ICU谵妄亚型发生率及风险因素分析

[目的]谵妄是ICU病人发生最为频繁且严重的并发症之一,具有可预防性和预测性,根据临床特征分为活动增多型、活动减少型和混合型谵妄。然而,目前国内尚无ICU谵妄亚型的流行病学资料,国际上对ICU谵妄亚型的风险因素也尚未完全确定。因此,本研究的目的是探讨ICU谵妄亚型的发生率及风险因素。[方法]采用前瞻性队列研究设计,以首都医科大学附属宣武医院心脏、胸外科、普外科和呼吸内科ICU为研究场所,以连续入组的方法根据病人的纳入标准和排除标准选择病人,收集病人的基线资料,每日应用简体中文版意识模糊评估法(CAM)对病人进行评估。[结果]研究期间共有412例病人纳入样本,73例病人发生谵妄,谵妄的总发生率为17.7%,其中活动减少型、活动增多型及混合型谵妄的分别为47.9%、17.8%和34.3%。应用Logistic回归分析发现,日常生活能力(ADL)为活动减少型谵妄的独立风险因素,OR值为1.196;活动增多型谵妄与机械通气相关;年龄、ADL及简易智能精神状态检测量表(MMSE)为混合型谵妄的独立风险因素,OR值分别为1.117、1.224和1.007。[结论]活动减少型谵妄的发生率最高,其次为混合型,活动增多型谵妄的发生率最低。谵妄亚型不同风险因素各异,临床护士应加强对病人进行谵妄及相关因素评估,及早识别谵妄的风险因素,以便早期预防和治疗,降低谵妄的发生。     

ICU护士对谵妄评估的认知与实践调查

目的调查ICU护士对谵妄评估的认知与实践情况。方法选取北京市10所三级甲等医院148名重症监护室护士进行谵妄及评估工具认知情况的问卷调查。结果 ICU护士对谵妄的临床表现、评估、机制、处理、危害及危险因素的认知度低,十分了解者占4.05%～10.81%,比较了解者占22.97%～40.54%;ICU护士不能熟练掌握谵妄评估工具,经常用重症监护室意识模糊评估法、护理谵妄筛查量表、检测重症监护谵妄筛查量表的护士非常少,分别占5.41%、3.38%和2.70%;科室目前评估谵妄的工具主要是格拉斯哥昏迷量表,每天评估1次及以上的护士占60.14%。结论 ICU护士对谵妄的认知和对谵妄评估工具的认知需要提高,医院的继续教育培训课程中应考虑增加ICU谵妄及其评估工具相关知识,且国内应采用客观专业的评估工具进行常规谵妄的评估。     

重症患者谵妄评估的现状调查及影响因素分析

目的 调查护士应用ICU意识模糊评估法评估重症患者谵妄的现状,探讨影响其准确性的相关因素,为临床常规监测谵妄提供依据。方法 选取某三级甲等医院ICU的300例患者作为研究对象,研究者和责任护士分别采用ICU意识模糊评估法对患者进行评估,分析谵妄评估的差异。结果 谵妄评估中,研究者和责任护士评估一致的患者有225例,一致性检验系数Kappa=0.546。44例谵妄患者中,低活动型谵妄评估一致率为17.6%,高活动型谵妄评估一致率为77.8%。Logistic回归分析显示,急性生理与慢性健康评分、Richmond躁动-镇静量表评分、谵妄分型是影响谵妄评估准确性的因素,OR值分别为0.878、1.778和0.405（P＜0.05）。结论 ICU护士进行谵妄评估的准确性一般,其中低活动型谵妄评估的准确率最差。     

