Risk factors and outcome of postoperative delirium after transcatheter aortic valve replacement

Incidence and related risk factors for postoperative delirium following revision total knee arthroplasty: a retrospective nationwide inpatient sample database study

BACKGROUND

Postoperative delirium (POD) is a common surgical complication. However, the incidence and risk factors associated with postoperative delirium after revision total knee arthroplasty (rTKA) have not been comprehensively explored through extensive national databases.

METHODS

Utilizing the National Inpatient Sample (NIS), the largest comprehensive U.S. hospital healthcare database, we undertook a retrospective investigation involving 127,400 patients who underwent rTKA between 2010 and 2019. We assessed various aspects, including patient demographics, hospital characteristics, pre-existing medical conditions, and perioperative complications.

RESULTS

The overall incidence of postoperative delirium (POD) in patients undergoing rTKA between 2010 and 2019 was 0.97%. The highest incidence rate of 1.31% was recorded in 2013. Notably, this patient cohort demonstrated advanced age, increased burden of co-morbidities, prolonged hospital stays, increased hospitalization costs, and elevated in-hospital mortality rates (P < 0.001). Moreover, non-elective admissions, non-private insurance payments, and a preference for teaching hospitals were commonly observed among these patients. During their hospitalization, individuals who developed delirium subsequent to rTKA were more prone to experiencing certain perioperative complications. These complications encompassed medical issues like acute myocardial infarction, continuous invasive mechanical ventilation, postoperative shock, sepsis, stroke and other medical problems. Additionally, surgical complications including hemorrhage / seroma / hematoma, irrigation and debridement, prosthetic joint infection, periprosthetic fracture, and wound dehiscence / nonunion were noted. Several risk factors were found to be linked with the development of POD. These included advanced age (≥ 75 years), alcohol abuse, coagulation disorders, congestive heart failure, depression, fluid and electrolyte imbalances, and more. Conversely, female sex, having private insurance, and undergoing elective hospitalization emerged as protective factors against POD.

CONCLUSION

Our findings suggest that the general prevalence of POD in rTKA is relatively low according to NIS. There was a significant connection between the POD of rTKA and advanced age, prolonged length of stay (LOS), more in-patients' costs, higher in-hospital mortality rate, increased comorbidities, postoperative medical complications and postoperative surgical complications. This study helps to understand the risk factors associated with POD to improve poor outcomes.

Postoperative delirium after transcatheter aortic valve replacement: An updated systematic review and meta-analysis

AIMS

To perform an updated systematic review and meta-analysis of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR).

METHODS

We conducted a systematic literature search of PubMed, Embase, and Cochrane Library databases from the time of the first human TAVR procedure in 2002 until December 24, 2021, which was supplemented by manual searches of bibliographies. Data were collected on incidence rates, risk factors, and/or associated mortality of POD after TAVR. Pooled analyses were conducted using random effects models to yield mean differences, odds ratios, hazard ratios, and risk ratios, with 95% confidence intervals.

RESULTS

A total of 70 articles (69 studies) comprising 413,389 patients were included. The study heterogeneity was substantial. The pooled mean incidence of POD after TAVR in all included studies was 9.8% (95% CI: 8.7%-11.0%), whereas that in studies using validated tools to assess for delirium at least once a day for at least 2 consecutive days after TAVR was 20.7% (95% CI: 17.8%-23.7%). According to the level of evidence and results of meta-analysis, independent preoperative risk factors with a high level of evidence included increased age, male sex, prior stroke or transient ischemic attack, atrial fibrillation/flutter, weight loss, electrolyte abnormality, and impaired Instrumental Activities of Daily Living; intraoperative risk factors included non-transfemoral access and general anesthesia; and acute kidney injury was a postoperative risk factor. POD after TAVR was associated with significantly increased mortality (pooled unadjusted RR: 2.20, 95% CI: 1.79-2.71; pooled adjusted RR: 1.62, 95% CI: 1.25-2.10), particularly long-term mortality (pooled unadjusted HR: 2.84, 95% CI: 1.91-4.23; pooled adjusted HR: 1.88, 95% CI: 1.30-2.73).

CONCLUSIONS

POD after TAVR is common and is associated with an increased risk of mortality. Accurate identification of risk factors for POD after TAVR and implementation of preventive measures are critical to improve prognosis.

