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Diep C, Patel K, Petricca J, Daza JF, Lee S, Xue Y, Kremic L, Xiao MZX, Pivetta B, Vigod SN, Wijeysundera DN, Ladha KS. Incidence and relative risk of delirium after major surgery for patients with pre-operative depression: a systematic review and meta-analysis. Anaesthesia 2024; 79:1237-1249. [PMID: 39229767 DOI: 10.1111/anae.16398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Delirium is a common and potentially serious complication after major surgery. A previous history of depression is a known risk factor for experiencing delirium in patients admitted to the hospital, but the generalised risk has not been estimated in surgical patients. METHODS We conducted a systematic review and meta-analysis of studies reporting the incidence or relative risk (or relative odds) of delirium in the immediate postoperative period for adults with pre-operative depression. We included studies that defined depression as either a formal pre-existing diagnosis or having clinically important depressive symptoms measured using a patient-reported instrument before surgery. Multilevel random effects meta-analyses were used to estimate the pooled incidences and pooled relative risks. We also conducted subgroup analyses by various study-level characteristics to identify important moderators of pooled estimates. RESULTS Forty-two studies (n = 4,664,051) from five continents were included. The pooled incidence of postoperative delirium for patients with pre-operative depression was 29% (95%CI 17-43%, I2 = 99.0%), compared with 15% (95%CI 6-28%, I2 = 99.8%) in patients without pre-operative depression and 21% (95% CI 11-33%, I2 = 99.8%) in the cohorts overall. For patients with pre-operative depression, the risk of delirium was 1.91 times greater (95%CI 1.68-2.17, I2 = 42.0%) compared with patients without pre-operative depression. CONCLUSIONS Patients with a previous diagnosis of depression or clinically important depressive symptoms before surgery have substantially greater risk of experiencing delirium after surgery. Clinicians and patients should be informed of these increased risks. Robust screening and other risk mitigation strategies for postoperative delirium are warranted, especially for patients with pre-operative depression.
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Affiliation(s)
- Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Krisha Patel
- Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jessica Petricca
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Julian F Daza
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Sandra Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Yuanxin Xue
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Luka Kremic
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Maggie Z X Xiao
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Bianca Pivetta
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Simone N Vigod
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, Women's College Hospital, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, Unity Health Toronto, Toronto, ON, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, Unity Health Toronto, Toronto, ON, Canada
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Wang CC, DeBose-Scarlett A, Irlmeier R, Ye F, Siegrist K, Shah AS, Kingeter M. Safe Landing: Feasibility and Safety of Operating Room Extubation in Minimally Invasive Cardiac Valve Surgery. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00609-8. [PMID: 39370310 DOI: 10.1053/j.jvca.2024.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/22/2024] [Accepted: 09/15/2024] [Indexed: 10/08/2024]
Abstract
OBJECTIVE This study was designed to explore key safety outcomes after operating room (OR) extubation in minimally invasive cardiac valve surgery. DESIGN Single-center retrospective chart review. SETTING Academic medical center in the United States. PARTICIPANTS Patients undergoing valvular surgery via thoracotomy (November 2017-October 2022) at a single institution. INTERVENTIONS The OR extubation protocol was implemented on August 20, 2020. MEASUREMENTS AND MAIN RESULTS Delirium rates, reintubation rates, and intubation duration were compared before and after OR extubation protocol implementation. Logistic regression identified patient perioperative characteristics associated with unsuccessful OR extubation. Among 312 patients, 254 were extubated in the intensive care unit (ICU) and 58 in the OR. Preoperative demographics were comparable except for the Charlson Comorbidity Index (median: 2.0 ICU extubation v 1.5 OR extubation). Interrupted time series analysis showed no change in postoperative delirium post-OR extubation implementation, with a trend toward decreasing delirium (risk ratio = 0.37, CI: 0.13-1.10, p = 0.07). The postimplementation era also had a lower median intubation duration (8 hours v 13 hours, p < 0.001) without increasing reintubation rates (1.7% v 7.9%, p = 0.159). Increased bypass length (odds ratio = 0.99, CI: 0.98-0.99, p < 0.001), intraoperative morphine milligram equivalents (odds ratio = 0.99, CI: 0.99-1.0, p = 0.009), and preoperative Charlson Comorbidity Index above 3 (odds ratio = 0.42, CI: 0.19-0.95, p = 0.037) were associated with decreased odds of OR extubation. CONCLUSIONS OR extubation was not associated with increased postoperative delirium or reintubation rates but did decrease intubation duration. Successful OR extubation relies upon the consideration of various patient perioperative characteristics.
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Affiliation(s)
- Chen Chia Wang
- Vanderbilt University School of Medicine, Nashville, TN.
| | | | - Rebecca Irlmeier
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN
| | - Fei Ye
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN
| | - Kara Siegrist
- Vanderbilt University Medical Center, Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Nashville, TN
| | - Ashish S Shah
- Vanderbilt University Medical Center, Department of Cardiac Surgery, Nashville, TN
| | - Meredith Kingeter
- Vanderbilt University Medical Center, Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Nashville, TN
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Fathy W, Hussein M, Elanwar R, Elmoutaz H, Abdelsadek DA, Kassim DY. Effect of intra-operative Magnesium sulphate on the occurrence of post-operative delirium and insomnia in patients undergoing lumbar fixation: a randomized controlled trial. BMC Anesthesiol 2024; 24:289. [PMID: 39138397 PMCID: PMC11320981 DOI: 10.1186/s12871-024-02579-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 05/27/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Over the last two decades, a large body of literature has focused on studying the prevalence and outcome of the postoperative delirium and sleep disturbance. The aim of this work was to evaluate the effect of intraoperative administration of Magnesium sulphate on the occurrence of post-operative delirium and insomnia in patients undergoing lumbar fixation. METHODS This prospective randomized controlled trial was carried out on 80 patients indicated for lumbar fixation; 40 of them received conventional general anesthesia with extra administration of intraoperative magnesium sulphate (Mg sulphate group), and the other 40 received conventional general anesthesia only (control group). Both groups were submitted to pre-operative assessment of depression using Beck Depression inventory (BDI) scale, pre-operative assessment of fatigue using a fatigue questionnaire, pre- and post-operative assessment of insomnia using Insomnia severity index (ISI), post-operative assessment of delirium using Memorial delirium assessment scale (MDAS), post-operative assessment of pain using Visual Analogue Scale (VAS), and pre- and post-operative Quantitative electroencephalography (QEEG). RESULTS Mg sulphate administration, age, pre-operative BDI, pre-operative ISI, and post-operative VAS were independent predictors of post-operative ISI (P-value < 0.001, 0.047, 0.021, < 0.001, and < 0.001 respectively). Age and post-operative VAS were independent predictors of post-operative MDAS (P-value = 0.008, 0.013 respectively). Mg sulphate administration and pre-operative ISI were independent predictors of post-operative VAS (P-value = 0.010, 0.006 respectively). CONCLUSION There was a significant relationship between intraoperative Mg sulphate administration and both post-operative insomnia and pain in unadjusted and adjusted analysis.
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Affiliation(s)
- Wael Fathy
- Department of Anesthesiology, Surgical ICU and Pain Management, Beni-Suef University, Salah Salem Street, Beni-Suef, 62511, Egypt.
| | - Mona Hussein
- Department of Neurology, Beni-Suef University, Beni-Suef, Egypt
| | - Rehab Elanwar
- Neuro Diagnostic Research Center, Beni-Suef University, Beni-Suef, Egypt
| | - Hatem Elmoutaz
- Department of Anesthesiology, Surgical ICU and Pain Management, Beni-Suef University, Salah Salem Street, Beni-Suef, 62511, Egypt
| | - Donya A Abdelsadek
- Department of Anesthesiology, Surgical ICU and Pain Management, Beni-Suef University, Salah Salem Street, Beni-Suef, 62511, Egypt
| | - Dina Y Kassim
- Department of Anesthesiology, Surgical ICU and Pain Management, Beni-Suef University, Salah Salem Street, Beni-Suef, 62511, Egypt
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Sadlonova M, Hansen N, Esselmann H, Celano CM, Derad C, Asendorf T, Chebbok M, Heinemann S, Wiesent A, Schmitz J, Bauer FE, Ehrentraut J, Kutschka I, Wiltfang J, Baraki H, von Arnim CAF. Preoperative Delirium Risk Screening in Patients Undergoing a Cardiac Surgery: Results from the Prospective Observational FINDERI Study. Am J Geriatr Psychiatry 2024; 32:835-851. [PMID: 38228452 DOI: 10.1016/j.jagp.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE Postoperative delirium (POD) is a common complication of cardiac surgery that is associated with higher morbidity, longer hospital stay, cognitive decline, and mortality. Preoperative assessments may help to identify patients´ POD risk. However, a standardized screening assessment for POD risk has not been established. DESIGN Prospective observational FINd DElirium RIsk factors (FINDERI) study. PARTICIPANTS Patients aged ≥50 years undergoing cardiac surgery. MEASUREMENTS The primary aim was to analyze the predictive value of the Delirium Risk Screening Questionnaire (DRSQ) prior to cardiac surgery. Secondary aims are to investigate cognitive, frailty, and geriatric assessments, and to use data-driven machine learning (ML) in predicting POD. Predictive properties were assessed using receiver operating characteristics analysis and multivariate approaches (regularized LASSO regression and decision trees). RESULTS We analyzed a data set of 504 patients (68.3 ± 8.2 years, 21.4% women) who underwent cardiac surgery. The incidence of POD was 21%. The preoperatively administered DRSQ showed an area under the curve (AUC) of 0.68 (95% CI 0.62, 0.73), and the predictive OR was 1.25 (95% CI 1.15, 1.35, p <0.001). Using a ML approach, a three-rule decision tree prediction model including DRSQ (score>7), Trail Making Test B (time>118), and Montreal Cognitive Assessment (score ≤ 22) was identified. The AUC of the three-rule decision tree on the training set was 0.69 (95% CI 0.63, 0.75) and 0.62 (95% CI 0.51, 0.73) on the validation set. CONCLUSION Both the DRSQ and the three-rule decision tree might be helpful in predicting POD risk before cardiac surgery.
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Affiliation(s)
- Monika Sadlonova
- Department of Cardiovascular and Thoracic Surgery (MS, IK, HB), University of Göttingen Medical Center, Göttingen, Germany; Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany; Department of Psychosomatic Medicine and Psychotherapy (MS,), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany; Department of Psychiatry (MS, CMC), Massachusetts General Hospital, Boston, MA.
| | - Niels Hansen
- Department of Psychiatry and Psychotherapy (NH, HE, JW), University of Göttingen Medical Center, Göttingen, Germany
| | - Hermann Esselmann
- Department of Psychiatry and Psychotherapy (NH, HE, JW), University of Göttingen Medical Center, Göttingen, Germany
| | - Christopher M Celano
- Department of Psychiatry (MS, CMC), Massachusetts General Hospital, Boston, MA; Department of Psychiatry (CMC), Harvard Medical Schol, Boston, MA
| | - Carlotta Derad
- Department of Medical Statistics (CD, TA), University of Göttingen Medical Center, Göttingen, Germany
| | - Thomas Asendorf
- Department of Medical Statistics (CD, TA), University of Göttingen Medical Center, Göttingen, Germany
| | - Mohammed Chebbok
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany; Department of Cardiology and Pneumology (MC), University of Göttingen Medical Center, Göttingen, Germany
| | - Stephanie Heinemann
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Adriana Wiesent
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Jessica Schmitz
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Frederike E Bauer
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Julia Ehrentraut
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Ingo Kutschka
- Department of Cardiovascular and Thoracic Surgery (MS, IK, HB), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany
| | - Jens Wiltfang
- Department of Psychiatry and Psychotherapy (NH, HE, JW), University of Göttingen Medical Center, Göttingen, Germany; German Center for Neurodegenerative Diseases (DZNE) (JW), Göttingen, Germany; Neurosciences and Signaling Group (JW), Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Hassina Baraki
- Department of Cardiovascular and Thoracic Surgery (MS, IK, HB), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany
| | - Christine A F von Arnim
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany
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5
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Sun Q, Wu W. Effect of near-infrared spectroscopy on postoperative delirium in cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis. Front Cardiovasc Med 2024; 11:1404210. [PMID: 38962088 PMCID: PMC11221214 DOI: 10.3389/fcvm.2024.1404210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/07/2024] [Indexed: 07/05/2024] Open
Abstract
Background Postoperative delirium (POD) is a common anesthetic side effect in cardiac surgery. However, the role of oxygen saturation monitoring in reducing postoperative delirium has been controversial. Therefore, this meta-analysis aimed to analyze whether NIRS monitoring during cardiac surgery under cardiopulmonary bypass could reduce the incidence of postoperative delirium. Methods PubMed, Web of Science, Cochrane Library, Embase and China National Knowledge Infrastructure (CNKI) databases were systematically searched using the related keywords for randomized-controlled trials (RCTs) published from their inception to March 16, 2024. This review was conducted by the Preferred Reporting Project and Meta-Analysis Statement (PRISMA) guidelines for systematic review. The primary outcome was postoperative delirium, and the second outcomes included the length of ICU stay, the incidence of kidney-related adverse outcomes, and the incidence of cardiac-related adverse outcomes. Results The incidence of postoperative delirium could be reduced under the guidance of near-infrared spectroscopy monitoring (OR, 0.657; 95% CI, 0.447-0.965; P = 0.032; I2 = 0%). However, there were no significant differences in the length of ICU stay (SMD, 0.005 days; 95% CI, -0.135-0.146; P = 0.940; I2 = 39.3%), the incidence of kidney-related adverse outcomes (OR, 0.761; 95% CI, 0.386-1.500; P = 0.430; I2 = 0%), and the incidence of the cardiac-related adverse outcomes (OR, 1.165; 95% CI, 0.556-2.442; P = 0.686; I2 = 0%) between the two groups. Conclusion Near-infrared spectroscopy monitoring in cardiac surgery with cardiopulmonary bypass helps reduce postoperative delirium in patients. Systematic Review Registration PROSPERO, identifier, CRD42023482675.
