首页
-
摘要:
目的 分析肝移植受者术后谵妄的发病率、发病时机及危险因素。 方法 收集2019年1月–2021年12月在中南大学湘雅三医院行肝移植的211例受者的临床资料，调查术后谵妄发病率及发病时间，采用单因素和多因素logistic回归分析谵妄发病的危险因素，并分析谵妄对受者临床结局的影响。 结果 肝移植受者术后谵妄的发病率为20.4%（43/211），发病距离肝移植手术的中位时间为19 h。单因素分析显示术前终末期肝病模型（model for end-stage liver disease, MELD）评分≥22、术前住院天数≥7 d、肝癌、术前肝性脑病、术前两个月内感染、术前淋巴细胞值<0.5×109 L－1、术中大量红细胞输注及使用碳青霉烯类抗生素≥3 d与肝移植受者术后谵妄发生相关。多因素logistic回归分析显示术前两个月内感染〔比值比（odds ratio, OR）=2.597，95%置信区间（confidence interval, CI）：1.135～5.944，P=0.024〕，术前MELD评分≥22（OR=2.967，95%CI：1.104～7.975，P=0.031）及术前肝性脑病（OR=4.700，95%CI：2.083～10.602，P<0.001）是肝移植受者术后谵妄发生的独立危险因素，而使用碳青霉烯类抗生素≥3 d（OR=0.192，95%CI：0.083～0.441，P<0.001）是保护肝移植受者术后免于发生谵妄的因素。对临床结局而言，发生谵妄者相较未发生谵妄者术后ICU住院时间延长（P=0.025）。 结论 肝移植术后谵妄发病率高，发病时间早。发病危险因素包括术前感染、高MELD评分及肝性脑病，而使用碳青霉烯类抗生素能预防谵妄发生。 Abstract:Objective To analyze the incidence, the onset time, and the risk factors of delirium after liver transplantation (LT). Methods The clinical data of 211 patients who underwent LT at Third Xiangya Hospital, Central South University between January 2019 and December 2021 were collected to investigate the incidence and the onset time of postoperative delirium. Univariate analysis and multivariate logistic regression analysis were conducted to analyze the risk factors of delirium and to analyze the effect of delirium on clinical outcomes. Results The incidence of delirium was 20.4% (43/211) and the median interval between LT and the onset of delirium was 19 hours. Univariate analysis showed that the preoperative Model for End-Stage Liver Disease (MELD) score≥22, preoperative length-of-stay≥7, liver cancer, preoperative hepatic encephalopathy, infections within 2 months before LT, preoperative lymphocyte value<0.5×109 L－1, massive amount of intraoperative red blood cell infusion, and carbapenem antibiotics use for 3 days or longer were associated with postoperative delirium. Multivariate logistic regression analysis showed that preoperative infections within 2 months before LT (odds ratio [OR]=2.597, 95% confidence interval [CI]: 1.135-5.944, P=0.024), preoperative MELD score≥22 (OR=2.967, 95% CI: 1.104-7.975, P=0.031), and preoperative hepatic encephalopathy (OR=4.700, 95% CI: 2.043-10.602, P<0.001) were independent risk factors for delirium after LT, while carbapenems antibiotics use for 3 days or longer (OR=0.192, 95% CI: 0.083-0.441, P<0.001) was a protective factor for postoperative delirium among LT recipients. Regarding clinical outcomes, patients with delirium had longer postoperative ICU length-of-stays than those without delirium did (P=0.025). Conclusion There is a high incidence of postoperative delirium among patients who undergo LT and the onset time of delirium after LT is early. Risk factors include preoperative infections, high MELD score, and hepatic encephalopathy. On the other hand, the use of carbapenems can help prevent delirium. -
Key words:
- Liver transplantation /
- Delirium /
- Risk factors /
- Prognosis /
- Prophylaxis and treatment
-
表 1 肝移植受者术后谵妄发生危险因素的单因素分析
Table 1. Univariate analysis of risk factors for delirium in LT recipients
