1
|
Khaled M, Sabac D, Fuda M, Koubaesh C, Gallab J, Qu M, Lo Bianco G, Shanthanna H, Paul J, Thabane L, Marcucci M. Postoperative pain and neurocognitive outcomes after noncardiac surgery: a systematic review and dose-response meta-analysis. Br J Anaesth 2024:S0007-0912(24)00550-6. [PMID: 39393998 DOI: 10.1016/j.bja.2024.08.032] [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: 11/21/2023] [Revised: 07/20/2024] [Accepted: 08/05/2024] [Indexed: 10/13/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are common after noncardiac surgery. Postsurgical pain is frequent and can persist as chronic postsurgical pain (CPSP). The association between postsurgical pain and POD or POCD is biologically plausible. We conducted this systematic review to evaluate the association between acute postsurgical pain or CPSP and POD or POCD in adults undergoing noncardiac surgery. METHODS We followed Preferred Reporting Items for Systematic Review and Meta-Analyses. We searched MEDLINE, EMBASE, Cochrane, CINAHL and PSYCHINFO up to May 2023. We included cohort, case-control, and cross-sectional studies of any language. Pairs of reviewers independently screened studies, extracted data and assessed the risk of bias using the CLARITY tool and the Joanna Briggs Institute checklist. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. Where possible, we conducted random-effects meta-analyses to summarise our findings. RESULTS We analysed 30 studies (>9000 participants) that assessed the association between acute postoperative pain and POD/POCD. Dose-response meta-analyses found that postoperative pain intensity was associated with occurrence of POD (adjusted relative risk [aRR]/unit of pain intensity: 1.26; 95% confidence interval [CI]: 1.17-1.35; low certainty of evidence) and risk of developing POD (aRR/unit of pain intensity: 1.18; 95% CI: 1.08-1.30; low certainty of evidence). There was very low certainty of evidence regarding the association between postoperative pain and POCD. No studies assessed the association between CPSP and POCD. Residual confounding and substantial methodological variability between studies prevented pooling data from many of the included studies and lowered certainty of evidence. CONCLUSIONS Dose-response meta-analyses found that postoperative pain intensity was associated with occurrence of and risk of developing POD. SYSTEMATIC REVIEW PROTOCOL PROSPERO-CRD42021192105.
Collapse
Affiliation(s)
- Maram Khaled
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Perioperative and Surgery Research Program, Population Health Research Institute, David Braley Research Institute, Hamilton, ON, Canada
| | - Denise Sabac
- Department of Health Sciences, McMaster University, Hamilton, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Matthew Fuda
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Chantal Koubaesh
- School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
| | - Joseph Gallab
- Department of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Marianna Qu
- Department of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Giuliana Lo Bianco
- Intensive Care & Anesthesia Residency: San Raffaele Hospital, Milan, Italy
| | - Harsha Shanthanna
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - James Paul
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Maura Marcucci
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Perioperative and Surgery Research Program, Population Health Research Institute, David Braley Research Institute, Hamilton, ON, Canada; Clinical Epidemiology and Research Centre (CERC), Department of Biomedical Sciences, Humanitas University & IRCCS Humanitas Research Hospital, Milan, Italy.
| |
Collapse
|
2
|
Wei L, Liu M, Zhang S, Chen Y, Wu M, Chen X, Liu J, He Y, Yang X, Xian J. Association of preoperative frailty with risk of postoperative delirium in older patients undergoing craniotomy: a prospective cohort study. BMC Surg 2024; 24:272. [PMID: 39354490 PMCID: PMC11443671 DOI: 10.1186/s12893-024-02573-2] [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: 02/16/2024] [Accepted: 09/16/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND Preoperative frailty is a risk factor associated with postoperative delirium (POD), which has attracted more attention from clinicians, but no research has shown that it is related to elderly patients undergoing craniotomy. Therefore, the aim of this study was to determine the effect of preoperative frailty on POD in older patients, especially those who underwent craniotomy. METHODS From October 2022 to May 2023, older patients who underwent elective craniotomy were collected. Assess the occurrence of frailty using the FRAIL scale one day before surgery. Evaluate the occurrence of POD using the Confusion Assessment Method (CAM) within three days after surgery. Participants were divided into two groups, one group being POD, Logistic regression analysis was used to find the risk variables for POD, and the predictive value of preoperative frailty to POD was determined by using the operating characteristic curve of the subjects. RESULTS A total of 300 patients were included in this study, among whom 83 patients (27.7%) exhibited preoperative frailty and 69 patients (23.0%) experienced POD. The results of the multivariate logistic regression analysis indicate that preoperative frailty (OR: 8.816, 95% CI: 3.972-19.572), preoperative hypoalbuminemia (OR: 0.893, 95% CI: 0.811-0.984), low BMI (OR: 0.793, 95% CI: 0.698-0.901), and prolonged operative duration (OR: 1.007, 95% CI: 1.004-1.010) are independent risk factors for POD in older patients who underwent craniotomy. We constructed a risk prediction model using these factors, which had an area under the ROC curve of 0.908 (95% CI: 0.869-0.947, P < 0.001). Preoperative frailty enhanced the discriminative ability of the prediction model by 0.037. POD was associated with a longer length of hospital stay and higher hospitalization costs. CONCLUSIONS Preoperative frailty is an independent risk factor for POD in older patients undergoing elective craniotomy and can predict the occurrence of POD to a certain extent. In addition, early identification of patients at risk of malnutrition and appropriate surgical planning can reduce the incidence of POD.
Collapse
Affiliation(s)
- Li Wei
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Brain Science Collaborative Innovation Center, Chongqing, 400038, China
| | - Miao Liu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Brain Science Collaborative Innovation Center, Chongqing, 400038, China
| | - Shisi Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Brain Science Collaborative Innovation Center, Chongqing, 400038, China
| | - Yujie Chen
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Brain Science Collaborative Innovation Center, Chongqing, 400038, China
| | - Min Wu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Brain Science Collaborative Innovation Center, Chongqing, 400038, China
| | - Xiaomei Chen
- Department of Nursing, Qionglai Medical Center Hospital, Qionglai, 611500, Sichuan Province, China
| | - Jia Liu
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Yuxuan He
- Nursing School, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Xue Yang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
- Chongqing Brain Science Collaborative Innovation Center, Chongqing, 400038, China.
| | - Jishu Xian
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
- Chongqing Brain Science Collaborative Innovation Center, Chongqing, 400038, China.
| |
Collapse
|
3
|
Othman SMA, Aziz MAA, Al-Mushiki GMA, Sriwayyapram C, Okubai T, Al-Muwaffaq G, Xu Q, Alqudaimi M. Association of postoperative delirium with hypotension in critically ill patients after cardiac surgery: a prospective observational study. J Cardiothorac Surg 2024; 19:476. [PMID: 39090732 PMCID: PMC11293154 DOI: 10.1186/s13019-024-02958-7] [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: 01/25/2024] [Accepted: 06/30/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD), an acute and variable disturbance in cognitive function, is an intricate and elusive phenomenon that occurs after cardiac surgery. Despite progress in surgical techniques and perioperative management, POD remains a formidable challenge, imposing a significant burden on patients, caregivers, and healthcare systems. METHODS This prospective observational study involved 307 patients who underwent cardiac surgery. Data on the occurrence of delirium, clinical parameters, and postoperative characteristics were collected. A multivariate analysis was performed to assess the relationship between POH and POD. RESULTS Sixty-one patients (21%) developed delirium, with an average onset of approximately 5 days postoperatively and a duration of approximately 6 days. On multivariate analysis, POH was significantly associated with POD, and the adjusted odds ratios indicated that patients with POH were more likely to develop delirium (OR, 5.61; p = 0.006). Advanced age (OR, 1.11; p = 0.002), emergency surgery (OR, 8.31; p = 0.001), and on-pump coronary artery bypass grafting were identified as risk factors of POD. Patients who developed delirium were typically older, more likely to be male, and had higher morbidity rates than those who did not. CONCLUSION POH is significantly associated with delirium in critically ill patients after cardiac surgery. Surgical complexity and advanced age contribute to the risk of developing POD and poor postoperative outcomes.
Collapse
Affiliation(s)
| | - Mohammed Ali Ali Aziz
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China
| | | | - Chanyanud Sriwayyapram
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China
| | - Tecleab Okubai
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China
| | - Gamil Al-Muwaffaq
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China
| | - Qin Xu
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China.
| | - Mohammed Alqudaimi
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China
| |
Collapse
|
4
|
Song LX, Qin Y, Yang L, Xing DB, Li Y, Lei FQ, Wang LH. Establishment and validation of the prediction model for postoperative delirium risk factors in older patients after total knee arthroplasty: A retrospective study. Medicine (Baltimore) 2024; 103:e38745. [PMID: 38941370 PMCID: PMC11466164 DOI: 10.1097/md.0000000000038745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/07/2024] [Indexed: 06/30/2024] Open
Abstract
This study aimed to establish an effective predictive model for postoperative delirium (POD) risk assessment after total knee arthroplasty (TKA) in older patients. The clinical data of 446 older patients undergoing TKA in the Orthopedics Department of our University from January to December 2022 were retrospectively analyzed, and the POD risk prediction model of older patients after TKA was established. Finally, 446 patients were included, which were divided into training group (n = 313) and verification group (n = 133). Logistic regression method was used to select meaningful predictors. The prediction model was constructed with nomographs, and the model was evaluated with correction curve and receiver operating characteristic curve. The logistic regression analysis showed that age, educational level, American Society of Anesthesiologists grade, accompaniment of chronic obstructive pulmonary disease, accompaniment of cerebral stroke, postoperative hypoxemia, long operation time, and postoperative pain were independent risk factors for POD after TKA (P < .05). The nomogram prediction model established. The area under receiver operating characteristic curve of the model group and the validation group were 0.954 and 0.931, respectively. The calibration curve of the prediction model has a high consistency between the 2 groups. The occurrence of POD was associated with age, educational level, American Society of Anesthesiologists grade, accompaniment of chronic obstructive pulmonary disease, accompaniment of cerebral stroke, postoperative hypoxemia, long operation time, and postoperative pain in TKA patients.
Collapse
Affiliation(s)
- Ling-Xia Song
- Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yi Qin
- Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Nursing, Zunyi Medical University, Zunyi, China
| | - Li Yang
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Ding-Bi Xing
- Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Nursing, Zunyi Medical University, Zunyi, China
| | - Ying Li
- Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Fu-Qi Lei
- Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Lian-Hong Wang
- Department of Nursing, Zunyi Medical University, Zunyi, China
| |
Collapse
|
5
|
Rehme-Röhrl J, Brand A, Dolt A, Grünewald D, Hoffmann R, Stuby F, Schweigkofler U, von Rüden C. Functional and Radiological Results Following Revision Blade Plating and Cephalomedullary Nailing in Aseptic Trochanteric and Subtrochanteric Nonunion. J Clin Med 2024; 13:3591. [PMID: 38930120 PMCID: PMC11205226 DOI: 10.3390/jcm13123591] [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: 04/13/2024] [Revised: 06/01/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Trochanteric and subtrochanteric fractures result in nonunion in more than 20% of cases. The aim of this study was to assess the functional and radiological results following revision cephalomedullary nailing and 95-degree angled blade plating in aseptic trochanteric and subtrochanteric nonunion. Methods: In a retrospective multi-center study between January 2010 and December 2020, a total of 68 consecutive patients (21 women and 47 men) from two European level I trauma centers with the diagnosis of aseptic nonunion were recruited. Follow-up assessment and the patients' convenience were assessed using the Harris Hip Score, Visual Analog Scale for pain at rest and on stress/exertion and Short Form-12. Results: The patients' mean age was 57 (range 26-85) years. After a follow-up period of 12 months, one case of persistent nonunion in the cephalomedullary nail group and 10 cases in the blade plate group were identified. The mean duration of surgery was 137 ± 47 min in the cephalomedullary nail group and 202 ± 59 min in the blade plate group (<0.0001). Short-term postoperative complications included wound dehiscence, bleeding, mismatched screw and hematoma. The mid-term results 12 months after surgical revision demonstrated significantly different osseous union rates (p = 0.018). The long-term functional outcome according to the Harris Hip Score 6 years (range 2-10) after revision surgery demonstrated 81 ± 21 points in the cephalomedullary nail group and 64 ± 23 points in the plate group (p = 0.026). Conclusions: This study demonstrated that the revision treatment of trochanteric and subtrochanteric nonunion using a 95-degree blade plate or cephalomedullary nail resulted in a high percentage of osseous union, with a low incidence of complications and good functional results for both methods.
Collapse
Affiliation(s)
- Julia Rehme-Röhrl
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Andreas Brand
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute for Biomechanics, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Annika Dolt
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, 60389 Frankfurt, Germany
| | - Dag Grünewald
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, 60389 Frankfurt, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, 60389 Frankfurt, Germany
| | - Fabian Stuby
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, 60389 Frankfurt, Germany
| | - Christian von Rüden
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Department of Trauma Surgery, Orthopaedics and Hand Surgery, Weiden Medical Center, 92637 Weiden, Germany
| |
Collapse
|
6
|
Sheehan KA, Shin S, Hall E, Mak DYF, Lapointe-Shaw L, Tang T, Marwaha S, Gandell D, Rawal S, Inouye S, Verma AA, Razak F. Characterizing medical patients with delirium: A cohort study comparing ICD-10 codes and a validated chart review method. PLoS One 2024; 19:e0302888. [PMID: 38739670 PMCID: PMC11090329 DOI: 10.1371/journal.pone.0302888] [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: 07/27/2023] [Accepted: 04/15/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Delirium is a major cause of preventable mortality and morbidity in hospitalized adults, but accurately determining rates of delirium remains a challenge. OBJECTIVE To characterize and compare medical inpatients identified as having delirium using two common methods, administrative data and retrospective chart review. METHODS We conducted a retrospective study of 3881 randomly selected internal medicine hospital admissions from six acute care hospitals in Toronto and Mississauga, Ontario, Canada. Delirium status was determined using ICD-10-CA codes from hospital administrative data and through a previously validated chart review method. Baseline sociodemographic and clinical characteristics, processes of care and outcomes were compared across those without delirium in hospital and those with delirium as determined by administrative data and chart review. RESULTS Delirium was identified in 6.3% of admissions by ICD-10-CA codes compared to 25.7% by chart review. Using chart review as the reference standard, ICD-10-CA codes for delirium had sensitivity 24.1% (95%CI: 21.5-26.8%), specificity 99.8% (95%CI: 99.5-99.9%), positive predictive value 97.6% (95%CI: 94.6-98.9%), and negative predictive value 79.2% (95%CI: 78.6-79.7%). Age over 80, male gender, and Charlson comorbidity index greater than 2 were associated with misclassification of delirium. Inpatient mortality and median costs of care were greater in patients determined to have delirium by ICD-10-CA codes (5.8% greater mortality, 95% CI: 2.0-9.5 and $6824 greater cost, 95%CI: 4713-9264) and by chart review (11.9% greater mortality, 95%CI: 9.5-14.2% and $4967 greater cost, 95%CI: 4415-5701), compared to patients without delirium. CONCLUSIONS Administrative data are specific but highly insensitive, missing most cases of delirium in hospital. Mortality and costs of care were greater for both the delirium cases that were detected and missed by administrative data. Better methods of routinely measuring delirium in hospital are needed.