急诊科老年患者谵妄评估工具的研究进展

对急诊科老年患者谵妄评估工具进行综述,并分析影响急诊科老年患者谵妄评估量表应用的障碍因素,为动态监测患者的谵妄进展,制订个性化的谵妄评估方案提供借鉴。     

ICU患者谵妄的研究及护理进展

综述了国内外ICU患者谵妄的危险因素、护士对于ICU谵妄的识别现状、ICU谵妄评估工具,并提出ICU谵妄的护理措施,主要包括密切观察病情变化;做好入室前访视;加强沟通,尊重患者;舒适护理;改善环境;保证患者的睡眠;防止跌伤或自我损伤。认为精心的治疗和护理对降低ICU谵妄有着十分重要的意义。     

家属参与ICU病人谵妄评估研究进展北大核心

介绍家属参与ICU谵妄评估的研究现状,总结家属参与ICU谵妄评估的相关流程,从家属参与ICU谵妄评估的发展历程、家属使用的评估工具、评估流程、评估方法、影响因素等方面阐述了家属参与病人谵妄评估的实施方法,旨在为国内学者开展家属参与ICU病人谵妄评估的研究提供参考。     

信息技术在谵妄患者评估中的研究进展

谵妄评估对早期识别谵妄并进行管理具有重要意义。信息技术在医疗领域的广泛应用, 为谵妄患者的评估提供了有利条件。本文对信息技术在谵妄评估中的研究现状及临床应用现状进行综述, 以期为我国谵妄评估信息化提供理论依据和参考。     

国内外亚谵妄研究的范围综述

目的:了解国内外亚谵妄的研究现状。方法:系统检索国内外数据库及指南网,由2名研究者独立筛选文献并提取关键信息,内容包括作者/发布机构、年份、国家/地区、研究主题、研究方法、研究结果。结果:共纳入文献39篇。国内外在亚谵妄的定义、研究内容和研究方法等方面存在一定差异,国外关于亚谵妄的研究起步较早,目前主要研究内容为亚谵妄的评估和影响因素分析。但国内对亚谵妄认识不足,并且缺乏诊断和管理经验。结论:应提高对亚谵妄的重视程度,开发有效的预测、评估和诊断工具,基于循证依据构建科学管理方案,以预防或减少亚谵妄的发生。     

谵妄患者护理的进展

临床上多种疾病均可引起谵妄，加重患的基础疾病，增加治疗、护理的难度。近来一系列的基础研究及临床研究进展表明，对谵妄患的护理极其重要。重点阐述谵妄的临床表现、评估标准、护理措施。旨在护理人员正确认识、早期发现、重在预防，从而提高临床护理质量。     

导师制模式在护士ICU谵妄评估培训中的应用

目的:探讨导师制模式在护士ICU谵妄评估培训中的应用效果。方法:2017年6月1日~8月31日,对50名ICU护士在谵妄评估培训中采用导师制模式,采用一般资料调查表、ICU谵妄评估现状调查表、自行设计的谵妄风险与识别评估水平问卷,比较培训前后护士的谵妄评估水平及与研究人员谵妄评估结果的一致情况。结果:ICU护士有谵妄护理经历史,但评估方式单一,需要进行谵妄评估培训;培训后,50名护士谵妄评估的合格率高于培训前(P<0.01),谵妄评估一致率高于培训前(P<0.01)。结论:导师制模式应用于ICU谵妄评估护士培训的效果显著,能提高ICU谵妄评估水平及评估准确性,值得临床推广。     

