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McCoy TH, Castro VM, Hart KL, Perlis RH. Stratified delirium risk using prescription medication data in a state-wide cohort. Gen Hosp Psychiatry 2021; 71:114-120. [PMID: 34091195 PMCID: PMC8249339 DOI: 10.1016/j.genhosppsych.2021.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Delirium is a common condition associated with increased morbidity and mortality. Medication side effects are a possible source of modifiable delirium risk and provide an opportunity to improve delirium predictive models. This study characterized the risk for delirium diagnosis by applying a previously validated algorithm for calculating central nervous system adverse effect burden arising from a full medication list. METHOD Using a cohort of hospitalized adult (age 18-65) patients from the Massachusetts All-Payers Claims Database, we calculated medication burden following hospital discharge and characterized risk of new coded delirium diagnosis over the following 90 days. We applied the resulting model to a held-out test cohort. RESULTS The cohort included 62,180 individuals of whom 1.6% (1019) went on to have a coded delirium diagnosis. In the training cohort (43,527 individuals), the medication burden feature was positively associated with delirium diagnosis (OR = 5.75, 95% CI 4.34-7.63) and this association persisted (aOR = 1.95; 1.31-2.92) after adjusting for demographics, clinical features, prescribed medications, and anticholinergic risk score. In the test cohort, the trained model produced an area under the curve of 0.80 (0.78-0.82). This performance was similar across subgroups of age and gender. CONCLUSION Aggregating brain-related medication adverse effects facilitates identification of individuals at high risk of subsequent delirium diagnosis.
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Affiliation(s)
- Thomas H McCoy
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Victor M Castro
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Kamber L Hart
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
| | - Roy H Perlis
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA.
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Shahrokni A, Tin AL, Sarraf S, Alexander K, Sun S, Kim SJ, McMillan S, Yulico H, Amirnia F, Downey RJ, Vickers AJ, Korc-Grodzicki B. Association of Geriatric Comanagement and 90-Day Postoperative Mortality Among Patients Aged 75 Years and Older With Cancer. JAMA Netw Open 2020; 3:e209265. [PMID: 32822490 PMCID: PMC7439108 DOI: 10.1001/jamanetworkopen.2020.9265] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Collaboration between geriatricians and surgeons in the perioperative treatment of older patients has been associated with improved outcomes in several nononcologic specialties. Similar associations may be possible among older patients with cancer. OBJECTIVE To investigate the associations of geriatric comanagement of care for older patients undergoing cancer-related surgical treatment with 90-day postoperative mortality, rate of adverse surgical events, and postoperative use of inpatient supportive care services. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed outcomes of patients who received geriatric comanaged care vs those who did not using multivariable logistic regression analysis, with 90-day mortality as the outcome and geriatric comanagement of care as the main variable, with adjustment for age, sex, American Society of Anesthesiology score, Memorial Sloan Kettering Frailty Index score, preoperative albumin level, operative time, and estimated blood loss. A similar model was used to assess the association of geriatric comanagement with adverse surgical events, defined as any major complication, readmission, or emergency department visit within 30 days. Patients aged 75 years and older who underwent an elective surgical procedure with a hospital stay of at least 1 day at a single tertiary-care cancer center between February 2015 and February 2018 were included. Data were analyzed from January to July 2019. EXPOSURES Postoperative care comanaged by the geriatrics service and surgical service (geriatric comanagement group) vs by the surgical service only (surgical service group). MAIN OUTCOMES AND MEASURES 90-day mortality, adverse surgical events, and use of supportive care services. RESULTS Of 1892 patients included, 1020 (53.9%) received geriatric comanagement of care; these patients, compared with those who received care managed by the surgery service only, were older (mean [SD] age, 81 [4] years vs 80 [4] years; P < .001), had longer operative time (mean [SD], 203 [146] minutes vs 138 [112] minutes; P < .001), and longer length of stay (median [interquartile range], 5 [3-8] days vs 4 [2-7] days; P < .001). There were no differences in the proportions of men (488 [47.8%] men vs 450 [51.6%] men; P = .11). Adverse surgical events were not significantly different between groups (odds ratio, 0.93 [95% CI, 0.73-1.18]; P = .54). However, the adjusted probability of death within 90 days after surgical treatment was 4.3% for the geriatric comanagement group vs 8.9% for the surgical service group (difference, 4.6% [95% CI, 2.3%-6.9%]; P < .001). Additionally, compared with patients who received postoperative care management from the surgery service only, a higher proportion of patients in the geriatric comanagement group received inpatient supportive care services, including physical therapy (555 patients [63.6%] vs 820 patients [80.4%]; P < .001), occupational therapy (220 patients [25.2%] vs 385 patients [37.7%]; P < .001), speech and swallow rehabilitation (42 patients [4.8%] vs 86 patients [8.4%]; P = .002), and nutrition services (637 patients [73.1%] vs 803 patients [78.7%]; P = .004). CONCLUSIONS AND RELEVANCE This cohort study found that geriatric comanagement was associated with significantly lower 90-day postoperative mortality among older patients with cancer. These findings suggest that such patients may benefit from geriatric comanagement, which could improve their ability to survive adverse postoperative events.
