중환자실 입원 노인의 섬망발생률과 위험요인

Abstract

본 연구는 중환자실 입원 노인을 대상으로 섬망 발생률과 발생 시기를 관찰하고 섬망 발생 위험요인을 전자의무기록을 통하여 분석한 후향적 서술적 조사연구이다. 본 연구는 서울 소재의 일 대학병원에서 하루에 한 번 정해진 시간에 CAM-ICU를 이용하여 섬망을 평가한 2014년 6월 1일부터 6월 25일까지 기간 동안 입실한 환자 중 선정기준을 만족한 99명을 대상자로 조사하였다. 중환자실 섬망 진단 도구는 RASS (Richmond Agitation and Sedation Scale)와 CAM-ICU (Confusion Assessment Method-ICU)를 이용하여 측정하며 성별, 연령, 동반질환, 환자의 계통별 질환, 병원 재원기간, 중환자실 재실기간, 수술유무, 인공호흡기 사용 유무와 환자에게 삽입된 각종 카테터의 개수, 통증 정도, 진정제 사용유무, 억제대 사용 유무와 Acute Physiology And Chronic Health Evaluation(APACHE Ⅱ) 점수로 측정한 중증도를 전자의무기록을 통해 자료 수집하였다. 수집된 자료는 SPSS 23.0 program for Windows version을 이용하여 실수, 백분율, 평균과 표준편차, 중위수와 사분위수, Chi-squared test, Fisher’s exact test, t-test, Mann Whitney U test, 단계적 다변량 로지스틱 회귀분석(stepwise logistic regression)을 시행하였다.

본 연구의 주요 결과는 다음과 같다. 1. 대상자의 일반적 특성 및 임상적 특성으로 성별은 남성(75.8%)이 여성(24.2%)보다 많았고, 평균 연령은 74.48(±7.15)세였다. 대상자의 중증도는 전체 평균 19.16(±8.94)점이었고 60명(60.6%)은 고혈압을 동반하고 있었다. 51명(51.5%)이 병동을 통하여 입실하였고, 평균 병원 재원일수는 30.32(±37.22)일, 중환자실 재실일수는 6.77(±10.95)일 이었다. 37명(37.4%)이 외과계 중환자실에 머물렀고 53명(53.5%)이 중환자실 입실 당일부터 입실 후 5일안에 수술을 시행 하였다. 계통별 질환은 심혈관, 소화기, 호흡기 질환 순으로 많은 분포를 보였다. 2. CAM-ICU를 통하여 섬망 양성으로 평가된 환자는 22명(22.2%)이었다. 3. 섬망 양상은 저활동형 섬망이 77.3%로 과활동형 섬망 22.7% 보다 더 많았다. 4. 섬망 발생시기는 중환자실 입실 후 평균 2.4±1.33일 이었으며, 입실 1일 째(31.8%)에 가장 높았다. 5. 섬망 발생군과 비섬망군간에 특성을 비교한 결과 입실시 APACHE Ⅱ의 평균 점수, 병원 재원 일수, 중환자실 유형에, 계통별 질환, 섬망 발생 이전 진정제 사용여부, 억제대 적용여부에 따라 유의한 차이를 보였다. 입실시 APACHE Ⅱ의 평균 점수는 섬망 발생군(22.09±7.98)이 비섬망군(18.33±9.08)보다 높았고 병원 재원 일수는 섬망 발생군이 23일로 비섬망군 18일에 비해 유의하게 길었다(Z=-2.39, p=.017), 또한 중환자실 유형은 외과계 중환자실이 섬망 발생군 63.6%로 가장 높아 비섬망군 29.9%에 비해 유의한 차이를 보였다(χ²=23.54, p<.001). 계통별 질환에 따른 섬망 발생 비율은 소화기 질환이 45.5%로 비섬망군(14.3%)보다 높았고(χ²=9.95, p=.006) 심혈관계 질환은 22.7%로 비섬망군 58.4%보다 낮게 나타났다(χ²=8.73, p=.004). 섬망 발생 이전 진정제 사용은 섬망 발생군(50.0%)이 비섬망군(19.5%)보다 많아 유의한 결과(χ²=8.23, p=.004)를 보였고, 억제대를 적용한 대상자도 섬망 발생군(59.1%)이 비섬망군(19.5%)보다 많았다(χ²=13.24, p<.001). 6. 섬망 발생군과 비섬망군간에 통계적으로 유의한 차이를 보였던 변수를 로지스틱 회귀분석한 결과는 억제대를 적용받고 있는 대상자가 억제대를 적용받고 있지 않은 대상자에 비해 섬망 발생을 6.29배(95% CI=1.47∼26.81, p=.013)로 높이는 것으로 나타났다. 본 연구를 통해 섬망 양상은 저활동형 섬망이 과활동형 섬망보다 더 많은 것으로 나타났다. 저활동형 섬망은 도구 없이 진단하는데 어려움이 있으므로 섬망 예방과 조기발견을 위해 표준화된 섬망 사정도구를 사용하는 것은 중요하다. 따라서 간호사가 섬망 사정 도구를 이용해서 적극적으로 일상적 간호에 적용하여 섬망을 사정할 필요가 있으며 섬망 발생률이 높은 질환자에 대해서는 좀 더 집중적인 관찰이 필요하고 나아가 섬망 예방 중재 프로그램을 개발하여 간호 실무에 적용할 수 있도록 하는 것이 필요할 것이다.| This study is a retrospective descriptive study conducted to investigate the incidence rate and time of delirium and analyze risk factors of delirium with medical records for the elderly hospitalized in intensive care units. We recruited 99 subjects among patients who were being hospitalized in one university hospital located in Seoul, Korea from June 1, 2014 to June 25, 2014, and whose delirium was assessed by using CAM-ICU once a day at the appointed time. The subjects met the selection criteria. The tool for diagnosis of intensive care unit delirium was RASS (Richmond Agitation and Sedation Scale) and CAM-ICU (Confusion Assessment Method-ICU). Sex, age, comorbid diseases, system-specific diseases, days of hospital stay, days of intensive care unit stay, history of surgery, use of a respirator, number of various catheters inserted in a patient, degree of pain, use of sedatives, physical restraint use and the severity of disease according to the Acute Physiology And Chronic Health Evaluation(APACHE Ⅱ) score were collected by using medical records. Frequency, percentage, mean and standard deviation, median and interquartile range of the collected data were analyzed and Chi-squared test, Fisher’s exact test, t-test, Mann Whitney U test and stepwise logistic regression were conducted by using SPSS 23.0 program for Windows version.