Delirium assessment in the critically ill

Objective To compare available instruments for assessing delirium in critically ill adults that have undergone validity testing and provide clinicians with strategies to incorporate these instruments into clinical practice. Design Medline (1966–September 2006) was searched using the key words: delirium, cognitive dysfunction, assessment, intensive care unit, and critical illness to identify assessment tools that have been used to evaluate delirium in critically ill adults. A special emphasis was placed on delirium assessment tools that have been properly validated. Data on how these tools have been adopted into clinical practice as well as strategies for clinicians to improve delirium assessment in the ICU are highlighted. Measurements and results Six delirium assessment instruments including the Cognitive Test for Delirium (CTD), abbreviated CTD, Confusion Assessment Method–ICU, Intensive Care Delirium Screening Checklist, NEECHAM scale, and the Delirium Detection Score were identified. While each of these scales have undergone validation in critically ill adults, substantial differences exist among the scales in terms of the quality and extent of the validation effort, the specific components of the delirium syndrome each address, their ability to identify hypoactive delirium, their use in patients with a compromised level of consciousness, and their ease of use. Conclusions Incorporation of delirium assessment into clinical practice in the intensive care unit using a validated tool may improve patient care. Clinicians can adopt a number of different strategies to overcome the many barriers associated with routine delirium assessment in the ICU.     

预防老年髋部骨折患者围手术期谵妄的最佳证据总结

目的 基于循证的方法和要求,遴选获取国内外老年髋部骨折患者围手术期谵妄预防的相关证据,并对最佳证据进行总结。方法 系统检索Joanna Briggs Institute（JBI）循证卫生保健中心数据库、美国国立指南数据库、英国国家医疗保健优化研究所指南库、加拿大安大略护理学会网站、Up to Date、Cochrane Database、PubMed、澳大利亚和新西兰老年医学会网站、美国麻醉护士学会网站、欧洲麻醉学会网站、印度精神病学会网站、美国骨科医师学会网站、欧洲创伤和急诊外科学会网站、万方医学网、中国生物医学文献数据库等国内外数据库,检索时限为2014年1月至2019年3月。分别采用AGREE Ⅱ评分、系统综述评价工具、JBI（2016）对纳入的临床实践指南、系统评价、专家共识进行2人独立文献质量评价,结合专业人员判断,对符合标准的文献进行资料提取。结果 共纳入9篇文献,其中临床实践指南4篇,系统评价2篇,最佳实践建议1篇,专家共识2篇。从谵妄危险因素评估、谵妄筛查、谵妄预防、患者及家属健康教育、医务工作者培训及评价等6个方面汇总最佳证据共13条。结论 骨科医护人员应接受谵妄预防知识培训,选择结构化的工具进行谵妄风险因素评估,定期进行谵妄筛查。证据应用人员需结合医院及临床实际,选择合适的最佳证据,降低老年髋部骨折患者术后谵妄发生率。     

ICU意识模糊量表与临床直接观察在心脏术后谵妄评估中的差异性研究

目的比较ICU意识模糊量表评估法(CAM-ICU)与临床直接观察法在心脏术后谵妄评估中的差异性,探讨CAM-ICU量表在谵妄评估中的临床意义。方法对心脏外科术后ICU监护期间的患者进行谵妄评估,每班1次,先后由责任护士和研究小组分别用临床直接观察法和CAM-ICU量表判断患者是否发生谵妄,记录结果并进行差异性分析。结果全组281例,CAM-ICU谵妄发生率23.84%(67/281)。共进行有效评估2 304组,其中临床直接观察法判断谵妄阳性的有228次,ICU-CAM判断阳性的263次,两种评估结果不一致的有55组。按CAM-ICU量表为谵妄诊断标准,55组中误诊10次,漏诊45次。结论临床直接观察法对谵妄评估可能存在漏诊或误诊,建议采用CAM-ICU量表对患者进行谵妄评估,及早、正确评估发现谵妄。     

A retrospective study of the psychiatric management and outcome of delirium in the cancer patient