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Affiliation(s)
- Armin Shahrokni
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy L. Tin
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Saman Sarraf
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Koshy Alexander
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Steve Sun
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Soo Jung Kim
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sincere McMillan
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Heidi Yulico
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Farnia Amirnia
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert J. Downey
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew J. Vickers
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beatriz Korc-Grodzicki
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Gan S, Yu Y, Wu J, Tang X, Zheng Y, Wang M, Zhu S. Preoperative assessment of cognitive function and risk assessment of cognitive impairment in elderly patients with orthopedics: a cross-sectional study. BMC Anesthesiol 2020; 20:189. [PMID: 32738902 PMCID: PMC7395982 DOI: 10.1186/s12871-020-01096-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 07/14/2020] [Indexed: 12/21/2022] Open
Abstract
Background Preexisting cognitive impairment is emerging as a predictor of poor postoperative outcomes in seniors. Nevertheless, cognitive impairment in a large proportion of geriatric patients has not been well identified and diagnosed. Methods This is a cross-sectional study. Mini-mental state examination scale was used to assess the cognitive function of elderly patients aged ≥65 years undergoing orthopedic surgery preoperatively. The baseline, living habits and laboratory examination results of two groups were compared, and a multivariable logistic regression model was used to identify independent predictors of preoperative cognitive impairment. Results A total of 374 elderly patients with orthopedic surgery indications met the inclusion criteria, and 28.61% of them had preoperative cognitive impairment. Multivariable logistic regression analysis showed that age (OR = 1.089, P < 0.001), subjective sleep disorders (OR = 1.996, P = 0.021), atherosclerosis (OR = 2.367, P = 0.017), and high cholesterol level (OR = 1.373, P = 0.028) were independent risk factors for preoperative cognitive impairment, while high education level performed as a protective factor (compared with the illiterate group, primary school group: OR = 0.413, P = 0.009; middle school or above group: OR = 0.120, P < 0.001). Conclusions The prevalence of preoperative cognitive dysfunction in geriatric elective orthopedic surgical patients was high. Our study identified venerable age, low level of education, subjective sleep disorders, atherosclerosis, and high cholesterol level as risk factors for preoperative cognitive impairment in these patients. Understanding these risk factors contributes to assisting in prevention and directed interventions for the high-risk population.
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Affiliation(s)
- Shuyuan Gan
- Department of Anesthesiology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, Zhejiang, China
| | - Yang Yu
- Department of Anesthesiology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, Zhejiang, China
| | - Jiateng Wu
- Department of Anesthesiology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, Zhejiang, China
| | - Xiaodong Tang
- Department of Anesthesiology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, Zhejiang, China
| | - Yueying Zheng
- Department of Anesthesiology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, Zhejiang, China
| | - Mingcang Wang
- Department of Anesthesiology, Taizhou Hospital, Wenzhou Medical University, Linhai, 317000, Zhejiang, China.
| | - Shengmei Zhu
- Department of Anesthesiology, the First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou, Zhejiang, China.
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Hendricks TM, Gutierrez CN, Stulak JM, Dearani JA, Miller JD. The Use of Virtual Reality to Reduce Preoperative Anxiety in First-Time Sternotomy Patients: A Randomized Controlled Pilot Trial. Mayo Clin Proc 2020; 95:1148-1157. [PMID: 32498771 DOI: 10.1016/j.mayocp.2020.02.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/25/2020] [Accepted: 02/17/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To report the first randomized controlled trial to investigate if immersive virtual reality (VR) treatment can reduce patient perceptions of anxiety compared with a tablet-based control treatment in adults undergoing a first-time sternotomy. METHODS Twenty first-time sternotomy patients were prospectively randomized (blinded to investigator) to a control or VR intervention. The VR intervention was a game module "Bear Blast" (AppliedVR) displayed using a Samsung Gear Oculus VR headset. The control intervention was a tablet-based game with comparable audio, visual, and tactile components. The State-Trait Anxiety Inventory was administered before and after the assigned intervention. Self-reported anxiety measures between the control and VR groups were evaluated using an unpaired t test. Changes in self-reported anxiety measures pre- and post-intervention were evaluated with a paired t test for both the control and VR groups. The study took place from May 1, 2017, through January 1, 2019 (Institutional Review Board 16-009784). RESULTS Both control and VR groups were 90.0% male, with a mean ± SD age of 63.4 ± 9.11 and 69.5 ± 6.9 years, respectively. VR users experienced significant reductions in feeling tense and strained, and significant improvements in feeling calm when compared with tablet controls (P<0.05). They also experienced significant reductions in feeling strained, upset, and tense when compared with their own self-reported anxiety measure pre- and post-intervention (P<0.05). Critically, control patients had no change in these categories. CONCLUSION Immersive VR is an effective, nonpharmacologic approach to reducing preoperative anxiety in adults undergoing cardiac surgery and shows the validity and utility of this technology in adult patients.