Prediction model for delirium in patients with cardiovascular surgery: development and validation

BACKGROUND

The aim of this study was to construct a nomogram model for discriminating the risk of delirium in patients undergoing cardiovascular surgery.

METHODS

From January 2017 to June 2020, we collected data from 838 patients who underwent cardiovascular surgery at the Affiliated Hospital of Nantong University. Patients were randomly divided into a training set and a validation set at a 5:5 ratio. A nomogram model was established based on logistic regression. Discrimination and calibration were used to evaluate the predictive performance of the model.

RESULTS

The incidence of delirium was 48.3%. A total of 389 patients were in the modelling group, and 449 patients were in the verification group. Logistic regression analysis showed that CPB duration (OR [Formula: see text] 1.004, 95% CI: 1.001-1.008, [Formula: see text] 0.018), postoperative serum sodium (OR [Formula: see text] 1.112, 95% CI: 1.049-1.178, [Formula: see text] 0.001), age (OR [Formula: see text] 1.027, 95% CI: 1.006-1.048, [Formula: see text] 0.011), and postoperative MV (OR [Formula: see text] 1.019, 95% CI: 1.008-1.030, [Formula: see text] 0.001) were independent risk factors. The results showed that AUC[Formula: see text] was 0.712 and that the 95% CI was 0.661-0.762. The Hosmer-Lemeshow goodness of fit test showed that the predicted results of the model were in good agreement with the actual situation ([Formula: see text] 6.200, [Formula: see text] 0.625). The results of verification showed that the AUC[Formula: see text] was 0.705, and the 95% CI was 0.657-0.752. The Hosmer-Lemeshow goodness of fit test results were [Formula: see text] 8.653 and [Formula: see text] 0.372, indicating that the predictive effect of the model is good.

CONCLUSIONS

The establishment of the model provides accurate and objective assessment tools for medical staff to start preventing postoperative delirium in a purposeful and focused manner when a patient enters the CSICU after surgery.

Outcomes of postoperative delirium in patients undergoing cardiac surgery: A systematic review and meta-analysis

Background

Postoperative delirium (POD) is an acute brain dysfunction that is frequently observed in patients undergoing cardiac surgery. Increasing evidence indicates POD is related to higher mortality among cardiac surgical patients, but the results remain controversial. Moreover, a quantitative evaluation of the influence of POD on hospital days, intensive care unit (ICU) time, and mechanical ventilation (MV) time has not been performed.

Objective

This study aimed to evaluate the correlation between POD and outcomes in patients undergoing cardiac surgery by a systematic review and meta-analysis.

Materials and methods

A total of 7 electronic databases (Cochrane Library, PubMed, EMBASE, CINAHL Complete, MEDLINE, Wan-fang database, and China National Knowledge Infrastructure) were searched from January 1980 to July 20, 2021, with language restrictions to English and Chinese, to estimate the impact of the POD on outcome in patients who underwent cardiac surgery. The meta-analysis was registered with PROSPERO (Registration: CRD42021228767).

Results

Forty-two eligible studies with 19785 patients were identified. 3368 (17.0%) patients were in the delirium group and 16417 (83%) were in the non-delirium group. The meta-analysis showed that compared to patients without POD, patients with POD had 2.77-fold higher mortality (OR = 2.77, 95% CI 1.86-4.11, P < 0.001), 5.70-fold higher MV (>24h) rate (OR = 5.70, 95% CI 2.93-11.09, P < 0.001); and longer MV time (SMD = 0.83, 95% CI 0.57-1.09, P < 0.001), ICU time (SMD = 0.91, 95% CI 0.60-1.22, P < 0.001), hospital days (SMD = 0.62, 95% CI 0.48-0.76, P < 0.001).

Conclusion

The synthesized evidence suggests that POD is causally related to the increased risk of mortality, prolonged length of ICU and hospital stay, and a longer duration of MV time. Future research should focus on the interventions for POD, to reduce the incidence.

Systematic review registration

[www.crd.york.ac.uk/PROSPERO], identifier [CRD42021228767].

Construction and Application of a Model for Predicting the Risk of Delirium in Postoperative Patients With Type a Aortic Dissection

Background: Postoperative delirium (POD), an alteration in a patient's consciousness pattern, can affect the treatment and prognosis of a disease.

