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Qian X, Sheng Y, Jiang Y, Xu Y. Associations of serum lactate and lactate clearance with delirium in the early stage of ICU: a retrospective cohort study of the MIMIC-IV database. Front Neurol 2024; 15:1371827. [PMID: 39011361 PMCID: PMC11246852 DOI: 10.3389/fneur.2024.1371827] [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: 01/17/2024] [Accepted: 06/12/2024] [Indexed: 07/17/2024] Open
Abstract
Aim This study aimed to investigate the associations of serum lactate level [within and after 24 h of the intensive care unit (ICU) admission] and lactate clearance rate with delirium and assess associations of lactate and lactate clearance rate with 30-day mortality in delirium patients. Methods Data in this retrospective cohort study were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database in 2012-2019. The associations of lactate and lactate clearance rate with delirium were explored through univariable and multivariable logistic regression analyses, whereas the associations of lactate and lactate clearance rate with 30-day mortality in delirium patients were investigated using univariable and multivariable Cox regression analyses. Subgroup analysis was performed for age, gender, sepsis, hypertension, sedative drug, ventilation, antibiotic drug, vasopressors, and the Sequential Organ Failure Assessment (SOFA) score. The evaluation indexes were odds ratios (ORs), hazard ratios (HRs), and 95% confidence intervals (CIs). Results Among 7,812 (14.58%) eligible participants, 4,338 (8.19%) had delirium and 1,903 (24.36%) died within 30 days. After adjusting for covariates, patients with lactic acidosis (lactate level > 5 mmol/L and PH < 7.35) at T0 (within 24 h of the ICU admission) had higher odds of delirium (OR = 1.235, 95%CI: 1.105-1.382). Hyperlactatemia (lactate level 2-5 mmol/L and PH > 7.35) at T1 (after 24 h of the ICU admission) was also associated with higher odds of delirium (OR = 1.277, 95%CI: 1.126-1.447). Lactate clearance rate > 50% was linked to lower odds of delirium (OR = 0.705, 95%CI: 0.613-0.811), and this relationship was also observed in ≥65 years old, female, male, non-sepsis, sepsis, non-hypertension, non-sedative drug use, sedative drug use, ventilation, antibiotic drug use, use of vasopressors, and different SOFA score subgroups (all p < 0.05). Additionally, hyperlactatemia and lactic acidosis (whether at T0 or T1) may be potential risk factors for 30-day mortality in delirium patients, whereas lactate clearance rate ≥ 0 had a potential protective effect on 30-day mortality (all p < 0.05). Conclusion Higher serum lactate levels in the early stage of the ICU were associated with a higher risk of delirium and subsequent mortality. Measures taken to increase the lactate clearance rate are necessary to reduce potential delirium or mortality risk in clinical settings. However, more evidence from prospective studies is needed to verify these findings.
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Affiliation(s)
- Xiangfeng Qian
- Department of Emergency Medicine, Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yi Sheng
- Department of Emergency Medicine, Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yinsheng Jiang
- Department of Emergency Medicine, Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yong'an Xu
- Department of Emergency Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Barreto Chang OL, Whitlock EL, Arias AD, Tsoy E, Allen IE, Hellman J, Bickler PE, Miller B, Possin KL. A novel approach for the detection of cognitive impairment and delirium risk in older patients undergoing spine surgery. J Am Geriatr Soc 2023; 71:227-234. [PMID: 36125032 PMCID: PMC9870968 DOI: 10.1111/jgs.18033] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/28/2022] [Accepted: 08/16/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative delirium is a common postsurgical complication in older patients and is associated with high morbidity and mortality. The objective of this study was to determine whether a digital cognitive assessment and patient characteristics could identify those at-risk. METHODS Patients 65 years and older undergoing spine surgeries ≥3 h were evaluated as part of a single-center prospective observational cohort study at an academic medical center, from January 1, 2019, to December 31, 2020. Of 220 eligible patients, 161 were enrolled and 152 completed the study. The primary outcome of postoperative delirium was measured by the Confusion Assessment Method for the Intensive Care Unit or the Nursing Delirium Screening Scale, administered by trained nursing staff independent from the study protocol. Baseline cognitive impairment was identified using the tablet-based TabCAT Brain Health Assessment. RESULTS Of the 152 patients included in this study, 46% were women. The mean [SD] age was 72 [5.4] years. Baseline cognitive impairment was identified in 38% of participants, and 26% had postoperative delirium. In multivariable analysis, impaired Brain Health Assessment Cognitive Score (OR 2.45; 95% CI, 1.05-5.67; p = 0.037), depression (OR 4.54; 95% CI, 1.73-11.89; p = 0.002), and higher surgical complexity Tier 4 (OR 5.88; 95% CI, 1.55-22.26; p = 0.009) were associated with postoperative delirium. The multivariate model was 72% accurate for predicting postoperative delirium, compared to 45% for the electronic medical record-based risk stratification model currently in use. CONCLUSION In this prospective cohort study of spine surgery patients, age, cognitive impairment, depression, and surgical complexity identified patients at high risk for postoperative delirium. Integration of scalable digital assessments into preoperative workflows could identify high-risk patients, automate decision support for timely interventions that can improve patient outcomes and lower hospital costs, and provide a baseline cognitive assessment to monitor for postoperative cognitive change.