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Affiliation(s)
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jordan D Miller
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN; Departments of Surgery and Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN.
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Ortner F, Eberl M, Otto S, Wang B, Schauberger G, Hofmann-Kiefer K, Saller T. Patient-related and anesthesia-dependent determinants for postoperative delirium after oral and maxillofacial surgery. Results from a register-based case-control study. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2020; 122:62-69. [PMID: 32302798 DOI: 10.1016/j.jormas.2020.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/06/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify risk factors for postoperative delirium (POD) after general oral and maxillofacial surgery. MATERIAL AND METHODS 2420 patients were screened postoperatively for POD using the Nursing Delirium Screening Scale (NuDESC) before discharge from the post anesthesia caring unit (PACU). Basic health data and risk factors were collected. For analysis the study group (n=41) was compared to a control group of 164 randomly selected patients (case-control-ratio=1:4). To identify risk factors for POD multivariable logistic regression models were used. To see whether estimations remain stable, regression analysis was repeated for the subgroup of patients not undergoing dentoalveolar surgery (n=105). To estimate the risk for dentoalveolar surgery a logistic regression model was performed. RESULTS Dementia was the only significant risk factor for POD (Odds ratio 41.5; 95% CI 5.48-314), also for patients undergoing other than dentoalveolar surgery (58.1; 1.70-1983). Patients undergoing dentoalveolar surgery were more often suffering from dementia (35.5; 2.85-441), other psychiatric and neurological disorders (3.15; 1.05-9.43), were of younger age (0.97; 0.94-1.00) and had higher anesthesiological risk (3.95; 1.04-14.9). CONCLUSION Patients with dementia are at higher risk to develop POD after oral and maxillofacial surgery. We found a strong interdependence between age, dementia, ASA-Score and dentoalveolar surgery.
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Affiliation(s)
- Florian Ortner
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; Department of Oral and Maxillofacial Surgery, University Hospital, LMU Munich, Lindwurmstraße 2a, 80337 Munich, Germany
| | - Marian Eberl
- Chair of Epidemiology, Faculty of Sport and Health Science, Technical University of Munich (TUM), Georg-Brauchle-Ring 60/62, 80992 Munich, Germany
| | - Sven Otto
- Department of Oral and Maxillofacial Surgery, University Hospital, LMU Munich, Lindwurmstraße 2a, 80337 Munich, Germany.
| | - Baocheng Wang
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Gunther Schauberger
- Chair of Epidemiology, Faculty of Sport and Health Science, Technical University of Munich (TUM), Georg-Brauchle-Ring 60/62, 80992 Munich, Germany
| | - Klaus Hofmann-Kiefer
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Thomas Saller
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
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Gerresheim G, Handschu R, Winkler B, Ritt M, Schwemmer U, Schuh A. [Prevention of postoperative delirium]. MMW Fortschr Med 2020; 162:50-57. [PMID: 32342402 DOI: 10.1007/s15006-020-0013-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Götz Gerresheim
- Klinik für Anästhesiologie und Intensivmedizin, Kliniken des Landkreises Neumarkt i. d. OPf.Kliniken des Landkreises Neumarkt i. d. OPf., Nürnberger Str. 12, D-92318, Neumarkt, Deutschland.