Objective: To construct a prediction model for delirium in patients with type A aortic dissection after surgery and to validate its effectiveness.

Methods: A retrospective cohort design was used to study 438 patients undergoing surgical treatment for type A aortic dissection from April 2019 to June 2020 in tertiary care hospitals. POD (n = 78) and non-delirium groups (n = 360) were compared and analyzed for each index in the perioperative period. A prediction model was established using multifactorial logistic regression, and 30 patients' perioperative data were collected for model validation.

Results: Eight predictors were included in this study: smoking, diabetes, previous cardiovascular surgery, ejection fraction (EF), time to aortic block, acute kidney injury, low cardiac output syndrome, and pulmonary complications. The area under the receiver operating characteristic (ROC) curve of the constructed prediction model was 0.98 ± 0.005, and the Youden index was 0.91. The validation results showed 97% sensitivity, 100% specificity, and 93% accuracy. The expression of the model was Z = Smoking assignment^* – 2.807 – 6.009^*Diabetes assignment – 2.994^*Previous cardiovascular surgery assignment – 0.129^*Ejection fraction assignment + 0.071^*Brain perfusion time assignment – 2.583^*Acute kidney injury assignment – 2.916^*Low cardiac output syndrome assignment – 3.461^*Pulmonary related complications assignment + 20.576.

Conclusion: The construction of an effective prediction model for the risk of delirium in patients after type A aortic stratification can help identify patients at high risk of POD early. It also provides a reference for healthcare professionals in the prevention and care of these patients.

Length of Stay in Older Patients Undergoing Transcatheter Aortic Valve Replacement: Value of a Geriatric Approach

BACKGROUND

For patients with transcatheter aortic valve replacement (TAVR), increased length of stay (LOS) is associated with increased long-term mortality. The main objective of our study was to analyze the association between geriatrics factors and the hospital LOS for older patients undergoing TAVR for severe aortic stenosis.

METHODS

This retrospective single-center study included all patients aged ≥75 who underwent TAVR between January 2018 and January 2019. Hospital LOS and postoperative complications were analyzed regarding the geriatric factors recorded during a systematic preoperative, comprehensive geriatric assessment (CGA). The individualized-care plans established after the preoperative CGA were also analyzed.

RESULTS

median LOS of the 196 patients included was 6 days (interquartile range: 4-8), and 29% of patients had prolonged LOS. In a multivariable analysis, the preoperative factors associated with a prolonged hospital LOS were EuroSCORE I (p value = 0.02), prior major neurocognitive disorders (p value = 0.01), femoral access (p value <0.001), all complications (p value <0.001), and discharge in a rehabilitation center (p value <0.001). One-fourth (27%) of the patients had at least 1 geriatric complication. After CGA, 69 patients did not need any geriatric recommendation, whereas for the 127 other patients, an individualized-care plan was established but only 46 (36%) of them were followed up.

CONCLUSION

Our results favor the preoperative screening for major neurocognitive disorders in order to reduce LOS. Furthermore, the proposed individual-care plans after CGA were poorly followed. Practitioners may perceive the preoperative CGA as a screening tool, but its primary objective is to develop an individualized-care plan as a prehabilitation plan in order to optimize the physical, functional, and social issues.

Predisposing and Precipitating Risk Factors for Delirium in Elderly Patients Admitted to a Cardiology Ward: An Observational Cohort Study in 1,042 Patients

Aim: Although the risk factors for delirium in general medicine are well-established, their significance in cardiac diseases remains to be determined. Therefore, we evaluated the predisposing and precipitating risk factors in patients hospitalized with acute and chronic heart disease.