Collapse
Affiliation(s)
- Kathleen A. Sheehan
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Centre for Mental Health, University Health Network, Toronto, ON, Canada
| | - Saeha Shin
- St. Michael’s Hospital, Unity Health Network, Toronto, ON, Canada
| | - Elise Hall
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, Unity Health Network, Toronto, ON, Canada
| | - Denise Y. F. Mak
- St. Michael’s Hospital, Unity Health Network, Toronto, ON, Canada
| | - Lauren Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Terence Tang
- Department of Medicine, University of Toronto, Toronto ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Seema Marwaha
- Department of Medicine, University of Toronto, Toronto ON, Canada
- Department of Medicine, Unity Health Network, Toronto, ON, Canada
| | - Dov Gandell
- Department of Medicine, University of Toronto, Toronto ON, Canada
- Department of Medicine, Sunnybrook Heatlh Sciences Centre, Toronto, ON, Canada
| | - Shail Rawal
- Department of Medicine, University of Toronto, Toronto ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Sharon Inouye
- Aging Brain Center, Hebrew Senior Life, Boston, MA, United States of America
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Amol A. Verma
- Department of Medicine, University of Toronto, Toronto ON, Canada
- Department of Medicine, Unity Health Network, Toronto, ON, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto ON, Canada
- Department of Medicine, Unity Health Network, Toronto, ON, Canada
| |
Collapse
|
7
|
Shang Z, Jiang Y, Fang P, Zhu W, Guo J, Li L, Liang Y, Zhang S, Ma S, Mei B, Fan Y, Xie Z, Shen Q, Liu X. The Association of Preoperative Diabetes With Postoperative Delirium in Older Patients Undergoing Major Orthopedic Surgery: A Prospective Matched Cohort Study. Anesth Analg 2024; 138:1031-1042. [PMID: 38335150 DOI: 10.1213/ane.0000000000006893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND Postoperative delirium (POD) is a common form of postoperative brain dysfunction, especially in the elderly. However, its risk factors remain largely to be determined. This study aimed to investigate whether (1) preoperative diabetes is associated with POD after elective orthopedic surgery and (2) intraoperative frontal alpha power is a mediator of the association between preoperative diabetes and POD. METHODS This was a prospective matched cohort study of patients aged 60 years or more, with a preoperative diabetes who underwent elective orthopedic surgery. Nondiabetic patients were matched 1:1 to diabetic patients in terms of age, sex, and type of surgery. Primary outcome was occurrence of POD, assessed using the 3-minute Diagnostic Confusion Assessment Method (3D-CAM) once daily from 6 pm to 8 pm during the postoperative days 1-7 or until discharge. Secondary outcome was the severity of POD which was assessed for all participants using the short form of the CAM-Severity. Frontal electroencephalogram (EEG) was recorded starting before induction of anesthesia and lasting until discharge from the operating room. Intraoperative alpha power was calculated using multitaper spectral analyses. Mediation analysis was used to estimate the proportion of the association between preoperative diabetes and POD that could be explained by intraoperative alpha power. RESULTS A total of 138 pairs of eligible patients successfully matched 1:1. After enrollment, 6 patients in the diabetes group and 4 patients in the nondiabetes group were excluded due to unavailability of raw EEG data. The final analysis included 132 participants with preoperative diabetes and 134 participants without preoperative diabetes, with a median age of 68 years and 72.6% of patients were female. The incidence of POD was 16.7% (22/132) in patients with preoperative diabetes vs 6.0% (8/134) in patients without preoperative diabetes. Preoperative diabetes was associated with increased odds of POD after adjustment of age, sex, body mass index, education level, hypertension, arrhythmia, coronary heart disease, and history of stroke (odds ratio, 3.2; 95% confidence interval [CI], 1.4-8.0; P = .009). The intraoperative alpha power accounted for an estimated 20% (95% CI, 2.6-60%; P = .021) of the association between diabetes and POD. CONCLUSIONS This study suggests that preoperative diabetes is associated with an increased risk of POD in older patients undergoing major orthopedic surgery, and that low intraoperative alpha power partially mediates such association.
Collapse
Affiliation(s)
- Zixiang Shang
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Yu Jiang
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Panpan Fang
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Wenjie Zhu
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Jiaxin Guo
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Lili Li
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Yongjie Liang
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Sichen Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, P.R. China
| | - Shenglan Ma
- Department of Psychiatry, Affiliated Psychological Hospital of Anhui Medical University, Hefei, P.R. China
| | - Bin Mei
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Yinguang Fan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, P.R. China
| | - Zhongcong Xie
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts
| | - Qiying Shen
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Xuesheng Liu
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| |
Collapse
|
8
|
Terré JA, Torrado J, George I, Harari R, Cox-Alomar PR, Villablanca PA, Faillace RT, Granada JF, Dangas G, Garcia MJ, Latib A, Wiley J. Aortic Stenosis Management in Patients With Acute Hip Fracture. JACC. ADVANCES 2024; 3:100912. [PMID: 38939644 PMCID: PMC11198465 DOI: 10.1016/j.jacadv.2024.100912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/04/2023] [Indexed: 06/29/2024]
Abstract
The treatment of severe aortic stenosis (SAS) has evolved rapidly with the advent of minimally invasive structural heart interventions. Transcatheter aortic valve replacement has allowed patients to undergo definitive SAS treatment achieving faster recovery rates compared to valve surgery. Not infrequently, patients are admitted/diagnosed with SAS after a fall associated with a hip fracture (HFx). While urgent orthopedic surgery is key to reduce disability and mortality, untreated SAS increases the perioperative risk and precludes physical recovery. There is no consensus on what the best strategy is either hip correction under hemodynamic monitoring followed by valve replacement or preoperative balloon aortic valvuloplasty to allow HFx surgery followed by valve replacement. However, preoperative minimalist transcatheter aortic valve replacement may represent an attractive strategy for selected patients. We provide a management pathway that emphasizes an early multidisciplinary approach to optimize time for hip surgery to improve orthopedic and cardiovascular outcomes in patients presenting with HFx-SAS.
Collapse
Affiliation(s)
- Juan A. Terré
- Section of Cardiology, Department of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Juan Torrado
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Isaac George
- Structural Heart and Valve Center, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York, USA
| | - Rafael Harari
- Department of Cardiology, Bellevue Hospital, New York, New York, USA
| | - Pedro R. Cox-Alomar
- Department of Cardiology, Louisiana State University, New Orleans, Louisiana, USA
| | | | - Robert T. Faillace
- Department of Medicine, Jacobi Medical Center/North Central Bronx Hospital, Bronx, New York, USA
| | | | - George Dangas
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mario J. Garcia
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - José Wiley
- Section of Cardiology, Department of Medicine, Tulane University, New Orleans, Louisiana, USA
| |
Collapse
|
9
|
Chen Y, Xu C, Mou Z, Hu Y, Yang C, Hu J, Chen X, Luo J, Zou L, Jiang H. Endoscopic Cryoablation Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma. Eur Urol Oncol 2024:S2588-9311(24)00104-4. [PMID: 38693018 DOI: 10.1016/j.euo.2024.04.012] [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: 01/21/2024] [Revised: 02/25/2024] [Accepted: 04/09/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND AND OBJECTIVE Cryoablation is a traditional antitumor therapy with good prospects for development. The efficacy of endoscopic management as a kidney-sparing surgery for high-risk upper tract urothelial carcinoma (UTUC) remains controversial. Our aim was to evaluate the impact of endoscopic cryoablation (ECA) versus radical nephroureterectomy (RNU) on survival outcomes, renal function, and complications. METHODS We retrospectively analyzed data for 116 patients with newly diagnosed high-risk UTUC who underwent either ECA (n = 13) or RNU (n = 103) from March 25, 2019 to December 8, 2021. Propensity score matching (1:4) using the nearest neighbor method was performed before analysis. The primary outcome was overall survival (OS). Secondary outcomes included progression-free survival (PFS), intravesical recurrence-free survival (RFS), the change in renal function, and treatment-emergent adverse events (TEAEs). KEY FINDINGS AND LIMITATIONS At median follow-up of 28.2 mo for the ECA group and 27.6 mo for the RNU group, 2-yr OS (82% vs 84%), PFS (73% vs 71%), and intravesical RFS (81% vs 83%) rates after matching did not significantly differ. A decline in renal function was observed after RNU, but not after ECA. Five (41.7%) patients in the ECA group reported six TEAEs, and 17 patients (35.4%) in the RNU group reported 20 TEAEs. CONCLUSIONS AND CLINICAL IMPLICATIONS In comparison to RNU, ECA for UTUC resulted in noninferior oncological outcomes and superior preservation of renal function. PATIENT SUMMARY Our study suggests that a treatment called endoscopic cryoablation for high-risk cancer in the upper urinary tract can help in preserving kidney function, with similar survival outcomes to those after more extensive surgery. This option can be considered for selected patients with a strong preference for kidney preservation.
Collapse
Affiliation(s)
- Yiling Chen
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Chenyang Xu
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Zezhong Mou
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Yun Hu
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Chen Yang
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Jinzhong Hu
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Xinan Chen
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Jianfeng Luo
- Department of Biostatistics and Social Medicine, School of Public Health, Fudan University, Shanghai, China.
| | - Lujia Zou
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China.
| | - Haowen Jiang
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China; National Clinical Research Center for Aging and Medicine, Fudan University, Shanghai, China.
| |
Collapse
|
10
|
Feng Y, Sun JF, Wei HC, Cao Y, Yao L, Du BX. Correlation Between Anesthesia Methods and Adverse Short-Term Postoperative Outcomes Depending on Frailty: A Prospective Cohort Study. Clin Interv Aging 2024; 19:613-626. [PMID: 38646591 PMCID: PMC11032161 DOI: 10.2147/cia.s448898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/28/2024] [Indexed: 04/23/2024] Open
Abstract
Purpose This study aims to investigate how the type of anesthesia used during major orthopedic surgery may impact adverse short-term postoperative outcomes depending on frailty. Methods To conduct this investigation, we recruited individuals aged 65 years and older who underwent major orthopedic surgery between March 2022 and April 2023 at a single institution. We utilized the FRAIL scale to evaluate frailty. The primary focus was on occurrences of death or the inability to walk 60 days after the surgery. Secondary measures included death within 60 days; inability to walk without human assistance at 60 days; death or the inability to walk without human assistance at 30 days after surgery, the first time out of bed after surgery, postoperative blood transfusion, length of hospital stay, hospital costs, and the occurrence of surgical complications such as dislocation, periprosthetic fracture, infection, reoperation, wound complications/hematoma. Results In a study of 387 old adult patients who had undergone major orthopedic surgery, 41.3% were found to be in a frail state. Among these patients, 262 had general anesthesia and 125 had neuraxial anesthesia. Multifactorial logistic regression analyses showed that anesthesia type was not linked to complications. Instead, frailty (OR 4.04, 95% CI 1.04 to 8.57, P< 0.001), age (OR 1.05, 95% CI 1.00-1.10, P= 0.017), and aCCI scores, age-adjusted Charlson Comorbidity Index, (OR 1.36, 95% CI 1.12 to 1.66, P= 0.002) were identified as independent risk factors for death or new walking disorders in these patients 60 days after surgery. After adjusting for frailty, anesthesia methods was not associated with the development of death or new walking disorders in these patients (P > 0.05). Conclusion In different frail populations, neuraxial anesthesia is likely to be comparable to general anesthesia in terms of the incidence of short-term postoperative adverse outcomes.
Collapse
Affiliation(s)
- Yan Feng
- The Affiliated Hospital 2 of Nantong University, Nantong City, Jiangsu Province, People’s Republic of China
| | - Jia-Feng Sun
- The Affiliated Hospital 2 of Nantong University, Nantong City, Jiangsu Province, People’s Republic of China
| | - Hai-Chao Wei
- The Affiliated Hospital 2 of Nantong University, Nantong City, Jiangsu Province, People’s Republic of China
| | - Ying Cao
- The Affiliated Hospital 2 of Nantong University, Nantong City, Jiangsu Province, People’s Republic of China
| | - Lei Yao
- The Affiliated Hospital 2 of Nantong University, Nantong City, Jiangsu Province, People’s Republic of China
| | - Bo-Xiang Du
- The Affiliated Hospital 2 of Nantong University, Nantong City, Jiangsu Province, People’s Republic of China
| |
Collapse
|
11
|
Guo H, Li LH, Lv XH, Su FZ, Chen J, Xiao F, Shi M, Xie YB. Association Between Preoperative Sleep Disturbance and Postoperative Delirium in Elderly: A Retrospective Cohort Study. Nat Sci Sleep 2024; 16:389-400. [PMID: 38646462 PMCID: PMC11032121 DOI: 10.2147/nss.s452517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/04/2024] [Indexed: 04/23/2024] Open
Abstract
Purpose Postoperative sleep disturbance, characterized by diminished postoperative sleep quality, is a risk factor for postoperative delirium (POD); however, the association between pre-existing sleep disturbance and POD remains unclear. This study aimed to evaluate the association between preoperative sleep disturbance and POD in elderly patients after non-cardiac surgery. Patients and methods This retrospective cohort study was conducted at a single center and enrolled 489 elderly patients who underwent surgery between May 1, 2020, and March 31, 2021. Patients were divided into the sleep disorder (SD) and non-sleep disorder (NSD) groups according to the occurrence of one or more symptoms of insomnia within one month or sleep- Numerical Rating Scale (NRS)≥6 before surgery. The primary outcome was the incidence of POD. Propensity score matching analysis was performed between the two groups. Multiple logistic regression analysis was performed to identify the risk factors for POD. Results In both the unmatched cohort (16.0% vs 6.7%, P=0.003) and the matched cohort (17.0% vs 6.2%, P=0.023), the incidence of POD was higher in the SD group than in the NSD group. In addition, the postoperative sleep quality and the VAS score at postoperative 24 h were significantly lower in the SD group than in the NSD group. Multivariate logistic regression analysis indicated that age (Odds Ratio, 1.13 [95% CI: 1.04-1.23], P=0.003) and preoperative sleep disturbance (Odds Ratio, 3.03 [95% CI: 1.09-9.52], P=0.034) were independent risk factors for the development of POD. Conclusion The incidence of POD was higher in patients with pre-existing sleep disturbance than those without it. Whether improving sleep quality for preoperative sleep disturbance may help prevent POD remains to be determined.