| | - René Handschu
- Neurologische Klinik, Kliniken des Landkreises Neumarkt i. d. OPf., Deutschland
| | - Barbara Winkler
- Leitung Pflegedienst, Kliniken des Landkreises Neumarkt i. d. OPf., Deutschland
| | - Martin Ritt
- Klinik III, Allgemeine Innere Medizin, Akutgeriatrie, Kliniken des Landkreises Neumarkt i. d. OPf., Deutschland
| | - Ulrich Schwemmer
- Klinik für Anästhesiologie und Intensivmedizin, Kliniken des Landkreises Neumarkt i. d. OPf., Deutschland
| | - Alexander Schuh
- Muskuloskelettales Zentrum, Kliniken des Landkreises Neumarkt i. d. OPf., Deutschland
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Powelson EB, Reed MJ, Bentov I. Perioperative Management of Delirium in Geriatric Patients. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00353-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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van Beek S, Kroon J, Rijs K, Mijderwijk HJ, Klimek M, Stolker RJ. The effect of midazolam as premedication on the quality of postoperative recovery after laparotomy: a randomized clinical trial. Can J Anaesth 2019; 67:32-41. [PMID: 31576513 DOI: 10.1007/s12630-019-01494-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 07/21/2019] [Accepted: 07/27/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Despite the uncertain effects of anxiolytic premedication with benzodiazepines on the quality of postoperative recovery, perioperative benzodiazepine administration is still a common practice in many hospitals. We evaluated the effect of premedication with midazolam on the quality of recovery in hospitalized patients undergoing a laparotomy. METHODS We conducted a single-centre randomized placebo-controlled, double-blinded clinical trial from July 2014 to September 2015. We included 192 patients aged > 18 yr scheduled for elective laparotomy with a planned postoperative stay of ≥ three days. Participants were randomized into two groups to receive either midazolam 3 mg or sodium chloride 0.9% intravenously as premedication prior to surgery. Patients were followed up for up to one week after surgery. The primary outcome was the Quality of Recovery-40 (QoR-40) score on postoperative day (POD) 3. The secondary outcomes included the QoR-40 score on POD 7, and the State-Trait Anxiety Inventory, State-Trait Anger Scale, Multidimensional Fatigue Inventory, and the Hospital Anxiety and Depression Scale scores. RESULTS The mean (standard deviation) postoperative QoR-40 scores on POD 3 were not significantly different in the midazolam group compared with controls [166.4 (17.0) vs 163.9 (19.8), respectively; mean difference, 2.3; 95% confidence interval, - 2.9 to 8.4; P = 0.35]. There were no between-group differences in any of the secondary outcomes. CONCLUSIONS Administration of midazolam as premedication for laparotomy patients did not improve the quality of recovery up to one week after surgery. General prescription of midazolam as premedication can be questioned and might only suit some patients. TRIAL REGISTRATION www.clinicaltrials.gov (NCT01993459); registered 29 October, 2013.
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Affiliation(s)
- Stefan van Beek
- Department of Anesthesiology, Erasmus University Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Jeroen Kroon
- Department of Anesthesiology, Erasmus University Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Koen Rijs
- Department of Anesthesiology, Erasmus University Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Hendrik-Jan Mijderwijk
- Department of Anesthesiology, Erasmus University Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Markus Klimek
- Department of Anesthesiology, Erasmus University Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Robert J Stolker
- Department of Anesthesiology, Erasmus University Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
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Hartog J, Blokzijl F, Dijkstra S, DeJongste MJL, Reneman MF, Dieperink W, van der Horst ICC, Fleer J, van der Woude LHV, van der Harst P, Mariani MA. Heart Rehabilitation in patients awaiting Open heart surgery targeting to prevent Complications and to improve Quality of life (Heart-ROCQ): study protocol for a prospective, randomised, open, blinded endpoint (PROBE) trial. BMJ Open 2019; 9:e031738. [PMID: 31537574 PMCID: PMC6756317 DOI: 10.1136/bmjopen-2019-031738] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/15/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The rising prevalence of modifiable risk factors (eg, obesity, hypertension and physical inactivity) is causing an increase in possible avoidable complications in patients undergoing cardiac surgery. This study aims to assess whether a combined preoperative and postoperative multidisciplinary cardiac rehabilitation (CR) programme (Heart-ROCQ programme) can improve functional status and reduce surgical complications, readmissions and major adverse cardiac events (MACE) as compared with standard care. METHODS AND ANALYSIS Patients (n=350) are randomised to the Heart-ROCQ programme or standard care. The Heart-ROCQ programme consists of a preoperative optimisation phase while waiting for surgery (three times per week, minimum of 3 weeks), a postoperative inpatient phase (3 weeks) and an outpatient CR phase (two times per week, 4 weeks). Patients receive multidisciplinary treatment (eg, physical therapy, dietary advice, psychological sessions and smoking cessation). Standard care consists of 6 weeks of postsurgery outpatient CR with education and physical therapy (two times per week). The primary outcome is a composite weighted score of functional status, surgical complications, readmissions and MACE, and is evaluated by a blinded endpoint committee. The secondary outcomes are length of stay, physical and psychological functioning, lifestyle risk factors, and work participation. Finally, an economic evaluation is performed. Data are collected at six time points: at baseline (start of the waiting period), the day before surgery, at discharge from the hospital, and at 3, 7 and 12 months postsurgery. ETHICS AND DISSEMINATION This study will be conducted according to the principles of the Declaration of Helsinki (V.8, October 2013). The protocol has been approved by the Medical Ethical Review Board of the UMCG (no 2016/464). Results of this study will be submitted to a peer-reviewed scientific journal and can be presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT02984449.