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Affiliation(s)
| | - Weiguo Wu
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
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Albazee E, Alsubaie HM, AlKandery M, Abdulrahman S, Alsaleh S. Efficacy of perioperative lidocaine infusion on surgical field quality during functional endoscopic sinus surgery: a systematic review and meta-analysis with trial sequential analysis. Eur Arch Otorhinolaryngol 2024; 281:2819-2831. [PMID: 38231242 DOI: 10.1007/s00405-024-08455-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/18/2024]
Abstract
PURPOSE To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) that assessed the efficacy of perioperative intravenous lidocaine versus placebo in improving the quality of surgical field during functional endoscopic sinus surgery (FESS). METHODS PubMed, Scopus, Web of Science, and CENTRAL were thoroughly searched from inception until June 2023. The included RCTs were evaluated via RoB-2 tool. Our primary endpoint included intraoperative surgical field quality, and secondary endpoints involved operative duration, estimated blood loss, time for post-anesthesia care unit (PACU) discharge, postoperative pain, mean difference in heart rate (HR), and mean difference in mean arterial pressure (MAP). Continuous data were pooled as mean difference (MD) or standardized mean difference (SMD) via RevMan software. Also, the certainty of evidence for each outcome were assessed according to the GRADE system. RESULTS Four RCTs with total of 267 patients were included. Regarding the intraoperative quality of surgical field, the results indicated a significant difference in favor of the lidocaine group compared to the placebo group (n = 3 RCTs, MD - 0.80, 95% CI [- 0.98, - 0.61], p < 0.001, moderate certainty of evidence). The trial sequential analysis showed there is a substantial and conclusive evidence. Regarding time for PACU discharge, there was a significant difference that favor lidocaine group (p < 0.05). On the contrary, there was no significant difference between lidocaine and placebo groups in terms of operative duration, estimated blood loss, postoperative pain, mean change in MAP and HR, (p > 0.05). CONCLUSION Our review revealed that lidocaine infusion, compared with a placebo, significantly improved the surgical field and shortened the time required for PACU discharge. However, lidocaine did not reduce surgery time, estimated blood loss, postoperative pain, MAP, or HR.
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Affiliation(s)
- Ebraheem Albazee
- Kuwait Institute for Medical Specializations (KIMS), Kuwait City, Kuwait.
| | - Hemail M Alsubaie
- Otorhinolaryngology-Head and Neck Surgery and Communication Sciences Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mashael AlKandery
- Kuwait Institute for Medical Specializations (KIMS), Kuwait City, Kuwait
| | - Shawkat Abdulrahman
- Department of Otolaryngology-Head and Neck Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Saad Alsaleh
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Lu N, Chi Y, Liu M. Relationship Between Coronary Artery Revascularization and Postoperative Delirium: Progress and Perspectives. Angiology 2024:33197241252467. [PMID: 38712998 DOI: 10.1177/00033197241252467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Brain dysfunction resulting from damage to the heart-brain link leads to a decline in cognitive function. This, in turn, gives rise to the clinical symptom of perioperative delirium in patients undergoing coronary artery revascularization. Those affected are provided symptomatic treatment, but many do not recover fully. Thus, medium- and long-term mortality and adverse event rates remain relatively high in patients with perioperative delirium. Despite the relatively high incidence of perioperative delirium in patients undergoing coronary artery revascularization, it has not been systematically investigated. Inflammation, vascular damage, neuronal damage, and embolism are all involved in the injury process. Here, we discuss the incidence rate, pathological mechanisms, and prognosis of delirium after coronary artery revascularization. We also discuss in detail the risk factors for delirium after coronary artery revascularization, such as anxiety, depression, mode of operation, and drug use. We hope that prevention, early diagnosis, assessment, and potential treatment can be achieved by cardiologists to improve patient prognosis.
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Affiliation(s)
- Nan Lu
- Department of Psycho-cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, People's Republic of China
| | - Yunpeng Chi
- Department of Psycho-cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, People's Republic of China
| | - Meiyan Liu
- Department of Psycho-cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, People's Republic of China
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Yang X, Regmi M, Wang Y, Liu W, Dai Y, Liu S, Lin G, Yang J, Ye J, Yang C. Risk stratification and predictive modeling of postoperative delirium in chronic subdural hematoma. Neurosurg Rev 2024; 47:152. [PMID: 38605210 DOI: 10.1007/s10143-024-02388-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/14/2024] [Accepted: 04/02/2024] [Indexed: 04/13/2024]
Abstract
Background- Postoperative delirium is a common complication associated with the elderly, causing increased morbidity and prolonged hospital stay. However, its risk factors in chronic subdural hematoma patients have not been well studied. Methods- A total of 202 consecutive patients with chronic subdural hematoma at Peking University Third Hospital between January 2018 and January 2023 were enrolled. Various clinical indicators were analyzed to identify independent risk factors for postoperative delirium using univariate and multivariate regression analyses. Delirium risk prediction models were developed as a nomogram and a Markov chain. Results- Out of the 202 patients (age, 71 (IQR, 18); female-to-male ratio, 1:2.7) studied, 63 (31.2%) experienced postoperative delirium. Univariate analysis identified age (p < 0.001), gender (p = 0.014), restraint belt use (p < 0.001), electrolyte imbalance (p < 0.001), visual analog scale score (p < 0.001), hematoma thickness (p < 0.001), midline shift (p < 0.001), hematoma side (p = 0.013), hematoma location (p = 0.018), and urinal catheterization (p = 0.028) as significant factors. Multivariate regression analysis confirmed the significance of restraint belt use (B = 7.657, p < 0.001), electrolyte imbalance (B = -3.993, p = 0.001), visual analog scale score (B = 2.331, p = 0.016), and midline shift (B = 0.335, p = 0.007). Hematoma thickness and age had no significant impact. Conclusion- Increased midline shift and visual analog scale scores, alongside restraint belt use and electrolyte imbalance elevate delirium risk in chronic subdural hematoma surgery. Our prediction models may offer reference value in this context.
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Affiliation(s)
- Xuan Yang
- Beijing Key Laboratory of Intraocular Tumor Diagnosis and Treatment, Beijing Ophthalmology & Visual Sciences Key Lab, Medical Artificial Intelligence Research and Verification Key Laboratory of the Ministry of Industry and Information Technology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Moksada Regmi
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, China
- Center for Precision Neurosurgery and Oncology of Peking University Health Science Center, Peking University, Beijing, China
- Peking University Health Science Center, Beijing, China
| | - Yingjie Wang
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, China
- Center for Precision Neurosurgery and Oncology of Peking University Health Science Center, Peking University, Beijing, China
| | - Weihai Liu
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, China
- Center for Precision Neurosurgery and Oncology of Peking University Health Science Center, Peking University, Beijing, China
- Peking University Health Science Center, Beijing, China
| | - Yuwei Dai
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, China
- Center for Precision Neurosurgery and Oncology of Peking University Health Science Center, Peking University, Beijing, China
- Peking University Health Science Center, Beijing, China
| | - Shikun Liu
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, China
- Center for Precision Neurosurgery and Oncology of Peking University Health Science Center, Peking University, Beijing, China
- Peking University Health Science Center, Beijing, China
| | - Guozhong Lin
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, China
- Center for Precision Neurosurgery and Oncology of Peking University Health Science Center, Peking University, Beijing, China
| | - Jun Yang
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, China
- Center for Precision Neurosurgery and Oncology of Peking University Health Science Center, Peking University, Beijing, China
| | - Jingyi Ye
- Peking University School of Economics, Beijing, China.
| | - Chenlong Yang
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, China.
- Center for Precision Neurosurgery and Oncology of Peking University Health Science Center, Peking University, Beijing, China.
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, China.
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9
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Butz M, El-Shazly J, Gerriets T, Meyer R, Tschernatsch M, Braun T, Schramm P, Doeppner TR, Gerner ST, Boening A, Choi YH, Schoenburg M, Juenemann M. Patient-Reported Postoperative Neuropsychological Deterioration After Heart Valve Replacement and Coronary Artery Bypass Grafting. CJC Open 2024; 6:615-623. [PMID: 38708044 PMCID: PMC11065655 DOI: 10.1016/j.cjco.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/09/2023] [Indexed: 05/07/2024] Open
Abstract
Background Postoperative cognitive decline (POCD) after cardiosurgical interventions are well described through objective psychometric tests. However, a patient's subjective perception is essential to clinical assessment and quality of life. This study systematically evaluated patient-reported POCD between subjects undergoing coronary artery bypass grafting and heart valve replacement. Methods This study was a multicentre, prospective questionnaire survey conducted at the cardiac surgery departments at the Kerckhoff Clinic in Bad Nauheim and the University Hospital in Giessen, Germany. We included patients undergoing elective coronary artery bypass grafting (CABG), aortic valve replacement (AVR), mitral valve replacement or reconstruction (MVR), and combined surgery (CABG + valve replacement [VR]) with extracorporeal circulation. The Hospital Anxiety and Depression Scale, the Cognitive Failures Questionnaire (CFQ) for Self-assessment (CFQ-S), and the external assessment (CFQ-foreign [F]) were completed preoperatively, as well as at 3 and 12 months postoperatively. Results A total of 491 patients were available for analyses (CABG = 182, AVR = 134, MVR = 93, CABG + VR = 82). POCD and postoperative depression increase (PODI) were observed for each surgical procedure. (At the 3-month follow-up: CFQ-S [CABG = 7.1%, AVR = 3.7%, MVR = 9.7%, CABG + VR = 9.8%]; CFQ-F [CABG = 9.9%, AVR = 9.7%, MVR = 9.7%, CABG + VR = 15.9%]; PODI [CABG = 7.7%, AVR = 9.7%, MVR = 6.5%, CABG + VR = 8.5%]. At the 12-month follow-up: CFQ-S [CABG = 6.6%, AVR = 7.5%, MVR = 15.1%, CABG + VR = 7.3%]; CFQ-F [CABG = 7.1%, AVR = 14.9%, MVR = 10.8%, CABG + VR = 9.8%]; PODI [CABG = 10.4%, AVR = 11.2%, MVR = 6.5%, CABG + VR = 4.9%]). No significant between-group effects were observed for the CFQ-S, CFQ-F, or the Hospital Anxiety and Depression Scale. Conclusions For clinicians, paying attention to patients' self-reported experiences of reduced cognitive function and symptoms of depression following cardiac surgery is important. Such reporting is an indication that interventions such as cognitive training or psychotherapy should be considered.
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Affiliation(s)
- Marius Butz
- Heart and Brain Research Group, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
- Department of Geriatrics, Health Centre Wetterau, Schotten, Germany
| | - Jasmin El-Shazly
- Department of Psychocardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Tibo Gerriets
- Heart and Brain Research Group, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
- Die Neurologen, Private Neurology Practice, Bad Nauheim, Germany
| | - Rolf Meyer
- Heart and Brain Research Group, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Marlene Tschernatsch
- Heart and Brain Research Group, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
- Die Neurologen, Private Neurology Practice, Bad Nauheim, Germany
| | - Tobias Braun
- Heart and Brain Research Group, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Patrick Schramm
- Heart and Brain Research Group, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Thorsten R. Doeppner
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Stefan T. Gerner
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
- Center for Mind, Brain and Behavior (CMBB), University of Marburg and Justus Liebig University Giessen, Germany
| | - Andreas Boening
- Department of Cardiovascular Surgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - Yeong-Hoon Choi
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Markus Schoenburg
- Heart and Brain Research Group, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Martin Juenemann
- Heart and Brain Research Group, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
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10
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Sun J, Ji Y, Huang J, Zhao H. Risk Factors for Postoperative Delirium in Patients Undergoing Major Head and Neck Cancer Surgery: A Meta-analysis. Cancer Nurs 2024:00002820-990000000-00216. [PMID: 38416070 DOI: 10.1097/ncc.0000000000001330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Postoperative delirium (POD) is a common and serious complication after extensive surgery. Understanding the independent and potential modifiable risk factors leading to POD in patients with head and neck cancer (HNC) can provide information for future intervention trials aimed at reducing this risk. OBJECTIVE To systematically analyze influencing factors of POD in patients with HNC and identify high-risk individuals for delirium. METHODS PubMed, EMBASE, Scopus, OVID, and Cochrane Library were searched for publications prior to June 2023. Comparative studies in which POD risk factors were investigated were identified following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Newcastle-Ottawa Scale was used to evaluate the study quality. Pooled odds ratios or mean differences for individual risk factors were estimated using the Mantel-Haenszel and inverse-variance methods. RESULTS This review included 17 studies with a total of 4188 patients undergoing HNC surgery. The pooled prevalence of POD was 15.44%. Based on pooled analysis, 8 significant risk factors were identified including age older than 70 years, male sex, history of smoking, history of psychiatric disorder, American Society of Anesthesiologists score, albumin level, postoperative insomnia, and fluid intake. CONCLUSION In the present study, 8 factors that correlated with POD were identified: 6 preoperative, 1 intraoperative, and 1 postoperative. IMPLICATIONS FOR PRACTICE The influencing factors for POD in patients with HNC were identified that can provide a reference for improving the psychological state of the patient population and further development of effective treatment interventions.
