个体化预测老年髋部骨折患者术后谵妄风险
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摘要
[目的]通过分析老年髋部骨折患者术后谵妄的相关危险因素,建立并验证个体化预测老年髋部骨折术后谵妄风险的列线图模型。[方法]纳入2013年1月～2018年3月于淄博市中心医院行手术治疗的老年髋部骨折患者257例,收集临床资料。应用单因素及多因素Logistic回归模型,分析老年髋部骨折患者术后谵妄的独立危险因素。应用R软件构建预测老年髋部骨折患者术后谵妄风险的列线图模型,并进行验证。[结果]多因素Logistic回归分析显示,年龄(OR=1.143,95%CI:1.076～1.214)、2型糖尿病(OR=4.591,95%CI:2.14～9.846)、ASA评分III级(OR=4.262,95%CI:1.600～11.352)、ASA评分IV级(OR=5.396,95%CI:1.868～15.583)、全身麻醉(OR=1.281,95%CI:1.066～1.540)及手术时间(OR=1.018,95%CI:1.001～1.035)是老年髋部骨折患者术后谵妄的独立危险因素(P<0.05)。对列线图模型进行验证,ROC曲线显示该模型预测老年髋部骨折患者术后谵妄风险的曲线下面积为0.818(95%CI:0.752～0.885);校准曲线为斜率接近于1的直线,Hosmer-Lemeshow拟合优度检验(x~2=8.760,P=0.363)均显示该模型预测老年髋部骨折患者术后谵妄风险具有良好准确度。[结论]本研究基于年龄、2型糖尿病、ASA分级、麻醉方式及手术时间这5项老年髋部骨折患者术后谵妄的独立危险因素,构建的预测老年髋部骨折患者术后谵妄风险的列线图模型,具有良好的区分度与准确度,可为临床个体化防治老年髋部骨折患者术后谵妄提供科学指导。
[Objective] To determine risk factors of postoperative delirium in elderly patients with hip fracture, and develop a nomogram model to predict these risks. [Methods] A total of 257 elderly patients who underwent surgical treatment for hip fracture hospitalized at our department from January 2013 to March 2018 were included into this study. Univariate and multivariate logistic regression were conducted to identify independent risk factors of postoperative delirium in the 257 patients. A nomogram was developed by R software and validated to predict the risk of post-operative delirium. [Results] Multivariate logistic regression analysis revealed that age(OR=1.143, 95%CI: 1.076-1.214), Type 2 Diabetes(OR=4.591, 95% CI: 2.14～9.846),ASA grade III(OR=4.262, 95% CI: 1.600～11.352), ASA grsde IV(OR=5.396, 95% CI: 1.868～15.583), general anesthesia(OR=1.281, 95% CI: 1.066～1.540) and surgery time(OR=1.018, 95% CI: 1.001～1.035) were independent risk factors of postoperative delirium in elderly patients with hip fracture(P<0.05). For validation of the nomogram, ROC curve revealed that the model predicting postoperative delirium in elderly patients with hip fracture was the area under the curve of 0.818(95%CI:0.752～0.885), the slope of the calibration plot was close to 1 and the model passed Hosmer-Lemeshow goodness of fit test(x~2=8.760, P=0.363), which demonstrated that the model was of good accuracy. [Conclusion] The nomogram predicting postoperative delirium in patients with hip fracture constructed based on age, type 2 diabetes, ASA score, anesthesia, and surgery time is of good discrimination and accuracy, which was of clinical significance.
[Objective] To determine risk factors of postoperative delirium in elderly patients with hip fracture, and develop a nomogram model to predict these risks. [Methods] A total of 257 elderly patients who underwent surgical treatment for hip fracture hospitalized at our department from January 2013 to March 2018 were included into this study. Univariate and multivariate logistic regression were conducted to identify independent risk factors of postoperative delirium in the 257 patients. A nomogram was developed by R software and validated to predict the risk of post-operative delirium. [Results] Multivariate logistic regression analysis revealed that age(OR=1.143, 95%CI: 1.076-1.214), Type 2 Diabetes(OR=4.591, 95% CI: 2.14～9.846),ASA grade III(OR=4.262, 95% CI: 1.600～11.352), ASA grsde IV(OR=5.396, 95% CI: 1.868～15.583), general anesthesia(OR=1.281, 95% CI: 1.066～1.540) and surgery time(OR=1.018, 95% CI: 1.001～1.035) were independent risk factors of postoperative delirium in elderly patients with hip fracture(P<0.05). For validation of the nomogram, ROC curve revealed that the model predicting postoperative delirium in elderly patients with hip fracture was the area under the curve of 0.818(95%CI:0.752～0.885), the slope of the calibration plot was close to 1 and the model passed Hosmer-Lemeshow goodness of fit test(x~2=8.760, P=0.363), which demonstrated that the model was of good accuracy. [Conclusion] The nomogram predicting postoperative delirium in patients with hip fracture constructed based on age, type 2 diabetes, ASA score, anesthesia, and surgery time is of good discrimination and accuracy, which was of clinical significance.
