Risk factors for postoperative delirium after colorectal surgery: a systematic review and meta-analysis

Short-term inhalation of xenon during anesthesia for prevention of postoperative delirium in elderly patients undergoing laparoscopic radical colectomy: study protocol for a randomized controlled clinical trial

BACKGROUND

Postoperative delirium (POD) is a common complication that is characterized by acute onset of impaired cognitive function and is associated with an increased mortality, a prolonged duration of hospital stay, and additional healthcare expenditures. The incidence of POD in elderly patients undergoing laparoscopic radical colectomy ranges from 8 to 54%. Xenon has been shown to provide neuroprotection in various neural injury models, but the clinical researches assessing the preventive effect of xenon inhalation on the occurrence of POD obtained controversial findings. This study aims to investigate the effects of a short xenon inhalation on the occurrence of POD in elderly patients undergoing laparoscopic radical colectomy.

METHODS/DESIGN

This is a prospective, randomized, controlled trial and 132 patients aged 65-80 years and scheduled for laparoscopic radical colectomy will be enrolled. The participants will be randomly assigned to either the control group or the xenon group (n = 66 in each group). The primary outcome will be the incidence of POD in the first 5 days after surgery. Secondary outcomes will include the subtype, severity, and duration of POD, postoperative pain score, Pittsburgh Sleep Quality Index (PQSI), perioperative non-delirium complications, and economic parameters. Additionally, the study will investigate the activation of microglial cells, expression of inflammatory factors in colon tissues, plasma inflammatory factors, and neurochemical markers.

DISCUSSION

Elderly patients undergoing laparoscopic radical colectomy are at a high risk of POD, with delayed postoperative recovery and increased healthcare costs. The primary objective of this study is to determine the preventive effect of a short xenon inhalation on the occurrence of POD in these patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300076666. Registered on October 16, 2023, http://www.chictr.org.cn .

Predictiveness of preoperative laboratory values for postoperative delirium

Background

Postoperative delirium (POD) is a common postoperative complication, especially in patients over 60 years, with an incidence ranging from 15% to 50%. In most cases, POD manifests in the first 5 days after surgery. Multiple contributing risk factors for POD have been detected. Besides the predisposing factors such as higher age, cognitive impairment, high blood pressure, atrial fibrillation, and past stroke, pathophysiological mechanisms like neuroinflammation are also considered as contributing factors.

Methods

In a subanalysis of the "PRe- Operative  Prediction of postoperative  DElirium by appropriate  SCreening" (PROPDESC) study, the preoperative laboratory values of sodium, potassium, total protein, hemoglobin concentration (Hgb), and white blood cells as well as the biomarkers creatinine, HbA1c, NT-pro-BNP, high sensitive Troponin T (hsTnT), and C-reactive protein (CRP) were assessed to investigate a possible relationship to the occurrence of POD.

Results

After correction for age, physical status classification, surgery risk after Johns Hopkins, and operative discipline (cardiac surgery vs. noncardiac surgery), male patients with a Hgb <13 g/dL had significantly higher odds for POD (p = 0.025). Furthermore, patients with CRP ≥ 10 mg/L, HbA1c value ≥ 8.5% as well as patients with hypernatraemia (>145 mmol/L) presented significantly higher odds to develop POD (p = 0.011, p < 0.001, and p = 0.021, respectively). A raised (>14-52 ng/L) or high (>52 ng/L) hsTnT value was also associated with a significantly higher chance for POD compared to the patient group with hsTnT <14 ng/L (p < 0.001 and p = 0.016, respectively).

Conclusions

Preoperative Hgb, CRP, HbA1c, sodium, and hsTnT could be used to complement and refine the preoperative screening for patients at risk for POD. Further studies should track these correlations to investigate the potential of targeted POD protection and enabling hospital staff to initiate POD-preventing measures in time.

Prognostic value of Geriatric-8 for adverse outcomes within 30 days of surgery in older adults with colorectal cancer: A retrospective cohort study

PURPOSE

It is unclear whether the Geriatric-8 (G8) has the accuracy to preselect patients for complete geriatric assessment, and has the ability to predict adverse outcomes in patients with colorectal cancer (CRC). We therefore aimed to determine whether the G8, or other variables present in the medical record, are applicable in predicting 30-day adverse outcomes in older patients undergoing surgery for CRC.

