[Bedside ultrasound monitoring of optic nerve sheath diameter is a predictive factor for 28-day coma, delirium and death in etiologically diverse critically ill patients].

Haijun Zhi, Xiaoya Cui, Fengwei Zhang, Shujuan Wang, Xuezheng Liang, Bo Wang, Jie Cui, Yong Li
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The Kaplan-Meier curves were plotted according to the optimal cut-off values, and the results showed that the higher the ONSD, the higher the 28-day survival rate and the shorter survival duration in above patient population. Multivariate Cox regression analysis showed that ONSD broadening was an independent risk factor for 28-day coma or delirium in all patients [hazard ratio (HR) = 1.513, 95% confidence interval (95%CI) was 1.093-2.095, P = 0.013] and patients with primary brain injury (HR = 5.739, 95%CI was 2.112-15.590, P = 0.001). However, ONSD broadening was not independently associated with 28-day death in all patients or in the five etiological subgroups.</p><p><strong>Conclusions: </strong>ONSD within 24 hours of ICU admission is an independent risk factor for 28-day coma or delirium in etiologically diverse critically ill patients. 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引用次数: 0

Abstract

Objective: To explore whether the optic nerve sheath diameter (ONSD) within 24 hours of intensive care unit (ICU) admission is the predictor of 28-day delirium or coma and death in etiologically diverse critically ill patients.

Methods: A prospective, observational study was conducted. The critically ill patients admitted to the emergency ICU of Cangzhou Central Hospital from January 2021 to October 2022 were enrolled. Bedside ultrasound monitoring ONSD was performed within 24 hours of ICU admission. The consciousness status was assessed daily during ICU hospitalization. Coma was defined as Glasgow coma scale (GCS) score < 8 or Richmond agitation-sedation scale (RASS) score -4 or -5. Delirium was defined as responsiveness to verbal stimulation and with a positive confusion assessment method-intensive care unit (CAM-ICU). A positive result of CAM-ICU was defined as acute change or fluctuating course of mental status+inattention+altered level of consciousness or disorganized thinking. X-tile software analysis was used to visualize the best cut-off value for creating divisions in predicting 28-day coma or delirium and death, and then Kaplan-Meier curves were plotted. ONSD≥the optimal cut-off value from X-tile analysis was defined as ONSD broadening. ONSD broadening and related indicators were enrolled, and multivariate Cox regression analysis was used to analyze the risk factors of 28-day coma or delirium and 28-day death in etiologically diverse critically ill patients.

Results: A total of 321 critically ill patients were enrolled. Of them, 49 had primary brain injury, 54 had hypoxic ischemic brain injury (HIBI) after cardiac arrest, 70 had acute heart failure, 73 had sepsis, and 75 had other causes. Coma affected 184 patients (57.3%), and delirium affected 173 patients (53.9%). At 28 days of follow-up, 100 patients died, 16 patients remained comatose and 20 patients remained delirious. In all patients, as the GCS score decreased upon admission to the ICU, there was a gradually increasing trend in ONSD [GCS score 15 group: 5.20 (4.93, 5.43) mm, GCS score 10-14 group: 5.30 (4.90, 5.65) mm, GCS score 6-9 group: 5.40 (5.10, 5.80) mm, GCS score < 6 group: 5.70 (5.20, 5.96) mm, P < 0.05]. X-tile software analysis showed that in all patients and five etiological subgroups, ONSD broadening was a predictor for 28-day coma or delirium, and the optimal cut-off value was obtained (5.60 mm for all patients, 4.90 mm for primary brain injury, 5.75 mm for HIBI after cardiac arrest, 5.40 mm for acute heart failure, 5.90 mm for sepsis, and 5.75 mm for other causes). The Kaplan-Meier curves were plotted according to the optimal cut-off values, and the results showed that the higher the ONSD, the higher the incidence and duration of coma or delirium within 28 days in above patient population. X-tile software analysis showed that in all patients, and HIBI after cardiac arrest, sepsis and other causes patients, ONSD was a predictor for 28-day death, and the optimal cut-off value was obtained (6.20 mm for all patients, 5.85 mm for HIBI after cardiac arrest, 5.35 mm for sepsis, and 6.10 mm for other causes). The Kaplan-Meier curves were plotted according to the optimal cut-off values, and the results showed that the higher the ONSD, the higher the 28-day survival rate and the shorter survival duration in above patient population. Multivariate Cox regression analysis showed that ONSD broadening was an independent risk factor for 28-day coma or delirium in all patients [hazard ratio (HR) = 1.513, 95% confidence interval (95%CI) was 1.093-2.095, P = 0.013] and patients with primary brain injury (HR = 5.739, 95%CI was 2.112-15.590, P = 0.001). However, ONSD broadening was not independently associated with 28-day death in all patients or in the five etiological subgroups.