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Affiliation(s)
- Johanneke Hartog
- Department of Cardio-thoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Fredrike Blokzijl
- Department of Cardio-thoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sandra Dijkstra
- Department of Cardio-thoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mike J L DeJongste
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel F Reneman
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Willem Dieperink
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joke Fleer
- Department of Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lucas H V van der Woude
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Massimo A Mariani
- Department of Cardio-thoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Agrawal S, Turk R, Burton BN, Ingrande J, Gabriel RA. The association of preoperative delirium with postoperative outcomes following hip surgery in the elderly. J Clin Anesth 2019; 60:28-33. [PMID: 31437598 DOI: 10.1016/j.jclinane.2019.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/26/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE To determine the association of preoperative delirium with postoperative outcomes following hip surgery in the elderly. DESIGN Retrospective cohort study. SETTING Postoperative recovery. PATIENTS 8466 patients all of whom were 65 years of age or older undergoing surgical repair of a femoral fracture. Of the total population studied, 1075 had preoperative delirium. Of those with preoperative delirium, 746 were ASA class 3 or below and 327 were ASA class 4 or above. Of the 7391 patients without preoperative delirium, 5773 were ASA class 3 or below and 1605 were ASA class 4 or above. The remainder in each group was of unknown ASA class. INTERVENTIONS We used multivariable logistic regression to explore the association of preoperative delirium with 30-day postoperative outcomes. The odds ratio (OR) with associated 95% confidence interval (CI) was reported for each covariate. MEASUREMENTS Data was collected regarding the incidence of postoperative outcomes including: delirium, pulmonary complications, extended hospital stay, infection, renal complications, vascular complications, cardiac complications, transfusion necessity, readmission, and mortality. MAIN RESULTS After adjusting for potential confounders, the odds of postoperative delirium (OR 9.38, 95% CI 7.94-11.14), pulmonary complications (OR 1.83, 95% CI 1.4-2.36), extended hospital stay (OR 1.47, 95% CI 1.26-1.72), readmission (OR 1.27, 95% CI 1.01-1.59) and mortality (OR 1.92, 95% CI 1.54-2.39) were all significantly higher in patients with preoperative delirium compared to those without. CONCLUSIONS After controlling for potential confounding variables, we showed that preoperative delirium was associated with postoperative delirium, pulmonary complications, extended hospital stay, hospital readmission, and mortality. Given the lack of studies on preoperative delirium and its postoperative outcomes, our data provides a strong starting point for further investigations as well as the development and implementation of targeted risk-reduction programs.
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Affiliation(s)
- Shubham Agrawal
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Robby Turk
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Brittany N Burton
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jerry Ingrande
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, San Diego, CA, USA; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, San Diego, CA, USA.
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Cai S, Lv M, Latour JM, Lin Y, Pan W, Zheng J, Cheng L, Li J, Zhang Y. Incidence and risk factors of PostopeRativE delirium in intensive care unit patients: A study protocol for the PREDICt study. J Adv Nurs 2019; 75:3068-3077. [PMID: 31197839 DOI: 10.1111/jan.14097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/18/2019] [Accepted: 04/09/2019] [Indexed: 01/14/2023]
Abstract
AIM The aims of this study are: (a) to determine the incidence of postoperative delirium (POD) among surgical intensive care unit (ICU) patients in China and identify risk factors, especially, which are modifiable and have value for developing a prediction model; (b) to develop and validate a prediction model of delirium to recognize high-risk patients in surgical ICUs; (c) to investigate the short- and long-term outcomes of delirious patients and identify the predictors of patient outcomes. DESIGN A single-centre prospective cohort study. METHODS Patients will be enrolled from three surgical ICUs in a tertiary teaching hospital. Delirium assessment and perioperative data will be collected throughout the hospitalization. Delirious patients will be followed up for 2 years. The study was approved by the ethics committee in May 2018 and was funded by the clinical research grant from Zhongshan hospital, Fudan University, Shanghai. DISCUSSION Developing POD can be a burden to patients both for the short- and long-term period. Due to the lack of effective treatments for POD, prevention remains the best strategy. This study will provide an effective tool for early screening of high-risk patients of POD and provide a better understanding of the aetiology and outcome of delirium. IMPACT In clinical practice, a prediction model will offer an effective tool for ICU nurses to assess high-risk patients, which can support them to implement preventive strategies at the early stages to targeted patients. The follow-up results will help us better understand the impact of delirium on patients' long-term outcome.