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Affiliation(s)
- Jiaqi Sun
- Author Affiliations: Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology (Ms Sun), School of Nursing (Mss Ji and Huang) and Department of Pediatric Dentistry, School and Hospital of Stomatology (Mrs Zhao), China Medical University, Shenyang
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11
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Yang T, Yang H, Liu Y, Liu X, Ding YJ, Li R, Mao AQ, Huang Y, Li XL, Zhang Y, Yu FX. Postoperative delirium prediction after cardiac surgery using machine learning models. Comput Biol Med 2024; 169:107818. [PMID: 38134752 DOI: 10.1016/j.compbiomed.2023.107818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 11/03/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE Postoperative delirium (POD) is a common postoperative complication in elderly patients, especially those undergoing cardiac surgery, which seriously affects the short- and long-term prognosis of patients. Early identification of risk factors for the development of POD can help improve the perioperative management of surgical patients. In the present study, five machine learning models were developed to predict patients at high risk of delirium after cardiac surgery and their performance was compared. METHODS A total of 367 patients who underwent cardiac surgery were retrospectively included in this study. Using single-factor analysis, 21 risk factors for POD were selected for inclusion in machine learning. The dataset was divided using 10-fold cross-validation for model training and testing. Five machine learning models (random forest (RF), support vector machine (SVM), radial based kernel neural network (RBFNN), K-nearest neighbour (KNN), and Kernel ridge regression (KRR)) were compared using area under the receiver operating characteristic curve (AUC-ROC), accuracy (ACC), sensitivity (SN), specificity (SPE), and Matthews coefficient (MCC). RESULTS Among 367 patients, 105 patients developed POD, the incidence of delirium was 28.6 %. Among the five ML models, RF had the best performance in ACC (87.99 %), SN (69.27 %), SPE (95.38 %), MCC (70.00 %) and AUC (0.9202), which was far superior to the other four models. CONCLUSION Delirium is common in patients after cardiac surgery. This analysis confirms the importance of the computational ML models in predicting the occurrence of delirium after cardiac surgery, especially the outstanding performance of the RF model, which has practical clinical applications for early identification of patients at risk of developing POD.
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Affiliation(s)
- Tan Yang
- Department of Cardiovascular Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Hai Yang
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Yan Liu
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Xiao Liu
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Yi-Jie Ding
- Yangtze Delta Region Institute (Quzhou), University of Electronic Science and Technology of China, 324000 Quzhou, Zhejiang, China
| | - Run Li
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - An-Qiong Mao
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Yue Huang
- Department of Anesthesiology, Zigong First People's Hospital, Zi Gong, 644099, Sichuan, China
| | - Xiao-Liang Li
- Department of Cardiothoracic Surgery, First Peoples Hospital of Neijiang, Nei Jiang, 641000, Sichuan, China
| | - Ying Zhang
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China.
| | - Feng-Xu Yu
- Department of Cardiovascular Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China.
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12
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Nowakowska K, Sakellarios A, Kaźmierski J, Fotiadis DI, Pezoulas VC. AI-Enhanced Predictive Modeling for Identifying Depression and Delirium in Cardiovascular Patients Scheduled for Cardiac Surgery. Diagnostics (Basel) 2023; 14:67. [PMID: 38201376 PMCID: PMC10795764 DOI: 10.3390/diagnostics14010067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
Several studies have demonstrated a critical association between cardiovascular disease (CVD) and mental health, revealing that approximately one-third of individuals with CVD also experience depression. This comorbidity significantly increases the risk of cardiac complications and mortality, a risk that persists regardless of traditional factors. Addressing this issue, our study pioneers a straightforward, explainable, and data-driven pipeline for predicting depression in CVD patients. METHODS Our study was conducted at a cardiac surgical intensive care unit. A total of 224 participants who were scheduled for elective coronary artery bypass graft surgery (CABG) were enrolled in the study. Prior to surgery, each patient underwent psychiatric evaluation to identify major depressive disorder (MDD) based on the DSM-5 criteria. An advanced data curation workflow was applied to eliminate outliers and inconsistencies and improve data quality. An explainable AI-empowered pipeline was developed, where sophisticated machine learning techniques, including the AdaBoost, random forest, and XGBoost algorithms, were trained and tested on the curated data based on a stratified cross-validation approach. RESULTS Our findings identified a significant correlation between the biomarker "sRAGE" and depression (r = 0.32, p = 0.038). Among the applied models, the random forest classifier demonstrated superior accuracy in predicting depression, with notable scores in accuracy (0.62), sensitivity (0.71), specificity (0.53), and area under the curve (0.67). CONCLUSIONS This study provides compelling evidence that depression in CVD patients, particularly those with elevated "sRAGE" levels, can be predicted with a 62% accuracy rate. Our AI-driven approach offers a promising way for early identification and intervention, potentially revolutionizing care strategies in this vulnerable population.
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Affiliation(s)
- Karina Nowakowska
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, 90-419 Lodz, Poland; (K.N.); (J.K.)
| | - Antonis Sakellarios
- Laboratory of Biomechanics and Biomedical Engineering, Department of Mechanical and Aeronautics Engineering, University of Patras, 26504 Patras, Greece;
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, 45110 Ioannina, Greece;
| | - Jakub Kaźmierski
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, 90-419 Lodz, Poland; (K.N.); (J.K.)
| | - Dimitrios I. Fotiadis
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, 45110 Ioannina, Greece;
- Biomedical Research Institute—FORTH, University Campus of Ioannina, 45110 Ioannina, Greece
| | - Vasileios C. Pezoulas
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, 45110 Ioannina, Greece;
- Biomedical Research Institute—FORTH, University Campus of Ioannina, 45110 Ioannina, Greece
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13
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Asai Y, Yanagawa T, Takahashi M. Effect of pharmacist-led intervention protocol on preventing postoperative delirium after elective cardiovascular surgery. PLoS One 2023; 18:e0292786. [PMID: 37824500 PMCID: PMC10569577 DOI: 10.1371/journal.pone.0292786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023] Open
Abstract
Postoperative delirium (PD) is an acute brain dysfunction, with a particularly high incidence after cardiovascular surgery. Pharmacist-led interventions show limited evidence in attenuating PD in cardiovascular surgery. In this retrospective cohort study, we aimed to clarify the risk factors of PD for cardiovascular surgery focused on pharmacotherapy and elucidate the effect of pharmacist-led intervention on the PD attenuation rate based on protocol-based pharmaceutical management (PBPM). This study included 142 adult patients who underwent elective valve replacement or valvuloplasty. The risk factors for PD were investigated using multivariate logistic regression analysis. Taking risk factors into consideration, a protocol was developed to discontinue benzodiazepines prescriptions by ward pharmacists, and replace with ramelteon and suvorexant if all the following factors apply: 1) number of medications ≥ 6 drugs, 2) number of doses to take ≥ 4 times, and 3) regular use of benzodiazepines or insomnia. Subsequently, the PD rate was compared during a period of two years and 6 months between the pre-PBPM (n = 39) and post-PBPM (n = 62). The PD rate for elective valve replacement or valvuloplasty was 25% (35/142). The adjusted odds ratio for polypharmacy was 3.3 (95% confidence interval: 1.2-8.9, p = 0.016), suggesting that preoperative risk assessment may be essential for patients with polypharmacy. The PD rate significantly decreased to 13% (8/62) in the post-PBPM group compared with 33% (13/39) in the pre-PBPM group (p = 0.014). There was a significant decrease in benzodiazepines use in post-PBPM compared with pre-PBPM (p = 0.026); however, the rate of ramelteon and orexin receptor antagonists use increased by PBPM introduction (p < 0.001). Although the present PBPM still requires further modification, it is simple and potentially useful for pharmacists to assess the risk of patients undergoing any elective cardiovascular surgery.
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Affiliation(s)
- Yuki Asai
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, Hisaimyojin, Tsu, Mie, Japan
| | - Tatsuki Yanagawa
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, Hisaimyojin, Tsu, Mie, Japan
| | - Masaaki Takahashi
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, Hisaimyojin, Tsu, Mie, Japan
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14
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Schaffer AJ, Li G, McIlroy DR, Lopez MG, Freundlich RE. Effects of Postoperative Blood Pressure Management on Delirium Among Patients in the Intensive Care Unit After Cardiac Surgery: An Observational Cohort Study. J Cardiothorac Vasc Anesth 2023; 37:1683-1690. [PMID: 37244820 PMCID: PMC10524613 DOI: 10.1053/j.jvca.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/17/2023] [Accepted: 05/05/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVES This study aimed to determine whether blood pressure control in the early postoperative period was associated with postoperative delirium in the cardiovascular intensive care unit (ICU). DESIGN Observational cohort study. SETTING Single large academic institution with a high volume of cardiac surgery. PARTICIPANTS Cardiac surgery patients admitted to the cardiovascular ICU after surgery. INTERVENTIONS Observational study. MEASUREMENTS AND MAIN RESULTS A total of 517 cardiac surgery patients had mean arterial pressure (MAP) data recorded minute-by-minute for 12 postoperative hours. The time spent in each of the 7 prespecified blood pressure bands was calculated, and the development of delirium was recorded in the ICU. A multivariate Cox regression model was developed using the least absolute shrinkage and selection operator approach to identify associations between time spent in each MAP range band and delirium. Compared with the reference band of 60-to-69 mmHg, longer durations spent in 3 bands were independently associated with a lower risk of delirium: 50-to-59 mmHg band (adjusted hazard ratio [HR] 0.907 [per 10 minutes]; 95% CI 0.861-0.955); 70-to-79 mmHg band (adjusted HR 0.923 [per 10 minutes]; 95% CI 0.902-0.944); 90-to-99 mmHg band (adjusted HR 0.898 [per 10 minutes]; 95% CI 0.853-0.945). CONCLUSIONS The MAP range bands above and below the authors' reference band of 60-to- 69 mmHg were associated with decreased risk of ICU delirium development; however, this was difficult to reconcile with a plausible biologic mechanism. Therefore, the authors did not find a correlation between early postoperative MAP control and increased risk of the development of ICU delirium after cardiac surgery.
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Affiliation(s)
| | - Gen Li
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David R McIlroy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Anaesthesia & Perioperative Medicine, Monash University, Melbourne, Australia
| | - Marcos G Lopez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert E Freundlich
- Department of Anesthesiology, Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.
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15
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Rengel KF, Boncyk CS, DiNizo D, Hughes CG. Perioperative Neurocognitive Disorders in Adults Requiring Cardiac Surgery: Screening, Prevention, and Management. Semin Cardiothorac Vasc Anesth 2023; 27:25-41. [PMID: 36137773 DOI: 10.1177/10892532221127812] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neurocognitive changes are the most common complication after cardiac surgery, ranging from acute postoperative delirium to prolonged postoperative neurocognitive disorder. Changes in cognition are distressing to patients and families and associated with worse outcomes overall. This review outlines definitions and diagnostic criteria, risk factors for, and mechanisms of Perioperative Neurocognitive Disorders and offers strategies for preoperative screening and perioperative prevention and management of neurocognitive complications.
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Affiliation(s)
- Kimberly F Rengel
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniella DiNizo
- Scope Anesthesia of North Carolina, Charlotte, NC, USA.,Pulmonary and Critical Care Consultants, Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Christopher G Hughes
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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16
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Deschamps A, Saha T, El-Gabalawy R, Jacobsohn E, Overbeek C, Palermo J, Robichaud S, Dumont AA, Djaiani G, Carroll J, Kavosh MS, Tanzola R, Schmitt EM, Inouye SK, Oberhaus J, Mickle A, Ben Abdallah A, Avidan MS, Clinical Trials Group CPA. Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial. F1000Res 2023; 8:1165. [PMID: 31588356 PMCID: PMC6760454 DOI: 10.12688/f1000research.19213.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Background: There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery. There is limited evidence in this regard for cardiac surgery. A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death. However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods: The Electroe ncephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites. The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery. One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25). The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients. The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review. Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion: The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov ( NCT02692300) 26/02/2016.
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Affiliation(s)
- Alain Deschamps
- Department of Anesthesiology and Pain Medicine, Montreal Heart Institute and Universite de Montreal, Montreal, Quebec, H1T 1C8, Canada,
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Renée El-Gabalawy
- Department of Clinical Health Psychology, Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Overbeek
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Palermo
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | | | - Andrea Alicia Dumont
- Montreal Health Innovation Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - George Djaiani
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Jo Carroll
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Morvarid S. Kavosh
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rob Tanzola
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
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17
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Deschamps A, Saha T, El-Gabalawy R, Jacobsohn E, Overbeek C, Palermo J, Robichaud S, Dumont AA, Djaiani G, Carroll J, Kavosh MS, Tanzola R, Schmitt EM, Inouye SK, Oberhaus J, Mickle A, Ben Abdallah A, Avidan MS, Clinical Trials Group CPA. Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial. F1000Res 2023; 8:1165. [PMID: 31588356 PMCID: PMC6760454 DOI: 10.12688/f1000research.19213.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2019] [Indexed: 01/27/2023] Open
Abstract
Background: There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery. There is limited evidence in this regard for cardiac surgery. A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death. However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods: The Electroe ncephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites. The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery. One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25). The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients. The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review. Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion: The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov ( NCT02692300) 26/02/2016.
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Affiliation(s)
- Alain Deschamps
- Department of Anesthesiology and Pain Medicine, Montreal Heart Institute and Universite de Montreal, Montreal, Quebec, H1T 1C8, Canada,
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Renée El-Gabalawy
- Department of Clinical Health Psychology, Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Overbeek
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Palermo
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | | | - Andrea Alicia Dumont
- Montreal Health Innovation Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - George Djaiani
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Jo Carroll
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Morvarid S. Kavosh
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rob Tanzola
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
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18
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Ormseth CH, LaHue SC, Oldham MA, Josephson SA, Whitaker E, Douglas VC. Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review. JAMA Netw Open 2023; 6:e2249950. [PMID: 36607634 PMCID: PMC9856673 DOI: 10.1001/jamanetworkopen.2022.49950] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups. OBJECTIVE To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting. EVIDENCE REVIEW A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium. FINDINGS A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity. CONCLUSIONS AND RELEVANCE In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.