引文
[1] Zenilman ME. Delirium:an important postoperative complication[J]. JAMA, 2017, 317(1):77-78.
[2] Lee KH, Ha YC, Lee YK, et al. Frequency risk factors and prognosis of prolonged delirium in elderly patients after hip fracture surgery[J]. Clin Orthop, 2011, 469(9):2612-2620.
[3] Dovjak PP, Mikosch UDP, Gosch MM, et al. Treatment and prevention of postoperative complications in hip fracture patients:infections and delirium[J]. Wien Med Wochenschr, 2013, 163(20):448-454.
[4] Oh ES, Sieber FE, Leoutsakos JM, et al. Sex differences in hip fracture surgery:preoperative risk factors for delirium and postoperative outcomes[J]. J Am Geriatr Soc, 2016, 64(8):1616-1621.
[5]王晓伟,孙天胜,刘智,等.老年髋部骨折后发生谵妄的研究现状[J].中华骨科杂志, 2016, 36(13):871-875.
[6] Rudolph JL, Marcantonio ER. Postoperative delirium:acute change with long-term implications[J]. Anesth Analg, 2011, 112(5):1202-1211.
[7]陶立元,张华,赵一鸣.列线图的制作要点及其应用[J].中华儿科杂志, 2017, 55(5):323-323.
[8] American Psychiatric Association DSM-Task Force Arlington VA US. Diagnostic and statistical manual of mental disorders:DSM-5?(5th ed.)[J]. Codas, 2013, 25(2):191-192.
[9] Sung-Rak L, Yong-Chan H, Kang H, et al. Morbidity and mortality in jeju residents over 50-years of age with hip fracture with mean 6-year follow-up:a prospective cohort study[J]. J Korean Med Sci, 2013, 28(7):1089–1094.
[10] Eastham JA, Kattan MW, Scardino PT. Nomograms as predictive models[J]. Semin Urol Oncol, 2002, 20(2):108-115.
[11] Choi NY, Kim EH, Baek CH, et al. Development of a nomogram for predicting the probability of postoperative delirium in patients undergoing free flap reconstruction for head and neck cancer[J]. Eur J Surg Oncol, 2017, 43(4):683-688.
[12] Oh ES, Li M, Fafowora TM, et al. Preoperative risk factors for postoperative delirium following hip fracture repair:a systematic review[J]. Int J Geriatr Psychiatr, 2015, 30(9):900-910.
[13] Yang Y, Zhao X, Dong T, et al. Risk factors for postoperative delirium following hip fracture repair in elderly patients:a systematic review and meta-analysis[J]. Aging Clin Exp Res, 2017, 29(2):115-126.
[14]李呈凯,白树财,宋秀钢,等.老年髋部骨折患者术后谵妄相关危险因素的回顾性研究[J].中华骨科杂志, 2018, 38(4):250-256.
[15] Guo Y, Jia P, Zhang J, et al. Prevalence and risk factors of postoperative delirium in elderly hip fracture patients[J]. J Int Med Res,2016, 44(2):317-327.
[16] Brouquet A, Cudennec T, Benoist S, et al. Impaired mobility, ASA status and administration of tramadol are risk factors for postoperative delirium in patients aged 75 years or more after major abdominal surgery[J]. Ann Surg, 2010, 251(4):759-765.
[17]李晖,李清,杨风顺,等.多模式镇痛对老年髋部骨折术后谵妄影响的研究[J].中华骨科杂志, 2013, 33(7):736-740.
[18] PraticòC, Quattrone D, Lucanto T, et al. Drugs of anesthesia acting on central cholinergic system may cause post-operative cognitive dysfunction and delirium[J]. Med Hypotheses, 2005, 65(5):972-982.
