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Zhang Y, Yu Y, Han Z, Diao L, Zhao R, Liu J, Luo Y, Wu H, Yang Y. Incidence and associated factors of delirium after primary total joint arthroplasty in elderly patients: A systematic review and meta-analysis. Medicine (Baltimore) 2024; 103:e38395. [PMID: 39259060 PMCID: PMC11142822 DOI: 10.1097/md.0000000000038395] [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: 10/16/2023] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND A total of 1.5% to 20.2% of total joint arthroplasty patients experience delirium. Until now, no formal systematic review or meta-analysis was performed to summarize the risk factors of delirium after primary total joint arthroplasty (TJA). METHODS A comprehensive search encompassing Medline, Embase, and the Cochrane central database was conducted, incorporating studies available up to June 2023. We systematically reviewed research on the risk factors contributing to delirium following TJA in elderly patients, without language restrictions. The methodological quality of the included studies was evaluated using the Newcastle-Ottawa Scale. Data synthesis through pooling and a meta-analysis were performed to analyze the findings. RESULTS A total of 23 studies altogether included 71,095 patients with primary TJA, 2142 cases of delirium occurred after surgery, suggesting the accumulated incidence of 3.0%. The results indicated that age, current smoker, heavy drinker, mini-mental state examination score, hypertension, diabetes mellitus, chronic kidney disease, history of stroke, coronary arterial disease, dementia, history of psychiatric illness, American Society of Anesthesiologists physical status III-IV, general anesthesia, anesthesia time, operative time, intraoperative blood loss, blood transfusion, β-blockers, ACEI drugs, use of psychotropic drugs, preoperative C-reactive protein level, and preoperative albumin level were significantly associated with postoperative delirium after primary TJA. CONCLUSIONS Related prophylaxis strategies should be implemented in the elderly involved with above-mentioned risk factors to prevent delirium after primary TJA.
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Affiliation(s)
- Yanju Zhang
- Nursing Department, Cangzhou People’s Hospital, Cangzhou, Hebei, People’s Republic of China
| | - Yanjie Yu
- Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
| | - Ziyu Han
- Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
| | - Li Diao
- Pharmacy Department, Cangzhou People’s Hospital, Cangzhou, Hebei, People’s Republic of China
| | - Runping Zhao
- Nursing Department, Cangzhou People’s Hospital, Cangzhou, Hebei, People’s Republic of China
| | - Jinzhu Liu
- Nursing Department, Cangzhou People’s Hospital, Cangzhou, Hebei, People’s Republic of China
| | - Yuhong Luo
- Oncology Department, Cangzhou People’s Hospital, Cangzhou, Hebei, People’s Republic of China
| | - Huiyuan Wu
- Nursing Department, Cangzhou People’s Hospital, Cangzhou, Hebei, People’s Republic of China
| | - Yanjiang Yang
- Trauma Emergency Center, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
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McGinigle KL, Spangler EL, Ayyash K, Arya S, Settembrini AM, Thomas MM, Dell KE, Swiderski IJ, Davies MG, Setacci C, Urman RD, Howell SJ, Garg J, Ljungvist O, de Boer HD. A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2023; 77:1295-1315. [PMID: 36931611 DOI: 10.1016/j.jvs.2023.01.018] [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: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 03/17/2023]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Olle Ljungvist
- Department of Surgery, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine, and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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An JY, Park JY, Cho J, Kim HE, Park J, Oh J. The Relationship between Delirium and Statin Use According to Disease Severity in Patients in the Intensive Care Unit. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2023; 21:179-187. [PMID: 36700324 PMCID: PMC9889904 DOI: 10.9758/cpn.2023.21.1.179] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/19/2022] [Accepted: 05/02/2022] [Indexed: 01/27/2023]
Abstract
Objective The aim of this study was to investigate the association between the use of statins and the occurrence of delirium in a large cohort of patients in the intensive care unit (ICU), considering disease severity and statin properties. Methods We obtained clinical and demographical information from 3,604 patients admitted to the ICU from January 2013 to April 2020. This included information on daily statin use and delirium state, as assessed by the Confusion Assessment Method for ICU. We used inverse probability of treatment weighting and categorized the patients into four groups based on the Acute Physiology and Chronic Health Evaluation II score (group 1: 0-10 - mild; group 2: 11-20 - mild to moderate; group 3: 21-30 - moderate to severe; group 4: > 30 - severe). We analyzed the association between the use of statin and the occurrence of delirium in each group, while taking into account the properties of statins. Results Comparisons between statin and non-statin patient groups revealed that only in group 2, patients who were administered statin showed significantly higher occurrence of delirium (p = 0.004, odds ratio [OR] = 1.58) compared to the patients who did not receive statin. Regardless of whether statins were lipophilic (p = 0.036, OR = 1.47) or hydrophilic (p = 0.032, OR = 1.84), the occurrence of delirium was higher only in patients from group 2. Conclusion The use of statins may be associated with the increases in the risk of delirium occurrence in patients with mild to moderate disease severity, irrespective of statin properties.