The main results of this research are as follows: 1. In general characteristics and clinical characteristics of the subjects, the number of male subjects(75.8%) was higher than that of female(24.2%). The average age was 74.48(±7.15) years old. The average severity of disease of the subjects was 19.16(±8.94) points. Sixty subjects(60.6%) had hypertension and 51 subjects(51.5%) were hospitalized through a ward. The average days of hospital stay was 30.32(±37.22) and the average days of intensive care unit stay was 6.77(±10.95). Thirty-seven subjects (37.4%) were included in the surgical intensive care unit and 53 subjects (53.5%) underwent surgery within five days after hospitalization in the intensive care unit. Cardiovascular, digestive and respiratory diseases included in system-specific diseases were frequent in order. 2. Total 22 subjects (22.2%) had a positive delirium score using CAM-ICU. 3. In the pattern of delirium, 77.3% had hypoactive delirium whereas 22.7% had hyperactive delirium. 4. The average time of delirium onset was 2.4±1.33 days after hospitalization in the intensive care unit and it was the highest on day 1(31.8%). 5. In the result of comparison between the delirium group and the non-delirium group, the characteristics were significantly different depending on the average score of APACHE Ⅱ at the time of hospitalization, days of hospital stay, type of intensive care unit, system-specific diseases, use of sedatives before delirium onset, and physical restraint use. The average score of APACHE Ⅱ at the time of hospitalization in the delirium group(22.09±7.98) was higher than that in the non-delirium group(18.33±9.08). The days of hospital stay in the delirium group was 23 which is significantly longer than that(18 days) in the non-delirium group(Z=-2.39, p=.017). In addition, based on the type of intensive care unit, 63.6% in the delirium group were included in the surgical intensive care unit and therefore it was significantly higher than 29.9% in the non-delirium group(χ²=23.54, p<.001). In analysis of the incidence rate of delirium depending on system-specific diseases, the rate was 45.5% in the delirium group in case of digestive diseases which is higher than 14.3% in the non-delirium group(χ²=9.95, p=.006), and 22.7% in case of cardiovascular diseases which is lower than 58.4% in the non-delirium group(χ²=8.73, p=.004). Sedatives before delirium onset were used significantly more in the delirium group (50.0%) than that in the non-delirium group (19.5%) (χ²=8.23, p=.004). Physical restraint use was also applied more in the delirium group (59.1%) than that in the non-delirium group (19.5%) (χ²=13.24, p<.001). 6. In the result of logistic regression analysis of variables which showed a statistically significant difference between the delirium group and the non-delirium group, the incidence rate of delirium in the subjects with physical restraint use was 6.286-fold higher than that in the subjects without physical restraint use (95% CI=1.47∼26.81, p=.013). In the pattern of delirium, hypoactive delirium was more frequent than hyperactive delirium. It is hard to diagnose hypoactive delirium without tool and thus a standardized delirium assessment tool is required for the prevention and early finding of delirium. Therefore, nurses need to apply a delirium assessment tool to routine nursing in order to evaluate delirium and to monitor patients with a higher incidence rate of delirium more intensively. Furthermore, delirium prevention intervention programs should be developed and applied to nursing practice.; This study is a retrospective descriptive study conducted to investigate the incidence rate and time of delirium and analyze risk factors of delirium with medical records for the elderly hospitalized in intensive care units. We recruited 99 subjects among patients who were being hospitalized in one university hospital located in Seoul, Korea from June 1, 2014 to June 25, 2014, and whose delirium was assessed by using CAM-ICU once a day at the appointed time. The subjects met the selection criteria. The tool for diagnosis of intensive care unit delirium was RASS (Richmond Agitation and Sedation Scale) and CAM-ICU (Confusion Assessment Method-ICU). Sex, age, comorbid diseases, system-specific diseases, days of hospital stay, days of intensive care unit stay, history of surgery, use of a respirator, number of various catheters inserted in a patient, degree of pain, use of sedatives, physical restraint use and the severity of disease according to the Acute Physiology And Chronic Health Evaluation(APACHE Ⅱ) score were collected by using medical records. Frequency, percentage, mean and standard deviation, median and interquartile range of the collected data were analyzed and Chi-squared test, Fisher’s exact test, t-test, Mann Whitney U test and stepwise logistic regression were conducted by using SPSS 23.0 program for Windows version.