Methods and Results: In this observational cohort study, 1,042 elderly patients (≥65 years) admitted to cardiology wards, 167 with and 875 without delirium, were included. The relevant sociodemographic and cardiac- and medical-related clusters were assessed by simple and multiple regression analyses and prediction models evaluating their association with delirium. The prevalence of delirium was 16.0%. The delirious patients were older (mean 80 vs. 76 years; p < 0.001) and more often institutionalized prior to admission (3.6 vs. 1.4%, p = 0.05), hospitalized twice as long (12 ± 10 days vs. 7 ± 7 days; p < 0.001), and discharged more often to nursing homes (4.8 vs. 0.6%, p < 0.001) or deceased (OR, 2.99; 95% CI, 1.53–5.85; p = 0.003). The most relevant risk factor was dementia (OR, 18.11; 95% CI, 5.77–56.83; p < 0.001), followed by history of stroke (OR, 6.61; 95% CI 1.35–32.44; p = 0.020), and pressure ulcers (OR, 3.62; 95% CI, 1.06–12.35; p = 0.040). The predicted probability for developing delirium was highest in patients with reduced mobility and institutionalization prior to admission (PP = 31.2%, p = 0.001). Of the cardiac diseases, only valvular heart disease (OR, 1.57; 95% CI, 1.01–2.44; p = 0.044) significantly predicted delirium. The patients undergoing cardiac interventions did not have higher rates of delirium (OR, 1.39; 95% CI 0.91–2.12; p = 0.124).

Conclusion: In patients admitted to a cardiology ward, age-related functional and cognitive impairment, history of stroke, and pressure ulcers were the most relevant risk factors for delirium. With regards to specific cardiological factors, only valvular heart disease was associated with risk for delirium. Knowing these factors can help cardiologists to facilitate the early detection and management of delirium.

The Use and Outcomes of Cerebral Protection Devices for Patients Undergoing Transfemoral Transcatheter Aortic Valve Replacement in Clinical Practice

OBJECTIVES

This study hypothesized that cerebral protection prevents strokes in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR) in clinical practice.

BACKGROUND

Preventing strokes is an important aim in TAVR procedures. Embolic protection devices may protect against cardiac embolism during TAVR, but their use and outcomes in clinical practice remain controversial.

METHODS

Isolated transfemoral TAVR procedures performed in Germany with or without cerebral protection devices were extracted from a comprehensive nationwide billing dataset.

RESULTS

A total of 41,654 TAVR procedures performed between 2015 and 2017 were analyzed. The overall share of procedures incorporating cerebral protection devices was 3.8%. Patients receiving cerebral protection devices were at increased operative risk (European System for Cardiac Operative Risk Evaluation score 13.8 vs. 14.7; p < 0.001) but of lower age (81.1 vs. 80.6 years; p = 0.001). To compare outcomes that may be related to the use of cerebral protection devices, a propensity score comparison was performed. The use of a cerebral protection device did not reduce the risk for stroke (adjusted risk difference [aRD]: +0.88%; 95% confidence interval [CI]: -0.07% to 1.83%; p = 0.069) or the risk for developing delirium (aRD: +1.31%; 95% CI: -0.28% to 2.89%; p = 0.106) as a sign of acute brain failure. Although brain damage could not be prevented, in-hospital mortality was lower in the group receiving a cerebral protection device (aRD: -0.76%; 95% CI: -1.46% to -0.06%; p = 0.034).

CONCLUSIONS

In this large national database, cerebral embolic protection devices were infrequently used during TAVR procedures. Device use was associated with lower mortality but not a reduction in stroke or delirium. Future studies are needed to confirm these findings.

Incidence, Risk Factors and Impact on Long-Term Outcome of Postoperative Delirium After Transcatheter Aortic Valve Replacement

Background: The aim of the present study was to analyze incidence, risk factors, and association with long-term outcome of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR).

Methods: Six hundred and sixty one consecutive patients undergoing TAVR were prospectively enrolled from January 2016 to December 2017. POD was assessed regularly during ICU-stay using the CAM-ICU test.

Results: The incidence of POD was 10.0% (n = 66). Patients developing POD were predominantly male (65%), had higher EuroSCORE II (5.4% vs. 3.9%; P = 0.041) and were more often considered frail (70% vs. 26%; P < 0.001). POD was associated with more peri-procedural complications including vascular complications (19.7 vs. 9.4; P = 0.017), bleeding (12.1 vs. 5.4%; P = 0.0495); stroke (4.5 vs. 0.7%; P = 0.025), respiratory failure requiring ventilation (16.7% vs. 1.8%; P < 0.001), and pneumonia (34.8% vs. 7.1%; P < 0.001). Consequently, patients with POD had significantly longer ICU- (7.9 vs. 3.2 days P < 0.001) and hospital-stay (14.9 vs. 9.0 days; P < 0.001), and higher in-hospital mortality (6.1 vs. 2.1%; P = 0.017). Logistic regression analysis identified male sex (odds ratio (OR) 2.2 [95% confidence interval (CI) 1.2–4.0); P = 0.012], atrial fibrillation [OR 3.0 (CI 1.6–5.6); P < 0.001], frailty [OR 4.3 (CI 2.4–7.9); P < 0.001], pneumonia [OR 4.4 (CI 2.3–8.7); P < 0.001], stroke [OR 7.0 (CI 1.2–41.6); P = 0.031], vascular complication [OR 2.9 (CI 1.3–6.3); P = 0.007], and general anesthesia [OR 2.0 (CI 1.0–3.7); P = 0.039] as independent predictors of POD. On Cox proportional hazard analysis POD emerged as a significant predictor of 2-year mortality [HR 1.89 (CI 1.06–3.36); P = 0.030].