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Affiliation(s)
- Odmara L. Barreto Chang
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Elizabeth L. Whitlock
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Aimee D. Arias
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Elena Tsoy
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California
| | - Isabel E. Allen
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Philip E. Bickler
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Bruce Miller
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California
| | - Katherine L. Possin
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California
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Profiling Delirium Progression in Elderly Patients via Continuous-Time Markov Multi-State Transition Models. J Pers Med 2021; 11:jpm11060445. [PMID: 34064001 PMCID: PMC8223967 DOI: 10.3390/jpm11060445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 12/12/2022] Open
Abstract
Poor recognition of delirium among hospitalized elderlies is a typical challenge for health care professionals. Considering methodological insufficiency for assessing time-varying diseases, a continuous-time Markov multi-state transition model (CTMMTM) was used to investigate delirium evolution in elderly patients. This is a longitudinal observational study performed in September 2016 in an Italian hospital. Change of delirium states was modeled according to the 4AT score. A Cox model (CM) and a CTMMTM were used for identifying factors affecting delirium onset both with a two-state and three-state model. In this study, 78 patients were enrolled and evaluated for 5 days. Both the CM and the CTMMTM show that urine catheter (UC), aging, drugs, and invasive devices (ID) are risk factors for delirium onset. The CTMMTM model shows that transition from no-delirium/cognitive impairment to delirium was associated with aging (HR = 1.14; 95%CI, 1.05, 1.23) and neuroleptics (HR = 4.3; 1.57, 11.77), dopaminergic drugs (HR = 3.89; 1.2, 12.6), UC (HR = 2.92; 1.09, 7.79) and ID (HR = 1.67; 103, 2.71). These results are confirmed by the multivariable model. Aging, ID, antibiotics, drugs affecting the central nervous system, and absence of moving ability are identified as the significant predictors of delirium. Additionally, it seems that modeling with CTMMTM may show associations that are not directly detectable with the traditional CM.
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The Association of Perioperative Serum Lactate Levels with Postoperative Delirium in Elderly Trauma Patients. BIOMED RESEARCH INTERNATIONAL 2019; 2019:3963780. [PMID: 31828102 PMCID: PMC6881750 DOI: 10.1155/2019/3963780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 09/25/2019] [Accepted: 10/23/2019] [Indexed: 02/04/2023]
Abstract
Background Several studies have shown the utility of lactate level as a predictor of early outcomes in trauma patients. We conducted this study to evaluate the association of perioperative serum lactate levels with postoperative delirium (POD) in elderly trauma patients. Materials and Methods This study included 466 elderly trauma patients with measurements of serum lactate levels on admission and 1 h after surgery. The associations of POD with serum lactate levels (on admission and 1 h after surgery) and lactate clearance were analyzed using Kendall's correlation. Perioperative serum lactate levels and lactate clearance as predictors of POD were evaluated using univariate and multivariable analyses. Results The incidence of POD in the present study was 38.1%. Serum lactate levels on admission and at 1 h after surgery were significantly higher in major trauma than in minor trauma. In univariate analysis of perioperative serum lactate levels and lactate clearance as predictors of POD, the odds ratio (OR) for serum lactate level on admission was 4.19 (P < 0.01, 2.91 < 95% confidence interval (CI) < 6.02) and that 1 h after surgery was 3.83 (P < 0.01, 2.79 < 95% CI < 5.25); however, the OR for serum change of lactate level was 0.99 ((P < 0.09, 0.99 < 95% CI < 1.00). In multivariable analysis for predictors of POD, the OR for serum lactate level on admission was 2.40 (P < 0.09, 0.87 < 95% CI < 6.7), that for serum lactate 1 h after surgery was 2.83 (P=0.01, 1.28 < 95% CI < 6.24), that for ICU admission was 3.01 (P=0.01, 2.09 < 95% CI < 6.03), and that for ISS was 1.47 (P < 0.01, 1.27 < 95% CI < 3.70). Conclusions Taking together the results of univariate and multivariable analyses, serum lactate level 1 h after surgery may be used as a prediction model of POD development in elderly trauma patients.