Collapse
Affiliation(s)
- Hao Guo
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Li-Heng Li
- Department of Anesthesiology, The Guilin Municipal Hospital of Traditional Chinese Medicine, Guangxi, People’s Republic of China
| | - Xiao-Hong Lv
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Feng-Zhi Su
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Jie Chen
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Fei Xiao
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Min Shi
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yu-Bo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| |
Collapse
|
12
|
Haruwaka K, Ying Y, Liang Y, Umpierre AD, Yi MH, Kremen V, Chen T, Xie T, Qi F, Zhao S, Zheng J, Liu YU, Dong H, Worrell GA, Wu LJ. Microglia enhance post-anesthesia neuronal activity by shielding inhibitory synapses. Nat Neurosci 2024; 27:449-461. [PMID: 38177340 PMCID: PMC10960525 DOI: 10.1038/s41593-023-01537-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 11/29/2023] [Indexed: 01/06/2024]
Abstract
Microglia are resident immune cells of the central nervous system and play key roles in brain homeostasis. During anesthesia, microglia increase their dynamic process surveillance and interact more closely with neurons. However, the functional significance of microglial process dynamics and neuronal interaction under anesthesia is largely unknown. Using in vivo two-photon imaging in mice, we show that microglia enhance neuronal activity after the cessation of isoflurane anesthesia. Hyperactive neuron somata are contacted directly by microglial processes, which specifically colocalize with GABAergic boutons. Electron-microscopy-based synaptic reconstruction after two-photon imaging reveals that, during anesthesia, microglial processes enter into the synaptic cleft to shield GABAergic inputs. Microglial ablation or loss of microglial β2-adrenergic receptors prevents post-anesthesia neuronal hyperactivity. Our study demonstrates a previously unappreciated function of microglial process dynamics, which enable microglia to transiently boost post-anesthesia neuronal activity by physically shielding inhibitory inputs.
Collapse
Affiliation(s)
| | - Yanlu Ying
- Department of Anesthesiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China.
| | - Yue Liang
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Min-Hee Yi
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Vaclav Kremen
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Tingjun Chen
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Tao Xie
- Translational Oncology Group, Faculty of Science, School of Life Sciences, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Fangfang Qi
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Shunyi Zhao
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Jiaying Zheng
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Yong U Liu
- Department of Anesthesiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | | | - Long-Jun Wu
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA.
- Department of Immunology, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
13
|
Gruendel MS, Brenneisen W, Wollborn J, Haaker G, Meersch M, Gurlit S, Goebel U. Perioperative point-of-care-testing of plasmacholinesterases identifies older patients at risk for postoperative delirium: an observational prospective cohort study. BMC Geriatr 2024; 24:136. [PMID: 38321383 PMCID: PMC10848373 DOI: 10.1186/s12877-023-04627-1] [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: 09/30/2023] [Accepted: 12/20/2023] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a severe perioperative complication that may increase mortality and length-of-stay in older patients. Moreover, POD is a major economic burden to any healthcare system. An altered expression of Acetylcholine- and Butyrylcholinesterases (AChE, BuChE) due to an unbalanced neuroinflammatory response to trauma or an operative stimulus has been reported to play an essential role in the development of POD. We investigated if perioperative measurement of cholinesterases (ChEs) can help identifying patients at risk for the occurrence of POD in both, scheduled and emergency surgery patients. METHODS This monocentric prospective observational cohort study was performed in a tertiary hospital (departments of orthopaedic surgery and traumatology). One hundred and fifty-one patients aged above 75 years were enrolled for scheduled (n = 76) or trauma-related surgery (n = 75). Exclusion criteria were diagnosed dementia and anticholinergic medication. Plasma samples taken pre- and postoperatively were analysed regarding AChE and BuChE activity. Furthermore, perioperative assessment using different cognitive tests was performed. The type of anaesthesia (general vs. spinal anaesthesia) was analysed. Primary outcome was the incidence of POD assessed by the approved Confusion Assessment Method (CAM) in combination with the expression of AChE and BuChE. RESULTS Of 151 patients included, 38 (25.2%) suffered from POD; 11 (14%) in scheduled and 27 (36%) in emergency patients. AChE levels showed no difference throughout groups or time course. Trauma patients had lower BuChE levels prior to surgery than scheduled patients (p < 0.001). Decline in BuChE levels correlated positively with the incidence of POD (1669 vs. 1175 U/l; p < 0.001). Emergency patients with BuChE levels below 1556 U/L were at highest risk for POD. There were no differences regarding length of stay between groups or incidence of POD. The type of anaesthesia had no influence regarding the incidence of POD. Only Charlson Comorbidity Index and Mini Nutrition Assessment demonstrated reliable strength in respect of POD. CONCLUSIONS Perioperative measurement of BuChE activity can be used as a tool to identify patients at risk of POD. As a point-of-care test, quick results may alter the patients' course prior to the development of POD. TRIAL REGISTRATION https://drks.de/search/de/trial/DRKS00017178 .
Collapse
Affiliation(s)
- Matthias S Gruendel
- Department of Anaesthesiology and Critical Care, St. Franziskus-Hospital GmbH, Hohenzollernring 70, Muenster, 48145, Germany
| | - Wibke Brenneisen
- Department of Anaesthesiology and Critical Care, St. Franziskus-Hospital GmbH, Hohenzollernring 70, Muenster, 48145, Germany
| | - Jakob Wollborn
- Department of Anaesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, USA
| | - Gerrit Haaker
- Department of Anaesthesiology and Critical Care, St. Franziskus-Hospital GmbH, Hohenzollernring 70, Muenster, 48145, Germany
| | - Melanie Meersch
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Simone Gurlit
- Department of Anaesthesiology and Critical Care, St. Franziskus-Hospital GmbH, Hohenzollernring 70, Muenster, 48145, Germany
- Department of Public Health, District Council, Muenster, Germany
| | - Ulrich Goebel
- Department of Anaesthesiology and Critical Care, St. Franziskus-Hospital GmbH, Hohenzollernring 70, Muenster, 48145, Germany.
| |
Collapse
|
14
|
Reider L, Furgiuele D, Wan P, Schaffler B, Konda S. Anesthetic Methods for Hip Fracture. Curr Osteoporos Rep 2024; 22:96-104. [PMID: 38129371 DOI: 10.1007/s11914-023-00835-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW To review the benefits, risks, and contraindications of traditional and new anesthesia approaches for hip fracture surgery and describe what is known about the impact of these approaches on postoperative outcomes. RECENT FINDINGS This review describes general and spinal anesthesia, peripheral nerve block techniques used for pain management, and novel, local anesthesia approaches which may provide significant benefit compared with traditional approaches by minimizing high-risk induction time and decreasing respiratory suppression and short- and long-term cognitive effects. Hip fracture surgery places a large physiologic stress on an already frail patient, and anesthesia choice plays an important role in managing risk of perioperative morbidity. New local anesthesia techniques may decrease morbidity and mortality, particularly in higher-risk patients.
Collapse
Affiliation(s)
- Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Furgiuele
- Department of Anesthesiology, New York University Langone Medical Center, New York, NY, USA
| | - Philip Wan
- Department of Anesthesiology, New York University Langone Medical Center, New York, NY, USA
| | - Benjamin Schaffler
- Department of Orthopaedic Surgery, NYU Langone Health, New York University Langone Orthopaedic Hospital, 310 East 17Th Street, Suite 1402, New York, NY, 10003, USA
| | - Sanjit Konda
- Department of Orthopaedic Surgery, NYU Langone Health, New York University Langone Orthopaedic Hospital, 310 East 17Th Street, Suite 1402, New York, NY, 10003, USA.
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA.
| |
Collapse
|
15
|
Han J, Ryu JH, Jeon YT, Koo CH. Comparison of Volatile Anesthetics Versus Propofol on Postoperative Cognitive Function After Cardiac Surgery: A Systematic Review and Meta-analysis. J Cardiothorac Vasc Anesth 2024; 38:141-147. [PMID: 37919165 DOI: 10.1053/j.jvca.2023.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/17/2023] [Accepted: 09/26/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To compare the effects of volatile anesthetics and propofol on neurocognitive function after cardiac surgery. DESIGN A systematic review and meta-analysis of randomized controlled trials. SETTING A literature search of PubMed, EMBASE, CENTRAL, CINAHL, Scopus, and Web of Science databases was conducted. PARTICIPANTS A total of 10 randomized controlled trials comparing volatile anesthetics and propofol in cardiac surgery were included in the study. INTERVENTIONS The standardized mean difference and risk ratio were calculated to estimate pooled effect sizes. MEASUREMENTS AND MAIN RESULTS The primary outcome was the postoperative neurocognitive function score, and the secondary outcome was the incidence of delirium after cardiac surgery. The analysis did not show significant differences in postoperative neurocognitive function scores (standardized mean difference -0.06, 95% CI -0.81-0.69; p = 0.879). The incidences of delirium (risk ratio 1.10, 95% CI 0.81-1.50) between the volatile anesthetics and propofol groups were not significant (p = 0.533). CONCLUSIONS Unlike noncardiac surgery, there are no differences between volatile anesthetics and propofol regarding postoperative neurocognitive dysfunction after cardiac surgery.
Collapse
Affiliation(s)
- Jiwon Han
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chang-Hoon Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
16
|
Zhao Y, Quon A, Luke K, Tivis LJ. Impact of nursing interventions on discharge disposition in patients with postoperative delirium. Nursing 2023; 53:51-57. [PMID: 37856302 DOI: 10.1097/01.nurse.0000978892.66327.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE To identify patient characteristics and perioperative factors associated with non-home patient discharges and the impact of current delirium nursing interventions on discharge disposition, especially non-home dispositions. METHODS A retrospective pilot chart review was conducted using electronic health records from five networked hospitals in the Mountain West region of the US. The sample comprised 75 randomly selected patients aged 65 or older who screened positive for delirium during hospitalization. Relationships between patient characteristics, nursing interventions, and discharge dispositions were analyzed using chi-square tests and logistic regression. RESULTS Most participants (69.3%) were discharged to non-home facilities. Delayed urinary catheter removal was a significant nursing intervention factor. Patients with delayed urinary catheter removal were at increased risk of being discharged to a non-home setting compared with those with early urinary catheter removal (aOR: 14.11, P = .010). Preoperative hypoalbuminemia and surgery durations exceeding 60 minutes were associated with non-home dispositions. CONCLUSION Delayed urinary catheter removal, surgery duration greater than 1 hour, and preoperative hypoalbuminemia increased the likelihood of non-home discharge placement for older adults who experience postoperative delirium.
Collapse
Affiliation(s)
- Yunchuan Zhao
- Yunchuan Zhao is an associate professor at Boise State University in Boise, Idaho and a nurse at St. Luke's Health System, where Anna Quon is a manager of nursing research, Kayla Luke is an ICU RN, and Laura Tivis is the director of nursing research
| | | | | | | |
Collapse
|
17
|
Reinhard J, Schindler M, Leiss F, Greimel F, Grifka J, Benditz A. No clinically significant difference in postoperative pain and side effects comparing conventional and enhanced recovery total hip arthroplasty with early mobilization. Arch Orthop Trauma Surg 2023; 143:6069-6076. [PMID: 37119325 PMCID: PMC10491546 DOI: 10.1007/s00402-023-04858-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/25/2023] [Indexed: 05/01/2023]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) leads to less morbidity, faster recovery, and, therefore, shorter hospital stays. The expected increment of primary total hip arthroplasty (THA) in the U.S. highlights the need for sufficient pain management. The favorable use of short-lasting spinal anesthesia enables early mobilization but may lead to increased opioid consumption the first 24 h (h) postoperatively. METHODS In a retrospective study design, we compared conventional THA with postoperative immobilization for two days (non-ERAS) and enhanced recovery THA with early mobilization (ERAS group). Data assessment took place as part of the "Quality Improvement in Postoperative Pain Treatment project" (QUIPS). Initially, 2161 patients were enrolled, resulting in 630 after performing a matched pair analysis for sex, age, ASA score (American-Society-of-Anesthesiology) and preoperative pain score. Patient-reported pain scores, objectified by a numerical rating scale (NRS), opioid consumption and side effects were evaluated 24 h postoperatively. RESULTS The ERAS group revealed higher activity-related pain (p = 0.002), accompanied by significantly higher opioid consumption (p < 0.001). Maximum and minimum pain as well as side effects did not show significant differences (p > 0.05). CONCLUSION This study is the first to analyze pain scores, opioid consumption, and side effects in a matched pair analyses at this early stage and supports the implementation of an ERAS concept for THA. Taking into consideration the early postoperative mobilization, we were not able to detect a difference regarding postoperative pain. Although opioid consumption appeared to be higher in ERAS group, occurrence of side effects ranged among comparable percentages.
Collapse
Affiliation(s)
- Jan Reinhard
- Department of Orthopedic Surgery, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Melanie Schindler
- Department of Orthopedic Surgery, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Franziska Leiss
- Department of Orthopedic Surgery, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Felix Greimel
- Department of Orthopedic Surgery, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Joachim Grifka
- Department of Orthopedic Surgery, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Achim Benditz
- Department of Orthopedic Surgery, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| |
Collapse
|
18
|
Ackermann LL, Schwenk ES, Li CJ, Vaile JR, Weitz H. The effects of a multidisciplinary pathway for perioperative management of patients with hip fracture. Hosp Pract (1995) 2023; 51:233-239. [PMID: 37927222 DOI: 10.1080/21548331.2023.2274307] [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: 03/15/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES To determine if a multidisciplinary pathway focused on non-opioid pain management, delirium assessment, and resource utilization improved outcomes in geriatric hip fracture patients. The goal was to reduce opioid usage, consultation not congruent with guidelines, and increase use of regional anesthesia to reduce delirium and improve outcomes. METHODS An observational study was performed on hip fracture patients before and after the intervention. Hospitalists were educated on indications for preoperative cardiac consultation and specialized preoperative cardiac testing according to evidence-based guidelines with the inpatient cardiology service. Additional education on multimodal analgesia, limiting opioids, and peripheral nerve blocks was provided by the acute pain service. Pre-intervention outcomes from 1 July 20171 July 2017 to 31 May 201831 May 2018 (N = 92) were compared to post-intervention outcomes from 1 July 20181 July 2018 to 31 May 201931 May 2019 (N = 98) and included delirium, length of stay, 30-day readmission rate, time from arrival to procedure start time, time to first physical therapy session, and completion of cardiology consult time. We examined adherence, use of nerve blocks, and pre- and post-operative pain scores and opioid use. RESULTS Delirium was reduced from 50.0% (N = 46/92) to 28.6% (N = 28/98); p = 0.002. Postoperative opioid use (IV morphine milligram equivalents) decreased from an average of 57.2 mg (±67.7) to 42.6 mg (±58.2),P < .0001. There was a significant decrease in mean pre-operative (5.4 ± 4.14 to 5.05 ± 2.8, P < .0001) and post-operative pain scores (4.3 ± 5.2 to 3.2 ± 2.2, P < .0001). There was a significant reduction in time to cardiology consultation from 18 h] to 12 h ; p < .001). CONCLUSIONS A multidisciplinary collaboration between hospitalists, anesthesiologists, and cardiologists for hip fracture patients was associated with a reduction in pain and delirium and time to cardiologist evaluation. Prospective studies focusing on additional patient-centered outcomes are warranted.