METHODS

We performed a retrospective cohort study involving patients ≥70 years who had surgery for CRC between 2018 and 2020 in a general hospital in the Netherlands. The primary outcome was adverse outcome(s), which is a composite of surgical and non-surgical complications, readmission and mortality, all within 30 days of surgery. The secondary endpoints were the individual components, such as delirium, infection and ileus. We explored potential prognostic factors using multivariable logistic regression analysis. Data were collected from the Dutch ColoRectal Audit (DRCA) and medical records.

RESULTS

The study included 200 patients (mean age 78.9 years: 50% female), with 36.5% having adverse outcomes in the first 30 days of surgery. In neither univariate nor multivariable analysis were G8 scores associated with adverse outcomes. Factors with higher odds of adverse outcomes were male gender, and having cognitive decline or previous delirium.

CONCLUSION

This study confirms that G8 scores have no prognostic value for adverse outcomes, complications and mortality within 30 days of surgery among older adults with CRC. Therefore, the G8 should not be the tool for short-term risk prediction of adverse outcomes in these patients.

The impact of melatonin on postoperative delirium in geriatric patients after colorectal surgery: a randomized placebo-controlled trial

BACKGROUND

The current study was designed to evaluate the role of prophylactic melatonin administration in reducing delirium occurrence in elderly patients undergoing colorectal cancer surgeries.

METHODS

One hundred patients of both genders undergoing elective colorectal cancer surgeries under general anesthesia were randomly allocated into two equal groups. A treatment group of patients (Melatonin group) received five mg of melatonin the night before surgery, twelve hours before the scheduled surgery time, and an additional five mg of melatonin two hours before surgery. The control group of patients received placebo tablets at the same time points. Delirium score, sedation score, pain score, hemodynamics, oxygen saturation, and blood requirements were recorded.

RESULTS

Twenty-eight patients (56%) in the control group versus 18 (36%) in the melatonin group developed delirium (P=0.045), OR=2.26, 95% CI: 1.013-5.05. Five patients (18%) in the control group versus six (33%) ‎in the melatonin group developed delirium on discharge from the ‎recovery room (P=0.749), OR=1.22, 95% CI: 0.34-4.31, while 23 patients (82%) in the control group versus ‎‎12 (66%) in the melatonin group developed delirium six hours postoperative (P=0.021), OR=1.705, 95% CI: 1.02-2.81 ‎with higher nursing delirium screening score in the control group 2 (1, 4) versus 1 (0, 2) in the melatonin group (P=0.002), 95% CI: 1.77-2.71.

CONCLUSIONS

The prophylactic administration of melatonin may decrease the incidence of postoperative delirium in elderly patients undergoing colorectal surgeries under general anesthesia.

Impact of nursing interventions on discharge disposition in patients with postoperative delirium

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.

Postoperative delirium after cholecystectomy in older patients: A retrospective study

Backgrounds/Aims

Postoperative delirium (POD) is a common complication that increases mortality and morbidity in older patients. This study aimed to evaluate the clinical significance of post-cholecystectomy delirium in older patients.

Methods

This retrospective study included 201 patients aged > 75 years who underwent cholecystectomy for acute or chronic cholecystitis between January 2016 and December 2019. Patients were divided into the POD (n = 21) and non-POD (n = 180) groups, and their demographic features and clinical results were compared.

Results

The mean patient age was 78.88 years; the female/male ratio was 44.8%/55.2%. Laparoscopic surgery was performed in 93.5% of patients. The univariate analysis showed that lower body mass index (BMI), immobilized admission status, neuropsychiatric disease history, preoperative intervention (percutaneous drainage), high C-reactive protein, hypoalbuminemia, neutrophilia, hypo-/hyperkalemia, and longer operative time were more frequently observed in the POD group. The multivariate analysis showed that lower BMI (odds ratio [OR], 2.796; p = 0.024), neuropsychiatric disease history (OR, 3.019; p = 0.049), hyperkalemia (OR, 5.972; p = 0.007), and longer operative time (OR, 1.011; p = 0.013) were significant risk factors for POD.

Conclusions

POD was associated with inflammation degree, general condition, poor nutritional status, electrolyte imbalance, and stressful conditions. Recognizing risk factors requiring multidisciplinary team approaches is important to prevent and treat POD.

Higher intraoperative mean arterial blood pressure does not reduce postoperative delirium in elderly patients following gastrointestinal surgery: A prospective randomized controlled trial

BACKGROUND

This study aimed to describe the relationship between the different levels of intraoperative mean arterial blood pressure (MAP) and postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery.