Conclusion: POD is a frequent finding after TAVR and is significantly associated with reduced 2-year survival. Predictors of delirium include not only peri-procedural parameters like stroke, pneumonia, vascular complications and general anesthesia but also baseline characteristics as male sex, atrial fibrillation and frailty.

Risk-Adjusted Comparison of In-Hospital Outcomes of Transcatheter and Surgical Aortic Valve Replacement

Background

Transfemoral transcatheter aortic valve replacement (TF‐TAVR) is recommended for patients suffering from aortic valve stenosis at increased operative risk. Beyond that, patients with different comorbidities could benefit from TF‐TAVR. The present study compares real‐world in‐hospital outcomes of surgical aortic valve replacement and TF‐TAVR.

Methods and Results

For all 33 789 isolated TF‐TAVR and surgical aortic valve replacement procedures performed in Germany in 2014 and 2015, comorbidities and in‐hospital outcomes were identified by International Classification of Diseases (ICD)‐ and OPS (Operation and procedure key)‐codes. Patients undergoing TF‐TAVR were older and at increased estimated risk. Outcomes were risk‐adjusted to allow comparison. TF‐TAVR was associated with a lower risk for acute kidney injuries (odds ratio [OR] 0.62, P<0.001), for bleeding (OR 0.17, P<0.001), and for prolonged mechanical ventilation (>48 hours, OR 0.21, P<0.001). Risk for stroke was similar (OR 1.07, P=0.558). As expected, the risk for pacemaker implantations was higher after TF‐TAVR (OR 4.61, P<0.001). In all patients, none of the treatment strategies had a clear advantage on the risk for in‐hospital mortality (OR 0.83, P=0.068). However, in patients aged >80 years and at high operative risk undergoing TF‐TAVR in‐hospital mortality was lower (TF‐TAVR versus surgical aortic valve replacement 80–84, OR 0.55; P=0.002; ≥85 years, OR 0.42, P=0.006; EuroSCORE (European System for Cardiac Operative Risk Evaluation) >9: OR 0.62, P=0.001). TF‐TAVR was superior in patients with renal failure and in NYHA (New York Heart Association)‐Class III/IV. Other risk groups were not found to be factors favoring a treatment strategy.

Conclusions

The present study indicates a superiority of TF‐TAVR in clinical practice for patients at increased operative risk, aged >80 years, in NYHA‐Class III/IV, and with renal failure.

Trends and effect of atrial fibrillation on inpatient outcomes after transcatheter aortic valve replacement

Background

Atrial fibrillation (AF) is common in patients undergoing transcatheter aortic valve replacement (TAVR) but there is conflicting evidence on whether AF impacts outcomes after TAVR.

Methods

Hospitalizations of adults ≥50 years old who had undergone elective TAVR from 2012 to 2015 were included. Poisson regression was used to assess changes in in-hospital complications, average length of stay (LOS) after TAVR, and discharge disposition over time. Multivariable logistic, linear, and generalized logistic regression models, adjusting for patient and hospital characteristics, were used to estimate the effect of AF on inpatient outcomes.