Collapse
Affiliation(s)
- Lily L Ackermann
- Department of Medicine, Division of Hospital Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric S Schwenk
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Chris J Li
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - John R Vaile
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Howard Weitz
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
19
|
Shaath MK, Yawman J, Anderson T, Avilucea FR, Langford JR, Munro MW, Haidukewych GJ. Fellowship-Trained Orthopaedic Trauma Surgeons Achieve Better Postoperative Radiographic Parameters After Intramedullary Nailing of Intertrochanteric Femur Fractures when Compared With Non-trauma-Trained Surgeons. J Am Acad Orthop Surg 2023; 31:995-1000. [PMID: 37279170 DOI: 10.5435/jaaos-d-22-00877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 05/07/2023] [Indexed: 06/08/2023] Open
Abstract
INTRODUCTION Intertrochanteric femoral fractures are common orthopaedic injuries accounting for nearly 30% of all fracture-related hospitalizations. Because many factors predictive of failure are related to technical aspects of the surgery, the purpose of this study was to compare radiographic parameters after fixation, comparing fellowship-trained orthopaedic trauma surgeons with surgeons who did not complete an orthopaedic trauma fellowship. METHODS We initiated a search for CPT code 27245 across our hospital network to identify 100 consecutive patients treated by five fellowship-trained orthopaedic traumatologists and 100 consecutive patients treated by community surgeons. Patients were then stratified based on their surgeon's subspecialty training (trauma vs community). Primary outcome variables were neck-shaft angle (NSA), a comparison of the repaired NSA with the uninjured side, tip-apex distance, and reduction quality. RESULTS One hundred patients were included in each group. The mean age in the community group was 77 years compared with 79 years in the trauma group. The mean tip-apex distance for the trauma group was 10 mm compared with 21 mm for the community group ( P < 0.001). The mean postoperative NSA for the trauma group was 133° compared with 127° for the community group ( P < 0.001). The mean difference of the NSA of the repaired side compared with the uninjured side was 2.5° of valgus in the trauma group compared with 5° of varus for the community group ( P < 0.001). There were 93 good reductions in the trauma group compared with 19 in the community group ( P < 0.001). There were 0 poor reductions in the trauma group and 49 in the community group ( P < 0.001). DISCUSSION Overall, we have shown that fellowship-trained orthopaedic trauma surgeons achieve better reductions when treating intertrochanteric femur fractures with intramedullary nails. Orthopaedic residency training should emphasize teaching proper techniques and acceptable parameters for reduction and implant placement when treating geriatric intertrochanteric femur fractures.
Collapse
Affiliation(s)
- M Kareem Shaath
- From the Orlando Health Orthopedic Institute, Florida State College of Medicine, University of Central Florida College of Medicine, Orlando, FL (Shaath, Avilucea, Langford, Munro, and Haidukewych), and the Orlando Health Jewett Orthopedic Institute (Yawman and Anderson)
| | | | | | | | | | | | | |
Collapse
|
20
|
McCullagh IJ, Salas B, Teodorczuk A, Callaghan M. Modifiable risk factors for post-operative delirium in older adults undergoing major non-cardiac elective surgery: a multi-centre, trainee delivered observational cohort feasibility study and trainee survey. BMC Geriatr 2023; 23:436. [PMID: 37454100 PMCID: PMC10349417 DOI: 10.1186/s12877-023-04122-7] [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: 12/09/2022] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Post-operative delirium (POD) is an acute brain failure which may occur following major surgery, with serious implications for participants and caregivers. Evidence regarding optimal anaesthetic management for older participants at higher risk of POD is conflicting. We conducted a feasibility study of our protocol in 5 centres to guide sample size estimation and inform future recruitment strategies for a larger cohort study. METHODS Participants aged over 65 and scheduled for major surgery were recruited. They were assessed pre-operatively for delirium, cognitive impairment, depression, comorbidity, activity levels and alcohol use. Details of management during surgery, all medications and complications were recorded by a trainee-led research team. Participants were assessed for delirium in the immediate recovery period and then on post-operative days 1-4 using the 4 question attention test (4AT) with complications assessed at day 4 using the post-operative morbidity survey (POMS). Primary outcomes were the incident rates of POD. Secondary outcomes were number of eligible patients, recruitment rates and retention rates throughout the study, time required for data collection, preoperative risk factors assessment and daily postoperative delirium assessments. Also to assess the added value of employing the regional trainee research network (INCARNNET) to deliver the study. Specifically, what proportion of patient consent, data collection and post-operative testing is performed by anaesthesia trainees from this group, especially the success of weekend delirium assessment by trainees? A survey was completed at the end of the study by the trainees involved regarding their involvement in the study. RESULTS Ninety-five participants were recruited, of whom 93 completed the study. Overall, POD occurred in 9 patients. Of these, three were detected in recovery and six on post-op days 1-4. Median length of stay was 6 days. Recruitment rates were high in all but one site. 59 (62%) participants were consented by trainees and 189 (63%) of post op delirium assessments were performed by trainees. A total of six patients declined the study (in a follow up survey of trainees). Pre-existing cognitive impairment, depression and problem drinking were detected in 4(4.3%), 3(3.2%) and 5(5.37%) participants, respectively. Co-morbidity was common with 55(59%) in class three or four of the geriatric index of morbidity. Overall, from a total of 641 data points, levels of missing data were as follows, site A = 9.3%, B = 13.5%, C = 15.4%, D = 10.9%, E = 11.1% (data could not be completed retrospectively). CONCLUSIONS A multi-centre observational cohort study of delirium carried out by UK trainee anaesthetists is feasible. Patients are content to undergo day of surgery consent and multiple short questionnaires pre-operatively. Proposed data, especially pharmacological, should be carefully considered for their relevance to modifiable mechanisms that can lead to POD. Future research to enable prognostic modelling of POD should involve large scale cohort studies of enriched populations to capture a higher POD incidence. POD remains a common complication in older persons undergoing major surgery in the UK and studies of interventions are urgently needed. TRIAL REGISTRATION All methods were carried out in accordance with relevant guidelines and regulations. The study was retrospectively registered with ISRCTN94663125 on 07/02/2018.
Collapse
Affiliation(s)
- Iain J McCullagh
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
- Newcastle University, Newcastle upon Tyne, UK.
| | - Barbara Salas
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Teodorczuk
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Metro North Mental Health, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Medicine and Dentistry, University of Queensland, Brisbane, Australia
| | - Mark Callaghan
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| |
Collapse
|
21
|
Zhou SL, Zhang SY, Si HB, Shen B. Regional versus general anesthesia in older patients for hip fracture surgery: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res 2023; 18:428. [PMID: 37312156 PMCID: PMC10262548 DOI: 10.1186/s13018-023-03903-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/02/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND The optimal anesthesia technique for older patients undergoing hip fracture surgery remains controversial. We performed a systematic review and meta-analysis of updated randomized controlled trials (RCTs) to assess whether regional anesthesia was superior to general anesthesia in hip fracture surgery. METHODS We searched PubMed, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials from January 2000 until April 2022. RCTs directly comparing regional and general anesthesia in hip fracture surgery were included in the analysis. The incidence of delirium and mortality were the primary outcomes and other perioperative outcomes including complications were secondary outcomes. RESULTS Thirteen studies involving 3736 patients were included in this study. There was no significant difference in the incidence of delirium (odds ratio [OR] 1.09; 95% confidence interval [CI] 0.86, 1.37) and mortality (OR 1.08; 95% CI 0.71, 1.64) between the two groups. Patients receiving regional anesthesia in hip fracture surgery were associated with a reduction in operative time (weighted mean difference [WMD]: - 4.74; 95% CI - 8.85, - 0.63), intraoperative blood loss (WMD: - 0.25; 95% CI - 0.37, - 0.12), postoperative pain score (WMD: - 1.77; 95% CI - 2.79, - 0.74), length of stay (WMD: - 0.10; 95% CI - 0.18, - 0.02), and risk of acute kidney injury (AKI) (OR 0.56; 95% CI 0.36, 0.87). No significant difference was observed in the other perioperative outcomes. CONCLUSIONS For older patients undergoing hip fracture surgery, RA did not significantly reduce the incidence of postoperative delirium and mortality compared to GA. Due to the limitations of this study, the evidence on delirium and mortality was still inconclusive and further high-quality studies are needed.
Collapse
Affiliation(s)
- Sheng-Liang Zhou
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Sichuan Province, 610041, Chengdu, People's Republic of China
| | - Shao-Yun Zhang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Sichuan Province, 610041, Chengdu, People's Republic of China
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, People's Republic of China
| | - Hai-Bo Si
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Sichuan Province, 610041, Chengdu, People's Republic of China
| | - Bin Shen
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Sichuan Province, 610041, Chengdu, People's Republic of China.
| |
Collapse
|
22
|
Niu JY, Yang N, Tao QY, He Y, Hou YB, Ning RD, Yu JM. Effect of Different Administration Routes of Dexmedetomidine on Postoperative Delirium in Elderly Patients Undergoing Elective Spinal Surgery: A Prospective Randomized Double-Blinded Controlled Trial. Anesth Analg 2023; 136:1075-1083. [PMID: 37058430 DOI: 10.1213/ane.0000000000006464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
BACKGROUND Intravenous dexmedetomidine has been reported to decrease the occurrence of postoperative delirium (POD) in elderly patients. Nevertheless, some previous studies have indicated that intratracheal dexmedetomidine and intranasal dexmedetomidine are also effective and convenient. The current study aimed to compare the effect of different administration routes of dexmedetomidine on POD in elderly patients. METHODS We randomly allocated 150 patients (aged 60 years or more) scheduled for spinal surgery to receive intravenous dexmedetomidine (0.6 μg/kg), intranasal dexmedetomidine (1 μg/kg) before anesthesia induction, or intratracheal dexmedetomidine (0.6 µg/kg) after anesthesia induction. The primary outcome was the frequency of delirium during the first 3 postoperative days. The secondary outcomes were the incidence of postoperative sore throat (POST) and sleep quality. Adverse events were recorded, and routine treatment was performed. RESULTS Compared with the intranasal group, the intravenous group had a significantly lower occurrence of POD within 3 days (3 of 49 [6.1%] vs 14 of 50 [28.0%]; odds ratio [OR], 0.17; 95% confidence intervals [CIs], 0.05-0.63; P < .017). Meanwhile, patients in the intratracheal group had a lower incidence of POD than those in the intranasal group (5 of 49 [10.2%] vs 14 of 50 [28.0%]; OR, 0.29; 95% CI, 0.10-0.89; P < .017). Whereas, there was no difference between the intratracheal and intravenous groups (5 of 49 [10.2%] vs 3 of 49 [6.1%]; OR, 1.74; 95% CI, 0.40-7.73; P > .017). The rate of POST was lower in the intratracheal group than that in the other 2 groups at 2 hours after surgery (7 of 49 [14.3%] vs 12 of 49 [24.5%] vs 18 of 50 [36.0%], P < .017, respectively). Intravenous dexmedetomidine had the lowest Pittsburgh Sleep Quality Index score on the second morning after surgery (median [interquartile range {IQR}]: 4 [3-5] vs 6 [4-7] vs 6 [4-7], P < .017, respectively). Compared with the intranasal group, the intravenous group had a higher rate of bradycardia and a lower incidence of postoperative nausea and vomiting ( P < .017). The intranasal group was associated with the highest incidence of hypertension ( P < .017). CONCLUSIONS For patients aged ≥60 years undergoing spinal surgery, compared with the intranasal route of dexmedetomidine, intravenous and intratracheal dexmedetomidine reduced the incidence of early POD. Meanwhile, intravenous dexmedetomidine was associated with better sleep quality after surgery, and intratracheal dexmedetomidine resulted in a lower incidence of POST. Adverse events were mild in all 3 administration routes of dexmedetomidine.
Collapse
Affiliation(s)
- Jing-Yi Niu
- From the Department of Anesthesiology, The Third Affiliated Hospital of Anhui Medical University (The First People's Hospital of Hefei), Hefei, Anhui, China
| | - Na Yang
- From the Department of Anesthesiology, The Third Affiliated Hospital of Anhui Medical University (The First People's Hospital of Hefei), Hefei, Anhui, China
| | - Qing-Yu Tao
- From the Department of Anesthesiology, The Third Affiliated Hospital of Anhui Medical University (The First People's Hospital of Hefei), Hefei, Anhui, China
| | - Yan He
- Department of Anesthesiology, Wannan Medical College, Wuhu, Anhui, China
| | - Yong-Bo Hou
- Department of Anesthesiology, Wannan Medical College, Wuhu, Anhui, China
| | - Ren-De Ning
- Department of Orthopedics, The Third Affiliated Hospital of Anhui Medical University (The First People's Hospital of Hefei), Hefei, Anhui, China
| | - Jun-Ma Yu
- From the Department of Anesthesiology, The Third Affiliated Hospital of Anhui Medical University (The First People's Hospital of Hefei), Hefei, Anhui, China
| |
Collapse
|
23
|
Pass B, Knauf T, Knobe M, Rascher K, Bliemel C, Maslaris A, Aigner R, Dirkmann D, Lendemans S, Schoeneberg C. Spinal anesthesia with better outcome in geriatric hip fracture surgery - An analysis of the Registry for Geriatric Trauma (ATR-DGU). Injury 2023:S0020-1383(23)00298-X. [PMID: 37032184 DOI: 10.1016/j.injury.2023.04.001] [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: 02/13/2023] [Accepted: 04/03/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Literature shows conflicting results regarding spinal (SA) or general anesthesia (GA) and their influence on the outcome of elderly patients with hip fractures. We, therefore, conducted an analysis from the Registry for Geriatric Trauma (ATR-DGU). METHODS A retrospective, multicenter registry study including patients aged 70 years or above with hip fractures requiring surgery from 131 Centers for Geriatric Trauma (AltersTraumaZentrum DGU®) from 2016 to 2021. Patients with SA or GA were compared using matched-pair analysis and linear and logistic regression models. RESULTS A total of 43,714 patients were included, of whom 3,242 received SA. The median age was 85 (SA) and 84 years (GA). Adjustments for the American Society of Anesthesiologists (ASA) grade, sex, age, additional injuries, and anticoagulation resulted in a higher in-hospital (odds ratio (OR) 1.31; 95% confidence interval [CI], 1.07 - 1.61, p = 0.009) and 120 days mortality (OR 1.47; 95% CI, 1.1 - 1.95, p = 0.009) in the GA group. GA had a significant negative influence on walking ability seven days after surgery and on the quality of life (QoL). The length of hospital stay (LoS) was significantly shorter in the SA group. CONCLUSIONS SA is associated with a higher survival rate, a better walking ability seven days after surgery, a higher QoL, and a shorter LoS.