This report describes the evaluation and treatment of delirium in the cancer patient in a major comprehensive cancer center. Ninety consecutive cases of delirium seen by the inpatient psychiatry consultation/liaison service were analyzed in a retrospective fashion to evaluate demographic information, alcohol use, central nervous system disease, coexisting medical disease, and past psychiatric history. Delirium cases were divided into hyperalert, hypoalert, and mixed subtypes. For these three subtypes, medication profiles including dose of medication, duration of delirium, outcome, and the venue where the delirium began were also evaluated. The hyperalert subtype of delirium was the commonest type observed (71%) and had the shortest duration (P <0.0001) and best outcome (P <0.001). The patients with a hyperalert delirium subtype were treated with the least amount of haloperidol (P <0.0001). Patients were delirious for longer when the delirium began in the intensivecare units (P < 0.04). In general, patients who received no haloperidol experienced delirium of longer duration (P < 0.02) than those receiving haloperidol. Since the data represent patients who were referred for psychiatric treatment, this may explain the increased number of hyperalert deliriums and, therefore, the generalizability of the results is limited. Delirium in the cancer patient is particularly problematic given the coexisting medical problems these patients experience. Because the outcome of delirium is better when the duration is shorter, it is important for clinicians to be sensitive to early symptoms so that treatment can be implemented faster, leading to less morbidity and mortality.     

Delirium in Emergency Departments: Is it Recognized?

BackgroundDelirium is a complex neurocognitive manifestation of an underlying medical or surgical abnormality such as substance abuse, infection, sepsis, or organ failure. A recognized risk factor for delirium is advanced age (age >65 years). The projected demographic changes over the next 2 decades suggest that the number of aging adults will grow dramatically, and emergency nurses will see an increasing number of older patients manifesting the wide range of neuropsychiatric symptoms associated with delirium.MethodAn examination of 5 commonly used delirium assessment tools was undertaken specific to clinical features, use, scoring, findings, advantages, and disadvantages.FindingsNumerous factors contribute to the lack of effective delirium recognition. However, emergency nurses, with educational support, can successfully use the delirium assessment tools to recognize delirium.ConclusionEmergency nurses face challenges in recognizing delirium. One key challenge for many of these nurses is the appropriate use of assessment tools suitable for the ED setting.     

An exploration of the reliability and usability of two delirium screening tools in an Australian intensive care unit: A pilot study

ObjectiveTo compare the inter-rater reliability and usability of two delirium screening tools designed for use in ICU; the Confusion Assessment Method for ICU and the Intensive Care Delirium Screening Checklist.Research methodology/designA multiple methods design was used. The intra and inter rater reliability of the tools were evaluated using Kappa statistics and intra class correlation coefficients. Focus groups were conducted to explore ICU staff perceptions of the usability of the tools and feasibility of delirium screening.SettingPrivate hospital ICU, Melbourne Australia.Results66 patients were assessed for delirium; median age of 71 (IQR 62–75) years. Seventeen patients (26%) scored positive for delirium using the screening tools and 11 (17%) had delirium confirmed on the medical ICU discharge summary. Ten nurse assessors performed 99 paired assessments using the two tools sequentially, demonstrating the intra and inter-rater agreement and reliability of the tools was moderate to high.Four focus groups were conducted with 16 participants. Content analysis identified three themes: (i) current recognition of delirium, (ii) benefits of delirium screening, and (iii) future directions for delirium management. Time and medical staff indifference were identified as barriers to screening, facilitators were education and having a follow-up plan.ConclusionThis study found that the reliability and usability of the CAM-ICU and ICDSC were acceptable and that using structured delirium screening was feasible as part of a wider, multi-disciplinary delirium management plan.     

ICU护士儿童谵妄评估认知的质性研究

目的了解重症监护室(Intensive Care Unit,ICU)护士应用康奈尔儿童谵妄评估量表(Cornell Assessment of Pediatric Delirium,CAPD)进行谵妄评估后的真实体验及感受,为完善儿童ICU谵妄评估提供参考和依据。方法采用目的抽样法,选取2020年2—4月上海市某三级甲等儿童专科医院11名应用CAPD评估儿童谵妄的ICU护士作为研究对象,采用质性研究中的现象学研究方法,对研究对象进行面对面、半结构式深入访谈,采用Colaizzi 7步分析法收集整理资料,分析提炼主题。结果分析得出ICU护士对儿童谵妄评估认知的4个主题,分别为ICU护士对儿童谵妄评估认识的转变、儿童谵妄评估的阻碍因素、儿童谵妄评估的促进因素、ICU护士关心谵妄评估阳性后的医护团队协作性干预。结论本研究中ICU护士主要表现为对谵妄评估认识的不足、评估过程中遇到的阻碍因素、医护团队协作缺乏等。为提高ICU护士谵妄评估的便捷性及准确性,建议加强对医护人员谵妄的培训,逐步优化评估执行的障碍因素,鼓励医护团队合作,根据监护室工作情境及模式,制定符合儿童ICU的谵妄评估流程。     