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Affiliation(s)
- Cora H. Ormseth
- Department of Emergency Medicine, University of California, San Francisco
| | - Sara C. LaHue
- Department of Neurology, University of California, San Francisco
| | - Mark A. Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | | | - Evans Whitaker
- University of California, San Francisco, School of Medicine
| | - Vanja C. Douglas
- Department of Neurology, University of California, San Francisco
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19
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Irqsusi M, Loos D, Dielmann K, Ramzan R, Wulf H, Ghazy T, Vogt S, Rastan AJ. Influence of cardioplegic solution on incidence of delirium after CABG surgery: Use of Calafiore blood cardioplegia versus HTK - Bretschneider - solution in a single-center retrospective analysis from 2017 to 2021. J Card Surg 2022; 37:4670-4678. [PMID: 36321752 DOI: 10.1111/jocs.17059] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Purpose of the present study is an evaluation of postoperative incidence for delirium after coronary artery bypass surgery (CABG). Study addressed whether application of Histidine-Tryptophan-Ketoglutarate (HTK) solution (Bretschneider) or blood cardioplegia (Calafiore) is associated with increased of postoperative delirium cases. MATERIALS AND METHODS In a retrospective, single center evaluation a total number of 273 patients were enrolled in the study from January 2017 to October 2021. There were 124 patients assigned to the Calafiore group blood cardioplegic solution (BCC) and 149 patients were included in the Bretschneider group (HTK). The primary endpoint was the postoperative delirium rate in its frequency of occurrence. Definition of the dilirium status was performed using the Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) score during the first three postoperative days. Secondary endpoints were the time intervals of intensive care duration of stay, mechanical ventilation, total extracorporeal circulation, ischemia and reperfusion. Serum levels of the electrolytes Sodium, Potassium, ionized Calcium, and Chloride were monitored. RESULTS Although no significant difference in delirium status between the groups were noticed, on third postoperative day, delirium rate dependent on cardioplegia solution used (HTK 12.0%; BCC 3.0%; p = .024) and duration of intensive care stay differed (HTK 4.5 vs. BCC 3.0 days; p = .001). Although Ischemic time (HTK 73.0 vs. BCC 83.0 min; p < .001) and reperfusion time (HTK 35.0 vs. Calafiore 24.0 min; p < .001) were extended in the BCC group less cases of delirium were diagnosed. Serum sodium levels after HTK cardioplegic infusion were decreased (HTK 129.68 vs. BCC 138.96 mmol/l; p < .001). The significant difference persists up to the hundredth extracorporeal circulation circuit min (p = .005). CONCLUSION The present data suggest an impact of the cardioplegic solution used upon postoperative delirium rates. Optimization of cardiac arrest protocols is needed. Present data encourage further prospective studies regarding the impact of cardioplegic solutions on electrolyte imbalance for postoperative delirium rates in CABG surgery.
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Affiliation(s)
- Marc Irqsusi
- Department of Cardiothoracic Surgery, University Hospital Marburg, Philipps University, Marburg, Baldingerstrasse, Germany
| | - Dominik Loos
- Department of Cardiothoracic Surgery, University Hospital Marburg, Philipps University, Marburg, Baldingerstrasse, Germany
| | - Kai Dielmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University, Marburg, Baldingerstrasse, Germany
| | - Rabia Ramzan
- Bioenergetic Res Lab, Heart Center, Philipps-University, Marburg, Germany
| | - Hinnerk Wulf
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University, Marburg, Baldingerstrasse, Germany
| | - Tamer Ghazy
- Department of Cardiothoracic Surgery, University Hospital Marburg, Philipps University, Marburg, Baldingerstrasse, Germany
| | - Sebastian Vogt
- Department of Cardiothoracic Surgery, University Hospital Marburg, Philipps University, Marburg, Baldingerstrasse, Germany.,Bioenergetic Res Lab, Heart Center, Philipps-University, Marburg, Germany
| | - Ardawan J Rastan
- Department of Cardiothoracic Surgery, University Hospital Marburg, Philipps University, Marburg, Baldingerstrasse, Germany
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20
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Pang Y, Li Y, Zhang Y, Wang H, Lang J, Han L, Liu H, Xiong X, Gu L, Wu X. Effects of inflammation and oxidative stress on postoperative delirium in cardiac surgery. Front Cardiovasc Med 2022; 9:1049600. [PMID: 36505383 PMCID: PMC9731159 DOI: 10.3389/fcvm.2022.1049600] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
The past decade has witnessed unprecedented medical progress, which has translated into cardiac surgery being increasingly common and safe. However, complications such as postoperative delirium remain a major concern. Although the pathophysiological changes of delirium after cardiac surgery remain poorly understood, it is widely thought that inflammation and oxidative stress may be potential triggers of delirium. The development of delirium following cardiac surgery is associated with perioperative risk factors. Multiple interventions are being explored to prevent and treat delirium. Therefore, research on the potential role of biomarkers in delirium as well as identification of perioperative risk factors and pharmacological interventions are necessary to mitigate the development of delirium.
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Affiliation(s)
- Yi Pang
- Bengbu Medical College, Bengbu, Anhui, China
| | - Yuntao Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yonggang Zhang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hongfa Wang
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Junhui Lang
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Liang Han
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - He Liu
- Department of Anesthesiology, The Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou Central Hospital, Huzhou, China
| | - Xiaoxing Xiong
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lijuan Gu
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaomin Wu
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,*Correspondence: Xiaomin Wu,
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21
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Mukaida H, Matsushita S, Minami Y, Sato G, Usuba M, Kondo R, Asai T, Amano A. Risk factors for postoperative delirium on oxygen delivery-guided perfusion. J Cardiothorac Surg 2022; 17:193. [PMID: 35987682 PMCID: PMC9392930 DOI: 10.1186/s13019-022-01938-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Studies have demonstrated the efficacy of oxygen delivery-guided perfusion (ODGP) in preventing postoperative acute kidney injury, but the benefit of ODGP for delirium has not been confirmed. We retrospectively investigated the risk factors for postoperative delirium in patients who underwent ODGP (with oxygen delivery index [DO2i] > 300 mL/min/m2).
Methods
Consecutive patients who underwent on-pump cardiovascular surgery with ODGP from January 2018 to December 2020 were retrospectively analyzed. In addition to examining patients’ DO2i during cardiopulmonary bypass (CPB), we quantified the two primary DO2 components-hematocrit (Hct) and pump flow. Delirium was defined based on the Intensive Care Delirium Screening Checklist (ICDSC). Patients were divided into three groups: no delirium (ICDSC score = 0), subsyndromal delirium (ICDSC score = 1–3), and clinical delirium (ICDSC score ≥ 4).
Results
Multivariate analysis identified only the number of red blood cell (RBC) units transfused, intubation time, and the cumulative time below the Hct threshold of 25% as predictive factors of postoperative delirium. Although patients with higher ICDSC scores had greater hemodilution during CPB, ODGP resulted in a higher pump flow, and DO2i was maintained above 300 mL/min/m2, with no significant difference between the three groups.
Conclusions
A low Hct level during CPB with ODGP, the number of RBC units transfused, and intubation time were associated with postoperative delirium. Further investigations are needed to determine the ability of ODGP to prevent low Hct during CPB.
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22
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Lin L, Zhang X, Xu S, Peng Y, Li S, Huang X, Chen L, Lin Y. Outcomes of postoperative delirium in patients undergoing cardiac surgery: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:884144. [PMID: 36017087 PMCID: PMC9395738 DOI: 10.3389/fcvm.2022.884144] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Postoperative delirium (POD) is an acute brain dysfunction that is frequently observed in patients undergoing cardiac surgery. Increasing evidence indicates POD is related to higher mortality among cardiac surgical patients, but the results remain controversial. Moreover, a quantitative evaluation of the influence of POD on hospital days, intensive care unit (ICU) time, and mechanical ventilation (MV) time has not been performed. Objective This study aimed to evaluate the correlation between POD and outcomes in patients undergoing cardiac surgery by a systematic review and meta-analysis. Materials and methods A total of 7 electronic databases (Cochrane Library, PubMed, EMBASE, CINAHL Complete, MEDLINE, Wan-fang database, and China National Knowledge Infrastructure) were searched from January 1980 to July 20, 2021, with language restrictions to English and Chinese, to estimate the impact of the POD on outcome in patients who underwent cardiac surgery. The meta-analysis was registered with PROSPERO (Registration: CRD42021228767). Results Forty-two eligible studies with 19785 patients were identified. 3368 (17.0%) patients were in the delirium group and 16417 (83%) were in the non-delirium group. The meta-analysis showed that compared to patients without POD, patients with POD had 2.77-fold higher mortality (OR = 2.77, 95% CI 1.86-4.11, P < 0.001), 5.70-fold higher MV (>24h) rate (OR = 5.70, 95% CI 2.93-11.09, P < 0.001); and longer MV time (SMD = 0.83, 95% CI 0.57-1.09, P < 0.001), ICU time (SMD = 0.91, 95% CI 0.60-1.22, P < 0.001), hospital days (SMD = 0.62, 95% CI 0.48-0.76, P < 0.001). Conclusion The synthesized evidence suggests that POD is causally related to the increased risk of mortality, prolonged length of ICU and hospital stay, and a longer duration of MV time. Future research should focus on the interventions for POD, to reduce the incidence. Systematic review registration [www.crd.york.ac.uk/PROSPERO], identifier [CRD42021228767].
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Affiliation(s)
- Lingyu Lin
- Department of Nursing, Fujian Medical University, Fuzhou, China
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xuecui Zhang
- Department of Nursing, Fujian Medical University, Fuzhou, China
| | - Shurong Xu
- Department of Nursing, Fujian Medical University, Fuzhou, China
| | - Yanchun Peng
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Sailan Li
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xizhen Huang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yanjuan Lin
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, China
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23
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Kaźmierski J, Miler P, Pawlak A, Woźniak J, Frankowska E, Nowakowska K, Kuchta K, Pazdrak M, Woźniak K, Magierski R, Krejca M, Wilczyński M. Lower Preoperative Verbal Memory Performance Is Associated with Delirium after Coronary Artery Bypass Graft Surgery: A Prospective Cohort Study. Arch Clin Neuropsychol 2022; 38:49-56. [PMID: 35915987 PMCID: PMC9868524 DOI: 10.1093/arclin/acac064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/22/2022] [Accepted: 07/07/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE Cognitive impairment constitutes one of the major risk factors of delirium after coronary artery bypass graft (CABG) surgery; however, it is unclear whether only patients with global cognitive decline are at increased risk for delirium or if individuals with preserved global cognitive functions but impairments in specific cognitive domains are also more vulnerable to developing delirium. Thus, this study aimed to analyze the neurocognitive status of patients scheduled for CABG surgery with the use of an advanced computerized cognitive battery (CNS Vital Signs) and to investigate possible associations between impaired performance in selective cognitive areas and the risk of postoperative delirium development. METHODS The study enrolled 127 participants with a median age of 67 years (IQR: 63-71). Postoperative delirium developed in 32 (25%) patients.Before surgery, the patients were screened for global cognitive impairment with the use of the Mini-Mental State Examination Test, and the individuals were asked to perform the CNS Vital Signs battery to investigate 12 specific cognitive domains. The Confusion Assessment Method and the Memorial Delirium Assessment Scale were used to screen for a diagnosis of delirium postoperatively. RESULTS In multivariate models, a lower score of verbal memory-assessed preoperatively was independently associated with the risk of postoperative delirium development. Other independent predictors of delirium included more advanced age, gender female, depression, postoperative pyrexia, and the presence of extracorporeal circulation. CONCLUSIONS As decreased verbal memory constitutes an independent risk factor for postoperative delirium, a verbal memory test may be a useful predictor of postoperative delirium development.
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Affiliation(s)
- Jakub Kaźmierski
- Corresponding author at: Department of Old Age Psychiatry and Psychotic Disorders, Faculty of Gerontology, Medical University of Lodz, Czechoslowacka 8/10, 92-216 Lodz, Poland. Tel.: 48 42 675 73 72; fax: 00 48 42 675 77 29. E-mail address: (J. Kaźmierski)
| | - Piotr Miler
- Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Agnieszka Pawlak
- Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Joanna Woźniak
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Emilia Frankowska
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Karina Nowakowska
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Katarzyna Kuchta
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Michał Pazdrak
- Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Katarzyna Woźniak
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Radosław Magierski
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Michał Krejca
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Mirosław Wilczyński
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
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24
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Elfeky A, Chen YF, Grove A, Hooper A, Wilson A, Couper K, Thompson M, Uthman O, Court R, Tomassini S, Yeung J. Perioperative oxygen therapy: a protocol for an overview of systematic reviews and meta-analyses. Syst Rev 2022; 11:140. [PMID: 35831881 PMCID: PMC9277880 DOI: 10.1186/s13643-022-02005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oxygen is routinely given to patients during and after surgery. Perioperative oxygen administration has been proposed as a potential strategy to prevent and treat hypoxaemia and reduce complications, such as surgical site infections, pulmonary complications and mortality. However, uncertainty exists as to which strategies in terms of amount, delivery devices and timing are clinically effective. The aim of this overview of systematic reviews and meta-analyses is to answer the research question, 'For which types of surgery, at which stages of care, in which sub-groups of patients and delivered under what conditions are different types of perioperative oxygen therapy clinically effective?'. METHODS We will search key electronic databases (MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, CENTRAL, Epistemonikos, PROSPERO, the INAHTA International HTA Database and DARE archives) for systematic reviews and randomised controlled trials comparing perioperative oxygen strategies. Each review will be mapped according to type of surgery, surgical pathway timepoints and clinical comparison. The highest quality reviews with the most comprehensive and up-to-date coverage of relevant literature will be chosen as anchoring reviews. Standardised data will be extracted from each chosen review, including definition of oxygen therapy, summaries of interventions and comparators, patient population, surgical characteristics and assessment of overall certainty of evidence. For clinical outcomes and adverse events, the overall pooled findings and results of subgroup and sensitivity analyses (where available) will be extracted. Trial-level data will be extracted for surgical site infections, mortality, and potential trial-level effect modifiers such as risk of bias, outcome definition and type of surgery to facilitate quantitative data analysis. This analysis will adopt a multiple indication review approach with panoramic meta-analysis using review-level data and meta-regression using trial-level data. An evidence map will be produced to summarise our findings and highlight any research gaps. DISCUSSION There is a need to provide a panoramic overview of systematic reviews and meta-analyses describing peri-operative oxygen practice to both inform clinical practice and identify areas of ongoing uncertainty, where further research may be required. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021272361.
