Risk Factors And Change Of Clinical Index Of The Postoperative Hyperactivity Delirium In Critical Ill Patients

BACKGROUNDDelirium frequently occurring in critically ill patients after operation,and it usually occurs in the early postoperative, course of this diseases often show volatility process, symptom by disturbance of thinking,memory,orientation,perception and emotion. This symptom occurring in 32-72% of older patients,while hyperactivity delirium rate is about 1.6%. Postoperative delirium has been proved that it associated with increased mortality, functional decline and increased cost. In the United States, according to a study in the intensive care unit, there is a more higher medical costs when delirium patients compared with non-delirium patients, increased an average of about 31%(us $41836 and $41836), it doesn’t contain the impact of delirium on psychological as well as the family economic burden. Delirium can be divided into hyperactivity delirium,hypodelirum andHybrid delirium.Despite the pathophysiology of post-operative delirium remains unknown,recently studies showed that inflammation plays an very important role during delirium of critical patients in intensive care unit.The occurrence of delirium is associated with many factors, such as age, cognitive reserve function, nutrition, alcohol, inflammation, etc. It is now established that an episode of delirium is associated with many factors as neurotransmitter imbalance(acetylcholine, dopamine and serotonin) amino acids perturbations, oxidative stress. Studies have shown that higher levels of inflammation biomarkers like C-reactive protein (CRP),interleukin (IL)-1β and interleukin (IL)-6 are associated with a greater incidence of delirium in postoperative patients. Procalcitonin used to be an early marker for sepsis recently, widely used in clinic and it can estimate the severity of inflammation of patients,but,the relationship between it and other factors like cholinesterase activity in delirium patients is still unkown.PCT,as a marker of inflammation, may obviously change in delirium, by detecting the PCT levels in the blood of those delirium and non-delirium patients, to research the change of PCT in delirium progress, and it may be a delirium diagnostic marker.We can also research the relationship between PCT and other markers in critically ill patients in the ICU delirium courses, and mechanism of delirium.OBJECTIVE:Delirium frequently occurring in critically ill patients after operation,recently studies showed that many biomarkers,espically inflammation,does association with it.However,the change of these biomarkers in hyperactivity delirium is not well studied.Our study sought to examine the basic biomarkers in hyperactivity delirious and nondelirious and the relationship between inflammatory biomarkers,PCT,with other factors.METHODSIn totle,53 hyperactivity delirious and 53 nondelirious patients were included in our analysis. Delirium group contains male 37 cases and 16 female cases, the average age (68.09-8.93).The control group contains 31 male and 22 female cases, the average age (66.40+7.82), The patients of hyperactive delirium and control group have previously been described in detail:postoperative patients in SICU from Shandong provincial hospital were enrolled between March 2014 and May 2015. Delirium was assessed twice a day by researchers who received training in the study assessment methods, until leave SICU or for up to 10 days using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).Studies have shown that most postoperative delirium occurs on postoperative days 2 and 3.Consciousness of patients was tested by the Richmond Agitation-Sedation Scale (RASS). Arterial blood gas analysis was carry out immediately after enrollment. Blood samples were collcted within 12 hours of enrollment and depart into two groups,one set was used to measure procalcitonin and colloid osmotic pressure. Plasma was separated from another group and stored at -20℃, while cholinesterase activity was be tested within 48 hours. Categorical variables were analyzed using 2-tailed Pearson Chi-Square tests with exact tests for small cell counts. The relationship between PCT with ACHE,LAC were further assessed with separate logistic regressionRESULTS(1) Patients more easily suffer from hyperactivity delirium who ever have Smoking history(64.2% versus 37.7%; P=0.01), Surgical history (45.3% versus 18.9%; P= 0.004), History of hepatitis b(56.6% versus 35.8%; P=0.03),and they have higher rate return to SICU(20.8% versus 5.8%; P=0.02).(2) No obviously differences were noted between hyperactivity delirium and nondelirious concerning age (68.09±8.93 versus 66.40±7.82years; P=0.30), gender (male,67.9%, versus 58.5%; P= 0.31), Hypertension(39.6% versus 47.2%; P= 0.43), Diabete (17% versus 11.3%; P= 0.40), Coronary heart disease (22.6% versus 28.3%; P=0.504), Operation duration(4.43±1.58 versus 4.44±1.65 hours; P= 1.00).(3) Blood sample of patients in two groups were obtained and analysis.biomarkers are not significantly different in hyperacitivity delirious patients compared with the nondelirious patients in view of CO2 (37.75±6.37 versus 39.47±4.48 mmHg; P= 0.111), Na+(137.70±5.29versus 136.28±3.58 mmol/L; P=0.110), K+(3.90±0.56 versus 3.85±0.45 mmol/L; P=0.529), Glu(8.02±2.60 versus 7.67±1.80 mmol/L; P= 0.422), COP16.28±2.83 versus 17.15±2.86 mmHg; P=0.119).(4) there are some index and biomarkers significantly higher in the hyperacitivity delirium group compared with the nondelirium group,such as HR(86.23±14.69 versus 77.70±13.08 time/min; P=0.002),PH(7.43±0.06 versus 7.40±0.05; P=0.004), Lac1.23±0.81 versus 1.02±0.42 mmol/L; P=0.034),PCT(4.71±9.18 versus 0.56±0.92 ng/ml; P=0.002), APACHEII(17.60±4.75versus 13.09±4.19; P=0.000).(5) some index and biomarkers showed the opposite trend,like O2 (88.15±36.16 versus 107.62±35.15 mmHg; P=0.006), ACHE(4.56±2.13 versus 6.75±2.69 U/ml; P =0.000).(6) The relationship was significantly between PCT and ACHE(R=0.316,P=0.021); PCT and APACHEII(R=0.661,P=0.000); PCT and LAC(R=0.029,P=0.034).While there is no linear correlation between PCT and PH(R=0.145,P=0.299); PCT and HR(R=0.059,P=0.674); PCT and O2 (R=0.080,P=0.571); This analysis suggest that PCT may affect ACHE,LAC in some way,and change score of APACHEII of hyperacitivity delirious.CONCLUSIONIn our clinical study,the level of PCT as a mark of inflammation is higher during hyperactivity deilirium than nondelirious,and it does correlation with ACHE,LAC, APACHE-II score, suggesting that inflammation affect occurrence of hyperactivity delirium though many ways. critically ill patients who have Smoking history, Surgical history, History of hepatitis b should get more attention about risk of delirium.Future studies are needed to elucidate mechanisms of delirium with inflammatory some other risk factors.