[19]杭太香,吴珊珊,王玉洁,等.手术时间对老年患者开腹手术后复苏的影响及可能机制探讨[J].河北医科大学学报, 2016, 37(9):1055-1059.
[20] Lee HB, Mears SC, Rosenberg PB, et al. Predisposing factors for postoperative delirium after hip fracture repair in individuals with and without dementia[J]. J Am Geriatr Soc, 2011, 59(12):2306–2313.
[2] Lee KH, Ha YC, Lee YK, et al. Frequency risk factors and prognosis of prolonged delirium in elderly patients after hip fracture surgery[J]. Clin Orthop, 2011, 469(9):2612-2620.
[3] Dovjak PP, Mikosch UDP, Gosch MM, et al. Treatment and prevention of postoperative complications in hip fracture patients:infections and delirium[J]. Wien Med Wochenschr, 2013, 163(20):448-454.
[4] Oh ES, Sieber FE, Leoutsakos JM, et al. Sex differences in hip fracture surgery:preoperative risk factors for delirium and postoperative outcomes[J]. J Am Geriatr Soc, 2016, 64(8):1616-1621.
[5]王晓伟,孙天胜,刘智,等.老年髋部骨折后发生谵妄的研究现状[J].中华骨科杂志, 2016, 36(13):871-875.
[6] Rudolph JL, Marcantonio ER. Postoperative delirium:acute change with long-term implications[J]. Anesth Analg, 2011, 112(5):1202-1211.
[7]陶立元,张华,赵一鸣.列线图的制作要点及其应用[J].中华儿科杂志, 2017, 55(5):323-323.
[8] American Psychiatric Association DSM-Task Force Arlington VA US. Diagnostic and statistical manual of mental disorders:DSM-5?(5th ed.)[J]. Codas, 2013, 25(2):191-192.
[9] Sung-Rak L, Yong-Chan H, Kang H, et al. Morbidity and mortality in jeju residents over 50-years of age with hip fracture with mean 6-year follow-up:a prospective cohort study[J]. J Korean Med Sci, 2013, 28(7):1089–1094.
[10] Eastham JA, Kattan MW, Scardino PT. Nomograms as predictive models[J]. Semin Urol Oncol, 2002, 20(2):108-115.
[11] Choi NY, Kim EH, Baek CH, et al. Development of a nomogram for predicting the probability of postoperative delirium in patients undergoing free flap reconstruction for head and neck cancer[J]. Eur J Surg Oncol, 2017, 43(4):683-688.
[12] Oh ES, Li M, Fafowora TM, et al. Preoperative risk factors for postoperative delirium following hip fracture repair:a systematic review[J]. Int J Geriatr Psychiatr, 2015, 30(9):900-910.
[13] Yang Y, Zhao X, Dong T, et al. Risk factors for postoperative delirium following hip fracture repair in elderly patients:a systematic review and meta-analysis[J]. Aging Clin Exp Res, 2017, 29(2):115-126.
[14]李呈凯,白树财,宋秀钢,等.老年髋部骨折患者术后谵妄相关危险因素的回顾性研究[J].中华骨科杂志, 2018, 38(4):250-256.
[15] Guo Y, Jia P, Zhang J, et al. Prevalence and risk factors of postoperative delirium in elderly hip fracture patients[J]. J Int Med Res,2016, 44(2):317-327.
[16] Brouquet A, Cudennec T, Benoist S, et al. Impaired mobility, ASA status and administration of tramadol are risk factors for postoperative delirium in patients aged 75 years or more after major abdominal surgery[J]. Ann Surg, 2010, 251(4):759-765.
[17]李晖,李清,杨风顺,等.多模式镇痛对老年髋部骨折术后谵妄影响的研究[J].中华骨科杂志, 2013, 33(7):736-740.
[18] PraticòC, Quattrone D, Lucanto T, et al. Drugs of anesthesia acting on central cholinergic system may cause post-operative cognitive dysfunction and delirium[J]. Med Hypotheses, 2005, 65(5):972-982.
[19]杭太香,吴珊珊,王玉洁,等.手术时间对老年患者开腹手术后复苏的影响及可能机制探讨[J].河北医科大学学报, 2016, 37(9):1055-1059.
[20] Lee HB, Mears SC, Rosenberg PB, et al. Predisposing factors for postoperative delirium after hip fracture repair in individuals with and without dementia[J]. J Am Geriatr Soc, 2011, 59(12):2306–2313.