Improving delirium recognition and assessment for people receiving inpatient palliative care: a mixed methods meta-synthesis

BackgroundDelirium is a serious acute neurocognitive condition frequently occurring for hospitalized patients, including those receiving care in specialist palliative care units. There are many delirium evidence-practice gaps in palliative care, including that the condition is under-recognized and challenging to assess.ObjectivesTo report the meta-synthesis of a research project investigating delirium epidemiology, systems and nursing practice in palliative care units.MethodsThe Delirium in Palliative Care (DePAC) project was a two-phase sequential transformative mixed methods design with knowledge translation as the theoretical framework. The project answered five different research questions about delirium epidemiology, systems of care and nursing practice in palliative care units. Data integration and metasynthesis occurred at project conclusion.ResultsThere was a moderate to high rate of delirium occurrence in palliative care unit populations; and palliative care nurses had unmet delirium knowledge needs and worked within systems and team processes that were inadequate for delirium recognition and assessment. The meta-inference of the DePAC project was that a widely-held but paradoxical view that palliative care and dying patients are different from the wider hospital population has separated them from the overall generation of delirium evidence, and contributed to the extent of practice deficiencies in palliative care units.ConclusionImproving palliative care nurses' capabilities to recognize and assess delirium will require action at the patient and family, nurse, team and system levels. A broader, hospital-wide perspective would accelerate implementation of evidence-based delirium care for people receiving palliative care, both in specialist units, and the wider hospital setting.     

Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients

Objective Acute brain dysfunction or delirium occurs in the majority of mechanically ventilated (MV) medical intensive care unit (ICU) patients and is associated with increased mortality. Unfortunately delirium often goes undiagnosed as health care providers fail to recognize in particular the hypoactive form that is characterized by depressed consciousness without the positive symptoms such as agitation. Recently, clinical tools have been developed that help to diagnose delirium and determine the subtypes. Their use, however, has not been reported in surgical and trauma patients. The objective of this study was to identify the prevalence of the motoric subtypes of delirium in surgical and trauma ICU patients. Methods Adult surgical and trauma ICU patients requiring MV longer than 24 h were prospectively evaluated for arousal and delirium using well validated instruments. Sedation and delirium were assessed using the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method in the ICU (CAM-ICU), respectively. Patients were monitored for delirium for a maximum of 10 days or until ICU discharge. Patients A total of 100 ICU patients (46 surgical and 54 trauma) were enrolled in this study. Three patients were excluded from the final analysis because they stayed persistently comatose prior to their death. Measurements and results Prevalence of delirium was 70% for the entire study population with 73% surgical and 67% trauma ICU patients having delirium. Evaluation of the subtypes of delirium revealed that in surgical and trauma patients, hypoactive delirium (64% and 60%, respectively) was significantly more prevalent than the mixed (9% and 6%) and the pure hyperactive delirium (0% and 1%). Conclusions The prevalence of the hypoactive or “quiet” subtype of delirium in surgical and trauma ICU patients appears similar to that of previously published data in medical ICU patients. In the absence of active monitoring with a validated clinical instrument (CAM-ICU), however, this subtype of delirium goes undiagnosed and the prevalence of delirium in surgical and trauma ICU patients remains greatly underestimated. An erratum to this article can be found at