Results

A total of 7,266 TAVR hospitalizations were included; AF was present in 44% of patients. Between 2012 and 2015, there was a significant decrease in the incidence of acute kidney injury, blood transfusion, average LOS, and inpatient mortality both for AF and non-AF patients. However, the incidences of vascular complications and major bleeding decreased only among non-AF patients. After adjustment, AF was associated with increased incidences of TIA/stroke (OR 1.36, 95% CI: 1.01, 1.85), acute kidney injury (OR 1.54, 95% CI: 1.33, 1.78), blood transfusion (OR 1.14, 95% CI: 1.00, 1.30), transfer to a skilled nursing facility (OR 1.38, 95% CI: 1.23, 1.55), and longer average LOS (CIE 1.30, 95% CI: 1.06, 1.54). AF was not associated with inpatient mortality (OR 1.09, 95% CI: 0.81, 1.48).

Conclusions

AF is prevalent among patients undergoing TAVR, and is associated with higher incidences of inpatient complications, discharge to a skilled nursing facility, and longer average LOS. While the incidence of many complications has declined in the past few years, continued efforts to further reduce complications in patients with AF is urgently required for expansion of TAVR to broader populations.

A logistic regression analysis comparing minimalistic approach and intubation anaesthesia in patients undergoing transfemoral transcatheter aortic valve replacement

Aims

Patients with postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR) are ventilated and hospitalized longer and suffer increased in-hospital mortality. This study hypothesized that a minimalistic approach with conscious sedation during transfemoral aortic valve replacement (TF-AVR) protects against delirium, time of mechanical ventilation, and increased length of stay in intensive care unit (ICU) compared to intubation anaesthesia.

Methods and results

308 patients which underwent TF-AVR in our centre between 01/2013 and 08/2017 were retrospectively evaluated regarding postoperative delirium, time of mechanical ventilation, and days in ICU. TF-AVR was performed with intubation anaesthesia in 245 patients and with conscious sedation in 63. The operative risk estimated by the logEUROScore was similar in both groups (intubation: 13.28 +/-9.06%, conscious sedation: 12.24 +/-6.77%, p = 0.395). In the conscious sedation group procedure duration was shorter (0.61 +/-0.91h vs. 1.75 +/-0.96h, p<0.001). The risk for intraprocedural complications was not influenced by the anaesthesia method (OR conscious sedation instead of intubation 1.66, p = 0.117), but days on ICU (-2.21 days, p<0.0001) and minutes of mechanical ventilation (-531.2 min, p < 0.0001) were reduced. Furthermore, the risk of POD was decreased when TF-AVR was performed under conscious sedation (6.35% vs. 18.18%, OR 0.29, p = 0.021).

Conclusions

Time of mechanical ventilation, risk of POD, and days on ICU were substantially reduced in patients who underwent TF-AVR under conscious sedation. Our data suggest that TF-AVR with conscious sedation is safe with a beneficial postoperative course in clinical practice, and should be considered the favoured approach.

Delirium After Transcatheter Aortic Valve Implantation Under General Anesthesia: Incidence, Predictors, and Relation to Long-Term Survival

BACKGROUND/OBJECTIVES

Prospectively collected data on postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) are scarce. The aim of this study was to report the incidence and risk factors of delirium after TAVI under general anesthesia and to assess the association of POD with clinical outcome and short‐ and long‐term survival.

DESIGN

Prospective cohort study.

SETTING

Academic medical center.

PARTICIPANTS

A total of 703 subsequent patients undergoing TAVI under general anesthesia between 2008 and 2017.

MEASUREMENTS

Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV), criteria. Outcomes were postprocedural clinical outcome and short‐ and long‐term survival (30 days and 5 years, respectively).

RESULTS

POD was observed in 16.5% (116/703), was the strongest independent predictor of long‐term mortality (hazard ratio = 1.91; 95% confidence interval [CI] = 1.36‐2.70), and was associated with impaired 30‐day and 5‐year survival (92.2% vs 96.8% [P = .025] and 40.0% vs 50.0% [P = .007], respectively). Stroke and new onset of atrial fibrillation were more often observed in delirious patients (6.9% vs 1.9% and 12.1% vs 5.1%, respectively). Strongest independent predictors of POD were prior delirium (odds ratio [OR] = 2.56; 95% CI = 1.52‐4.31) and aortic valve area less than 0.75 cm² (OR = 2.39; 95% CI = 1.53‐3.74).