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Denny DL, Lindseth G. Preoperative Risk Factors for Subsyndromal Delirium in Older Adults Who Undergo Joint Replacement Surgery. Orthop Nurs 2018; 36:402-411. [PMID: 29189623 DOI: 10.1097/nor.0000000000000401] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Older adults with subsyndromal delirium have similar risks for adverse outcomes following joint replacement surgery as those who suffer from delirium. PURPOSE This study examined relationships among subsyndromal delirium and select preoperative risk factors in older adults following major orthopaedic surgery. METHODS Delirium assessments of a sample of 62 adults 65 years of age or older were completed on postoperative Days 1, 2, and 3 following joint replacement surgery. Data were analyzed for relationships among delirium symptoms and the following preoperative risk factors: increased comorbidity burden, cognitive impairment, fall history, and preoperative fasting time. RESULTS Postoperative subsyndromal delirium occurred in 68% of study participants. A recent fall history and a longer preoperative fasting time were associated with delirium symptoms (p ≤ .05). CONCLUSIONS Older adults with a recent history of falls within the past 6 months or a longer duration of preoperative fasting time may be at higher risk for delirium symptoms following joint replacement surgery.
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Affiliation(s)
- Dawn L Denny
- Dawn L. Denny, PhD, RN, ONC, Assistant Professor, College of Nursing and Professional Disciplines, University of North Dakota, Grand Forks, ND. Glenda Lindseth, PhD, RN, FADA, FAAN, Professor, College of Nursing and Professional Disciplines, University of North Dakota, Grand Forks
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Bennett C. Identifying delirium in older adults with pre-existing mental illness. Nurse Pract 2017; 42:39-44. [PMID: 28514272 DOI: 10.1097/01.npr.0000516123.22868.c6] [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: 06/07/2023]
Abstract
Acute delirium complicates care and can be easily overlooked in older adults with preexisting mental illness. Evidence-based measures have demonstrated that early diagnosis, identification, and correction of modifiable factors can lead to improved care and less morbidity in these patients.