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Affiliation(s)
- Adel Elfeky
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Yen-Fu Chen
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Amy Grove
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Amy Hooper
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anna Wilson
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Keith Couper
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Marion Thompson
- Independent patient and public involvement and engagement advisor, Birmingham, UK
| | - Olalekan Uthman
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Sara Tomassini
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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25
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Falk A, Kåhlin J, Nymark C, Hultgren R, Stenman M. Depression is associated with delirium after cardiac surgery-a population-based cohort study. Interact Cardiovasc Thorac Surg 2022; 35:ivac151. [PMID: 35640560 PMCID: PMC9297521 DOI: 10.1093/icvts/ivac151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/26/2022] [Accepted: 05/27/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Depression is common in patients with cardiac disease, and preoperative depression is associated with worse outcomes after cardiac surgery. Depression is also correlated with postoperative delirium (POD) after major surgery. However, the association between preoperative depression and POD after cardiac surgery is sparsely studied. The aim of this study was to investigate depression as a predictor for POD in cardiac surgery patients. METHODS This population-based cohort study included 1133 cardiac surgery patients in Stockholm 2013-2016. Depression was defined by the Patient Health Questionnaire-9, and POD was evaluated by assessing medical records for symptoms of POD according to Diagnostic and Statistical Manual of Mental Disorders criteria. The association between depression and POD was determined through multivariable logistic regression analysis. RESULTS A total of 162 (14%) individuals reported depressive symptoms preoperatively. The incidence of POD was 26% and highest among elderly patients. Among patients with depression, 34% developed POD. In the group of non-depressed patients, 24% developed POD. The overall adjusted odds of delirium were 2.19 times higher in individuals with depressive symptoms compared to controls (95% confidence interval 1.43-3.34). The onset of delirium was most common on Days 0-2 after surgery. CONCLUSIONS This unique population-based study in patients undergoing cardiac surgery shows that preoperative depression is associated with POD in a large proportion of treated patients. The findings support the need for improved preoperative screening for depression, especially in younger patients, and enhanced clinical surveillance in the early postoperative period for all patients.
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Affiliation(s)
- Anna Falk
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Jessica Kåhlin
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Carolin Nymark
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Stenman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
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26
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Lewis C, Dokucu ME, Brown CH, Balmert L, Srdanovic N, Madhan AS, Samra SS, Csernansky J, Grafman J, Hogue CW. Postoperative but not preoperative depression is associated with cognitive impairment after cardiac surgery: exploratory analysis of data from a randomized trial. BMC Anesthesiol 2022; 22:157. [PMID: 35606688 PMCID: PMC9125857 DOI: 10.1186/s12871-022-01672-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In this study we hypothesize that depression is associated with perioperative neurocognitive dysfunction and altered quality of life one month after surgery. METHODS Data were obtained as part of a study evaluating cerebral autoregulation monitoring for targeting arterial pressure during cardiopulmonary bypass. Neuropsychological testing was performed before surgery and one month postoperatively. Testing included the Beck Depression Inventory, a depression symptoms questionnaire (0-63 scale), as well as anxiety and quality of life assessments. Depression was defined as a Beck Depression Inventory score > 13. RESULTS Beck Depression data were available from 320 patients of whom cognitive domain endpoints were available from 88-98% at baseline and 69-79% after surgery. This range in end-points data was due to variability in the availability of each neuropsychological test results between patients. Depression was present in 50 (15.6%) patients before surgery and in 43 (13.4%) after surgery. Baseline depression was not associated with postoperative domain-specific neurocognitive function compared with non-depressed patients. Those with depression one month after surgery, though, had poorer performance on tests of attention (p = 0.017), memory (p = 0.049), verbal fluency (p = 0.010), processing speed (p = 0.017), and fine motor speed (p = 0.014). Postoperative neurocognitive dysfunction as a composite outcome occurred in 33.3% versus 14.5% of patients with and without postoperative depression (p = 0.040). Baseline depression was associated with higher anxiety and lower self-ratings on several quality of life domains, these measures were generally more adversely affected by depression one month after surgery. CONCLUSIONS The results of this exploratory analysis suggests that preoperative depression is not associated with perioperative neurocognitive dysfunction, but depression after cardiac surgery may be associated with impairment in in several cognitive domains, a higher frequency of the composite neurocognitive outcome, and altered quality of life. TRIAL REGISTRATION www. CLINICALTRIALS gov, NCT00981474 (parent study).
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Affiliation(s)
- Choy Lewis
- Department of Anesthesiology, The Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, 251 East Huron St, Feinberg 5-704, Chicago, IL, 60611, USA
| | - Mehmet E Dokucu
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Charles H Brown
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lauren Balmert
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nina Srdanovic
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ashwin Shaan Madhan
- Medical Student, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sahej Singh Samra
- Medical Student, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John Csernansky
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jordan Grafman
- Department of Physical Medicine & Rehabilitation, Neurology, Cognitive Neurology and Alzheimer's Center, Department of Psychiatry, Northwestern University Feinberg School of Medicine, Weinberg College of Arts and Sciences, Northwestern University, Chicago, IL, USA
| | - Charles W Hogue
- Department of Anesthesiology, The Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, 251 East Huron St, Feinberg 5-704, Chicago, IL, 60611, USA.
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Zhou Y, Ma B, Sun W, Wang J, Fu Y, Wang A, Wang G, Han R. Effect of esketamine on perioperative depressive symptoms in major surgery patients (PASSION II): study protocol for a randomised controlled trial. BMJ Open 2022; 12:e056713. [PMID: 35473735 PMCID: PMC9045044 DOI: 10.1136/bmjopen-2021-056713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Depressive symptoms are common for patients undergoing major surgery and may worsen their mental health and lead to poor clinical outcomes. It is essential to seek a safe rapid-acting treatment for relieving moderate-to-severe depressive symptoms in patients undergoing major surgery. METHODS AND ANALYSIS This study is a randomised, placebo-controlled and double-blinded trial aiming to determine the effect of esketamine on moderate-to-severe depressive symptoms in patients undergoing major surgery. Five hundred and sixty-four participants, aged 18-65 years old, undergoing major surgery will be randomly allocated into the esketamine and placebo groups at a 1:1 ratio. Esketamine or placebo will be given intravenously at the same speed on suturing the incision by anaesthesiologists in charge who are blinded to the randomisation. In the esketamine group, the total dosage of esketamine will be 0.2 mg/kg body weight. To estimate the efficacy and safety endpoints, blinded evaluation by trained researchers will be completed at 3 days, 5 days, 1 month, 3 months and 6 months after surgery. The primary outcome is the remission rate at the third postoperative day. The secondary outcomes include depression-related scores, severe pain events and safety-related endpoints such as psychotic symptoms, manic symptoms and dissociative symptoms. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Board of Beijing Tiantan Hospital, Capital Medical University, Beijing, China on 30 October 2020 (KY-2020-058-02). This trial is designed to explore whether the administration of esketamine could improve the mental health of patients with depressive symptoms undergoing major surgery. The conclusions of this study will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04425473.
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Affiliation(s)
- Yang Zhou
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Bo Ma
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Wanchen Sun
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Juan Wang
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yuxuan Fu
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Anxin Wang
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Gang Wang
- China & Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders, Beijing An Ding Hospital, Capital Medical University, Beijing, People's Republic of China
- Department of Psychiatry, Capital Medical University, China & Center of Depression, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
| | - Ruquan Han
- Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
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Tian LJ, Yuan S, Zhou CH, Yan FX. The Effect of Intraoperative Cerebral Oximetry Monitoring on Postoperative Cognitive Dysfunction and ICU Stay in Adult Patients Undergoing Cardiac Surgery: An Updated Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 8:814313. [PMID: 35178431 PMCID: PMC8846308 DOI: 10.3389/fcvm.2021.814313] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 12/31/2021] [Indexed: 12/29/2022] Open
Abstract
Aim Determining whether intraoperative cerebral oximetry monitoring-guided intervention reduces the risk of postoperative cognitive dysfunction remains controversial. The objective of this study was to conduct an up-to-date meta-analysis to comprehensively assess the effects of regional cerebral oxygen saturation (rSO2) monitoring-guided intervention on cognitive outcomes after cardiac surgery. Methods PubMed, EMBASE, Ovid, and Cochrane Library databases were systematically searched using the related keywords for cardiac surgical randomized-controlled trials (RCTs) published from their inception to July 31, 2021. The primary outcome was postoperative delirium (POD). The secondary outcomes were postoperative cognitive decline (POCD) and other major postoperative outcomes. The odds ratio (OR) or weighted mean differences (WMDs) with 95% confidence interval (CI) were used to pool the data. The random-effect model was used for the potential clinical inconsistency. We performed meta-regression and subgroup analyses to assess the possible influence of rSO2 monitoring-guided intervention on clinical outcomes. Results In total, 12 RCTs with 1,868 cardiac surgical patients were included. Compared with controls, the incidences of POD (n = 6 trials; OR, 0.28; 95% CI, 0.09–0.84; p = 0.02; I2 = 81%) and POCD (n = 5 trials; OR, 0.38; 95% CI, 0.16–0.93; p = 0.03; I2 = 78%) were significantly lower in the intervention group. Cerebral oximetry desaturation also showed a positive association with the incidence of POD (n = 5 trials; OR, 2.02; 95% CI, 1.25–3.24; p = 0.004; I2 = 81%). The duration of intensive care unit (ICU) stay was markedly shorter in the intervention group than in the control group (n = 10 trials; WMD, −0.22 days; 95% CI, −0.44 to −0.00; p = 0.05; I2 = 74%). Univariate meta-regression analyses showed that the major sources of heterogeneity were age (p = 0.03), body mass index (BMI, p = 0.05), and the proportion of congenital heart disease (CHD, p = 0.02) for POD, age (p = 0.04) for POCD, diabetes mellitus (DM, p = 0.07), cerebrovascular accident (CVA, p = 0.02), and chronic obstructive pulmonary disease (COPD, p = 0.09) for ICU stay. Subsequent subgroup analyses also confirmed these results. Conclusion Available evidence from the present study suggests that an intraoperative cerebral oximetry desaturation is associated with an increased POD risk, and the rSO2 monitoring-guided intervention is correlated with a lower risk of POD and POCD, and a shorter ICU stay in adults undergoing cardiac surgery. These clinical benefits may be limited in patients with older age, diabetes status, high BMI, non-CHD, non-COPD, or a previous cardiovascular accident. Systematic Review Registration: [PROSPREO], identifier: [CRD42021252654].
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Affiliation(s)
- Li-Juan Tian
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cheng-Hui Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fu-Xia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Choi H, Park CS, Huh J, Koo J, Jeon J, Kim E, Jung S, Kim HW, Lim JY, Hwang W. Intraoperative Glycemic Variability and Mean Glucose are Predictors for Postoperative Delirium After Cardiac Surgery: A Retrospective Cohort Study. Clin Interv Aging 2022; 17:79-95. [PMID: 35153478 PMCID: PMC8827640 DOI: 10.2147/cia.s338712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/20/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose Postoperative delirium (POD) is a common but serious complication after cardiac surgery and is associated with various short- and long-term outcomes. In this study, we investigated the effects of intraoperative glycemic variability (GV) and other glycemic variables on POD after cardiac surgery. Patients and Methods A retrospective single-center cohort analysis was conducted using data from electronic medical record from 2018 to 2020. A total of 705 patients undergoing coronary artery bypass graft surgery and/or valve surgery, and/or aortic replacement surgery were included in the analysis. Intraoperative GV was assessed with a coefficient of variation (CV), which was defined as the standard deviation of five intraoperative blood glucose measurements divided by the mean. POD assessment was performed three times a day in the ICU and twice a day in the ward until discharge by trained medical staff. POD was diagnosed if any of the Confusion Assessment Method for the Intensive Care Unit was positive in the ICU, and the Confusion Assessment Method was positive in the ward. Multivariable logistic regression was used to identify associations between intraoperative GV and POD. Results POD occurred in 306 (43.4%) patients. When intraoperative glycemic CV was compared as a continuous variable, the delirium group had higher intraoperative glycemic CV than the non-delirium group (22.59 [17.09, 29.68] vs 18.19 [13.00, 23.35], p < 0.001), and when intraoperative glycemic CV was classified as quartiles, the incidence of POD increased as intraoperative glycemic CV quartiles increased (first quartile 29.89%; second quartile 36.67%; third quartile 44.63%; and fourth quartile 62.64%, p < 0.001). In the multivariable logistic regression model, patients in the third quartile of intraoperative glycemic CV were 1.833 times (OR 1.833, 95% CI: 1.132–2.967, p = 0.014), and patients in the fourth quartile of intraoperative glycemic CV were 3.645 times (OR 3.645, 95% CI: 2.235–5.944, p < 0.001) more likely to develop POD than those in the first quartile of intraoperative glycemic CV. Conclusion Intraoperative blood glucose fluctuation, manifested by intraoperative GV, is associated with POD after cardiac surgery. Patients with a higher intraoperative GV have an increased risk of POD.
