 2(2):184-193.
[27]	Bigatello LM, Amirfarzan H, Haghighi AK, et al. Effects of rou-tine monitoring of delirium in a surgical/trauma intensive care unit[J]. J Trauma Acute Care Surg, 2013, 74(3):876-883. DOI PMID
[28]	Bihari S, Doug McEvoy R, Matheson E, et al. Factors affecting sleep quality of patients in intensive care unit[J]. J Clin Sleep Med, 2012, 8(3):301-307. DOI URL
[29]	万建红, 李晓姝, 韩淳, 等.A型主动脉夹层患者术后急性呼吸功能不全护理干预的研究进展[J]. 中华护理杂志, 2020, 55(4):553-557. Wan JH, Li XS, Han C, et al. Research progress on nursing intervention of acute respiratory dysfunction in patients with type A aortic dissection after surgery[J]. Chin J Nurs, 2020, 55(4):553-557.