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Affiliation(s)
- Courtney Bennett
- Courtney Bennett is an adult psychiatric mental health NP at East Mississippi State Hospital, Meridian, Miss
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Shulman RW, Kalra S, Jiang JZ. Validation of the Sour Seven Questionnaire for screening delirium in hospitalized seniors by informal caregivers and untrained nurses. BMC Geriatr 2016; 16:44. [PMID: 26879927 PMCID: PMC4754883 DOI: 10.1186/s12877-016-0217-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 02/03/2016] [Indexed: 12/21/2022] Open
Abstract
Background Delirium is a common condition in hospitalized seniors that nonetheless often goes undetected by nurses or is delayed in being detected which negatively impacts quality of care and outcomes. We sought to develop a new screening tool for delirium, The Sour Seven Questionnaire, a 7-item questionnaire suitable to be completed from informal or untrained caregiver observation. The study aimed to develop the scoring criteria for a positive delirium screen and assess concurrent validity of the questionnaire against a geriatric psychiatrist’s assessment. Methods A pilot study of 80 hospitalized seniors over age 65 recruited from three units (2 medical, 1 orthopedic). Participants were assessed using the Confusion Assessment Method (CAM) with a brief cognitive screen and the Sour Seven Questionnaire posed to the appointed informal caregiver (family member) or untrained nurse for up-to 7 days. Subjects testing positive on the CAM and a random sample of negatively CAM screened subjects were assessed by the geriatric psychiatrist. Results From 80 participants, 21 screened positive for delirium on the CAM. 18 of the 21 CAM positive screens were diagnosed to have delirium by the geriatric psychiatrist, and 17 of the 18 randomly assigned negative CAM screens were confirmed as not having delirium. From the questionnaires on these 39 participants, weighted scoring for each of the 7 questions of the Sour Seven Questionnaire was developed based on their relative risks for correctly predicting delirium when compared to the geriatric psychiatrist’s clinical assessment. Total scoring of the questionnaire resulted in the following positive predictive values for delirium: 89 % with a total score of 4 (sensitivity 89.5 %, specificity 90 %), and 100 % with a total score of 9 (sensitivity 63.2 %, specificity 100 %). Comparison between scoring on questionnaires posed to informal caregivers versus untrained nurses showed no differences. Conclusion A weighted score of 4 in the Sour Seven Questionnaire has concurrent validity as a screening tool for delirium and a score of 9 is diagnostic for delirium. The Sour Seven Questionnaire is the first screening tool for delirium shown to be suitable for use by informal caregivers and untrained nurses in hospitalized seniors. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0217-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Richard W Shulman
- Trillium Health Partners, Queensway Health Centre, 150 Sherway Drive, 4th floor, Toronto, ON, M9C 1A5, Canada. .,Faculty of Medicine, Department of Psychiatry, Division of Geriatric Psychiatry, University of Toronto, Toronto, Canada. .,Mississauga Academy of Medicine, University of Toronto, Mississauga, Canada.
| | - Saurabh Kalra
- Mississauga Academy of Medicine, University of Toronto, Mississauga, Canada.
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Martins S, Fernandes L. Delirium in elderly people: a review. Front Neurol 2012; 3:101. [PMID: 22723791 PMCID: PMC3377955 DOI: 10.3389/fneur.2012.00101] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 06/01/2012] [Indexed: 01/12/2023] Open
Abstract
The present review aims to highlight this intricate syndrome, regarding diagnosis, pathophysiology, etiology, prevention, and management in elderly people. The diagnosis of delirium is based on clinical observations, cognitive assessment, physical, and neurological examination. Clinically, delirium occurs in hyperactive, hypoactive, or mixed forms, based on psychomotor behavior. As an acute confusional state, it is characterized by a rapid onset of symptoms, fluctuating course and an altered level of consciousness, global disturbance of cognition or perceptual abnormalities, and evidence of a physical cause. Although pathophysiological mechanisms of delirium remain unclear, current evidence suggests that disruption of neurotransmission, inflammation, or acute stress responses might all contribute to the development of this ailment. It usually occurs as a result of a complex interaction of multiple risk factors, such as cognitive impairment/dementia and current medical or surgical disorder. Despite all of the above, delirium is frequently under-recognized and often misdiagnosed by health professionals. In particular, this happens due to its fluctuating nature, its overlap with dementia and the scarcity of routine formal cognitive assessment in general hospitals. It is also associated with multiple adverse outcomes that have been well documented, such as increased hospital stay, function/cognitive decline, institutionalization and mortality. In this context, the early identification of delirium is essential. Timely and optimal management of people with delirium should be performed with identification of any possible underlying causes, dealing with a suitable care environment and improving education of health professionals. All these can be important factors, which contribute to a decrease in adverse outcomes associated with delirium.
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Affiliation(s)
- Sónia Martins
- Research and Education Unit on Aging, UNIFAI/ICBAS, University of PortoPorto, Portugal
| | - Lia Fernandes
- Research and Education Unit on Aging, UNIFAI/ICBAS, University of PortoPorto, Portugal
- Clinical Neuroscience and Mental Health Department, Faculty of Medicine, University of PortoPorto, Portugal
- Psychiatry Service, S. João HospitalPorto, Portugal
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