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Affiliation(s)
- Hoon Choi
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Soo Park
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jaewon Huh
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jungmin Koo
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joonpyo Jeon
- Department of Anesthesia and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eunsung Kim
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sangmin Jung
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hwan Wook Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Yong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Wonjung Hwang
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Correspondence: Wonjung Hwang, Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea, Tel +82-2-22586162, Fax +82-2-5371951, Email
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Hulde N, Zittermann A, Tigges-Limmer K, Koster A, Weinrautner N, Gummert J, von Dossow V. Preoperative Risk Factors and Early Outcomes of Delirium in Valvular Open-Heart Surgery. Thorac Cardiovasc Surg 2022; 70:558-565. [PMID: 35042244 DOI: 10.1055/s-0041-1740984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Compared with coronary artery bypass grafting surgery, data regarding postoperative delirium are scant in valvular open-heart surgery. Therefore, the goal of this retrospective study was to investigate the incidence, preoperative risk factors, and early outcomes of delirium in a large group of patients undergoing valvular open-heart surgery. METHODS In 13,229 patients with isolated valvular or combined valvular and bypass surgery, the incidence of postoperative delirium was assessed until discharge. Independent risk factors of delirium were evaluated by multivariable logistic regression analysis. Moreover, we assessed the multivariable-adjusted risk of prolonged intensive care unit (ICU) stay (>48 hours) and in-hospital mortality in patients with delirium. RESULTS Overall, the incidence of postoperative delirium was 8.4%. The incidence in patients experiencing a postoperative stroke or seizure was 23.1 and 29.7%, respectively. Twelve preoperative risk factors, mostly nonmodifiable, were independently associated with the risk of delirium, including advanced age, renal impairment, stroke, the need for emergency surgery, and severe preoperative anemia (hemoglobin < 9 g/dL). Postoperative delirium was associated with an adjusted odds ratio (OR) of prolonged ICU stay of 9.48 (95% confidence interval [CI]: 7.96-11.30). Adjusted in-hospital mortality was, however, significantly lower in patients with delirium versus patients without delirium (OR, 0.56; 95% CI: 0.38-0.83). CONCLUSION In valvular open-heart surgery, postoperative delirium is a frequent neurological complication that is associated with other postoperative neurological complications and several, mostly nonmodifiable, preoperative risk factors. Although postoperative delirium was associated with a significantly increased risk of prolonged ICU stay, this did not translate into an increased short-term mortality.
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Affiliation(s)
- Nikolai Hulde
- Institute of Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Katharina Tigges-Limmer
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Andreas Koster
- Institute of Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Nicole Weinrautner
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Vera von Dossow
- Institute of Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
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Kaźmierski J, Miler P, Pawlak A, Jerczyńska H, Woźniak J, Frankowska E, Brzezińska A, Nowakowska K, Woźniak K, Krejca M, Wilczyński M. Oxidative stress and soluble receptor for advanced glycation end-products play a role in the pathophysiology of delirium after cardiac surgery. Sci Rep 2021; 11:23646. [PMID: 34880331 PMCID: PMC8655063 DOI: 10.1038/s41598-021-03007-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 11/22/2021] [Indexed: 12/17/2022] Open
Abstract
Coronary-artery bypass graft (CABG) surgery is known to improve cardiac function and decrease mortality, albeit, this method of treatment is also associated with a neuropsychiatric complications including postoperative delirium. The pathophysiology of delirium after cardiac surgery remains poorly understood. Thus, the purpose of this study was to investigate whether oxidative stress reflected by decreased preoperative and postoperative plasma antioxidant activity is independently associated with delirium after cardiac surgery. The second aim was to assess whether decreased antioxidant activity is stress-related or mediated by other pathologies such as major depressive disorder (MDD), anxiety disorders, and cognitive impairment. Furthermore, the putative relationship between pre- and postoperative soluble receptor for advanced glycation end-products (sRAGE) overexpression and plasma antioxidant capacity was evaluated. The patients cognitive status was assessed 1 day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of MDD and anxiety disorders was established on the basis of DSM-5 criteria. Blood samples for antioxidant capacity and sRAGE levels were collected both preoperatively and postoperatively. The Confusion Assessment Method for the Intensive Care Unit was used within the first 5 days postoperatively to screen for a diagnosis of delirium. Postoperative delirium was diagnosed in 34% (61 of 177) of individuals. Multivariate logistic regression analysis revealed that low baseline antioxidant capacity was independently associated with postoperative delirium development. Moreover, increased risk of delirium was observed among patients with a preoperative diagnosis of MDD associated with antioxidant capacity decreased postoperatively. According to receiver operating characteristic analysis, the most optimal cutoff values of the preoperative and postoperative antioxidant capacity that predict the development of delirium were 1.72 mM and 1.89 mM, respectively. Pre- and postoperative antioxidant capacity levels were negatively correlated with postoperative sRAGE concentration (Spearman's Rank Correlation − 0.198 and − 0.158, p < 0.05, respectively). Patients with decreased preoperative antioxidant activity and those with depressive episodes complicated with lower postoperative antioxidant activity are at significantly higher risk of delirium after cardiac surgery development. sRAGE overexpression may be considered as protective mechanism against increased oxidative stress and subsequent cell damage.
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Affiliation(s)
- Jakub Kaźmierski
- Department of Old Age Psychiatry and Psychotic Disorders, Faculty of Gerontology, Medical University of Lodz, Czechoslowacka 8/10, 92-216, Lodz, Poland.
| | - Piotr Miler
- Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Agnieszka Pawlak
- Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Hanna Jerczyńska
- CoreLab Central Scientific Laboratory of Medical University of Lodz, Medical University of Lodz, Lodz, Poland
| | - Joanna Woźniak
- Department of Old Age Psychiatry and Psychotic Disorders, Faculty of Gerontology, Medical University of Lodz, Czechoslowacka 8/10, 92-216, Lodz, Poland
| | - Emilia Frankowska
- Department of Old Age Psychiatry and Psychotic Disorders, Faculty of Gerontology, Medical University of Lodz, Czechoslowacka 8/10, 92-216, Lodz, Poland
| | | | - Karina Nowakowska
- Department of Old Age Psychiatry and Psychotic Disorders, Faculty of Gerontology, Medical University of Lodz, Czechoslowacka 8/10, 92-216, Lodz, Poland
| | - Katarzyna Woźniak
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Michał Krejca
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Mirosław Wilczyński
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
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He J, Ling Q, Chen Y. Construction and Application of a Model for Predicting the Risk of Delirium in Postoperative Patients With Type a Aortic Dissection. Front Surg 2021; 8:772675. [PMID: 34869569 PMCID: PMC8636852 DOI: 10.3389/fsurg.2021.772675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Postoperative delirium (POD), an alteration in a patient's consciousness pattern, can affect the treatment and prognosis of a disease. Objective: To construct a prediction model for delirium in patients with type A aortic dissection after surgery and to validate its effectiveness. Methods: A retrospective cohort design was used to study 438 patients undergoing surgical treatment for type A aortic dissection from April 2019 to June 2020 in tertiary care hospitals. POD (n = 78) and non-delirium groups (n = 360) were compared and analyzed for each index in the perioperative period. A prediction model was established using multifactorial logistic regression, and 30 patients' perioperative data were collected for model validation. Results: Eight predictors were included in this study: smoking, diabetes, previous cardiovascular surgery, ejection fraction (EF), time to aortic block, acute kidney injury, low cardiac output syndrome, and pulmonary complications. The area under the receiver operating characteristic (ROC) curve of the constructed prediction model was 0.98 ± 0.005, and the Youden index was 0.91. The validation results showed 97% sensitivity, 100% specificity, and 93% accuracy. The expression of the model was Z = Smoking assignment* – 2.807 – 6.009*Diabetes assignment – 2.994*Previous cardiovascular surgery assignment – 0.129*Ejection fraction assignment + 0.071*Brain perfusion time assignment – 2.583*Acute kidney injury assignment – 2.916*Low cardiac output syndrome assignment – 3.461*Pulmonary related complications assignment + 20.576. Conclusion: The construction of an effective prediction model for the risk of delirium in patients after type A aortic stratification can help identify patients at high risk of POD early. It also provides a reference for healthcare professionals in the prevention and care of these patients.
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Affiliation(s)
- Junfeng He
- Department of Nursing, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Qing Ling
- Department of Nursing, Nanjing First Hospital, Nanjing, China
| | - Yuhong Chen
- Department of Nursing, Nanjing First Hospital, Nanjing, China
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Matsumoto S, Omiya H, Fujinaka W, Morimatsu H. Association between intraoperative hyperglycemia and postoperative end-organ dysfunctions after cardiac surgery: a retrospective observational study. J Anesth 2021; 36:174-184. [PMID: 34807289 DOI: 10.1007/s00540-021-03024-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 11/14/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE Hyperglycemia has been associated with postoperative morbidity in patients who undergo cardiac surgery. However, it remains unclear whether the duration of hyperglycemia is as important as its magnitude in the development of postoperative end-organ dysfunction (PEOD). This retrospective study investigated the hypothesis that the intraoperative blood glucose (BG) exposure index (GE index), calculated by the product of the magnitude and duration of BG concentration ≥ 180 mg/dL, which is an integration of the severity and duration of hyperglycemia, is associated with the incidence of PEOD in patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS The primary outcome in this study was PEOD within 72 h of surgery, which was defined as a composite of postoperative acute kidney injury, delirium, myocardial injury, and prolonged mechanical ventilation. The GE index (the magnitude of BG concentration deviation ≥ 180 mg/dL [Formula: see text] duration of BG concentration ≥ 180 mg/dL) of each patient was calculated based on the intraoperative BG concentration. The relationship between the GE index and the primary outcome was examined via logistic regression model with adjustment for potential confounders. RESULTS Within 72 h of surgery, 301 patients (54.5%) developed PEOD. PEOD was more common in patients with greater GE index quartiles (first versus third quartile; adjusted odds ratio, 5.65, 95% confidence interval (95% CI), 2.94-10.90; P < 0.001; first versus forth quartile, adjusted odds ratio, 20.80; 95% CI, 8.01-54.00; P < 0.001). CONCLUSION In patients undergoing cardiac surgery with cardiopulmonary bypass, the GE index was an independent predictor of PEOD.
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Affiliation(s)
- Shinsaku Matsumoto
- Department of Anesthesiology and Intensive Care, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan.
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.
| | - Hiroki Omiya
- Department of Anesthesiology and Intensive Care, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Waso Fujinaka
- Department of Anesthesiology and Intensive Care, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Postoperative delirium after cardiac surgery of elderly patients as an independent risk factor for prolonged length of stay in intensive care unit and in hospital. Aging Clin Exp Res 2021; 33:3047-3056. [PMID: 33813686 PMCID: PMC8595147 DOI: 10.1007/s40520-021-01842-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/19/2021] [Indexed: 12/20/2022]
Abstract
Background Postoperative delirium (POD) is a relevant and underdiagnosed complication after cardiac surgery that is associated with increased intensive care unit (ICU) and hospital length of stay (LOS). The aim of this subgroup study was to compare the frequency of tested POD versus the coded International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis of POD and to evaluate the influence of POD on LOS in ICU and hospital. Methods 254 elective cardiac surgery patients (mean age, 70.5 ± 6.4 years) at the University Hospital Bonn between September 2018 and October 2019 were evaluated. The endpoint tested POD was considered positive, if one of the tests Confusion Assessment Method for ICU (CAM-ICU) or Confusion Assessment Method (CAM), 4 'A's Test (4AT) or Delirium Observation Scale (DOS) was positive on one day. Results POD occurred in 127 patients (50.0%). LOS in ICU and hospital were significantly different based on presence (ICU 165.0 ± 362.7 h; Hospital 26.5 ± 26.1 days) or absence (ICU 64.5 ± 79.4 h; Hospital 14.6 ± 6.7 days) of POD (p < 0.001). The multiple linear regression showed POD as an independent predictor for a prolonged LOS in ICU (48%; 95%CI 31–67%) and in hospital (64%; 95%CI 27–110%) (p < 0.001). The frequency of POD in the study participants that was coded with the ICD F05.0 and F05.8 by hospital staff was considerably lower than tests revealed by the study personnel. Conclusion Approximately 50% of elderly patients who underwent cardiac surgery developed POD, which is associated with an increased ICU and hospital LOS. Furthermore, POD is highly underdiagnosed in clinical routine.
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Zhang GQ, Canner JK, Prince EJ, Stem M, Taylor JP, Efron JE, Atallah C, Safar B. History of depression is associated with worsened postoperative outcomes following colectomy. Colorectal Dis 2021; 23:2559-2566. [PMID: 34166552 DOI: 10.1111/codi.15790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/21/2021] [Accepted: 06/10/2021] [Indexed: 02/08/2023]
Abstract
AIM Depression is a prevalent disorder that is associated with adverse health outcomes, but an understanding of its effect in colorectal surgery remains limited. The purpose of this study was to examine the impact of history of depression among patients undergoing colectomy. METHOD United States patients from Marketscan (2010-2017) who underwent colectomy were included and stratified by whether they had a history of depression within the past year, defined as (1) a diagnosis of depression during the index admission, (2) a diagnosis of depression during any inpatient or (3) outpatient admission within the year, and/or (4) a pharmacy claim for an antidepressant within the year. The primary outcomes were length of stay (LOS) and inpatient hospital charge. Secondary outcomes included in-hospital mortality and postoperative complications. Logistic, negative binomial, and quantile regressions were performed. RESULTS Among 88 981 patients, 21 878 (24.6%) had a history of depression. Compared to those without, patients with a history of depression had significantly longer LOS (IRR = 1.06, 95% CI [1.05, 1.07]), increased inpatient charge (β = 467, 95% CI [167, 767]), and increased odds of in-hospital mortality (OR = 1.37, 95% CI [1.08, 1.73]) after adjustment. History of depression was also independently associated with increased odds of respiratory complication, pneumonia, and delirium (all P < 0.05). CONCLUSION History of depression was prevalent among individuals undergoing colectomy, and associated with greater mortality and inpatient charge, longer LOS, and higher odds of postoperative complication. These findings highlight the impact of depression in colorectal surgery patients and suggest that proper identification and treatment may reduce postoperative morbidity.
