冠狀動脈繞道術病患譫妄發生率及認知功能變化之探討

Incidence of Delirium and Cognition Changes in Patients Undergoing Elective CABG Surgery

李秀卿(Hsiu-Ching Li)

指導教授 ： 陳佳慧

國立臺灣大學/醫學院/護理學研究所/碩士(2011年)

https://doi.org/10.6342/NTU.2011.02095

摘要

各種術式中以心臟術後的譫妄發生機率最高，並伴隨短期和長期的認知功能改變，使得病患會明顯出現生理、認知及精神行為障礙等問題，因而會危害病患的身體日常生活功能獨立程度，增加照護需求。本研究自2010年7月1日起至同年11月30日止，依立意取樣方式選取冠狀動脈繞道術病患有效樣本數38位，以譫妄評估方法及加護病房譫妄表為工具，觀察病患手術後第1~7天譫妄發生情形，另以簡易心智狀態檢查表，測量病患入院時、出院時及出院後2~4週的認知功能情形，同時收集人口特性及臨床相關因素，初探與暸解病患術後7天譫妄發生情形、發生譫妄的相關因素以及認知功能的變化情形。結果分析以費雪爾正確概率檢定（Fisher’s exact test）、曼-惠特尼Ｕ檢定（Mann-Whitney U-test）及魏可遜配對組符號等級檢定（Wilcoxon matched-pairs signes-rank test）進行分析。研究結果顯示：(一) 術後譫妄發生率：整體發生率為18.0%。接受體外循環技術者譫妄發生率為45.5%(5/11)，高於未接受體外循環技術者(7.4%)，兩者譫妄首次發生時間與高峰發生時間同為術後第1天，譫妄發生持續天數方面，接受體外循環技術者可長達4天。≧65歲者接受體外循環技術譫妄發生率較高(20% v.s 13.3%)。(二) 易感性因素與促發因素對於譫妄發生的影響：以年齡(平均71.2 v.s 60.4歲)﹙Z=－2.2; P=0.03＜0.05﹚、有無接受體外循環技術﹙X2=7.9; P=0.01＜0.05﹚、術中及術後有無接受輸紅血球血品﹙X2=8.6; P=0.008＜0.05﹚、術中平均血壓＜60mmHg的時間﹙Z=－2.7; P=0.008＜0.05﹚、及術中及術後輸紅血球血品總輸血量﹙Z=－3.5; P=0.000＜0.05﹚，在術後有無譫妄發生達顯著差異。(三) 術後認知功能的變化：三個時間點認知功能得分，發生譫妄者的得分皆低於無譫妄發生者，並在出院時兩者間差異最大(5.3分)，並達顯著差異（Z=－1.9，P=0.049＜0.05）。這些結果顯示譫妄的發生常見於冠狀動脈繞道術後，對於具有易感性因素與促發因素的病患，可進一步進行介入措施之臨床試驗，以評估預防或治療譫妄的策略，是否可能降低譫妄發生率及持續天數，及術後認知功能的恢復。

關鍵字

認知功能 ； 譫妄 ； 冠狀動脈繞道術 ； 體外循環術

並列摘要

Delirium is common after cardiac surgery. The aims of this study were to evaluate: 1) the incidence of delirium one week after Coronary Artery Bypass Graft Surgery (CABG); and 2) changes of cognitive function at discharge and 2-4 weeks following hospitalization in patients underwent CABG surgery. We enrolled 38 patients from July to November, 2010 who scheduled for an elective CABG in a tertiary medical center in northern Taiwan. Delirium was assessed daily by the confusion assessment method (CAM) or ICU-CAM one week after CABG. Demographics and clinical factors were also collected as covariates. Changes of cognitive function were assessed by the mini-mental state examination (MMSE) at three time points: admission, discharge, and 2-4 weeks after discharge. The data were analyzed by the SPSS software package and p value <0.05 was considered significant.
The results showed that delirium occurred in 18.4% (n=7) of the sample. For patients undergoing CABG with CPB (Cardiac Pumonary Bypass), the incidence was significantly higher to 45.5%. Overall, time to onset of delirium was on day one postoperatively; the duration of delirium was one day with the maximum up to four days long. Five risk factors including age (71.2 v.s 60.4 years; Z =- 2.2; P = 0.03), CABG with CPB (X2 = 7.9; P = 0.01), intra-operative/postoperative blood transfusion (X2 = 8.6; P = 0.008) , amounts of intra-operative/postoperative blood transfusion﹙Z=－3.5; P=0.000＜0.05﹚and duration time of intra-operative mean blood pressure＜60 mmHg﹙Z=－2.7; P=0.008＜0.05﹚were significantly associated with incidence of delirium. Patients who experienced delirium had lower cognitive function than non-delirium group at three time points (admission, discharge, and 2-4 weeks after discharge) with the between group difference as large as 5.3 MMSE points by hospital discharge (Z =- 1.9, P = 0.049). These findings suggested that delirium after CABG is common and justification was provided for intervention trials to evaluate whether delirium prevention or treatment strategies might reduce incidence and duration of delirium and improve postoperative cognitive function, particularly for those who had multiple susceptibility and precipitating risk factors.

並列關鍵字

Cognitive Function ； Delirium ； Coronary Artery Bypass Graft ； Cardiac Pulmonary Bypass

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