Variable With delirium (n=43) Without delirium (n=168) χ2 P Male/case (%) 35 (81.4) 140 (83.3) 0.091 0.763 Age≥55 yr./case (%) 17 (39.5) 64 (38.1) 0.030 0.862 Pre-LT MELD score≥22/case (%) 37 (86.0) 86 (51.2) 17.109 <0.001 Length-of-stay prior to LT≥7 d/case (%) 32 (74.4) 85 (50.6) 7.866 0.005 Hepatic tumor/case (%) 1 (2.3) 27 (16.1) 5.621 0.018 Hepatic cirrhosis/failure due to hepatitis/case (%) 29 (67.4) 109 (64.9) 0.099 0.753 Alcoholic cirrhosis/case (%) 6 (13.9) 15 (8.9) 0.965 0.326 Pre-LT hepatic encephalopathy/case (%) 24 (55.8) 34 (20.2) 21.740 <0.001 Pre-LT diabetes/case (%) 4 (9.3) 23 (13.7) 0.591 0.442 Infection within 2 months prior to LT/case (%) 29 (67.4) 73 (43.5) 7.890 0.005 WBC count prior to LT<4×109 L－1/case (%) 9 (20.9) 59 (35.1) 3.156 0.076 Lymphocyte count prior to LT<0.5×109 L－1/case (%) 5 (11.6) 49 (29.2) 5.531 0.019 Platelet count prior to LT<50×109 L－1/case (%) 17 (39.5) 56 (33.3) 0.582 0.446 Albumin prior to LT<30 g/L/case (%) 8 (18.6) 35 (20.8) 0.105 0.746 Dyskalemia prior to LT/case (%) 13 (30.2) 30 (17.9) 3.231 0.072 Cold ischemia time>360 min/case (%) 22 (51.2) 87 (51.8) 0.005 0.942 Duration of surgery≥400 min/case (%) 13 (30.2) 58 (34.5) 0.282 0.595 Intraoperative blood loss≥3000 mL/case (%) 21 (48.8) 96 (57.1) 0.956 0.328 Intraoperative RBC transfusion≥8 U/case (%) 40 (93.0) 135 (80.4) 3.882 0.049 Intraoperative use of remimazolam/case (%) 4 (9.3) 36 (21.4) 3.277 0.070 Intraoperative use of dexmedetomidine/case (%) 29 (20.9) 131 (77.9) 2.073 0.150 Intraoperative dosage propofol≥500 mg/case (%) 33 (76.7) 147 (87.5) 3.160 0.075 ALT on day 1 post-LT>1000 U/L/case (%) 17 (39.5) 49 (29.2) 1.712 0.191 Albumin level on day 1 post-LT<30 g/L/case (%) 1 (2.3) 10 (5.9) 0.325 0.569 Carbapenem use≥3 d/case (%) 21 (48.8) 138 (82.1) 20.450 <0.001 LT: liver transplant; MELD: Model for End-Stage Liver Disease; WBC: white blood cell; RBC: red blood cell; ALT: alanine aminotransferase. 
下载: 导出CSV
表 2 肝移植受者术后谵妄发生危险因素的多因素logistic回归分析
Table 2. Multivariate logistic regression analysis of risk factors for delirium in LT recipients
Variable β SE Wald χ2 OR (95% CI) P Infection within 2 months prior to LT 0.954 0.423 5.102 2.597 (1.135-5.944) 0.024 Pre-LT MELD score≥22 1.088 0.504 4.649 2.967 (1.104-7.975) 0.031 Pre-LT hepatic encephalopathy 1.547 0.415 13.898 4.700 (2.083-10.602) <0.001 Carbapenem use≥3 d −1.651 0.425 15.079 0.192 (0.083-0.441) <0.001 LT: liver transplant; β: regression coefficient; SE: standard error; OR: odds ratio; CI: confidence interval; the other abbreviations are explained in the note to Table 1.
下载: 导出CSV
表 3 肝移植术后谵妄结局
Table 3. Postoperative outcome for patients with/without delirium following liver transplant
Outcome With delirium (n=43) Without delirium (n=168) P ICU stay post-LT/d, median (interquartile range) 6 (6-8) 6 (5-7) 0.025 Lenghth-of-stay post-LT/d, median (interquartile range) 27 (24-29) 26 (22-31) 0.449 Bacterial infection within 2 months after LT/case (%) 19 (44.2) 52 (31) 0.101 Crude mortality within 2 months after LT/case (%) 5 (11.6) 8 (4.8) 0.095 ICU: intensive care unit; LT: liver transplant.