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Affiliation(s)
- George Q Zhang
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth J Prince
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James P Taylor
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Fu Z, Xu Q, Zhang C, Bai H, Chen X, Zhang Y, Luo W, Lin G. Admission Systolic Blood Pressure Predicts Post-Operative Delirium of Acute Aortic Dissection Patients in the Intensive Care Unit. Int J Gen Med 2021; 14:5939-5948. [PMID: 34584446 PMCID: PMC8464373 DOI: 10.2147/ijgm.s329689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/01/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Post-operative delirium (POD) is a common complication after aortic surgery with poor outcomes. Blood pressure may play a role in the occurrence of POD. The study aimed to identify whether admission systolic blood pressure (SBP) level in the intensive care unit (ICU) is correlated with POD in acute Stanford type A aortic dissection (AAAD) patients undergoing aortic surgery. Patients and Methods We conducted a single-center retrospective cohort study enrolling consecutive 205 patients with acute type A aortic dissection undergoing aortic surgery. Patients were divided into 3 groups: low, normal, and high SBP level group. Outcomes of interest were POD, 30-day mortality and other complications including acute kidney injury, cardiac complications, spinal cord ischemia, stroke, and pneumonia. Confusion Assessment Method for Intensive Care Unit (CAM-ICU) method was used to assess POD. Univariate and multivariate logistic regression, Cox regression, and subgroup analysis were performed to uncover the association between SBP and POD. Results The mean age of these patients was 51±16 years old. Thirty-six patients (17.6%) developed POD. Patients with high admission SBP were more likely to develop POD (P < 0.01). Univariate analysis showed that high admission SBP was associated with a higher risk of POD among AAAD patients (OR, 3.514; 95% CI, 1.478-8.537, P < 0.01). Multivariate logistic regression model confirmed that high SBP was an independent predictor of POD. Subgroup analysis indicated that patients with anemia and high admission SBP were at higher risk of POD. Conclusion High admission SBP was positively associated with the incidence of POD in AAAD patients who underwent surgical repair in ICU.
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Affiliation(s)
- Zuli Fu
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Qian Xu
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Chiyuan Zhang
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Department of Cardiovascular Medicine, The Third Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Hui Bai
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Xuliang Chen
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Yanfeng Zhang
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Wanjun Luo
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Guoqiang Lin
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
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Xu N, Li LX, Wang TL, Jiao LQ, Hua Y, Yao DX, Wu J, Ma YH, Tian T, Sun XL. Processed Multiparameter Electroencephalogram-Guided General Anesthesia Management Can Reduce Postoperative Delirium Following Carotid Endarterectomy: A Randomized Clinical Trial. Front Neurol 2021; 12:666814. [PMID: 34322079 PMCID: PMC8311024 DOI: 10.3389/fneur.2021.666814] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 06/09/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Patients undergoing carotid endarterectomy (CEA) for severe carotid stenosis are vulnerable to postoperative delirium, a complication frequently associated with poor outcome. This study investigated the impact of processed electroencephalogram (EEG)-guided anesthesia management on the incidence of postoperative delirium in patients undergoing CEA. Methods: This single-center, prospective, randomized clinical trial on 255 patients receiving CEA under general anesthesia compared the outcomes of patient state index (PSI) monitoring [SEDLine Brain Function Monitor (Masimo, Inc, Irvine, CA)] (standard group, n = 128) with PSI combined with density spectral array(DSA) -guided monitoring (intervention group, n = 127) to reduce the risk of intraoperative EEG burst suppression. All patients were monitored by continuous transcranial Doppler ultrasound (TCD) and near-infrared spectroscopy (NIRS) to avoid perioperative cerebral hypoperfusion or hyperperfusion. According to the surgical process, EEG suppression time was calculated separately for three stages: S1 (from anesthesia induction to carotid artery clamping), S2 (from clamping to declamping), and S3 (from declamping to the end of surgery). The primary outcome was incidence of postoperative delirium according to the Confusion Assessment Method algorithm during the first 3 days post-surgery, and secondary outcomes were other neurologic complications and length of hospital stay. Results: There were no episodes of cerebral hypoperfusion or hyperperfusion according to TCD and NIRS monitoring in either group during surgery. The incidence of postoperative delirium within 3 days post-surgery was significantly lower in the intervention group than the standard group (7.87 vs. 28.91%, P < 0.01). In the intervention group, the total EEG suppression time and the EEG suppression time during S2 and S3 were shorter (Total, 0 "0" vs. 0 "1.17" min, P = 0.04; S2, 0 "0" vs. 0 "0.1" min, P < 0.01; S3, 0 "0" vs. 0 "0" min, P = 0.02). There were no group differences in incidence of neurologic complications and length of postoperative hospital stay. Conclusion: Processed electroencephalogram-guided general anesthesia management, consisting of PSI combined with DSA monitoring, can significantly reduce the risk of postoperative delirium in patients undergoing CEA. Patients, especially those exhibiting hemodynamic fluctuations or receiving surgical procedures that disrupt cerebral perfusion, may benefit from the monitoring of multiple EEG parameters during surgery. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03622515.
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Affiliation(s)
- Na Xu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li-Xia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tian-Long Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li-Qun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasound, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Dong-Xu Yao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Wu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan-Hui Ma
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tian Tian
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xue-Li Sun
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Hong E, Brovman EY. Delirium: Time to look pre-operatively at prevention. J Clin Anesth 2021; 74:110380. [PMID: 34144498 DOI: 10.1016/j.jclinane.2021.110380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/28/2021] [Accepted: 05/29/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Edward Hong
- Tufts Medical Center, Boston, Massachusetts, USA
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Fatehi Hassanabad A, Bahrami N, Novick RJ, Ali IS. Delirium and depression in cardiac surgery: A comprehensive review of risk factors, pathophysiology, and management. J Card Surg 2021; 36:2876-2889. [PMID: 34120376 DOI: 10.1111/jocs.15610] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Mental health and wellbeing continue to gain more attention as they are inextricably associated with clinical outcomes, particularly quality of life. Many medical ailments and major surgeries affect patients' mental health, including depression and delirium. AIMS The objective of this manuscript was to comprehensively review and critically examine the literature pertaining to cardiac surgery, depression, and delirium. METHODS This is a narrative review article. We performed our search analysis by using the following key words: "Cardiac Surgery", "Depression", "Delirium", "Clinical outcomes", and "Mental Health". Search analysis was done on MedLine PubMed, accessing indexed peer-reviewed publications. RESULTS Cardiac Surgery is a life-altering intervention indicated to improve morbidity and mortality in patients with cardiovascular diseases. Psychiatric conditions before and after cardiac surgery worsen patient prognosis and increase mortality rate. Specifically, preoperative depression increases postoperative depression and is associated with impaired functional status, slow physical recovery, and an increased readmission rate. DISCUSSION Although the exact pathophysiology between depression and cardiovascular disease (CVD) is unknown, several pathways have been implicated. Unmanaged depression can also lead to other psychological conditions such as delirium. Like depression, the exact association between delirium and CVD is not well understood, but believed to be multifactorial. CONCLUSION Herein, we provide a comprehensive review of the links between depression, delirium, and cardiovascular surgery. We critically examine the current data that pertains to the pathophysiology of these debilitating mental health issues in the context of cardiac surgery. Finally, we summarize the various treatment options available for managing depression and delirium in the cardiac surgery patient population.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Nabila Bahrami
- Department of Medicine, Department of Medicine, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Richard J Novick
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Imtiaz S Ali
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
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Kalra SS, Jaber J, Alzghoul BN, Hyde R, Parikh S, Urbine D, Reddy R. Pre-Existing Psychiatric Illness Is Associated With an Increased Risk of Delirium in Patients With Acute Respiratory Distress Syndrome. J Intensive Care Med 2021; 37:647-654. [PMID: 34041934 DOI: 10.1177/08850666211019009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with acute respiratory distress syndrome (ARDS) are highly susceptible to developing delirium for a multitude of reasons. Previous studies have linked pre-existing depression with an increased risk of postoperative delirium in patients undergoing cardiac and non-cardiac surgery. However, the evidence regarding the association between pre-existing psychiatric illnesses and delirium in ARDS patients is unknown. In this study, we aim to determine the relationship between pre-existing psychiatric illness and the risk of development of delirium amongst ARDS patients. STUDY DESIGN AND METHODS We performed a retrospective study of a mixed group of patients admitted to the intensive care unit (ICU) between January 2016 and December 2019 with a diagnosis of ARDS per the Berlin definition. The study group was divided into 2 cohorts: subjects with delirium and subjects without delirium. Comparison between the 2 groups was conducted to examine the impact of pre-existing psychiatric illnesses including major depressive disorder (MDD), generalized anxiety disorder (GAD), bipolar disorder, schizophrenia, or post-traumatic stress disorder. Multivariable logistic regression analysis was performed adjusting for benzodiazepine use, sedatives, analgesics, sequential organ failure assessment score, and corticosteroid use to determine the association between pre-existing psychiatric disorders and delirium. RESULTS 286 patients with ARDS were identified; 124 (43%) of whom were diagnosed with ICU delirium. In patients diagnosed with ICU delirium, 49.2% were found to have preexisting psychiatric illnesses, compared to 34.0% without any preexisting psychiatric illness (OR = 1.94, P = 0.01). In a subgroup analysis of individual psychiatric illnesses, GAD and MDD were associated with the development of delirium (OR = 1.88, P = 0.04 and OR = 1.76, P = 0.05 respectively). INTERPRETATION ARDS patients with preexisting psychiatric illnesses, particularly GAD and MDD are associated with an increased risk of developing ICU delirium. Clinicians should be aware of the effect of psychiatric co-morbidities on developing delirium in critically ill patients.
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Affiliation(s)
- Saminder Singh Kalra
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Johnny Jaber
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Bashar N Alzghoul
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Ryan Hyde
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sarina Parikh
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Daniel Urbine
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Raju Reddy
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, FL, USA.,Oregon Health and Science University, Portland, Oregon
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Chen H, Mo L, Hu H, Ou Y, Luo J. Risk factors of postoperative delirium after cardiac surgery: a meta-analysis. J Cardiothorac Surg 2021; 16:113. [PMID: 33902644 PMCID: PMC8072735 DOI: 10.1186/s13019-021-01496-w] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/11/2021] [Indexed: 12/13/2022] Open
Abstract
Background Postoperative delirium is a frequent event after cardiac surgery. This meta-analysis aimed to identify relevant risk factors. Method In this meta-analysis, all original researches regarding patients undergoing mixed types of cardiac surgery (excluding transcatheter procedures) and postoperative delirium were evaluated for inclusion. On July 28th 2020, we searched PubMed, Embase, Web of Science and Scopus. Data about name of first author, year of publication, inclusion and exclusion criteria, research design, setting, method of delirium assessment, incidence of delirium, odds ratio (OR) and corresponding 95% confidence interval (CI) of risk factors, and other information relevant was collected. OR and 95% CI were used as metrics for summarized results. Random effects model was applied. Results Fourteen reports were included with a total sample size of 13,286. The incidence of delirium ranged from 4.1 to 54.9%. Eight risk factors were identified including aging, diabetes, preoperative depression, mild cognitive impairment, carotid artery stenosis, NYHA functional class III or IV, time of mechanical ventilation and length of intensive care unit stay. Conclusion In this study several risk factors associated with postoperative delirium after cardiac surgery were identified. Utilizing the information may allow us to identifying patients at high risk of developing postoperative delirium prior to delirium onset. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01496-w.
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Affiliation(s)
- Haiyan Chen
- Education and Training Department, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Liang Mo
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of University of South China, Hengyang, China.
| | - Hongjuan Hu
- Nursing Department, The First Affiliated Hospital of University of South China, Hengyang, China.
| | - Yulan Ou
- Nursing Department, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Juan Luo
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of University of South China, Hengyang, China
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Kaźmierski J, Miler P, Pawlak A, Jerczyńska H, Woźniak J, Frankowska E, Brzezińska A, Woźniak K, Krejca M, Wilczyński M. Elevated Monocyte Chemoattractant Protein-1 as the Independent Risk Factor of Delirium after Cardiac Surgery. A Prospective Cohort Study. J Clin Med 2021; 10:jcm10081587. [PMID: 33918634 PMCID: PMC8070441 DOI: 10.3390/jcm10081587] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The pathogenesis of postoperative delirium is largely unknown. The primary objective of this study is to assess whether increased levels of monocyte chemoattractant protein-1 (MCP-1) and high-sensitivity C-reactive protein (hsCRP) are associated with postoperative delirium in patients who have undergone cardiac surgery. The secondary objective is to investigate whether any association between raised inflammatory biomarkers levels and delirium is related to surgical and anesthetic procedures or mediated by pre-existing psychiatric conditions associated with raised pro-inflammatory markers levels. METHODS The patients were screened for cognitive impairment one day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of major depressive disorder (MDD) and anxiety disorders was established on the basis of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Blood samples were collected pre- and postoperatively for hsCRP and chemokine levels. RESULTS Postoperative delirium developed in 34% (61 of 177) of patients. Both pre- and postoperative hsCRP, and preoperative MCP-1 levels were associated with postoperative delirium in univariate comparisons; p = 0.001; p < 0.001; p < 0.001, respectively. However, according to a multivariable logistic regression analysis, only a raised MCP-1 concentration before surgery was independently associated with postoperative delirium, and related to advancing age, preoperative anxiety disorders and prolonged intubation. CONCLUSIONS The present study suggests that an elevated preoperative MCP-1 concentration is associated with delirium after cardiac surgery. Monitoring of this inflammatory marker may reveal the cardiovascular disease (CVD) patients who are at risk of neuropsychiatric syndromes development.
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Affiliation(s)
- Jakub Kaźmierski
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, 92-216 Lodz, Poland; (J.W.); (E.F.)