Collapse
Affiliation(s)
- Bastian Pass
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany.
| | - Tom Knauf
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany.
| | - Matthias Knobe
- Medical Faculty, University of Zurich, Zurich, Switzerland; Medical Faculty, RWTH Aachen University Hospital, Aachen, Germany.
| | | | - Christopher Bliemel
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany.
| | - Alexander Maslaris
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany.
| | - Rene Aigner
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany.
| | - Daniel Dirkmann
- Department of Anesthesiology, Intensive Care and Pain Medicine, Alfried Krupp Hospital Essen, Germany.
| | - Sven Lendemans
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany.
| | - Carsten Schoeneberg
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany.
| |
Collapse
|
24
|
Lee DH, Chang CH, Chang CW, Chen YC, Tai TW. Postoperative Delirium in Patients Receiving Hip Bipolar Hemiarthroplasty for Displaced Femoral Neck Fractures: The Risk Factors and Further Clinical Outcomes. J Arthroplasty 2023; 38:737-742. [PMID: 36273712 DOI: 10.1016/j.arth.2022.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Postoperative delirium in patients who have hip fractures may lead to poor outcomes. This study aimed to determine perioperative risk factors and clinical outcomes of postoperative delirium in patients undergoing hip bipolar hemiarthroplasty for displaced femoral neck fractures. METHODS Among 1,353 patients who underwent hemiarthroplasty at our institution during 2013-2021, we identified 78 patients with postoperative delirium diagnosed with the confusion assessment method. The mean delirium duration was 28 hours (range: 15-520). We also included 1:2 sex- and age-matched patients who did not have postoperative delirium after the same surgery as a matching cohort for comparison. Patient comorbidities, perioperative data, delirium occurrence, and outcomes were collected for analyses. RESULTS A Charlson Comorbidity Index (CCI) score ≥6 (odds ratio (OR): 2.08, P = .017), nighttime surgery (OR: 3.47, p =<.001), surgical delays (OR: 1.01, P = .012), preoperative anemia (OR: 2.1, P = .012), and blood transfusions (OR: 2.47, P = .01) may increase the risk of postoperative delirium. The presentation of delirium was associated with sepsis (OR: 3.77, P = .04), longer hospital stays (P < .001), higher 1-year mortality (OR: 3.97, P = .002), and overall mortality (OR: 2.1, P = .02). CONCLUSION Postoperative delirium predicted poor outcomes. Our results emphasized the importance of early identification of patients at risk and optimization of the medical conditions before and after surgery.
Collapse
Affiliation(s)
- Deng Horng Lee
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Hsun Chang
- Departments of Orthopedics, National Cheng Kung University Hospital Dou-Liou Branch, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Wei Chang
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Chen Chen
- Departments of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ta-Wei Tai
- Departments of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|
25
|
Hawley S, Inman D, Gregson CL, Whitehouse M, Johansen A, Judge A. Risk Factors and 120-day Functional Outcomes of Delirium After Hip Fracture Surgery: A Prospective Cohort Study Using the UK National Hip Fracture Database (NHFD). J Am Med Dir Assoc 2023; 24:694-701.e7. [PMID: 36933569 DOI: 10.1016/j.jamda.2023.02.008] [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: 12/01/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVES To identify risk factors of postoperative delirium among patients with hip fracture with normal preoperative cognition, and examine associations with returning home or recovery of mobility. DESIGN Prospective cohort study. SETTING AND PARTICIPANTS We used the National Hip Fracture Database (NHFD) to identify patients presenting with hip fracture in England (2018-2019), but excluded those with abnormal cognition (abbreviated mental test score [AMTS] < 8) on presentation. METHODS We examined the results of routine delirium screening performed using the 4 A's Test (4AT), to assess alertness, attention, acute change, and orientation in a 4-item mental test. Associations between 4AT score and return home or to outdoor mobility at 120 days were estimated, and risk factors identified for abnormal 4AT scores: (1) 4AT ≥4 suggesting delirium and (2) 4AT = 1-3 being an intermediate score not excluding delirium. RESULTS Overall, 63,502 patients (63%) had a preoperative AMTS ≥8, in whom a postoperative 4AT score ≥4 suggestive of delirium was seen in 4454 (7%). These patients were less likely to return home (odds ratio [OR], 0.46; 95% CI, 0.38-0.55) or regain outdoor mobility (OR, 0.63; 95% CI, 0.53-0.75) by 120 days. Multiple factors including any deficit in preoperative AMTS and malnutrition were associated with higher risk of 4AT ≥4, while use of preoperative nerve blocks was associated with lower risk (OR, 0.88; 95% CI, 0.81-0.95). Poorer outcomes were also seen in 12,042 (19%) patients with 4AT = 1-3; additional risk factors associated with this score included socioeconomic deprivation and surgical procedure types that were not compliant with National Institute of Health and Care Excellence guidance. CONCLUSION AND IMPLICATIONS Delirium after hip fracture surgery significantly reduces the likelihood of returning home or to outdoor mobility. Our findings underline the importance of measures to prevent postoperative delirium, and aid the identification of high-risk patients for whom delirium prevention might potentially improve outcomes.
Collapse
Affiliation(s)
- Samuel Hawley
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Dominic Inman
- Department of Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK; Care Quality Improvement Department, Royal College of Physicians, London, UK
| | - Celia L Gregson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Antony Johansen
- Care Quality Improvement Department, Royal College of Physicians, London, UK; University Hospital of Wales and School of Medicine, Cardiff University, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| |
Collapse
|
26
|
The Lateral Femoral Cutaneous and Over the Hip (LOH) Block for the Surgical Management of Hip Fractures: A Safe and Effective Anesthetic Strategy. J Orthop Trauma 2023; 37:135-141. [PMID: 36253914 DOI: 10.1097/bot.0000000000002508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip (LOH) block. DESIGN Retrospective. SETTING Orthopedic specialty hospital. PATIENTS/PARTICIPANTS 40 patients who presented between November 2021 and February 2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used. INTERVENTION Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve, and accessory obturator nerve. MAIN OUTCOME MEASUREMENTS Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates. RESULTS A total of 120 patients (40 each: general, spinal, and LOH block) were compared. The cohorts were similar in age, race, body mass index, sex, Charlson comorbidity index, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block cohort ( P < 0.05). Total OR time and anesthesia time were the shortest for the LOH block cohort ( P < 0.05). Patients in the LOH block cohort also had lower postoperative pain scores ( P < 0.05). Length of hospital stay was the shortest for patients in the LOH block cohort ( P < 0.05), and during discharge, patients in the LOH block cohort ambulated the furthest ( P < 0.05). No differences were found for anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates. CONCLUSIONS The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly patients requiring surgery. In addition, this block may decrease postoperative pain and length of hospital stay, and allow for greater ambulation in the early postoperative period for patients with hip fracture. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
27
|
Cao MM, Zhang YW, Sheng RW, Gao W, Kang QR, Gao YC, Qiu XD, Rui YF. General Anesthesia Versus Regional Anesthesia in the Elderly Patients Undergoing Hip Fracture Surgeries: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. World J Surg 2023; 47:1444-1456. [PMID: 36826487 DOI: 10.1007/s00268-023-06949-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Surgery is the preferred treatment option for the elderly patients with hip fractures. However, the choice of general anesthesia (GA) or regional anesthesia (RA) remains controversial. The quality of evidence has further improved with the advent of several high-quality randomized clinical trials (RCTs) in the last two years. The purpose of this study was to compare the clinical outcomes of two anesthetic techniques in elderly patients undergoing hip fracture surgeries. METHODS Eligible studies were identified from PubMed/MEDLINE, Web of Science, Scopus, EMBASE and reference lists from January 2000 to June 2022 in this current systematic review and meta-analysis. The outcomes included the surgery-related outcomes (duration of surgery, duration of anesthesia, intraoperative blood loss and number of transfusions) and postoperative outcomes (30-day mortality, postoperative delirium,cardiovascular events and other complications). RESULTS A total of 10 RCTs were included, and a total of 3594 patients were analyzed. RA was associated with shorter duration of surgery, shorter length of hospital stays and less intraoperative blood loss compared to GA. There were no significant differences between the two groups in the number of blood transfusions, duration of anesthesia, 30-day mortality or postoperative delirium. CONCLUSIONS Our pooled analysis identified no significant differences in terms of the safety between RA and GA, while RA reduces intraoperative blood loss, length of hospital stays and duration of surgery. These results suggest that RA appears to be preferable for the elderly patients with hip fractures.
Collapse
Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China.,School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China.,Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China.,School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China.,Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Ren-Wang Sheng
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China.,School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China.,Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Wang Gao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China.,School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China.,Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Qian-Rui Kang
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Yu-Cheng Gao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China.,School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China.,Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Xiao-Dong Qiu
- School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu, People's Republic of China. .,School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China. .,Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China. .,Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.
| |
Collapse
|
28
|
de Haan E, van Rijckevorsel VAJIM, Bod P, Roukema GR, de Jong L. Delirium After Surgery for Proximal Femoral Fractures in the Frail Elderly Patient: Risk Factors and Clinical Outcomes. Clin Interv Aging 2023; 18:193-203. [PMID: 36818548 PMCID: PMC9936875 DOI: 10.2147/cia.s390906] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023] Open
Abstract
Purpose The primary aim of this study was to identify risk factors for delirium after hip fracture surgery. The secondary purpose of this study was to verify peri-operative clinical outcomes, adverse events and mortality rates in delirium patients after hip fracture surgery. Patients and Methods A prospective hip fracture database was used to obtain data. In total, 2051 patients older than 70 years undergoing a hip fracture surgery between 01-01-2018 and 01-01-2021 were included. A delirium was diagnosed by a geriatrician based on the DSM-V criteria. Results The results showed that 16% developed a delirium during hospital admission. Multivariable analysis showed that male gender (OR: 1.99, p<0.001), age (OR: 1.06, p<0.001), dementia (OR: 1.66, p=0.001), Parkinson's disease (OR: 2.32, p=0.001), Δhaemoglobin loss (OR: 1.19, p=0.022), pneumonia (OR: 3.86, p<0.001), urinary tract infection (UTI) (OR: 1.97, p=0.001) and wound infection (OR: 3.02, p=0.007) were significant independent prognostic risk factors for the development of a delirium after hip surgery. The median length in-hospital stay was longer in patients with a delirium (9 days) vs patients without a delirium (6 days) (p<0.001). The 30-day mortality was 7% (with delirium 16% vs with no delirium 6% (p<0.001)). Conclusion Significant independent prognostic factors associated with delirium after hip surgery were male gender, age, dementia, Parkinson's disease, Δhaemoglobin loss, pneumonia, UTI and wound infection.
Collapse
Affiliation(s)
- Eveline de Haan
- Surgery Department, Maasstad Hospital, Rotterdam, the Netherlands,Surgery Department, Franciscus Hospital, Rotterdam, the Netherlands,Correspondence: Eveline de Haan, Tel +31654922535, Email
| | | | - Pepijn Bod
- Surgery Department, Maasstad Hospital, Rotterdam, the Netherlands
| | - Gert R Roukema
- Surgery Department, Maasstad Hospital, Rotterdam, the Netherlands
| | - Louis de Jong
- Surgery Department, Maasstad Hospital, Rotterdam, the Netherlands
| | | |
Collapse
|
29
|
Imai T, Morita S, Hasegawa K, Goto T, Katori Y, Asada Y. Postoperative serum interleukin-6 level as a risk factor for development of hyperactive delirium with agitation after head and neck surgery with free tissue transfer reconstruction. Auris Nasus Larynx 2023:S0385-8146(23)00023-8. [PMID: 36754686 DOI: 10.1016/j.anl.2023.01.005] [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: 07/04/2022] [Revised: 09/19/2022] [Accepted: 01/11/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVE Occurrence of hyperactive postoperative delirium (POD) with agitation after head and neck surgery with free tissue transfer reconstruction (HNS-FTTR) is associated with the risk of life-threatening complications. The relationships between occurrence of hyperactive POD after HNS-FTTR and inflammatory markers reflecting the surgical stress response, represented by postoperative interleukin-6 levels, are not fully understood. METHODS A retrospective study was conducted on 221 consecutive patients who underwent HNS-FTTR at our department between September 2016 and December 2021. Potential risk factors for POD were examined, including age, operation time, intraoperative blood loss, and postoperative serum levels of blood parameters such as interleukin-6, C-reactive protein, and neutrophil-to-lymphocyte ratio. RESULTS Hyperactive POD with agitation was observed in 54 subjects (24.4%). The postoperative hospital stay in the POD group was significantly longer than that in the non-POD group (median: 32.5 days vs. 28 days; p=0.0129). Multivariate logistic regression analysis identified age (in years) (odds ratio: 1.102; p<0.0001), operation time (min) (odds ratio: 1.004; p=0.0359), and postoperative serum interleukin-6 level (pg/mL) (odds ratio: 1.005; p=0.0384) as significant risk factors for development of POD. In a receiver operating characteristic curve and area under the curve analysis, the cut-off value for postoperative serum interleukin-6 level to predict POD development was 82.5 pg/mL. The postoperative serum interleukin-6 ≥82.5 pg/mL group developed hyperactive POD with agitation significantly more often than the postoperative serum IL-6 <82.5 pg/mL group (odds ratio: 4.400; p<0.0001). The postoperative serum IL-6 ≥82.5 pg/mL group also had significantly longer postoperative hospital stay (41.58 ± 33.42 days vs. 31.73 ± 22.89 days; p=0.0151), older age (68.60 ± 9.99 years vs. 64.30 ± 12.58 years; p=0.0054), and longer operation time (625.4 ± 114.05 min vs. 575.5 ± 98.73 min; p=0.0009) than the postoperative serum IL-6 <82.5 pg/mL group. CONCLUSION Postoperative serum interleukin-6 level, as well as age and operation time, were identified as significant independent risk factors for development of hyperactive POD with agitation after HNS-FTTR. Inflammation is a potential target for the prevention and treatment of POD after HNS-FTTR.