下载: 导出CSV
-
[1] SEYFFERT S, MOIZ S, COGHLAN M, et al. Decreasing delirium through music listening (DDM) in critically ill, mechanically ventilated older adults in the intensive care unit: a two-arm, parallel-group, randomized clinical trial. Trials,2022,23(1): 576. doi: 10.1186/s13063-022-06448-w [2] BINDA F, GALAZZI A, BRAMBILLA A, et al. Risk factors for delirium in intensive care unit<BR>in liver transplant patients. Assist Inferm Ric,2017,36(2): 90–97. doi: 10.1702/2721.27754 [3] LEE H, OH S Y, YU J H, et al. Risk factors of postoperative delirium in the intensive care unit after liver transplantation. World J Surg,2018,42(9): 2992–2999. doi: 10.1007/s00268-018-4563-4 [4] LEE H, YANG S M, CHUNG J, et al. Effect of perioperative low-dose dexmedetomidine on postoperative delirium after living-donor liver transplantation: a randomized controlled trial. Transplant Proc,2020,52(1): 239–245. doi: 10.1016/j.transproceed.2019.11.015 [5] ZHOU S, DENG F, ZHANG J, et al. Incidence and risk factors for postoperative delirium after liver transplantation: a systematic review and meta-analysis. Eur Rev Med Pharmacol Sci,2021,25(8): 3246–3253. doi: 10.26355/eurrev_202104_25733 [6] OLIVER N, BOHORQUEZ H, ANDERS S, et al. Post-liver transplant delirium increases mortality and length of stay. Ochsner J,2017,17(1): 25–30. [7] BECKMANN S, SCHUBERT M, BURKHALTER H, et al. Postoperative delirium after liver transplantation is associated with increased length of stay and lower survival in a prospective cohort. Prog Transplant,2017,27(1): 23–30. doi: 10.1177/1526924816679838 [8] BHATTACHARYA B, MAUNG A, BARRE K, et al. Postoperative delirium is associated with increased intensive care unit and hospital length of stays after liver transplantation. J Surg Res,2017,207: 223–228. doi: 10.1016/j.jss.2016.08.084 [9] DHAR R, YOUNG G B, MAROTTA P. Perioperative neurological complications after liver transplantation are best predicted by pre-transplant hepatic encephalopathy. Neurocrit Care,2008,8(2): 253–258. doi: 10.1007/s12028-007-9020-4 [10] KORK F, RIMEK A, ANDERT A, et al. Visual quality assessment of the liver graft by the transplanting surgeon predicts postreperfusion syndrome after liver transplantation: a retrospective cohort study. BMC Anesthesiol,2018,18(1): 29. doi: 10.1186/s12871-018-0493-9 [11] ZHOU J, XU X, LIANG Y, et al. Risk factors of postoperative delirium after liver transplantation: a systematic review and meta-analysis. Minerva Anestesiol,2021,87(6): 684–694. doi: 10.23736/S0375-9393.21.15163-6 [12] MOTTAGHI S, NIKOUPOUR H, FIROOZIFAR M, et al. The effect of taurine supplementation on delirium post liver transplantation: a randomized controlled trial. Clin Nutr,2022,41(10): 2211–2218. doi: 10.1016/j.clnu.2022.07.042 [13] FIORE G, FERRARI S, CUTINO A, et al. Delirium in COVID-19 and post-liver transplant patients: an observational study. Int J Psychiatry Clin Pract,2022,26(4): 343–351. doi: 10.1080/13651501.2022.2026403 [14] CHANG W J, HSIEH C E, HUNG Y J, et al. Length of alcohol abstinence predicts posttransplant delirium in living donor liver transplant recipients with alcoholic cirrhosis. Exp Clin Transplant,2022,20(8): 750–756. doi: 10.6002/ect.2022.0199 [15] BERRY K, COPELAND T, KU E, et al. Perioperative delta sodium and post-liver transplant neurological complications in liver transplant recipients. Transplantation,2022,106(8): 1609–1614. doi: 10.1097/TP.0000000000004102 [16] AWADA H N, STEINTHORSDOTTIR K J, SCHULTZ N A, et al. High-dose preoperative glucocorticoid for prevention of emergence and postoperative delirium in liver resection: a double-blinded randomized clinical trial substudy. Acta Anaesthesiol Scand,2022,66(6): 696–703. doi: 10.1111/aas.14057 [17] HORAN T C, ANDRUS M, DUDECK M A. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control,2008,36(5): 309–332. doi: 10.1016/j.ajic.2008.03.002 [18] WIESNER R, EDWARDS E, FREEMAN R, et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology,2003,124(1): 91–96. doi: 10.1053/gast.2003.50016 [19] DUTTA C, PASHA K, PAUL S, et al. Urinary tract infection induced delirium in elderly patients: a systematic review. Cureus,2022,14(12): e32321. doi: 10.7759/cureus.32321 [20] 于夏, 王蕾, 高雅, 等. 惊厥患儿镇静后谵妄发生的危险因素及风险列线图预测模型的建立. 中国当代儿科杂志,2022,24(11): 1238–1245. doi: 10.7499/j.issn.1008-8830.2205076 [21] JOO P, GRANT L, RAMSAY T, et al. Effect of inpatient antibiotic treatment among older adults with delirium found with a positive urinalysis: a health record review. BMC Geriatr,2022,22(1): 916. doi: 10.1186/s12877-022-03549-8 [22] Van GOOL W A, Van De BEEK D, EIKELENBOOM P. Systemic infection and delirium: when cytokines and acetylcholine collide. Lancet,2010,375(9716): 773–775. doi: 10.1016/s0140-6736(09)61158-2 [23] RIKER R R, SHEHABI Y, BOKESCH P M, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA,2009,301(5): 489–499. doi: 10.1001/jama.2009.56 [24] PEREZ-ZOGHBI J F, ZHU W, GRAFE M R, et al. Dexmedetomidine-mediated neuroprotection against sevoflurane-induced neurotoxicity extends to several brain regions in neonatal rats. Br J Anaesth,2017,119(3): 506–516. doi: 10.1093/bja/aex222 -
下载: 
点击查看大图
表(3)
计量
- 文章访问数: 24
- HTML全文浏览量: 5
- PDF下载量: 3
- 被引次数: 0