- Correspondence: ; Tel.: +48-42-675-7372
| | - Piotr Miler
- Central Clinical Hospital of Medical University of Lodz, 92-216 Lodz, Poland; (P.M.); (A.P.); (A.B.)
| | - Agnieszka Pawlak
- Central Clinical Hospital of Medical University of Lodz, 92-216 Lodz, Poland; (P.M.); (A.P.); (A.B.)
| | - Hanna Jerczyńska
- CoreLab Central Scientific Laboratory of Medical University of Lodz, Medical University of Lodz, 92-215 Lodz, Poland;
| | - Joanna Woźniak
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, 92-216 Lodz, Poland; (J.W.); (E.F.)
| | - Emilia Frankowska
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, 92-216 Lodz, Poland; (J.W.); (E.F.)
| | - Agnieszka Brzezińska
- Central Clinical Hospital of Medical University of Lodz, 92-216 Lodz, Poland; (P.M.); (A.P.); (A.B.)
| | - Katarzyna Woźniak
- Department of Cardiac Surgery, Medical University of Lodz, 92-213 Lodz, Poland; (K.W.); (M.K.); (M.W.)
| | - Michał Krejca
- Department of Cardiac Surgery, Medical University of Lodz, 92-213 Lodz, Poland; (K.W.); (M.K.); (M.W.)
| | - Mirosław Wilczyński
- Department of Cardiac Surgery, Medical University of Lodz, 92-213 Lodz, Poland; (K.W.); (M.K.); (M.W.)
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Falk A, Kåhlin J, Nymark C, Hultgren R, Stenman M. Depression as a predictor of postoperative delirium after cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2021; 32:371-379. [PMID: 33831217 PMCID: PMC8906754 DOI: 10.1093/icvts/ivaa277] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/07/2020] [Accepted: 10/13/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Depression is common in patients with cardiac disease. The importance of preoperative depression for development of postoperative delirium (POD) following cardiac surgery is not well known. The aim is to provide a summary estimate of depression as a predictor of POD following cardiac surgery. METHODS Systematic search of MEDLINE, EMBASE, Cochrane Library, Web of Science Core Collection and Psycinfo (Ovid) was performed from inception to October 2019, including cohort studies reporting odds ratios (ORs) and 95% confidence intervals (CIs) for POD following cardiac surgery in patients with preoperative depression compared to patients without depression. ORs and 95% CIs for POD were calculated using random-effects meta-analyses. Subgroup and sensitivity analyses were performed. RESULTS Seven studies were included with a combined study population of 2066 patients. The pooled prevalence of POD in the combined study population was 26% and preoperative depression was present in ∼9% of the total study population. All studies showed a positive association between preoperative depression and POD; and in 5 studies, the association was statistically significant. Patients with depression had a pooled OR of 2.31 (95% CI 1.37-3.90) for POD. CONCLUSIONS This systematic review and meta-analysis confirm the findings that the previous association between preoperative depression and increased risk for developing POD reported for other patient groups is found also in cardiac surgery. Depression screening prior to cardiac surgery may be effective in identifying patients at higher risk for POD.
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Affiliation(s)
- Anna Falk
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Jessica Kåhlin
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Carolin Nymark
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Stenman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
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Perelman SI, Shander A, Mabry C, Ferraris VA. Preoperative anemia management in the coronavirus disease (COVID-19) era. JTCVS OPEN 2021; 5:85-94. [PMID: 34173552 PMCID: PMC7836783 DOI: 10.1016/j.xjon.2020.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/30/2020] [Indexed: 01/28/2023]
Affiliation(s)
- Seth I. Perelman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Aryeh Shander
- TeamHealth Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, NJ
| | - Christian Mabry
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Victor A. Ferraris
- Department of Cardiothoracic Surgery, Lexington VA Medical Center, University of Kentucky, Lexington, Ky
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45
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Ordóñez-Velasco LM, Hernández-Leiva E. Factors associated with delirium after cardiac surgery: A prospective cohort study. Ann Card Anaesth 2021; 24:183-189. [PMID: 33884974 PMCID: PMC8253013 DOI: 10.4103/aca.aca_43_20] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background: Delirium is a frequent complication after cardiac surgery and is associated with a higher incidence of morbidity and mortality and a prolonged hospital stay. However, knowledge of the variables involved in its occurrence is still limited; therefore, in this study, we evaluated the perioperative risk factors independently associated with this complication. Methods: This study was conducted in a referral tertiary care university hospital with a cardiovascular focus. A total of 311 consecutive adult patients undergoing any type of cardiac surgery were evaluated. The subjects were examined at regular intervals in the postoperative period using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) tool. Results: The incidence of postoperative delirium (PD) was 10%. Among the 18 pre-, intra- and postoperative variables evaluated, the logistic regression analysis showed that low education level, history of diabetes or stroke, type of surgery, prolonged extracorporeal circulation, or red blood cell transfusion in the intra- or postoperative period were independently associated with delirium after cardiac surgery. An increased body mass index was identified as a protective factor. Conclusions: The aforementioned risk factors are significantly and independently associated with the presentation of PD. Because some of these factors can be treated or avoided, the results of this study are highly relevant to reduce the risk of this complication and improve the care of patients undergoing cardiac surgery.
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Affiliation(s)
- Lina Maria Ordóñez-Velasco
- Intensivist at Cardiovascular Intensive Care Unit. Instituto de Cardiología - Fundación Cardioinfantil, Colombia
| | - Edgar Hernández-Leiva
- Department of Cardiology, Head of the Cardiac Surgical Intensive Care Unit, Instituto de Cardiología - Fundación Cardioinfantil, Colombia
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Sohrevardi SM, Nasab FS, Mirjalili MR, Bagherniya M, Tafti AD, Jarrahzadeh MH, Azarpazhooh MR, Saeidmanesh M, Banach M, Jamialahmadi T, Sahebkar A. Effect of atorvastatin on delirium status of patients in the intensive care unit: a randomized controlled trial. Arch Med Sci 2021; 17:1423-1428. [PMID: 34522273 PMCID: PMC8425261 DOI: 10.5114/aoms.2019.89330] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 09/29/2019] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Delirium is one of the most prevalent complications in intensive care unit (ICU) patients, which is related to worse clinical outcomes including a longer ICU stay, longer duration of mechanical ventilation, higher mortality rates and increased risk of cognitive impairment. Observational studies have suggested that statins might have a positive effect on delirium status of hospitalized patients. To date, there has been no trial assessing the effect of atorvastatin on delirium status in critically ill patients. Thus, the aim of the current study was to determine the efficacy of atorvastatin on delirium status of patients in the ICU. METHODS In this randomized, double-blind and controlled trial, a total of 90 patients in the general ICU who had delirium for at least 2 days were randomly divided into atorvastatin (40 mg/day) (n = 40) and control (n = 50) groups. Delirium status of the patients was determined twice a day at 10:00 a.m. and 18:00 p.m. using the Richmond Agitation-Sedation Scale (RASS). RESULTS Administration 40 mg/day of atorvastatin significantly reduced the mean RASS score and increased delirium-free days at both morning and afternoon time points compared to the control group (p < 0.05). CONCLUSIONS Administration of atorvastatin had a significant positive effect on delirium status in patients admitted to the ICU.
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Affiliation(s)
- Seyed Mojtaba Sohrevardi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Stroke Prevention & Atherosclerosis Research Centre, University of Western Ontario, Canada
| | - Fatemeh Shojaei Nasab
- Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Shahid Sadoughi University of Medical Silences, Yazd, Iran
| | - Mohammad Reza Mirjalili
- Department of Anesthesia and Intensive Care Medicine, Faculty of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Bagherniya
- Department of Community Nutrition, School of Nutrition and Food Science, Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Arefeh Dehghani Tafti
- Department of Biostatistics and Epidemiology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Hossein Jarrahzadeh
- Department of Anesthesia and Intensive Care Medicine, Faculty of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mahmoud Reza Azarpazhooh
- Department of Clinical Neurological Sciences, University of Western Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, Canada
| | | | - Maciej Banach
- Department of Hypertension, WAM University Hospital in Lodz, Medical University of Lodz, Lodz, Poland
- Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
| | - Tannaz Jamialahmadi
- Halal Research Center of IRI, FDA, Tehran, Iran
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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Abstract
This article provides an overview of knowledge gaps that need to be addressed in cardiac anesthesia, including mitigating the inflammatory effects of cardiopulmonary bypass, defining myocardial infarction after cardiac surgery, improving perioperative neurologic outcomes, and the optimal management of patients undergoing valve replacement. In addition, emerging approaches to research conduct are discussed, including the use of new analytical techniques like machine learning, pragmatic trials, and adaptive designs.
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Affiliation(s)
- Jessica Spence
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, HSC 2V9 - 1280 Main Street West, Hamilton, ON L8S 4K1, Canada; Population Health Research Institute (PHRI), C3-7B David Braley Cardiac, Vascular and Stroke Research Institute (DBCVSRI), 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - C David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada; Departments of Anesthesia and Physiology, University of Toronto, Toronto, ON, Canada.
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Lim L, Nam K, Lee S, Cho YJ, Yeom CW, Jung S, Moon JY, Jeon Y. The relationship between intraoperative cerebral oximetry and postoperative delirium in patients undergoing off-pump coronary artery bypass graft surgery: a retrospective study. BMC Anesthesiol 2020; 20:285. [PMID: 33189145 PMCID: PMC7666484 DOI: 10.1186/s12871-020-01180-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 10/01/2020] [Indexed: 12/18/2022] Open
Abstract
Background Cerebral oximetry has been widely used to measure regional oxygen saturation in brain tissue, especially during cardiac surgery. Despite its popularity, there have been inconsistent results on the use of cerebral oximetry during cardiac surgery, and few studies have evaluated cerebral oximetry during off pump coronary artery bypass graft surgery (OPCAB). Methods To evaluate the relationship between intraoperative cerebral oximetry and postoperative delirium in patients who underwent OPCAB, we included 1439 patients who underwent OPCAB between October 2004 and December 2016 and among them, 815 patients with sufficient data on regional cerebral oxygen saturation (rSO2) were enrolled in this study. We retrospectively analyzed perioperative variables and the reduction in rSO2 below cut-off values of 75, 70, 65, 60, 55, 50, 45, 40, and 35%. Furthermore, we evaluated the relationship between the reduction in rSO2 and postoperative delirium. Results Delirium occurred in 105 of 815 patients. In both univariable and multivariable analyses, the duration of rSO2 reduction was significantly longer in patients with delirium at cut-offs of < 50 and 45% (for every 5 min, adjusted odds ratio (OR) 1.007 [95% Confidence interval (CI) 1.001 to 1.014] and adjusted OR 1.012 [1.003 to 1.021]; p = 0.024 and 0.011, respectively). The proportion of patients with a rSO2 reduction < 45% was significantly higher among those with delirium (adjusted OR 1.737[1.064 to 2.836], p = 0.027). Conclusions In patients undergoing OPCAB, intraoperative rSO2 reduction was associated with postoperative delirium. Duration of rSO2 less than 50% was 40% longer in the patients with postoperative delirium. The cut-off value of intraoperative rSO2 that associated with postoperative delirium was 50% for the total patient population and 55% for the patients younger than 68 years. Supplementary information Supplementary information accompanies this paper at 10.1186/s12871-020-01180-x.
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Affiliation(s)
- Leerang Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Chan-Woo Yeom
- Department of Neuropsychiatry, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Sanghyup Jung
- Department of Neuropsychiatry, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Jung Yoon Moon
- Department of Neuropsychiatry, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080.
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49
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Preoperative Anxiety and Depression Increases the Incidence of Delirium After Coronary Artery Bypass Graft Surgery. J Perianesth Nurs 2020; 35:496-501. [DOI: 10.1016/j.jopan.2020.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/19/2020] [Accepted: 01/19/2020] [Indexed: 12/18/2022]
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50
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Hamiko M, Charitos EI, Velten M, Hilbert T, Putensen C, Treede H, Duerr GD. Mannitol Is Associated with Less Postoperative Delirium after Aortic Valve Surgery in Patients Treated with Bretschneider Cardioplegia. Thorac Cardiovasc Surg 2020; 70:549-557. [PMID: 32886926 PMCID: PMC9556161 DOI: 10.1055/s-0040-1715891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background
Heart surgery with extracorporeal circulation (ECC) often leads to postoperative delirium (POD). This is associated with increased morbidity resulting in longer hospital stay and associated costs. The purpose of our study was to analyze the effect of intraoperative mannitol application on POD in patients undergoing elective aortic valve replacement (AVR).
Materials and Method
s In our retrospective single-center study, 259 patients underwent elective AVR, using Bretschneider cardioplegic solution for cardiac arrest, between 2014 and 2017. Patients were divided in mannitol (
n
= 188) and nonmannitol (
n
= 71) groups. POD was assessed using the confusion assessment method for the intensive care unit (ICU). Statistical significance was assumed at
p
< 0.05.
Results
Baseline patient characteristics did not differ between the groups. Incidence of POD was significantly higher in the nonmannitol group (33.8 vs. 13.8%;
p
= 0.001). These patients required longer ventilation time (24.1 vs. 17.1 hours;
p
= 0.021), higher reintubation rate (11.3 vs. 2.7%;
p
= 0.009), ICU readmission (12.7 vs. 4.8%;
p
= 0.026), prolonged ICU (112 vs. 70 hours;
p
= 0.040), and hospital stay (17.8 vs. 12.6 days;
p
< 0.001), leading to higher expenses (19,349 € vs. 16,606 €,
p
< 0.001). A 30-day mortality was not affected, but nonmannitol group showed higher Simplified Acute Physiology Score II score (32.2 vs. 28.7;
p
< 0.001). Mannitol substitution was independently associated with lower incidence of POD (odds ratio: 0.40; 95% confidence interval: 0.18–0.89;
p
= 0.02).
Conclusion
Treatment with mannitol during ECC was associated with decreased incidence of POD. This was accompanied by shorter ventilation time, ICU and hospital stay, and lower treatment expenses.
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Affiliation(s)
- Marwan Hamiko
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Efstratios I Charitos
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Markus Velten
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Tobias Hilbert
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Hendrik Treede
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Georg Daniel Duerr
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
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