Collapse
Affiliation(s)
- Takayuki Imai
- Department of Head and Neck Surgery, Miyagi Cancer Center, 47-1 Nodayama, Medeshima-Shiode, Natori, Miyagi 981-1293, Japan.
| | - Sinkichi Morita
- Department of Head and Neck Surgery, Miyagi Cancer Center, 47-1 Nodayama, Medeshima-Shiode, Natori, Miyagi 981-1293, Japan
| | - Kohsei Hasegawa
- Department of Head and Neck Surgery, Miyagi Cancer Center, 47-1 Nodayama, Medeshima-Shiode, Natori, Miyagi 981-1293, Japan
| | - Takahiro Goto
- Department of Plastic and Reconstructive Surgery, Miyagi Cancer Center, 47-1 Nodayama, Medeshima-Shiode, Natori, Miyagi 981-1293, Japan
| | - Yukio Katori
- Department of Otolaryngology-Head and Neck Surgery, Tohoku University Graduate School of Medicine, 2-1 Seriryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Yukinori Asada
- Department of Head and Neck Surgery, Miyagi Cancer Center, 47-1 Nodayama, Medeshima-Shiode, Natori, Miyagi 981-1293, Japan
| |
Collapse
|
30
|
Cognitive deficits after general anaesthesia in animal models: a scoping review. Br J Anaesth 2023; 130:e351-e360. [PMID: 36402576 DOI: 10.1016/j.bja.2022.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/15/2022] [Accepted: 10/06/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND It remains controversial whether general anaesthetic drugs contribute to perioperative neurocognitive disorders in adult patients. Preclinical studies have generated conflicting results, likely because of differing animal models, study protocols, and measured outcomes. This scoping review of preclinical studies addressed the question: 'Do general anaesthetic drugs cause cognitive deficits in adult animals that persist after the drugs have been eliminated from the brain?' METHODS Reports of preclinical studies in the MEDLINE database published from 1953 to 2021 were examined. A structured review process was used to assess original studies of cognitive behaviours, which were measured after treatment (≥24 h) with commonly used general anaesthetic drugs in adult animals. RESULTS The initial search yielded 380 articles, of which 106 were fully analysed. The most frequently studied animal model was male (81%; n=86/106) rodents (n=106/106) between 2-3 months or 18-20 months of age. Volatile anaesthetic drugs were more frequently studied than injected drugs, and common outcomes were memory behaviours assessed using the Morris water maze and fear conditioning assays. Cognitive deficits were detected in 77% of studies (n=82/106) and were more frequent in studies of older animals (89%), after inhaled anaesthetics, and longer drug treatments. Limitations of the studies included a lack of physiological monitoring, mortality data, and risk of bias attributable to the absence of randomisation and blinding. CONCLUSIONS Most studies reported cognitive deficits after general anaesthesia, with age, use of volatile anaesthetic drugs, and duration of anaesthesia as risk factors. Recommendations to improve study design and guide future research are presented.
Collapse
|
31
|
Zajic P, Eichinger M, Eichlseder M, Hallmann B, Honnef G, Fellinger T, Metnitz B, Posch M, Rief M, Metnitz PGH. Association of immediate versus delayed extubation of patients admitted to intensive care units postoperatively and outcomes: A retrospective study. PLoS One 2023; 18:e0280820. [PMID: 36689444 PMCID: PMC9870150 DOI: 10.1371/journal.pone.0280820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/09/2023] [Indexed: 01/24/2023] Open
Abstract
AIM OF THIS STUDY This study seeks to investigate, whether extubation of tracheally intubated patients admitted to intensive care units (ICU) postoperatively either immediately at the day of admission (day 1) or delayed at the first postoperative day (day 2) is associated with differences in outcomes. MATERIALS AND METHODS We performed a retrospective analysis of data from an Austrian ICU registry. Adult patients admitted between January 1st, 2012 and December 31st, 2019 following elective and emergency surgery, who were intubated at the day 1 and were extubated at day 1 or day 2, were included. We performed logistic regression analyses for in-hospital mortality and over-sedation or agitation following extubation. RESULTS 52 982 patients constituted the main study population. 1 231 (3.3%) patients extubated at day 1 and 958 (5.9%) at day 2 died in hospital, 464 (1.3%) patients extubated at day 1 and 613 (3.8%) at day 2 demonstrated agitation or over-sedation after extubation during ICU stay; OR (95% CI) for in-hospital mortality were OR 1.17 (1.01-1.35, p = 0.031) and OR 2.15 (1.75-2.65, p<0.001) for agitation or over-sedation. CONCLUSIONS We conclude that immediate extubation as soon as deemed feasible by clinicians is associated with favourable outcomes and may thus be considered preferable in tracheally intubated patients admitted to ICU postoperatively.
Collapse
Affiliation(s)
- Paul Zajic
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Michael Eichinger
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Michael Eichlseder
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Barbara Hallmann
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Gabriel Honnef
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Tobias Fellinger
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Barbara Metnitz
- Austrian Center for Documentation and Quality Assurance in Intensive Care, Vienna, Austria
| | - Martin Posch
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Martin Rief
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Philipp G. H. Metnitz
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| |
Collapse
|
32
|
Hung KC, Chiu CC, Hsu CW, Ho CN, Ko CC, Chen IW, Sun CK. Association of preoperative prognostic nutritional index with risk of postoperative delirium: A systematic review and meta-analysis. Front Med (Lausanne) 2023; 9:1017000. [PMID: 36698831 PMCID: PMC9868631 DOI: 10.3389/fmed.2022.1017000] [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: 08/11/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Study objective To assess the association between prognostic nutritional index (PNI) and risk of postoperative delirium (POD) in adult patients. Methods MEDLINE, Google scholar, EMBASE, and Cochrane library databases were searched from inception till April 2022. The primary outcome was the association between PNI and the risk of POD, while the secondary outcomes were correlations of other prognostic factors with POD risk. The correlation between PNI and the incidence of POD was assessed with three approaches: Difference in preoperative PNI between POD and non-POD groups (Model 1) as well as the association of PNI as a continuous parameter (Model 2) or as a binary variable (i.e., low vs. high using a PNI cut-off value of 50) (Model 3) with POD risk. Results Analysis of nine observational studies published from 2010 to 2021 recruiting 3,743 patients showed a POD incidence of 6.4-35%. Our meta-analysis demonstrated a lower PNI among patients in the POD group (MD: -3.78, 95% CI: -4.85 to -2.71, p < 0.0001, I 2 = 54.2%) compared to the non-POD group (Model 1). Pooled results revealed a negative association between PNI and POD risk for both Model 2 (OR: 0.91, 95% CI: 0.86-0.97, p = 0.002, I 2 = 71%) and Model 3 (OR: 1.68, 95% CI: 1.26-2.23, p < 0.0001, I 2 = 0%). Besides, while our results supported an age-dependent increase in POD risk, other factors including body-mass index, surgical time, health status, hypertension, diabetes mellitus, and male gender were non-significant predictors of POD. Conclusion Our results demonstrated a negative association between PNI and POD, which warrant further large-scale studies for validation. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022323809.
Collapse
Affiliation(s)
- Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan,Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, E-Da Cancer Hospital, Kaohsiung City, Taiwan,School of Medicine, College of Medicine, I-Shou University, Kaohsiung City, Taiwan,Department of Medical Education and Research, E-Da Cancer Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Chun-Ning Ho
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Ching-Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, Tainan City, Taiwan,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan,Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung City, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan,*Correspondence: I-Wen Chen,
| | - Cheuk-Kwan Sun
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung City, Taiwan,Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan,Cheuk-Kwan Sun,
| |
Collapse
|
33
|
Haeuser L, Marchese M, Noldus J, Kibel AS, Carvalho F, Preston MA, Cooper Z, Trinh QD, Mossanen M. Association between Operative Time and Short-Term Radical Cystectomy Complications. Urol Int 2023; 107:273-279. [PMID: 35306500 DOI: 10.1159/000522141] [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: 07/20/2021] [Accepted: 01/03/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of this study was to examine the relationship between duration of surgical intervention and postoperative complications in radical cystectomy (RC). We hypothesized that the complication rate increases with longer operative time. METHODS We analyzed the National Surgical Quality Improvement Program database 2011-2017 to identify all patients who underwent RC. Clinicodemographic characteristics, operative time, and perioperative complications using the Clavien-Dindo Classification (CDC) were abstracted. We fit a generalized linear model with linear splines for operative time to analyze if the relationship between operative time and probability of complication changed over time. RESULTS A total of 10,520 RC patients were identified with a mean operative time of 5.5 h (standard deviation 2.03). In 55% and 18.2%, any complication and major complications (CDC ≥3) occurred within 30 days postoperatively, respectively. The spline regression model for any complication showed an almost linear relationship between the complication rate and operative time, ranging from 55% at 2.5 h to 82% at 10 h. For major complications, the model revealed the inflection point (knot) at 4.5 h, which corresponds to the lowest complication rate with 15%. Operative times at the extremes of the distribution had higher complication rates: 17.5% if <2.5 h and 28% if >10 h. DISCUSSION/CONCLUSION Operative time of RC is associated with postoperative complications. Though many factors impact the duration of surgery, surgeries that lasted between 4 and 5 h had trend toward the lowest complication rates. Attention to factors impacting operative time may allow surgeons to identify strategies for optimizing surgical care and reducing complications after RC.
Collapse
Affiliation(s)
- Lorine Haeuser
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Urology and Neuro-Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Maya Marchese
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joachim Noldus
- Department of Urology and Neuro-Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Adam S Kibel
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Filipe Carvalho
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Preston
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zara Cooper
- Department of Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Mossanen
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
34
|
Chen Y, Liang S, Wu H, Deng S, Wang F, Lunzhu C, Li J. Postoperative delirium in geriatric patients with hip fractures. Front Aging Neurosci 2022; 14:1068278. [PMID: 36620772 PMCID: PMC9813601 DOI: 10.3389/fnagi.2022.1068278] [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: 10/12/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.
Collapse
Affiliation(s)
- Yang Chen
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shuai Liang
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Huiwen Wu
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shihao Deng
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Fangyuan Wang
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Ciren Lunzhu
- Department of Orthopedics, Shannan City People’s Hospital, Shannan, China
| | - Jun Li
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China,*Correspondence: Jun Li,
| |
Collapse
|
35
|
Saller T, Hubig L, Seibold H, Schroeder Z, Wang B, Groene P, Perneczky R, von Dossow V, Hinske LC. Association between post-operative delirium and use of volatile anesthetics in the elderly: A real-world big data approach. J Clin Anesth 2022; 83:110957. [PMID: 36084424 DOI: 10.1016/j.jclinane.2022.110957] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Early post-operative delirium is a common perioperative complication in the post anesthesia care unit. To date it is unknown if a specific anesthetic regime can affect the incidence of delirium after surgery. Our objective was to examine the effect of volatile anesthetics on post-operative delirium. DESIGN Single Center Observational Study. SETTING Post Anesthesia Care Units at a German tertiary medical center. PATIENTS 30,075 patients receiving general anesthesia for surgery. MEASUREMENTS Delirium was assessed with the Nursing Delirium Screening Scale at the end of the recovery period. Subgroup-specific effects of volatile anesthetics on post-operative delirium were estimated using generalized-linear-model trees with inverse probability of treatment weighting. We further assessed the age-specific effect of volatiles using logistic regression models. MAIN RESULTS Out of 30,075 records, 956 patients (3.2%) developed delirium in the post anesthesia care unit. On average, patients who developed delirium were older than patients without delirium. We found volatile anesthetics to increase the risk (Odds exp. (B) for delirium in the elderly 1.8-fold compared to total intravenous anesthesia. Odds increases with unplanned surgery 3.0-fold. In the very old (87 years or older), the increase in delirium is 6.2-fold. This result was confirmed with internal validation and in a logistic regression model. CONCLUSIONS Our exploratory study indicates that early postoperative delirium is associated with the use of volatile anesthetics especially in the sub-cohort of patients aged 75 years and above. Further studies should include both volatile and intravenous anesthetics to find the ideal anesthetic in elderly patients.
Collapse
Affiliation(s)
- Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Scientific Commission on Gerontoanaesthesiology, German Association for Anaesthesiology and Intensive Care Medicine, Roritzer Str. 19, 90419 Nuremberg, Germany.
| | - Lena Hubig
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Heidi Seibold
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Zoé Schroeder
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Baocheng Wang
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Philipp Groene
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Robert Perneczky
- Department of Psychiatry, University Hospital, LMU Munich, Nussbaumstr. 7, 80336 Munich, Germany; German Center for Neurodegenerative Disorders (DZNE), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Feodor-Lynen-Strasse 17, 81377 Munich, Germany; Ageing Epidemiology Research Unit, School of Public Health, Imperial College London, Level 2 Faculty Building South Kensington Campus, London SW7 2AZ, UK; Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, 385A Glossop Road, Sheffield S10 2HQ, UK
| | - Vera von Dossow
- Scientific Commission on Gerontoanaesthesiology, German Association for Anaesthesiology and Intensive Care Medicine, Roritzer Str. 19, 90419 Nuremberg, Germany; Institute for Anesthesiology, Heart and Diabetes Center NRW, Ruhr University of Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany
| | - Ludwig C Hinske
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Professorship for Data Management und Clinical Decision Support, Faculty of Medicine, Augsburg University, University Hospital, Stenglinstr. 2, 86156 Augsburg, Germany
| |
Collapse
|
36
|
Ní Chróinín D, Chuan A. Post-operative delirium in the patient with hip fracture: The journey from hospital arrival to discharge. Front Med (Lausanne) 2022; 9:1080253. [PMID: 36507517 PMCID: PMC9728584 DOI: 10.3389/fmed.2022.1080253] [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: 10/26/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022] Open
Abstract
Delirium- an acute disorder of attention and cognition- is the commonest complication following hip fracture. Patients with hip fracture are particularly vulnerable to delirium, and many of the lessons from the care of the patient with hip fracture will extend to other surgical cohorts. Prevention and management of delirium for patients presenting with hip fracture, extending along a continuum from arrival through to the post-operative setting. Best practice guidelines emphasize multidisciplinary care including management by an orthogeriatric service, regular delirium screening, and multimodal interventions. The evidence base for prevention is strongest in terms of multifaceted interventions, while once delirium has set in, early recognition and identification of the cause are key. Integration of effective strategies is often suboptimal, and may be supported by approaches such as interactive teaching methodologies, routine feedback, and clear protocol dissemination. Partnering with patients and carers will support person centered care, improve patient experiences, and may improve outcomes. Ongoing work needs to focus on implementing recognized best practice, in order to minimize the health, social and economic costs of delirium.
Collapse
Affiliation(s)
- Danielle Ní Chróinín
- Liverpool Hospital, Liverpool, NSW, Australia,South Western Sydney Clinical School, UNSW Sydney, Liverpool, NSW, Australia,*Correspondence: Danielle Ní Chróinín,
| | - Alwin Chuan
- Liverpool Hospital, Liverpool, NSW, Australia,South Western Sydney Clinical School, UNSW Sydney, Liverpool, NSW, Australia,Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| |
Collapse
|
37
|
Xu Y, Ma Q, Du H, Yang C, Lin G. Postoperative Delirium in Neurosurgical Patients: Recent Insights into the Pathogenesis. Brain Sci 2022; 12:brainsci12101371. [PMID: 36291305 PMCID: PMC9599232 DOI: 10.3390/brainsci12101371] [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: 08/17/2022] [Revised: 10/04/2022] [Accepted: 10/07/2022] [Indexed: 11/16/2022] Open
Abstract
Postoperative delirium (POD) is a complication characterized by disturbances in attention, awareness, and cognitive function that occur shortly after surgery or emergence from anesthesia. Since it occurs prevalently in neurosurgical patients and poses great threats to the well-being of patients, much emphasis is placed on POD in neurosurgical units. However, there are intricate theories about its pathogenesis and limited pharmacological interventions for POD. In this study, we review the recent insights into its pathogenesis, mainly based on studies within five years, and the five dominant pathological theories that account for the development of POD, with the intention of furthering our understanding and boosting its clinical management.