MATERIALS AND METHODS

This prospective controlled clinical trial enrolled 116 patients aged 65 to 85 years who underwent gastrointestinal laparoscopic surgery. These patients were randomized 1:1 to a MAP goal of 65 to 85 mmHg (L group) or an 86 to 100 mmHg (H group). The primary endpoint was the incidence of postoperative delirium, assessed twice daily with the Confusion Assessment Method (CAM) and Richmond Agitation-Sedation Scale (RASS) during the first five postoperative days. Delirium severity was evaluated with the Delirium-O-Meter (D-O-M).

RESULTS

108 patients (L group n = 55, H group n = 53) were eventually included in intention-to-treat analyses. Postoperative delirium occurred in 18 (32.7%) of 55 cases of L group and in 15 (28.3%) of 53 cases of H group. The incidence of delirium subtypes between the two groups: hypoactive delirium 14.5% (8/55) vs 11.3% (6/53); hyperactive delirium 7.3% (4/55) vs 3.8% (2/53); mixed delirium 10.9% (6/55) vs 13.2% (7/53). However, the L group showed higher D-O-M scores of the first episode of delirium: 14.5 (Q1 = 12, Q3 = 18.5) vs 12 (Q1 = 10, Q3 = 14), which means the delirium is more severe.

CONCLUSIONS

Compared with 65 to 85 mmHg, maintaining intraoperative MAP at 86-100 mmHg did not reduce the incidence of postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery. However, the severity of delirium could be reduced and blood loss is a risk factor for postoperative delirium.

Subjective cognitive decline may mediate the occurrence of postoperative delirium by P-tau undergoing total hip replacement: The PNDABLE study

OBJECTIVE

We again investigated the relationship between subjective cognitive decline (SCD) and postoperative delirium (POD) with a larger sample queue. We also determined whether SCD could cause the occurrence of POD through cerebrospinal fluid (CSF) biomarkers.

METHODS

A prospective, observational cohort study was implemented in the Qingdao Municipal Hospital Affiliated with Qingdao University. This study recruited 1,471 qualified patients affiliated with the Perioperative Neurocognitive Disorder And Biomarker Lifestyle (PNDABLE) study scheduled for total hip replacement under combined spinal and epidural anesthesia from June 2020 to May 2022. The Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) were used to assess the cognitive level of the patients the day before surgery. Pittsburgh sleeps quality index (PSQI) scale was used to assess sleep status. Patients were divided into the SCD group and the non-SCD (NSCD) group based on the Subjective Cognitive Decline Scale (SCDS). CSF was collected after a successful spinal-epidural combined puncture, and amyloid-β40 (Aβ40), amyloid-β42 (Aβ42), total tau (T-tau), and phosphorylated tau (P-Tau) in CSF were analyzed by enzyme-linked immunosorbent assays. After the surgery, the incidence of POD was determined by the Confusion Assessment Scale (CAM), and Memorial Delirium Assessment Scale (MDAS) score was used to determine the severity of POD. Logistic regression and sensitivity analyses were performed to determine the relationship between CSF biomarkers, SCD, and POD. The mediating effect was used to analyze the function of specific CSF biomarkers in the relationship between SCD and POD. The risk factors of SCD were also separately verified by logistic regression and sensitivity analysis models.

RESULTS

The total incidence rate of POD was 19.60% (n = 225/1148), which was 29.3% (n = 120/409) in the SCD group and 14.2% (n = 105/739) in the NSCD group. We comprehensively considered the effect of covariates such as age, hypertension, and diabetes. Multivariate logistic regression analysis showed that SCD (OR = 1.467, 95%CI: 1.015-2.120, p = 0.042) and P-tau (OR = 1.046, 95%CI: 1.028-1.063, p < 0.001) were risk factors for POD. The sensitivity analysis results were consistent with the above results. Mediation analysis showed that the relationship between SCD and POD was partially mediated by P-tau, which accounted for 31.25% (P-tau, IE = 4.279 × 10-2, p < 0.001). For SCD, the results of logistic regression analysis models showed that age (OR = 1.035, 95% CI: 1.020-1.049, p < 0.001), higher preoperative PSQI score (OR = 1.047, 95%CI: 1.014-1.080, p = 0.005), and P-tau (OR = 1.015, 95%CI: 1.002-1.028, p = 0.021) were risk factors for SCD, and subsequent sensitivity analysis confirmed this result after adjustment for ASA grade, height, and weight.