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Affiliation(s)
- Shining Cai
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Minzhi Lv
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jos M Latour
- Faculty of Health and Human Sciences, School of Nursing and Midwifery, University of Plymouth, Plymouth, UK
| | - Ying Lin
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenyan Pan
- Department of Surgery Intensive Care Unit, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jili Zheng
- Department of Cardiac Surgery Intensive Care Unit, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lihong Cheng
- Department of Liver Surgery Intensive Care Unit, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingjing Li
- Department of Surgery Intensive Care Unit, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuxia Zhang
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
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van der Wulp K, van Wely M, van Heijningen L, van Bakel B, Schoon Y, Verkroost M, Gehlmann H, Van Garsse L, Vart P, Kievit P, Rikkert MO, Morshuis W, van Royen N. Delirium After Transcatheter Aortic Valve Implantation Under General Anesthesia: Incidence, Predictors, and Relation to Long-Term Survival. J Am Geriatr Soc 2019; 67:2325-2330. [PMID: 31342524 PMCID: PMC6899857 DOI: 10.1111/jgs.16087] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/21/2019] [Accepted: 06/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVES Prospectively collected data on postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) are scarce. The aim of this study was to report the incidence and risk factors of delirium after TAVI under general anesthesia and to assess the association of POD with clinical outcome and short‐ and long‐term survival. DESIGN Prospective cohort study. SETTING Academic medical center. PARTICIPANTS A total of 703 subsequent patients undergoing TAVI under general anesthesia between 2008 and 2017. MEASUREMENTS Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV), criteria. Outcomes were postprocedural clinical outcome and short‐ and long‐term survival (30 days and 5 years, respectively). RESULTS POD was observed in 16.5% (116/703), was the strongest independent predictor of long‐term mortality (hazard ratio = 1.91; 95% confidence interval [CI] = 1.36‐2.70), and was associated with impaired 30‐day and 5‐year survival (92.2% vs 96.8% [P = .025] and 40.0% vs 50.0% [P = .007], respectively). Stroke and new onset of atrial fibrillation were more often observed in delirious patients (6.9% vs 1.9% and 12.1% vs 5.1%, respectively). Strongest independent predictors of POD were prior delirium (odds ratio [OR] = 2.56; 95% CI = 1.52‐4.31) and aortic valve area less than 0.75 cm2 (OR = 2.39; 95% CI = 1.53‐3.74). CONCLUSION One in six patients experienced POD after TAVI under general anesthesia. POD was the strongest predictor of long‐term mortality and was associated with impaired short‐ and long‐term survival. Prior delirium and a more calcified aortic valve were the strongest independent predictors of POD. J Am Geriatr Soc 67:2325–2330, 2019
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Affiliation(s)
- Kees van der Wulp
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marleen van Wely
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lars van Heijningen
- Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bram van Bakel
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne Schoon
- Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michel Verkroost
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Helmut Gehlmann
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leen Van Garsse
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Priya Vart
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Kievit
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel Olde Rikkert
- Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim Morshuis
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
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63
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Prediction of postoperative delirium by comprehensive geriatric assessment among elderly patients with hip fracture. Ir J Med Sci 2019; 188:1311-1315. [PMID: 30915678 DOI: 10.1007/s11845-019-02011-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/20/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The purpose of this study is to investigate whether the preoperative comprehensive geriatric assessment (CGA) would predict postoperative delirium (POD) in elderly patients with hip fracture. METHODS This is an observational study, performed in a tertiary hospital from June 2014 to May 2018, which enrolled patients with hip fracture aged over 65 years. The comprehensive geriatric assessment for recruited patients was carried out before surgery. POD was recorded prospectively until discharge. Delirium was diagnosed according to the Confusion Assessment Method (CAM) algorithm. RESULTS POD occurred in 22.09% of the 507 patients who underwent hip surgery. The Barthel index, Mini-Mental State Examination (MMSE), instrumental activities of daily living (IADL), vitality index, and Geriatric Depression Scale (GDS) results were related to the occurrence of POD. All of them were independent factors related to the occurrence of POD after adjusting other traditional risk factors. CONCLUSIONS The comprehensive geriatric assessment before hip fracture surgery can predict the occurrence of POD in elderly patients.