Collapse
Affiliation(s)
- Yinuo Xu
- Department of Neurosurgery, Peking University Third Hospital, Beijing 100191, China
- School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
| | - Qianquan Ma
- Department of Neurosurgery, Peking University Third Hospital, Beijing 100191, China
- Center for Precision Neurosurgery and Oncology, Peking University Health Science Center, Beijing 100191, China
| | - Haiming Du
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Chenlong Yang
- Department of Neurosurgery, Peking University Third Hospital, Beijing 100191, China
- Center for Precision Neurosurgery and Oncology, Peking University Health Science Center, Beijing 100191, China
- North America Medical Education Foundation, Union City, CA 94587, USA
- Correspondence: (C.Y.); (G.L.); Tel.: +86-135-1108-7060 (C.Y.); +86-135-5240-0103 (G.L.)
| | - Guozhong Lin
- Department of Neurosurgery, Peking University Third Hospital, Beijing 100191, China
- Center for Precision Neurosurgery and Oncology, Peking University Health Science Center, Beijing 100191, China
- Correspondence: (C.Y.); (G.L.); Tel.: +86-135-1108-7060 (C.Y.); +86-135-5240-0103 (G.L.)
| |
Collapse
|
38
|
Reese M, Heifets BD, Berger M. Intraoperative Anesthetic Probes of Brain Health: Ketamine as a Canary in the Coal Mine? Anesth Analg 2022; 135:679-682. [PMID: 36108180 PMCID: PMC9490862 DOI: 10.1213/ane.0000000000005965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Melody Reese
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Boris Dov Heifets
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Palo Alto CA
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| |
Collapse
|
39
|
Burad J, Date R, Al Ismaili M, Sharma P, Kuriakose N, Kodange S, Birur SK, Al Yaqoubi K, Al Mawali A, Padmalayan A, El Mady H, Elawdy M, Jaju S, Al Abady A. The Assessment of Immediate Postoperative Delirium in Neurologically Intact Adult Patients Admitted to the Post-anesthesia Care Unit: A Cross-Sectional Study. Cureus 2022; 14:e29312. [PMID: 36277521 PMCID: PMC9580606 DOI: 10.7759/cureus.29312] [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] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background Immediate postoperative delirium (IPD) in the post-anesthesia care unit (PACU) can cause significant morbidity affecting everyday activities and length of stay with cost implications. This study was undertaken to find the proportion of IPD in PACU and its association with anesthesia and other perioperative factors. Methods After obtaining ethical approval and informed consent, this cross-sectional study was conducted in the PACU. A total of 600 consecutive adult patients (American Society of Anesthesiologists (ASA) 1-3) posted for surgery were approached between January and March 2019, of which 402 patients without neurological diseases and language and hearing discrepancies were studied. All patients had the intervention of surgery under anesthesia in a usual manner. Delirium was assessed preoperatively, postoperatively at 15 and 30 minutes, and before discharge from the PACU. IPD was assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) score, while sedation/agitation was assessed using the Richmond Agitation-Sedation Scale (RASS). The primary outcomes were the proportion of IPD, association with anesthesia, and perioperative risk factors. The secondary outcomes were the length of stay, delirium treatment, and mortality. Results Overall, the IPD proportion was 14.7%. A significant association was demonstrated with premedication with midazolam (odds ration (OR): 3.2; 95% confidence interval (CI): 1.42-7.35; P=0.003), general anesthesia (GA) (OR: 6.3; 95% CI: 2.23-17.8; P<0.001), duration of anesthesia (126 versus 95 minutes; P=0.001), laparoscopic mode of surgical access (OR: 3.4; 95% CI: 1.8-6.4; P<0.001), and postoperative RASS >/< 0 (OR: 10.6; 95% CI: 4.69-24.11; P<0.001) at 30 minutes and before discharge from the PACU. Multivariate analysis showed the strongest association of RASS at 30 minutes with IPD. Conclusion The proportion of IPD was found to be 14.7% in this study, and the chances of developing IPD are high if the patient is not awake and calm in the PACU, especially if midazolam is administered as premedication, followed by general anesthesia (GA) for a long duration.
Collapse
|
40
|
Bhushan S, Huang X, Duan Y, Xiao Z. The impact of regional versus general anesthesia on postoperative neurocognitive outcomes in elderly patients undergoing hip fracture surgery: A systematic review and meta-analysis. Int J Surg 2022; 105:106854. [PMID: 36031067 DOI: 10.1016/j.ijsu.2022.106854] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Randomized trials have shown conflicting results regarding differences in outcomes according to anesthesia type on the prevalence of postoperative delirium (POD) or postoperative cognitive dysfunction (POCD) in hip surgery patients. The aim of this Meta analysis is to compare the effect of general and regional anesthesia in older patients undergoing hip fracture surgery. METHODS A literature search for meta-analysis was performed using Pubmed, The Cochrane Library, Embase and Web of Science citation index for randomized controlled trials (RCTs) to compare the regional anesthesia (RA) to general anesthesia (GA) for postoperative outcomes in elderly undergoing hip fracture surgery till June 2022. The primary outcomes were the incidence of POD or POCD at 24 h, 3 days and 7 days postoperatively. The secondary outcomes were 30 days mortality rate and other adverse events. The risk of bias was assessed using the Cochrane methodology. RESULTS Eight studies including 3555 elderly patients over 65 years old showed that there was no significant difference in the prevalence of POD or POCD between RA and GA at 24 h [OR 0.73; 95% coincidence interval (CI) 0.19, 2.71, I2 = 53%; n = 452; P = 0.63], at 3 days [OR 1.03; 95% CI 0.79, 1.35, I2 = 0%; n = 1362; P = 0.82], at 7 days [OR 0.79; 95% CI 0.41, 1.52, I2 = 51%; n = 1336; P = 0.47], respectively. No significant differences were observed in the incidence of other adverse events. CONCLUSIONS No significant difference was found in the incidence of cognitive dysfunction after either general or regional anesthesia in elderly patients. Our finding of similar outcomes at 24 h, 3 days and 7 days postoperatively with either technique suggests that anesthesia choices for hip-fracture surgery may be based on the individual characteristics of each patient rather than on anticipated differences in clinical outcomes.
Collapse
Affiliation(s)
- Sandeep Bhushan
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan, 610017, China.
| | - Xin Huang
- Department of Anesthesiology, West China Hospital of Sichuan University, Sichuan, Chengdu, 610041, China.
| | - Yuanqiong Duan
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Sichuan, 610041, China.
| | - Zongwei Xiao
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan, 610017, China.
| |
Collapse
|
41
|
Clinical Factors Contributing to Cognitive Function in the Acute Stage after Treatment of Intracranial Aneurysms: A Cross-Sectional Study. J Clin Med 2022; 11:jcm11175053. [PMID: 36078981 PMCID: PMC9457194 DOI: 10.3390/jcm11175053] [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: 07/21/2022] [Revised: 08/21/2022] [Accepted: 08/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background: The factors affecting cognitive function after treatment of subarachnoid haemorrhage (SAH) can be categorised into aneurysmal factors, procedural factors, and complications. The aim of this study was to investigate which of these factors has greater influence on the cognitive function. Methods: We retrospectively identified 14 patients with unruptured intracranial aneurysms (UIAs) and 34 patients with SAH with mild symptoms at disease onset (Hunt and Hess grade: >3). All patients underwent neuropsychological tests within 35 days of discharge from hospitalisation for treatment. The relationship between the clinical factors and each neuropsychological test score was evaluated using multiple linear regression analysis after controlling for age and years of education. Results: Patients with UIA showed greater cognitive impairment in visual memory and the frontal/executive domains. Hypertension was associated with cognitive impairment. Patients with SAH showed greater cognitive impairment in the visuospatial, verbal memory, and frontal/executive domains. The dome-to-neck ratio, aneurysms located in the posterior circulation, microsurgical clipping, procedure time, anaesthesia duration, and complications were associated with cognitive impairment. Conclusions: Underlying diseases, procedural factors, and complications contributed to cognitive impairment after treatment of intracranial aneurysms. Since the effect of each factor on each cognitive domain was slightly different, a more in-depth study of these effects is needed.
Collapse
|
42
|
Desrochers RM, Lynch LJ, Gates JD, Ricaurte D, Wade JT, Dicks RS, Keating JJ. Outcomes in Post-operative Delirium Following Bowel Resection: A Single Center Retrospective Review. J Surg Res 2022; 280:163-168. [PMID: 35973340 DOI: 10.1016/j.jss.2022.07.009] [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: 01/05/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Delirium is associated with adverse post-operative outcomes, long-term cognitive dysfunction, and prolonged hospitalization. Risk factors for its development include longer surgical duration, increased operative complexity and invasiveness, and medical comorbidities. This study aims to further evaluate the incidence of delirium and its impact on outcomes among patients undergoing both elective and emergency bowel resections. METHODS This is a retrospective cohort study using an institutional patient registry. All patients undergoing bowel resection over a 3.5-year period were included. The study measured the incidence of post-operative delirium via the nursing confusion assessment method. This incidence was then compared to patient age, emergency versus elective admission, length of stay, mortality, discharge disposition, and hospital cost. RESULTS A total of 1934 patients were included with an overall delirium incidence of 8.8%. Compared to patients without delirium, patients with delirium were more likely to have undergone emergency surgery, be greater than 70 y of age, have a longer length of stay, be discharged to a skilled nursing facility, and have a more expensive hospitalization. In addition, the overall mortality was 14% in patients experiencing delirium versus 0.1% in those that did not. Importantly, when broken down between elective and emergency groups, the mortality of those experiencing delirium was similar (11 versus 13%). CONCLUSIONS The development of delirium following bowel resection is an important risk factor for worsened outcomes and mortality. Although the incidence of delirium is higher in the emergency surgery population, the development of delirium in the elective population infers a similar risk of mortality.
Collapse
Affiliation(s)
| | - Lindsay J Lynch
- Department of Surgery, Hartford Hospital, Hartford, Connecticut
| | | | - Daniel Ricaurte
- Department of Surgery, Hartford Hospital, Hartford, Connecticut
| | - Jason T Wade
- Department of Surgery, Hartford Hospital, Hartford, Connecticut
| | - Robert S Dicks
- Department of Geriatrics, Hartford Hospital, Hartford, Connecticut
| | - Jane J Keating
- Department of Surgery, Hartford Hospital, Hartford, Connecticut
| |
Collapse
|
43
|
Qi YM, Li YJ, Zou JH, Qiu XD, Sun J, Rui YF. Risk factors for postoperative delirium in geriatric patients with hip fracture: A systematic review and meta-analysis. Front Aging Neurosci 2022; 14:960364. [PMID: 35992597 PMCID: PMC9382199 DOI: 10.3389/fnagi.2022.960364] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/18/2022] [Indexed: 12/04/2022] Open
Abstract
Objectives This systematic review and meta-analysis was conducted to identify the potential risk factors for postoperative delirium in geriatric patients with hip fracture. Methods PubMed, EMBASE, and Cochrane Library were searched from inception until December 31st, 2021. A combined searching strategy of subject words and free words was adopted. Studies involving risk factors for postoperative delirium in elderly patients undergoing hip fracture surgeries were reviewed. Qualities of included studies were assessed using the Newcastle–Ottawa Scale. Data were pooled and a meta-analysis was performed using Review Manager 5.3. Results A total of 37 studies were included. The following risk factors were significant: advanced age (per year increase) (OR: 1.05, 95% CI 1.04–1.07), age>80 years (OR: 2.26, 95% CI 1.47–3.47), male (OR: 1.53, 95% CI 1.37–1.70), preoperative cognitive impairment (OR:3.20, 95% CI 2.12–4.83), preoperative dementia (OR: 2.74, 95% CI 2.18–3.45), preoperative delirium (OR: 9.23, 95% CI 8.26–10.32), diabetes (OR: 1.18, 95% CI 1.05–1.33), preoperative functional dependence (OR: 1.31, 95% CI 1.11–1.56), ASA level (per level increase) (OR: 1.63, 95% CI 1.04–2.57), ASA level≥3(OR: 1.76, 95% CI 1.39–2.24), low albumin (OR: 3.30, 95% CI 1.44–7.55), medical comorbidities (OR: 1.15, 95% CI 1.06–1.25), Parkinson's disease (OR: 4.17, 95% CI 1.68–10.31) and surgery delay>48 h (OR: 1.90, 95% CI 1.36–2.65). Conclusions Clinicians should be alert to patients with those risk factors. To identify the risk factors more precisely, more research studies with larger sample size and better design should be conducted.
Collapse
Affiliation(s)
- Yi-ming Qi
- Department of Orthopaedics, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- Orthopaedic Trauma Institute, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
| | - Ying-juan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Department of Geriatrics, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Ji-hong Zou
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Department of Geriatrics, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Xiao-dong Qiu
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Department of Anesthesiology, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jie Sun
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Department of Anesthesiology, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- Jie Sun
| | - Yun-feng Rui
- Department of Orthopaedics, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
- Orthopaedic Trauma Institute, Southeast University, Nanjing, China
- School of Medicine, Southeast University, Nanjing, China
- Trauma Center, Zhongda Hospital, Southeast University, Nanjing, China
- *Correspondence: Yun-feng Rui
| |
Collapse
|
44
|
Elnour AA, Babkir S, A AKK. The predictors of postoperative delirium at surgical units in Sudan: A multicenter, cross-sectional, prospective study. Pharm Pract (Granada) 2022; 20:2705. [PMID: 36733520 PMCID: PMC9851826 DOI: 10.18549/pharmpract.2022.3.2705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/02/2022] [Indexed: 02/05/2023] Open
Abstract
Background Knowledge of potential and amenable risk factors involved in the development of postoperative delirium (POD) is imperative for successful prevention and subsequent management. Objective The current study objective was to delineate the risk factors associated with the occurrence of POD among patients undergoing surgical procedures. Methods This multi-center (6 hospitals), cross-sectional prospective hospital-based study recruited 415 subjects aged ≥50 years who were scheduled to undergo different types of surgery. Delirium Observational Screening Scale used for the diagnosis of POD. Short Nutritional Assessment Questionnaire used for assessing the nutritional and the hydration status of patients. Pre and postoperative risk factors analyzed by univariate (chi square) and then multivariate analyses and the incidence rate of POD, was reported. Results The main outcome measure was the development of POD. Out of the 385, only 43 subjects (11.2%) developed POD. High American Society of Anesthesiologists score (OR: 10.76, 95% CI: 1.379-83.99, P =0.023), duration of surgery (OR: 5.426, 95% CI: [2.249-13.092]; P =0.0001), were the strongest independent risk factors for the development of POD. Katz Index of Independence in Activities of Daily Living score (OR: 3.227, 95% CI: [1.177-8.844], P =0.023), and age ≥ 70 years (OR: 1.174, 95% CI: [1.015-1.359]; P =0.027) were additional strongest independent risk factors for the development of POD. Conclusion Based on analysis or study, we found High American Society of Anesthesiologist sore, Katz-ADL, duration of surgery, and advanced age were predictors of POD. Our findings suggest preventive measures initiated in subjects identified at risk of developing POD. These results support the healthcare providers in the early prevention, diagnosis, and timely management of POD.