CONCLUSION

Patients with SCD are more likely to develop POD undergoing total hip replacement, and SCD can mediate the occurrence of POD via P-tau.

CLINICAL TRIAL REGISTRATION

This study was registered at China Clinical Trial Registry (Chictr2000033439).

The absence of dominant alpha-oscillatory EEG activity during emergence from delta-dominant anesthesia predicts neurocognitive impairment- results from a prospective observational trial

STUDY OBJECTIVE

Postoperative neurocognitive disorders (PND) are common complications after surgery under general anesthesia. In our aging society the incidence of PND will increase. Hence, interdisciplinary efforts should be taken to minimize the occurrence of PND. Electroencephalographic (EEG) monitoring of brain activity during anesthesia or emergence from anesthesia is a promising tool to identify patients at risk. We therefore investigated whether we could identify specific EEG signatures during emergence of anesthesia that are associated with the occurrence of PND.

DESIGN AND PATIENTS

We performed a prospective observational investigation on 116 patients to evaluate the EEG features during emergence from general anesthesia dominated by slow delta waves in patients with and without delirium in the postoperative care unit (PACU-D) as assessed by the CAM-ICU and the RASS.

MAIN RESULTS

During emergence both the frontal and global EEG of patients with PACU-D were significantly different from patients without PACU-D. PACU-D patients had lower relative alpha power and reduced fronto-parietal alpha coherence.

CONCLUSIONS

With our analysis we show differences in EEG features associated with anesthesia emergence in patients with and without PACU-D. Frontal and global EEG alpha-band features could help to identify patients with PACU-D.

CLINICAL TRIAL NUMBER

NCT03287401.

The effect of neostigmine on postoperative delirium after colon carcinoma surgery: a randomized, double-blind, controlled trial

Background

Postoperative delirium (POD) is a critical complication in patients accepting colon carcinoma surgery. Neostigmine, as a cholinesterase inhibitor, can enhance the transmission of cholinergic transmitters in synaptic space, and play an important role in maintaining the normal level of cognition, attention and consciousness. The objective of this study was to investigate the effect of neostigmine on POD and clinical prognosis.

Methods

A randomized, double-blind controlled trial was implemented in Qingdao Municipal Hospital Affiliated to Qingdao University. A total of 454 patients aged 40 to 90 years old accepted colon carcinoma surgery were enrolled between June 7, 2020, and June 7, 2021, with final follow-up on December 8, 2021. Patients were randomly assigned to two groups: the neostigmine group (group N) and the placebo group (group P), the patients in group N were injected with 0.04 mg/kg neostigmine and 0.02 mg/kg atropine intravenously. The primary endpoint was the incidence of POD, researchers evaluated the occurrence of POD by the Confusion Assessment Method (CAM) twice daily (at 10 a.m. and 2 p.m.) during the first 7 postoperative days, POD severity was assessed by the Memorial Delirium Assessment Scale (MDAS). The secondary endpoints were the extubating time, postanesthesia care unit (PACU) time, the incidence of various postoperative complications, length of hospital stays, and 6 months postoperative mortality.

Results

The incidence of POD was 20.20% (81/401), including 19.39% (38/196) in group N and 20.98% (43/205) in group P. There was no significant statistical significance in the incidence of POD between group N and group P (P > 0.05); Compared to group P, the extubating time and PACU time in group N were significantly reduced (P < 0.001), the incidence of postoperative pulmonary complications (POPCs) decreased significantly in group N (P < 0.05), while no significant differences were observed in postoperative hospital stay and mortality in 6 months between the two groups (P > 0.05).

Conclusion

For patients accepted colon carcinoma surgery, neostigmine did not significantly reduce the incidence of POD, postoperative mortality and postoperative hospital stay, while it indeed reduced the extubating time, PACU time and the incidence of POPCs.

Trial registration

The randomized, double-blind, controlled trial was registered retrospectively at www.chictr.org.cn on 07/06/2020 (ChiCTR2000033639).

