摘要
目的 建立合并轻度脑卒中老年患者非心脏非颅内手术后谵妄的预测模型.方法 本研究为巢式病例对照研究.选择2023年5月至12月唐山市工人医院胃肠外科、骨科、泌尿外科全身麻醉下行择期手术、合并轻度脑卒中的老年患者750例,性别不限,年龄≥65岁.收集患者围术期临床资料.于术后1～7d或出院前1d,采用意识模糊评估量表评估术后谵妄发生情况.采用简单随机抽样方法按照7∶3比例将患者分配至训练集和验证集.采用多因素logistic回归法筛选术后谵妄的危险因素,基于危险因素构建术后谵妄风险预测模型并绘制列线图,绘制受试者工作特征(ROC)曲线、校准曲线和决策曲线,评价预测模型的准确性.验证集对预测模型进行验证,绘制校准曲线和ROC曲线,评估模型的预测效果.结果 最终纳入721例患者,108例发生术后谵妄.年龄大、较高的ASA分级、术前高血压病史、受教育年限短、术前高匹兹堡睡眠质量指数(PSQI)评分、术前较高的美国国立卫生院卒中量表(NIHSS)评分、术中低体温、术中低血压和术后较高的疼痛数字评定量表(NRS)评分是术后谵妄的独立危险因素(P＜0.05),基于危险因素构建的预测模型ROC曲线下面积0.996,灵敏度1.000,特异度0.945;校准曲线斜率接近1,预测术后谵妄的风险与实际发生风险一致性较好;决策曲线阈值概率为0～0.9范围内净收益均高于无效线.验证集:预测模型校准曲线中队列和校正曲线与理想线接近,ROC曲线下面积0.997,灵敏度1.000,特异度0.962.结论 基于年龄、ASA分级、高血压病史、受教育年限、术前PSQI评分、NIHSS评分、术中低体温、术中低血压和术后NRS评分,建立的合并轻度脑卒中老年患者非心脏非颅内手术后谵妄预测模型,具有良好的预测效能.
Abstract
Objective To establish the prediction model for postoperative delirium in elderly pa-tients with mild stroke undergoing non-cardiac and non-intracranial surgery.Methods This was a nested case-control study.Seven hundred and fifty elderly patients of either sex with mild stroke,aged ≥65 yr,un-dergoing elective surgical procedures under general anesthesia in the Department of Gastrointestinal Surgery,Orthopedics and Urology at the Tangshan Workers Hospital from May to December 2023,were selected.The perioperative clinical data were collected.The incidence of postoperative delirium was assessed using the Confusion Assessment Scale 1-7 days after surgery or 1 day before discharge.The patients were assigned to the training set and the validation set in a ratio of 7∶3 using a simple random sampling method.Multivariate logistic regression was used to identify the risk factors for postoperative delirium,a postoperative delirium risk prediction model was established based on the risk factors,the nomogram was developed,and the re-ceiver operating characteristic(ROC)curve,calibration curve and decision curve were plotted to assess the accuracy of the prediction model.The prediction model was verified using the validation set,and the calibra-tion curve and ROC curve were plotted to assess the predictive performance of the model.Results A total of 721 patients were finally included,and 108 patients developed postoperative delirium.Older age,high American Society of Anesthesiologists Physical Status classification,history of preoperative hypertension,short years of education,high preoperative Pittsburgh sleep quality index score,high preoperative National Institutes of Health Stroke Scale score,high intraoperative hypothermia,intraoperative hypotension and high postoperative numerical rating scale score were independent risk factors for postoperative delirium(P＜0.05).The area under the ROC curve of the training set prediction model was 0.996,with a sensitivity of 1.000,and specificity of 0.945.The slope of the calibration curve was close to 1,and the predicted risk of postoperative delirium was in good agreement with the actual risk.When the threshold probability of the de-cision curve was 0-0.9,the net return rate was higher than the null line.Validation set:In the calibration curve of the prediction model,the cohort and calibration curves were close to the ideal line,with an area under the ROC curve of 0.997,sensitivity of 1.000,and specificity of 0.962.Conclusions Based on age,American Society of Anesthesiologists Physical Status classification,history of preoperative hypertension,years of education,preoperative Pittsburgh sleep quality index score,National Institutes of Health Stroke Scale score,intraoperative hypothermia and hypotension and postoperative numerical rating scale score,the prediction model for postoperative delirium is developed and has a good predictive performance in elderly pa-tients with mild stroke undergoing non-cardiac and non-intracranial surgery.
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