Collapse
Affiliation(s)
- Asim Ahmed Elnour
- PhD, MSc. Program of Clinical Pharmacy, College of Pharmacy, Al Ain University, Abu Dhabi campus, Abu Dhabi-United Arab Emirates. AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates.
| | - Sara Babkir
- MSc, B-Pharm. Clinical Pharmacist, Clinical and Drug Supply Chain Management, MSc in Medical Health Professions Education - Alneelain University and MSc in Hospital Pharmacy - National University, Doctors Without Borders "Medicines Sans Frontiers-MSF": Supply Department Khartoum-Sudan, Sudan.
| | - Al-Kubaissi Khalid A
- PhD, MSc. Department of Pharmacy Practice & Pharmacotherapeutics, College of Pharmacy-University of Sharjah, Sharjah-United Arab Emirates.
| |
Collapse
|
45
|
Teng IC, Sun CK, Ho CN, Wang LK, Lin YT, Chang YJ, Chen JY, Chu CC, Hsing CH, Hung KC. Impact of combined epidural anaesthesia/analgesia on postoperative cognitive impairment in patients receiving general anaesthesia: a meta-analysis of randomised controlled studies. Anaesth Crit Care Pain Med 2022; 41:101119. [PMID: 35777653 DOI: 10.1016/j.accpm.2022.101119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/20/2022] [Accepted: 03/31/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND To investigate the efficacy of combined epidural anaesthesia/analgesia (EAA) against postoperative delirium/cognitive dysfunction (POD/POCD) in adults after major non-cardiac surgery under general anaesthesia (GA). METHODS The databases of PubMed, Google scholar, Embase and Cochrane Central Register were searched from inception to November 2021 for available randomised controlled trials (RCTs) that assessed the impact of EAA on risk of POD/POCD. The primary outcome was risk of POD/POCD, while the secondary outcomes comprised postoperative pain score, length of hospital stay (LOS), risk of complications, and postoperative nausea/vomiting (PONV). RESULTS Meta-analysis of eight studies with a total of 2376 patients (EAA group: 1189 patients; non-EAA group: 1187 patients) revealed no difference in risk of POD/POCD between the EAA and the non-EAA groups [Risk ratio (RR): 0.68; 95% CI: 0.41 to 1.13, p = 0.14, I2 = 73%], but the certainty of evidence was very low. Nevertheless, the EAA group had lower pain score at postoperative 24 h [mean difference (MD): -1.49, 95% CI: -2.38 to -0.61; I2 = 98%; five RCTs; n = 476] and risk of PONV (RR = 0.73, 95% CI: 0.57 to 0.93, p = 0.01, I2 = 0%; three RCTs, 1876 patients) than those in the non-EAA group. Our results showed no significant impact of EAA on the pain score at postoperative 36-72 h, LOS, and risk of complications. CONCLUSION This meta-analysis demonstrated that EAA had no significant impact on the incidence of POD/POCD in patients following non-cardiac surgery.
Collapse
Affiliation(s)
- I-Chia Teng
- Department of Anaesthesiology, Chi Mei Medical Centre, Tainan, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung city, Taiwan; College of Medicine, I-Shou University, Kaohsiung city, Taiwan
| | - Chun-Ning Ho
- Department of Anaesthesiology, Chi Mei Medical Centre, Tainan, Taiwan
| | - Li-Kai Wang
- Department of Anaesthesiology, Chi Mei Medical Centre, Tainan, Taiwan; Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan city, Taiwan
| | - Yao-Tsung Lin
- Department of Anaesthesiology, Chi Mei Medical Centre, Tainan, Taiwan; Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan city, Taiwan
| | - Ying-Jen Chang
- Department of Anaesthesiology, Chi Mei Medical Centre, Tainan, Taiwan; Department of Recreation and Health-Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan city, Taiwan
| | - Jen-Yin Chen
- Department of Anaesthesiology, Chi Mei Medical Centre, Tainan, Taiwan
| | - Chin-Chen Chu
- Department of Anaesthesiology, Chi Mei Medical Centre, Tainan, Taiwan
| | - Chung-Hsi Hsing
- Department of Anaesthesiology, Chi Mei Medical Centre, Tainan, Taiwan; Department of Medical Research, Chi-Mei Medical Centre, Tainan, Taiwan
| | - Kuo-Chuan Hung
- Department of Anaesthesiology, Chi Mei Medical Centre, Tainan, Taiwan; Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan city, Taiwan.
| |
Collapse
|
46
|
Brooks DE, Ritchie-McLean SN, Chevannes W, Parker MJ, Griffiths R. Hip fracture specialists facilitate low-dose spinal anaesthesia in fractured neck of femur surgery. Acta Orthop Belg 2022; 88:311-317. [DOI: 10.52628/88.2.8978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fractured neck of femur is a common but potentially devastating complication of frailty. In other surgical specialities, there is an inverse relationship between surgical experience and duration of surgery; however, this has not been quantified in hip trauma. In perioperative hip fracture care, prolonged surgery may be associated with increased morbidity and significantly impacts on the conduct of anaesthesia. Specifically, low-dose spinal anaesthesia, which is associated with improved haemodynamic stability, cannot be used if surgery is likely to be prolonged. We studied the duration of hip fracture surgery undertaken in our institution and compared this to surgical expertise. We retrospectively explored our theatre database to identify patients who underwent hip fracture surgery in our hospital over a 62-month period, recording duration of surgery and primary operating surgeon. Surgeons were classified into one of 3 groups: Consultant hip surgeon (specialist interest in hip surgery), Consultant orthopaedic surgeon but non-hip specialist, or Non-consultant (trainee or non-training grade). We identified 1426 hip fracture procedures. Consultant hip surgeons performed all types of hip fracture surgery faster, and with reduced variation in surgical duration, than did either non-hip specialist consultants or non-consultant grades. Consultant hip surgeons consistently performed hip fracture surgery in under 60 minutes. Specialist consultant hip surgeons make low-dose spinal anaesthesia (with shorter block duration but increased haemodynamic stability) feasible. Our data supports the development of dedicated hip fracture trauma lists where patients should be operated on by specialist hip surgeons or trainees directly under their supervision.
Collapse
|
47
|
Mizuno T, Higo S, Kamei N, Mori K, Sakamoto A, Ozawa H. Effects of general anesthesia on behavioral circadian rhythms and clock-gene expression in the suprachiasmatic nucleus in rats. Histochem Cell Biol 2022; 158:149-158. [PMID: 35614272 DOI: 10.1007/s00418-022-02113-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 12/19/2022]
Abstract
The suprachiasmatic nucleus (SCN) of the hypothalamus is a nucleus that regulates circadian rhythms through the cyclic expression of clock genes. It has been suggested that circadian-rhythm-related, adverse postoperative events, including sleep disturbances and delirium, are partly caused by anesthesia-induced disruption of clock-gene expression. We examined the effects of multiple general anesthetics on the expression cycle of Period2 (Per2), one of the clock genes that regulate circadian rhythms in the SCN, and on the behavioral rhythms of animals. Rats were treated with sevoflurane, propofol, and dexmedetomidine for 4 h. The expression of Per2 in SCN was analyzed using in situ hybridization, and the behavioral rhythm before and after anesthesia was analyzed. Per2 expression in the SCN decreased significantly immediately after anesthesia in all groups compared with corresponding control groups. However, Per2 returned to normal levels within 24 h, and there was no phase change in the gene expression cycle or behavioral rhythm. This study suggests that acute suppression of Per2 expression may be a general phenomenon induced by general anesthesia, but that the molecular mechanism of the body clock is resilient to disturbances to some extent.
Collapse
Affiliation(s)
- Tomoki Mizuno
- Department of Anatomy and Neurobiology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan.,Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Shimpei Higo
- Department of Anatomy and Neurobiology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan.
| | - Nobutaka Kamei
- Department of Anatomy and Neurobiology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan.,Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Keisuke Mori
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan.,Department of Anesthesiology, Sakakibara Heart Institute, Asahicho 3-16-1, Fuchu, Tokyo, 183-0003, Japan
| | - Atsuhiro Sakamoto
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Hitoshi Ozawa
- Department of Anatomy and Neurobiology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
| |
Collapse
|
48
|
Ahmed N, Kuo YH. Delirium risk in geriatric hip hemi-arthroplasty (DRIGHA): Development and validation of a novel score using a national data. Injury 2022; 53:1469-1476. [PMID: 35144810 DOI: 10.1016/j.injury.2022.01.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/23/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND In-hospital delirium after hip hemi-arthroplasty results in a prolonged hospital course and an increase in morbidity and mortality. Early identification of high-risk patients and preventive strategies can reduce the occurrence of delirium. The purpose of the study is to identify the risk factors of delirium and create a scoring system for point of care physicians. The risk factors were created and validated in the study. HYPOTHESIS Certain factors are associated with in-hospital delirium after hip hemi-arthroplasty in geriatric patients. METHODS The National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2019 was accessed for the study. The study included all geriatric patients, ages 65 years and older, who underwent hip hemi-arthroplasty following a hip fracture. A multivariable analysis was performed to identify the risk of delirium using all the available information including patient demography, timing of surgery, comorbidities, and infective complications. Eighty percent of the data were used to develop a risk model, and 20% of the data were used to validate the model. A Receiving Operating Characteristics (ROC) curve was created. The Area Under the Curve (AUC) was calculated with a 95% confidence interval (CI). A Delirium Risk in Geriatric Hip Hemi-Arthroplasty (DRIGHA) score was created. RESULTS Out of 13,174 patients who qualified for the study, 3924 (29.8%) patients developed in-hospital delirium. The risk model showed advanced age, male gender, prior history of delirium and dementia, certain comorbidities, and complications were associated with a higher incidence of in-hospital delirium. The AUC was 0.79 (95% CI, 0.78-0.80). The DRIGHA score predicted the risk of delirium from 8 to 99.4%. CONCLUSION Certain demography characteristics, comorbidities and infective complications were associated with a higher risk of developing in-hospital delirium. A DRIGHA score can be calculated at the bedside through a web-based calculator. Preventive strategies in high-risk patients will reduce the incidence of delirium.
Collapse
Affiliation(s)
- Nasim Ahmed
- Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, United States; Hackensack Meridian School of Medicine, Nutley, NJ, United States.
| | - Yen-Hong Kuo
- Office of Research Administration, Jersey Shore University Medical Center, Neptune, NJ, United States
| |
Collapse
|
49
|
Zhao X, Yuan W. Perioperative Multicomponent Interdisciplinary Program Reduces Delirium Incidence in Elderly Patients With Hip Fracture. J Am Psychiatr Nurses Assoc 2022; 28:154-163. [PMID: 32281905 DOI: 10.1177/1078390320915250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Delirium is common in elderly patients with hip fracture. Although several multicomponent care pathways have been developed, few nurse-led perioperative multicomponent programs have been evaluated. AIMS The current study aimed to evaluate the effect of a nurse-led perioperative multicomponent interdisciplinary program in preventing postoperative delirium in elderly patients with hip fracture. METHOD The participants in the usual care group were recruited from March 2012 to February 2013, and these in the experimental group were recruited from May 2013 to June 2014. The participants in the usual care group (n = 174) received usual medical and nursing care from admission to hospital discharge and the participants in the experimental group (n = 192) received the nurse-led perioperative multicomponent interdisciplinary intervention. The STROBE checklist was used to report this study. RESULTS There were no statistical differences between the two cohorts in terms of the baseline data such as gender, age, fracture type, and so on. The experimental group had a lower incidence of delirium and postoperative hypoxia than the usual care group. No statistical differences in terms of delirium severity, delirium duration, and mean hospitalization length were observed. CONCLUSIONS The nurse-led perioperative multicomponent interdisciplinary program described in the current study is feasible and effective in reducing the incidence of postoperative delirium in elderly patients with hip fracture.
Collapse
Affiliation(s)
- Xin Zhao
- Xin Zhao, RN, The First Hospital of China Medical University, Shenyang, China
| | - Wei Yuan
- Wei Yuan, MD, PhD, The First Hospital of China Medical University, Shenyang, China
| |
Collapse
|
50
|
Liu YM, Huang H, Gao J, Zhou J, Chu HC. Hemoglobin Concentration and Post-Operative Delirium in Elderly Patients Undergoing Femoral Neck Fracture Surgery. Front Med (Lausanne) 2022; 8:780196. [PMID: 35071265 PMCID: PMC8766508 DOI: 10.3389/fmed.2021.780196] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/03/2021] [Indexed: 02/05/2023] Open
Abstract
This study aimed to determine the relationship between hemoglobin (Hb) concentration and post-operative delirium (POD) in elderly patients undergoing femoral neck fracture (FNF) surgery and to investigate whether the change in Hb concentration is associated with POD and the risk factors for POD. A total of 889 patients admitted with FNF between January 2016 and December 2020 were enrolled in this single-center, retrospective, case–control study. Hb concentrations were determined at admission and post-operative day 1 and the change in Hb concentration was defined as the absolute value of difference in pre-operative and post-operative Hb concentration. POD was assessed using the Confusion Assessment Method for the Intensive Care Unit (ICU) or the Confusion Assessment Method once a daily after surgery. The logistic regression analysis was performed for statistical analysis. In total, 172 (19.3%) patients developed POD and 151 (87.8%) patients developed POD within post-operative 3 days. Low pre-operative Hb concentration [p = 0.026, odds ratio (OR) = 0.978] and significant change in Hb concentration (p = 0.006, OR = 1.033) were significantly associated with POD. After excluding change in Hb concentration or pre-operative Hb concentration, neither of them was significantly associated with POD (p > 0.05). The interaction analysis of change in Hb concentration and pre-operative Hb concentration in the logistic regression model was negative. There was no significant relationship between post-operative Hb concentration and POD. Age (p < 0.001, OR = 1.072), stroke history (p = 0.003, OR = 2.489), post-operative ICU transfer (p = 0.007, OR = 1.981), and visual analog scale score within post-operative 2 days (p1 = 0.016 and p2 = 0.006) were independently associated with POD in the logistic regression analysis. Patients with low pre-operative Hb concentrations and high changes in Hb concentration seem to have an increased risk of POD and should receive more attention. Old age, stroke history, post-operative ICU transfer, and pain within post-operative 2 days were significantly associated with POD.
Collapse
Affiliation(s)
- Yu-Mei Liu
- School of Clinical Medicine, Qingdao University, Qingdao, China
| | - Hui Huang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, School of Clinical Medicine, Qingdao University, Qingdao, China
| | - Jie Gao
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, School of Clinical Medicine, Qingdao University, Qingdao, China
| | - Jian Zhou
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Hai-Chen Chu
- School of Clinical Medicine, Qingdao University, Qingdao, China
| |
Collapse
|