Conclusions: ONSD within 24 hours of ICU admission is an independent risk factor for 28-day coma or delirium in etiologically diverse critically ill patients. It serves as a predictor for 28-day coma or delirium in 5 subgroups of etiology including primary brain injury, HIBI after cardiac arrest, acute heart failure, sepsis, and other causes, but not for 28-day death.

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[床旁超声监测视神经鞘直径是不同病因重症患者 28 天昏迷、谵妄和死亡的预测因素]。
目的探讨重症监护病房(ICU)患者入院 24 小时内的视神经鞘直径(ONSD)是否能预测 28 天内不同病因重症患者的谵妄或昏迷以及死亡:进行了一项前瞻性观察研究。研究对象为 2021 年 1 月至 2022 年 10 月期间入住沧州市中心医院急诊重症监护室的重症患者。在患者入院 24 小时内进行床旁超声监测 ONSD。在重症监护室住院期间,每天评估意识状态。昏迷定义为格拉斯哥昏迷量表(GCS)评分<8分或里士满躁动镇静量表(RASS)评分-4或-5分。谵妄的定义是对言语刺激有反应,且意识模糊评估方法-重症监护室(CAM-ICU)呈阳性。CAM-ICU 阳性结果定义为精神状态急性改变或波动过程+注意力不集中+意识水平改变或思维紊乱。采用X-tile软件分析,以直观的方式确定预测28天昏迷或谵妄和死亡的最佳临界值,然后绘制Kaplan-Meier曲线。ONSD≥X-tile分析得出的最佳临界值被定义为ONSD增宽。对ONSD增宽及相关指标进行登记,并采用多变量Cox回归分析法对不同病因的重症患者28天昏迷或谵妄及28天死亡的风险因素进行分析:共有321名重症患者入选。其中,49 名患者为原发性脑损伤,54 名患者为心脏骤停后缺氧缺血性脑损伤(HIBI),70 名患者为急性心力衰竭,73 名患者为败血症,75 名患者为其他原因。昏迷患者有 184 人(57.3%),谵妄患者有 173 人(53.9%)。在 28 天的随访中,100 名患者死亡,16 名患者仍然昏迷,20 名患者仍然神志不清。所有患者在进入重症监护室后,随着 GCS 评分的降低,ONSD 有逐渐增加的趋势[GCS 评分 15 组:5.20(4.93,4.93);GCS 评分 15 组:5.20(4.93,4.93);GCS 评分 15 组:5.20(4.93,4.93):GCS评分15分组:5.20(4.93,5.43)毫米,GCS评分10-14分组:5.30(4.90,5.43)毫米:5.30(4.90,5.65)毫米,GCS 评分 6-9 组:5.40(5.10,5.80)毫米,GCS 评分小于 6 分组:5.70 (5.20, 5.96) mm,P < 0.05]。X-tile软件分析表明,在所有患者和五个病因亚组中,ONSD增宽是28天昏迷或谵妄的预测因子,并得出了最佳临界值(所有患者为5.60毫米,原发性脑损伤为4.90毫米,心脏骤停后HIBI为5.75毫米,急性心力衰竭为5.40毫米,败血症为5.90毫米,其他原因为5.75毫米)。根据最佳截断值绘制了卡普兰-梅耶曲线,结果显示 ONSD 越高,上述患者人群 28 天内昏迷或谵妄的发生率和持续时间就越长。X-tile软件分析显示,在所有患者、心脏骤停后HIBI患者、败血症患者和其他原因患者中,ONSD是28天内死亡的预测因子,并得出了最佳临界值(所有患者为6.20毫米,心脏骤停后HIBI患者为5.85毫米,败血症患者为5.35毫米,其他原因患者为6.10毫米)。根据最佳临界值绘制了 Kaplan-Meier 曲线,结果显示 ONSD 越高,上述患者人群的 28 天存活率越高,存活时间越短。多变量 Cox 回归分析显示,ONSD 增宽是所有患者 28 天昏迷或谵妄的独立危险因素[危险比(HR)= 1.513,95% 置信区间(95%CI)为 1.093-2.095,P = 0.013],也是原发性脑损伤患者 28 天昏迷或谵妄的独立危险因素(HR = 5.739,95%CI 为 2.112-15.590,P = 0.001)。然而,在所有患者或五个病因亚组中,ONSD扩大与28天死亡并无独立关联:结论:在不同病因的重症患者中,入院 24 小时内的 ONSD 是 28 天昏迷或谵妄的独立风险因素。在原发性脑损伤、心脏骤停后HIBI、急性心力衰竭、败血症和其他病因等5个病因亚组中,它是28天昏迷或谵妄的预测因子,但不是28天死亡的预测因子。
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Zhonghua wei zhong bing ji jiu yi xue
Zhonghua wei zhong bing ji jiu yi xue Medicine-Critical Care and Intensive Care Medicine
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