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64
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Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urman RD, Chang GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS ®) Society Recommendations: 2018. World J Surg 2019; 43:659-695. [PMID: 30426190 DOI: 10.1007/s00268-018-4844-y] [Citation(s) in RCA: 1014] [Impact Index Per Article: 202.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Danderyd Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - M J Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, VA, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - M Hubner
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - J Nygren
- Department of Surgery, Ersta Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - N Demartines
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - N Francis
- Colorectal Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK
- University of Bath, Wessex House Bath, BA2 7JU, UK
| | - T A Rockall
- Department of Surgery, Royal Surrey County Hospital NHS Trust, and Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - T M Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland Middlemore Hospital, Auckland, New Zealand
| | - M Soop
- Irving National Intestinal Failure Unit, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - H D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, The Netherlands
| | - R D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G J Chang
- Department of Surgical Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - A Fichera
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, USA
| | - F Grass
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - E E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - W J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust and University of Surrey, Guildford, UK
| | - F Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - K E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - A Balfour
- Department of Colorectal Surgery, Surgical Services, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - G Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - O Ljungqvist
- Department of Surgery, Örebro University and University Hospital, Örebro & Institute of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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65
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Kang SY, Seo SW, Kim JY. Comprehensive risk factor evaluation of postoperative delirium following major surgery: clinical data warehouse analysis. Neurol Sci 2019; 40:793-800. [DOI: 10.1007/s10072-019-3730-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 01/16/2019] [Indexed: 12/19/2022]
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Kassie GM, Kalisch Ellett LM, Nguyen TA, Roughead EE. Use of medicines that may precipitate delirium prior to hospitalisation in older Australians with delirium: An observational study. Australas J Ageing 2019; 38:124-131. [DOI: 10.1111/ajag.12608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 11/26/2018] [Accepted: 12/05/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Gizat M. Kassie
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
| | - Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
| | - Tuan A. Nguyen
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
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Zhang J, Gao J, Guo G, Li S, Zhan G, Xie Z, Yang C, Luo A. Anesthesia and surgery induce delirium-like behavior in susceptible mice: the role of oxidative stress. Am J Transl Res 2018; 10:2435-2444. [PMID: 30210682 PMCID: PMC6129548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/20/2018] [Indexed: 06/08/2023]
Abstract
Anesthesia and surgery (A + S) are risk factors for patients to develop postoperative delirium (POD). However, the pathogenesis of POD remains largely to be determined. We employed battery of behavioral tests including open-filed test (OFT), elevated plus maze test (EPMT) and buried food test (BFT) to investigate the role of oxidative stress in the development of POD and to explore the therapeutic target for POD in mice after A + S (simple laparotomy under 1.4% isoflurane anesthesia). We initially found that 6 hours after A + S, mice failed to alter the behavioral changes in OFT and the adenosine triphosphate (ATP) level in hippocampus. After hierarchical cluster analysis, however, there was a significant change in the behavior tests between POD unsusceptible (non-POD) and susceptible (POD-like) mice. Interestingly, cyclosporine A, an inhibitor of mitochondrial permeability transition pore (mPTP) opening, exerted pharmacologically beneficial effects on symptoms, decreased reactive oxygen species (ROS) and ATP, and increased superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) and catalase (CAT) levels in the hippocampus of POD-like mice. These findings suggest that abnormally activated oxidative stress might be involved in the underlying mechanisms of POD. Novel therapeutic agents targeting inhibition of oxidative stress would provide an available strategy for POD treatment.
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Affiliation(s)
- Jie Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Jie Gao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Guojun Guo
- Department of Hand Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Shan Li
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Gaofeng Zhan
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Zhongcong Xie
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical SchoolCharlestown, MA, US
| | - Chun Yang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Ailin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
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68
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Kassie GM, Nguyen TA, Kalisch Ellett LM, Pratt NL, Roughead EE. Do Risk Prediction Models for Postoperative Delirium Consider Patients' Preoperative Medication Use? Drugs Aging 2018; 35:213-222. [PMID: 29423780 DOI: 10.1007/s40266-018-0526-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medicines are potentially modifiable risk factors for postoperative delirium. However, the extent to which preoperative medicines are included in risk prediction models (RPMs) is unknown. OBJECTIVE This systematic review aimed to assess the extent of inclusion of preoperative medications in RPMs for postoperative delirium. METHODS Articles were systematically searched from MEDLINE, EMBASE and CINAHL using Medical Subject Headings (MeSH) where possible and keywords for postoperative delirium and prediction model. Studies published until May 2017 with a primary outcome of postoperative delirium that developed an RPM containing preoperative patient information were considered. Where a study had two cohorts, a derivation and a validation cohort, findings from the derivation cohort were extracted and reported. RESULTS Eighteen prospective and one retrospective cohort studies were included for review. Of the 19 studies, only nine considered preoperative medication data, with medications appearing as predictor variables in five models. There was wide variability in the factors included in the final models, with the most frequent predictors being age and cognitive impairment, appearing in 13 (68%) and 11 (58%) RPMs, respectively. CONCLUSION While medications are commonly cited risk factors for delirium, they are not adequately considered when developing RPMs. Future studies aiming to develop an RPM for postoperative delirium should include preoperative medication data as a potential predictor variable because of the modifiable nature of medication use and its impact on other factors commonly in models, such as cognition.