The Age-adjusted Charlson Comorbidity Index predicts post-operative delirium in the elderly following thoracic and abdominal surgery: A prospective observational cohort study

Background

Post-operative delirium (POD) presents as a serious neuropsychiatric syndrome in the elderly undergoing thoracic and abdominal surgery, which is mostly associated with poor prognosis. The Age-adjusted Charlson Comorbidity Index (ACCI) has been widely recognized as an independently predictive factor for overall survival rate and mortality in various surgeries. However, no studies demonstrated the potential relationship between ACCI and POD. The current study was to explore the correlation between ACCI and POD, and determine the predictive effect of ACCI on POD in the elderly after thoracic and abdominal surgery.

Materials and methods

Total 184 patients (≥60 years) who underwent thoracic and abdominal surgery from 2021.10 to 2022.5 were enrolled in this prospective observational cohort study. ACCI was calculated by weighting comorbidities and age. POD was diagnosed using Confusion Assessment Method (CAM) twice a day in the first 3 days after surgery. The Visual Analog Scale (VAS) was applied to measure pre-operative and post-operative pain at rest and in motion. All demographic and perioperative data were compared in patients with POD and without POD. ACCI and other variables were analyzed by univariate and multivariate logistic regression analysis. The characteristic curve of receiver operating characteristic (ROC) was used to further evaluate the accuracy of ACCI to predict POD.

Results

Post-operative delirium was diagnosed in 36 of 184 patients included in our study. The prevalence of POD in the elderly after thoracic and abdominal surgery was 19.6%. The outcomes by multivariate regression analysis showed the independent risk factors for POD were ACCI (OR: 1.834; 95%CI: 1.434–2.344; P < 0.001), pre-operative Mini-Mental State Examination (MMSE) scores (OR: 0.873; 95%CI: 0.767–0.994; P = 0.040), serum albumin (OR: 0.909; 95%CI: 0.826–1.000; P = 0.049) and pain scores in the post-operative third day (OR: 2.013; 95%CI: 1.459–2.778; P < 0.001). ACCI can predict POD more accurately with the largest area under curve (AUC) of 0.794 and sensitivity of 0.861, respectively.

Conclusion

Age-adjusted Charlson Comorbidity Index, pre-operative MMSE scores, serum albumin and post-operative pain were independently associated with POD in geriatric patients following thoracic and abdominal surgery. Moreover, ACCI may become an accurate indicator to predict POD early.

Delirium in hospitalised adults with acute burns - A systematic review

INTRODUCTION

Delirium is a potentially modifiable, acutely altered mental state, commonly characterised as a hospital-acquired complication. Studies of adult inpatients with acute burns with and without delirium identify causative risks related to the injury or treatment and outcomes related to the patient and healthcare system. We compare patients with and without delirium, providing a high-level quantitative synthesis of delirium risks and outcomes to inform guidelines and future research.

METHODS

A systematic review, meta-analysis and GRADE evaluation of risks and outcomes associated with delirium in adults with acute burns was conducted using PRISMA guidelines and PROSPERO protocol CRD42021283055. The Newcastle-Ottawa Scale was used to assess quality.

RESULTS

Investigators reviewed ten studies. ASA score ≥ 3, Total Body Surface Area Percentage (TBSA)> 10%, surgery done, ICU admission, hospital and also Intensive Care Unit (ICU) lengths of stay all had statistically significant associations with delirium, with low-very low certainty on GRADE evaluation. Limitations were heterogeneous studies, review methodology and study bias.

CONCLUSION

Delirium represents a significant risk to comorbid patients with burns that are hospitalised, receive ICU care, and surgery. Further research is indicated to precisely categorise delirium along the clinical journey to identify modifiable factors, prevention, and proactive therapy.

Impact of combined epidural anaesthesia/analgesia on postoperative cognitive impairment in patients receiving general anaesthesia: a meta-analysis of randomised controlled studies

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.

The assessment of risk factors for postoperative delirium using cubic spline curves in gastroenterological surgery

PURPOSE

Delirium is associated with longer hospital stays and increased medical costs and mortality. This study explored the risk factors for postoperative delirium in gastroenterological surgery and investigated the association between qualitative changes in risk factors and the incidence of postoperative delirium.

METHODS

A total of 418 patients > 18 years old who underwent gastroenterological surgery at our department between April 2018 and September 2019 were included. Risk factors were identified by comparing patients with and without postoperative delirium. Continuous variables were evaluated graphically using cubic spline curves. A logistic regression analysis was performed to assess independent risk factors.