The main results of this research are as follows: 1. In general characteristics and clinical characteristics of the subjects, the number of male subjects(75.8%) was higher than that of female(24.2%). The average age was 74.48(±7.15) years old. The average severity of disease of the subjects was 19.16(±8.94) points. Sixty subjects(60.6%) had hypertension and 51 subjects(51.5%) were hospitalized through a ward. The average days of hospital stay was 30.32(±37.22) and the average days of intensive care unit stay was 6.77(±10.95). Thirty-seven subjects (37.4%) were included in the surgical intensive care unit and 53 subjects (53.5%) underwent surgery within five days after hospitalization in the intensive care unit. Cardiovascular, digestive and respiratory diseases included in system-specific diseases were frequent in order. 2. Total 22 subjects (22.2%) had a positive delirium score using CAM-ICU. 3. In the pattern of delirium, 77.3% had hypoactive delirium whereas 22.7% had hyperactive delirium. 4. The average time of delirium onset was 2.4±1.33 days after hospitalization in the intensive care unit and it was the highest on day 1(31.8%). 5. In the result of comparison between the delirium group and the non-delirium group, the characteristics were significantly different depending on the average score of APACHE Ⅱ at the time of hospitalization, days of hospital stay, type of intensive care unit, system-specific diseases, use of sedatives before delirium onset, and physical restraint use. The average score of APACHE Ⅱ at the time of hospitalization in the delirium group(22.09±7.98) was higher than that in the non-delirium group(18.33±9.08). The days of hospital stay in the delirium group was 23 which is significantly longer than that(18 days) in the non-delirium group(Z=-2.39, p=.017). In addition, based on the type of intensive care unit, 63.6% in the delirium group were included in the surgical intensive care unit and therefore it was significantly higher than 29.9% in the non-delirium group(χ²=23.54, p<.001). In analysis of the incidence rate of delirium depending on system-specific diseases, the rate was 45.5% in the delirium group in case of digestive diseases which is higher than 14.3% in the non-delirium group(χ²=9.95, p=.006), and 22.7% in case of cardiovascular diseases which is lower than 58.4% in the non-delirium group(χ²=8.73, p=.004). Sedatives before delirium onset were used significantly more in the delirium group (50.0%) than that in the non-delirium group (19.5%) (χ²=8.23, p=.004). Physical restraint use was also applied more in the delirium group (59.1%) than that in the non-delirium group (19.5%) (χ²=13.24, p<.001). 6. In the result of logistic regression analysis of variables which showed a statistically significant difference between the delirium group and the non-delirium group, the incidence rate of delirium in the subjects with physical restraint use was 6.286-fold higher than that in the subjects without physical restraint use (95% CI=1.47∼26.81, p=.013). In the pattern of delirium, hypoactive delirium was more frequent than hyperactive delirium. It is hard to diagnose hypoactive delirium without tool and thus a standardized delirium assessment tool is required for the prevention and early finding of delirium. Therefore, nurses need to apply a delirium assessment tool to routine nursing in order to evaluate delirium and to monitor patients with a higher incidence rate of delirium more intensively. Furthermore, delirium prevention intervention programs should be developed and applied to nursing practice.