老年腹部恶性肿瘤患者围手术期发生谵妄的风险因素分析

Risk factors for perioperative delirium in elderly patients with abdominal malignancies

摘要:

目的 分析老年腹部恶性肿瘤患者围手术期发生谵妄的风险因素。方法 选取2023年6月—2024年12月南通大学附属第三人民医院收治的164例老年腹部恶性肿瘤患者，均接受手术治疗，在围手术期通过重症监护意识模糊评估法（CAM-ICU）评估患者是否发生谵妄，根据评估结果将所有患者分为谵妄组（52例）和非谵妄组（112例）。收集患者性别、年龄、受教育程度、基础疾病（高血压、高脂血症、冠心病、糖尿病）、围手术期指标（手术时间、麻醉时间、术中出血量）、术中风险事件（低血压、低体温、中转开腹）、术中用药、术前基本生化指标等，通过多因素一般Logistic回归模型筛选老年腹部恶性肿瘤患者围手术期发生谵妄的风险因素，构建列线图模型，并评价模型效能。结果 谵妄组患者的年龄、冠心病患病率、糖尿病患病率、手术时间、麻醉时间、术中出血量、低血压率、低体温率、氯胺酮使用率、白细胞计数均高于非谵妄组（P <0.05）；氟比洛芬酯使用率、血红蛋白水平均低于非谵妄组（P <0.05）。多因素一般Logistic回归分析结果显示：高龄［O^R=1.137（95% CI：1.037，1.246）］、合并冠心病［O^R=4.297（95% CI：1.164，15.862）］、术中出血量多［O^R=1.047（95% CI：1.030，1.064）］、术中低血压［O^R=3.362（95% CI：1.016，11.118）］、术中低体温［O^R=4.919（95% CI：1.168，20.714）］、术前血红蛋白水平低［O^R=0.970（95% CI：0.941，1.000）］均为谵妄的危险因素（P <0.05），氟比洛芬酯的使用［O^R=0.287（95% CI：0.083，0.991）］是谵妄的保护因素（P <0.05）。根据多因素分析结果建立列线图模型，结果显示，高龄、合并冠心病、术中出血量高、术中低血压、术中低体温、术前血红蛋白水平低均发生谵妄的风险因素，使用氟比洛芬酯是保护因素（P <0.05）。受试者工作特征曲线结果分析，列线图模型预测谵妄发生的敏感性为86.5%（95% CI：0.742，0.944），特异性为96.4%（95% CI：0.911，0.990），曲线下面积为0.937（95% CI：0.893，0.981）。结论 老年腹部恶性肿瘤患者围手术期发生谵妄的风险因素包括高龄、合并冠心病、术中出血量高、术中低血压及低体温、术前血红蛋白水平低，使用氟比洛芬酯为保护因素，且基于多因素分析建立的列线图模型预测效能较高。

Abstract:

Objective To analyze the risk factors for perioperative delirium in elderly patients with abdominal malignancies.Methods The study included 164 elderly patients with abdominal malignancies admitted to the Third People's Hospital Affiliated to Nantong University from June 2023 to December 2024, all of whom underwent surgical treatment. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used to assess the occurrence of delirium during the perioperative period, based on which the patients were divided into a delirium group (52 cases) and a non-delirium group (112 cases). Clinical data including sex, age, education level, underlying diseases (hypertension, hyperlipidemia, coronary heart disease, diabetes mellitus), perioperative indicators (operative duration, anesthesia duration, intraoperative blood loss), intraoperative risk events (hypotension, hypothermia, conversion to open surgery), intraoperative medications, and preoperative basic biochemical indicators were collected. A multivariable logistic regression model was used to identify risk factors for delirium in elderly patients with abdominal malignant tumors during the perioperative period. A nomogram prediction model was constructed and its diagnostic performance was evaluated.Results Patients in the delirium group had higher age, prevalence of coronary heart disease, and prevalence of diabetes mellitus, longer operative duration and anesthesia duration, greater intraoperative blood loss, higher incidence of intraoperative hypotension and hypothermia, higher rate of ketamine use, and higher white blood cell counts, but lower rate of flurbiprofen axetil use and hemoglobin levels compared with the non-delirium group (P < 0.05). The multivariable logistic regression analysis showed that advanced age [O^R = 1.137 (95% CI: 1.037, 1.246) ], coronary heart disease [O^R = 4.297 (95% CI: 1.164, 15.862) ], great intraoperative blood loss [O^R = 1.047 (95% CI: 1.030, 1.064) ], intraoperative hypotension [O^R = 3.362 (95% CI: 1.016, 11.118) ], and intraoperative hypothermia [O^R = 4.919 (95% CI: 1.168, 20.714) ], and low preoperative hemoglobin levels [O^R = 0.970 (95% CI: 0.941, 1.000) ] were all risk factors for delirium (P < 0.05), and that usage of flurbiprofen axetil [O^R = 0.287 (95% CI: 0.083, 0.991) ] was a protective factor for delirium (P < 0.05). A nomogram model was constructed based on the results of multivariable analysis, which demonstrated that advanced age, presence of coronary heart disease, greater intraoperative blood loss, intraoperative hypotension, intraoperative hypothermia, and lower preoperative hemoglobin levels were independent risk factors for perioperative delirium, whereas the use of flurbiprofen ester was identified as a protective factor (P < 0.05). The ROC curve analysis revealed that the nomogram prediction model had a sensitivity of 86.5% (95% CI: 0.742, 0.944), a specificity of 96.4% (95% CI: 0.911, 0.990), and an area under the curve of 0.937 (95% CI: 0.893, 0.981) for predicting the occurrence of delirium.Conclusion Risk factors for delirium in elderly patients with abdominal malignancies during the perioperative period include advanced age, presence of coronary heart disease, great intraoperative blood loss, intraoperative hypotension and hypothermia, and low preoperative hemoglobin levels. The use of flurbiprofen axetil is a protective factor, and the nomogram model based on multivariable analysis demonstrates good predictive performance.