RESULTS

The incidence of postoperative delirium was 6.9%. The cubic spline curve showed that the incidence of postoperative delirium began to increase at 50 years old and increased sharply at 70 years old. A multiple logistic regression analysis of patients > 50 years old identified 5 risk factors: age ≥ 70 years, preoperative serum albumin ≤ 3.8 g/dL, psychosis, sedative-hypnotics, and intensive-care unit admission.

CONCLUSION

The risk of postoperative delirium increases progressively at 50 years old and sharply at 70 years old. Advanced age, preoperative hypoalbuminemia, psychosis, sedative-hypnotics, and intensive-care unit admission are risk factors for postoperative delirium in patients > 50 years old undergoing gastroenterological surgery.

Enhanced Recovery After Surgery in Older Adults Undergoing Colorectal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Enhanced recovery after surgery is increasingly applied in older adults undergoing colorectal surgery.

OBJECTIVE

This systematic review and meta-analysis evaluated the impact of enhanced recovery protocols on clinical outcomes including hospital-acquired geriatric syndromes in older adults undergoing colorectal surgery.

DATA SOURCES

This review was conducted according to PRISMA guidelines. Ovid MEDLINE, Embase, PsycINFO, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and trial registry databases were searched (January 1980 to April 2020).

STUDY SELECTION

Two researchers independently screened all articles for eligibility. Randomized controlled trials evaluating enhanced recovery protocols in older adults undergoing colorectal surgery were included.

INTERVENTION

The enhanced recovery protocol was utilized.

MAIN OUTCOME MEASURES

Primary outcomes of interest were functional decline and delirium. Other outcomes studied were length of stay, complications, readmission, mortality, gut function, mobilization, pain, reoperation, quality of life, and psychological status.

RESULTS

Seven randomized trials (n = 1277 participants) were included. In terms of hospital-acquired geriatric syndromes, functional decline was reported in 1 study with benefits reported in enhanced recovery after surgery participants, and meta-analyses showed reduced incidence of delirium (risk ratio, 0.45; 95% CI, 0.21-0.98). Meta-analyses also showed reduction in urinary tract infections (risk ratio, 0.53; 95% CI, 0.31-0.90), time to first flatus (standardized mean differences, -1.00; 95% CI, -1.98 to -0.02), time to first stool (standardized mean differences, -0.59; 95% CI, -0.76 to -0.42), time to mobilize postoperatively (standardized mean differences, -0.92; 95% CI, -1.27 to -0.58), time to achieve pain control (standardized mean differences, -0.59; 95% CI, -0.90 to -0.28), and hospital stay (mean differences, -2.20; 95% CI, -3.46 to -0.94).

LIMITATIONS

The small number of randomized trials in older adults is a limitation of this study.

CONCLUSIONS

Enhanced recovery protocols in older adults undergoing colorectal surgery appear to reduce the incidence of delirium and functional decline, 2 important hospital-acquired geriatric syndromes, as well as to improve other clinical outcomes. Future research should measure these geriatric syndromes and focus on high-risk older adults including those with frailty.

A clinical risk analysis of early post-operative delirium after laparoscopic colorectal cancer surgery in elderly patients: a retrospective study

PURPOSE

Early post-operative delirium (EPOD) is a frequent complication following colorectal surgery. The present study investigated the risk factors for EPOD after laparoscopic colorectal surgery in elderly patients.

METHODS

A retrospective study was conducted among 208 patients ≥70 years old who underwent laparoscopic colorectal surgery. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with the EPOD.

RESULTS

The overall incidence of EPOD was 10.1% (21/208). The univariate analysis showed that an older age (≥80 years old; P=0.002), sleeping pill medication before surgery (P=0.037), a history of dementia (P=0.030) and cerebrovascular disease (P=0.017), elevated levels of D-dimer (P=0.016), maximum intraoperative temperature ≥37 °C (P=0.036), and non-continuous usage of droperidol with analgesia (P=0.005) were associated with EPOD. The multivariate logistic regression analysis revealed an older age (≥80 years old; odds ratio [OR]: 6.26, 95% confidence interval [CI]: 1.94-20.15, P=0.002), sleeping pill medication before surgery (OR: 5.39, 95% CI: 1.36-21.28, P=0.016), history of cerebrovascular disease (OR: 3.91, 95% CI: 1.12-13.66, P=0.033), and maximum intraoperative temperature ≥37 °C (OR: 5.10, 95% CI: 1.53-16.92, P=0.008) to be independent risk factors. When the patients were divided into groups according to the number of positive risk factors, the prevalence rate was 6.5%, 16.0%, and 63.6% for patients with 1, 2, and 3 positive risk factors, respectively.