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Affiliation(s)
- Gizat M Kassie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia.
| | - Tuan A Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia.,University of South Australia, GPO Box 2471 (CEA-18), Adelaide, SA, 5001, Australia
| | - Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Nicole L Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia.,University of South Australia, GPO Box 2471 (R3-17A), Adelaide, SA, 5001, Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
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69
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Adeola M, Azad R, Kassie GM, Shirkey B, Taffet G, Liebl M, Agarwal K. Multicomponent Interventions Reduce High-Risk Medications for Delirium in Hospitalized Older Adults. J Am Geriatr Soc 2018; 66:1638-1645. [PMID: 30035315 DOI: 10.1111/jgs.15438] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/03/2018] [Accepted: 04/10/2018] [Indexed: 12/28/2022]
Abstract
Delirium threatens the functional independence and cognitive capacity of patients. Medications, especially those with strong anticholinergic effects, have been implicated as a preventable cause of delirium. We evaluated the effect of multicomponent interventions aimed at reducing the use of 9 target medications in hospitalized older adults at risk of delirium. This continuous quality improvement program was undertaken at a tertiary care facility and 4 community hospitals in a hospital system. We included 21, 541 hospital admissions with patients aged 70 and older on acute care medical or surgical units from the preintervention (2012) period, and 27,764 from the postintervention (2015) period. Implemented interventions include formulary and policy changes, technology-assisted medication review, age-conditional order set modifications, best practice alerts, and education. The proportion of hospital admissions with individual's receiving at least 1 target medication declined from 45.6% to 31.3% (relative reduction (RR)=31.4%) from before to after the intervention, meaning that target medication exposure was avoided in approximately 4,000 older adults. The greatest effect was observed for zolpidem (11.2% to 5.3%, RR=52.6%) and diphenhydramine (12.9% to 7.1%, RR=45%). Furthermore, the mean number of doses administered during all hospital admissions was reduced for 7 of 9 medications. Multicomponent interventions implemented in our hospital system were effective at reducing exposure to target medications in hospitalized older adults at risk of delirium. These systematic changes applied throughout the medication use process are sustained today.
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Affiliation(s)
- Mobolaji Adeola
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Rejena Azad
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Gizat M Kassie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Beverly Shirkey
- Center for Outcomes Research, Department of Surgery, Houston Methodist Hospital Research Institute, Houston, Texas
| | - George Taffet
- Section of Geriatrics, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Michael Liebl
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Kathryn Agarwal
- Section of Geriatrics, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Department of Quality and Patient Safety, Houston Methodist Hospital System, Houston, Texas
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Safavynia SA, Arora S, Pryor KO, García PS. An update on postoperative delirium: Clinical features, neuropathogenesis, and perioperative management. CURRENT ANESTHESIOLOGY REPORTS 2018; 8:252-262. [PMID: 30555281 PMCID: PMC6290904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE OF REVIEW We present a focused review on postoperative delirium for anesthesiologists, encompassing clinical features, neuropathogenesis, and clinical identification and management strategies based on risk factors and current delirium treatments. RECENT FINDINGS The literature on postoperative delirium is dominated by non-experimental studies. We review delirium phenotypes, diagnostic criteria, and present standard nomenclature based on current literature. Disruption of cortical integration of complex information (CICI) may provide a framework to understand the neuropathogenesis of postoperative delirium, as well as risk factors and clinical modifiers in the perioperative period. We further divide risk factors into patient factors, surgical factors, and medical/pharmacological factors, and present specific considerations for each in the preoperative, intraoperative, and postoperative periods. SUMMARY Postoperative delirium is prevalent, poorly understood, and often missed with current screening techniques. Proper identification of risk factors is useful for perioperative interventions and can help tailor patient-specific management strategies.
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Affiliation(s)
- Seyed A. Safavynia
- Department of Anesthesiology, Weill Cornell Medical
College, New York, NY, USA
| | - Sona Arora
- Department of Anesthesiology, Emory University, Atlanta,
GA, USA
| | - Kane O. Pryor
- Department of Anesthesiology, Weill Cornell Medical
College, New York, NY, USA
| | - Paul S. García
- Department of Anesthesiology, Emory University, Atlanta,
GA, USA
- Neuroanesthesia Laboratory, Atlanta VA Medical Center/Emory
University, Atlanta, GA, USA
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71
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Safavynia SA, Arora S, Pryor KO, García PS. An Update on Postoperative Delirium: Clinical Features,
Neuropathogenesis, and Perioperative Management. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0282-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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