CONCLUSION

One in six patients experienced POD after TAVI under general anesthesia. POD was the strongest predictor of long‐term mortality and was associated with impaired short‐ and long‐term survival. Prior delirium and a more calcified aortic valve were the strongest independent predictors of POD. J Am Geriatr Soc 67:2325–2330, 2019

Risk Factors for Postoperative Delirium in Type A Aortic Dissection Patients: A Retrospective Study

BACKGROUND Postoperative delirium (POD) is a common complication in cardiac surgery among adult patients. This retrospective study was designed to identify the risk factors associated with POD of type A aortic dissection patients. MATERIAL AND METHODS Clinical data of 148 patients with type A aortic dissection in the Department of Critical Care Medicine was retrospectively analyzed. All these patients underwent Sun's procedure with anesthetic treatment. The confusion assessment method for intensive care unit (CAM-ICU) was adapted to evaluate the delirium status of these patients. They were divided into 2 groups: the delirium group and the control group. Univariate analysis and multivariate logistic regression were performed in succession to determine the independent risk factors for POD. RESULTS The average age of these patients was 54.41±11.676 years old. Among the 148 patients, POD was detected in 68 patients, with an incidence of 45.95%. According to univariate analysis, age, irritability, alcohol use, extracorporeal circulation duration (cardiopulmonary bypass, CPB time), antegrade selective cerebral perfusion (ASCP) time, lowest partial pressure of oxygen (lowest PO2), mechanical ventilation time, blood loss, low PO₂ and oxygenation index, hemoglobin (Hb), Intensive Care Unit (ICU) stay, and dihydroxyphenylalanine (DEX) were associated with higher odds of POD among type A aortic dissection patients. According to further analysis of multivariate logistic regression, ASCP time and irritability were confirmed as the independent factors for POD of type A aortic dissection patients. CONCLUSIONS We determined 2 independent risk factors for POD: ASCP time and irritability. Identifying and adjusting these risk factors are very important in reducing the incidence of POD among type A aortic dissection patients.

Handover of anesthesia care is associated with an increased risk of delirium in elderly after major noncardiac surgery: results of a secondary analysis

In patients undergoing major surgery, complete handover of intraoperative anesthesia care is associated with adverse postoperative outcomes including high mortality and more major complications. The purpose of this study was to explore the association between the intraoperative complete handover between anesthesiologists and the occurrence of postoperative delirium. This was a secondary analysis of the database of a previously published clinical trial. Seven hundred patients aged 65 years or older, who were admitted to the intensive care unit after noncardiac surgery, were included. Delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit twice daily during the first 7 postoperative days. Other postoperative outcomes were also monitored. The association between the intraoperative complete handover of anesthesia care and the development of postoperative delirium was analyzed with a logistic regression model. Of the 700 enrolled patients, 111 (15.9%) developed postoperative delirium within 7 days. After correction for confounding factors, intraoperative complete handover between anesthesiologists was associated with an increased risk of postoperative delirium (OR 1.787, 95% CI 1.012–3.155, P = 0.046). Patients with intraoperative complete handover also had higher incidence of non-delirium complications (P = 0.003) and stayed longer in hospital after surgery (P = 0.002). For elderly patients admitted to the intensive care unit after noncardiac surgery, intraoperative complete handover of anesthesia care was associated with an increased risk of postoperative delirium. Chinese Clinical Trial Registry (http://www.chictr.org.cn): ChiCTR-TRC-10000802.

Functional capacity as a predictor of postoperative delirium in transurethral resection of prostate patients in Northeast Brazil

INTRODUCTION

Postoperative delirium (POD) is a common disorder and its frequency varies from 15% to 25% after major elective surgery. There are few data on the incidence of POD in Brazil. Here, we sought to assess the incidence of POD following transurethral resection of the prostate (TURP) and to examine precipitating and predisposing factors associated.

METHOD

We performed a prospective observational study of elderly male patients undergoing TURP (N=55) in Northeast Brazil. Information on demographic, medical, cognitive and functional characteristics were collected. The participants were followed until hospital discharge. POD was diagnosed by the Confusion Assessment Method.

RESULTS

A total of three participants (5.45%) were identified with POD. Episodes of delirium lasted 3±1 days. The study sample consisted of a healthy population. Patients with POD had longer hospital stay and more precipitating factors. The POD group showed statistically significant lower Barthel index score (p<0.001) and higher Pfeffer's Functional Activities Questionnaire scores (p<0.01).

CONCLUSION

Loss of functional capacity was associated with POD in a healthy population of elderly patients undergoing TURP.