CONCLUSION

Our findings suggest that an older age, sleeping pill medication before surgery, history of cerebrovascular disease, and maximum intraoperative temperature ≥37 °C are independent risk factors of EPOD after laparoscopic colorectal surgery in elderly patients.

The risk factors for postoperative delirium in adult patients after hip fracture surgery: a systematic review and meta-analysis

OBJECTIVES

Postoperative delirium (POD) is the most common complication in patients after hip fracture surgery, and the incidence of POD is associated with mortality and disability in patients following hip fracture surgery. Therefore, this study aimed to identify the individual as well as anesthetic and operative risk factors associated with the POD in adult patients after hip fracture surgery.

METHODS

We searched relevant articles published to February 2020 in Cochrane Library, PubMed, and Embase. Studies involving adult patients who underwent hip fracture surgery were regarded as relevant if the studies contained the individual or anesthetic and surgical characteristics of participants. The pooled relative risk ratios (RRs) or weight mean difference of the variables were estimated by the Mantel-Haenszel or Inverse-Variance methods.

RESULTS

A total of 44 studies were included, which altogether included 104572 participants with hip fracture surgery (17703 patients with POD and 86869 patients without POD) and the incidence of POD was 16.93%. A total of 14 risk factors, classified into two categories which were individual as well as anesthetic and operative factors, were identified originally, which included age (weight mean difference [WMD]:2.33;95% confidential interval [CI]: 1.64-3.03), sex (RR: 0.89; 95% CI:0.85-0.93), American society of Anesthesiologists classification(RR:0.56; 95%CI:0.51-0.59), body mass index (WMD:-0.62; 95%CI:-0.81 to -0.44), function dependency(RR:1.52; 95% CI:1.24-1.87), visual impairment (RR:1.62; 95% CI: 1.16-2.27), smoking (RR:0.86; 95% CI:0.79-0.94), preoperative delirium (RR: 2.71; 95% CI: 2.50-2.72), dementia (RR:2.60; 95% CI:2.50-2.72), hypertension (RR: 1.10; 95% CI:1.04-1.15), chronic obstructive pulmonary disease (RR:1.08; 95% CI: 1.01-1.16), regional anesthesia (RR:1.20; 95% CI: 1.01-1.43), transfusion (RR: 1.41; 95% CI: 1.22-1.63), and elective surgery (RR: 0.91; 95% CI: 0.84-0.99).

CONCLUSIONS

Patients possessed above risk factors might be high-risk patients. Clinician should maintain keen vigilance at those patients.

Emergence delirium is associated with increased postoperative delirium in elderly: a prospective observational study

Background

The clinical significance of emergence delirium remains unclear. The purpose of this study was to investigate the association between emergence delirium and postoperative delirium in elderly after general anesthesia and surgery.

Methods

This prospective observational study was done in a tertiary hospital in Beijing, China. Elderly patients (65–90 years) who underwent major noncardiac surgery under general anesthesia and admitted to the postanesthesia care unit (PACU) after surgery were enrolled. Emergence delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit during PACU stay. Postoperative delirium was assessed with the Confusion Assessment Method during the first 5 postoperative days. The association between emergence delirium and postoperative delirium was analyzed with a multivariable logistic regression model.

Results

A total of 942 patients were enrolled and 915 completed the study. Emergence delirium developed in 37.0% (339/915) of patients during PACU stay; and postoperative delirium developed in 11.4% (104/915) of patients within the first 5 postoperative days. After adjusted confounding factors, the occurrence of emergence delirium is independently associated with an increased risk of postoperative delirium (OR 1.717, 95% CI 1.078–2.735, P = 0.023). Patients with emergence delirium stayed longer in PACU and hospital after surgery, and developed more non-delirium complications within 30 days.

Conclusions

Emergence delirium in elderly admitted to the PACU after general anesthesia and major surgery is independently associated with an increased risk of postoperative delirium. Patients with emergence delirium had worse perioperative outcomes.

Chinese Clinical Trial Registry (chictr.org.cn) ChiCTR-OOC-17012734

Electronic supplementary material

The online version of this article (10.1007/s00540-020-02805-8) contains supplementary material, which is available to authorized users.