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Affiliation(s)
- Jun Yong An
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea,Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Young Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Korea,Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Jaehwa Cho
- Department of Pulmonary and Critical Care Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hesun Erin Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jaesub Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Korea,Department of Psychiatry, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jooyoung Oh
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea,Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Korea,Address for correspondence: Jooyoung Oh Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea, E-mail: , ORCID: https://orcid.org/0000-0001-6721-399X
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Zhao J, Liang G, Hong K, Pan J, Luo M, Liu J, Huang B. Risk factors for postoperative delirium following total hip or knee arthroplasty: A meta-analysis. Front Psychol 2022; 13:993136. [PMID: 36248575 PMCID: PMC9565976 DOI: 10.3389/fpsyg.2022.993136] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesThe purpose of this study was to identify risk factors for delirium after total joint arthroplasty (TJA) and provide theoretical guidance for reducing the incidence of delirium after TJA.MethodsThe protocol for this meta-analysis is registered with PROSPERO (CRD42020170031). We searched PubMed, the Cochrane Library and Embase for observational studies on risk factors for delirium after TJA. Review Manager 5.3 was used to calculate the relative risk (RR) or standard mean difference (SMD) of potential risk factors related to TJA. STATA 14.0 was used for quantitative publication bias evaluation.ResultsIn total, 25 studies including 3,767,761 patients from 9 countries were included. Old age has been widely recognized as a risk factor for delirium. Our results showed that the main risk factors for delirium after TJA were patient factors (alcohol abuse: RR = 1.63; length of education: SMD = −0.93; and MMSE score: SMD = −0.39), comorbidities (hypertension: RR = 1.26; diabetes mellitus: RR = 1.67; myocardial infarction: RR = 17.75; congestive heart failure: RR = 2.54; dementia: RR = 17.75; renal disease: RR = 2.98; history of stroke: RR = 4.83; and history of mental illness: RR = 2.36), surgical factors (transfusion: RR = 1.53; general anesthesia: RR = 1.10; pre-operative albumin: SMD = −0.38; pre-operative hemoglobin: SMD = −0.29; post-operative hemoglobin: SMD = −0.24; total blood loss: SMD = 0.15; duration of surgery: SMD = 0.29; and duration of hospitalization: SMD = 2.00) and drug factors (benzodiazepine use: RR = 2.14; ACEI use: RR = 1.52; and beta-blocker use: RR = 1.62).ConclusionsMultiple risk factors were associated with delirium after TJA. These results may help doctors predict the occurrence of delirium after surgery and determine the correct treatment.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier: CRD42020170031.
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Affiliation(s)
- Jinlong Zhao
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Guihong Liang
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Kunhao Hong
- Guangdong Second Traditional Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, China
| | - Jianke Pan
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Minghui Luo
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jun Liu
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Guangdong Second Traditional Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, China
- The Fifth Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- *Correspondence: Jun Liu
| | - Bin Huang
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Bin Huang
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Duprey MS, Devlin JW, Griffith JL, Travison TG, Briesacher BA, Jones R, Saczynski JS, Schmitt EM, Gou Y, Marcantonio ER, Inouye SK. Association Between Perioperative Medication Use and Postoperative Delirium and Cognition in Older Adults Undergoing Elective Noncardiac Surgery. Anesth Analg 2022; 134:1154-1163. [PMID: 35202006 PMCID: PMC9124692 DOI: 10.1213/ane.0000000000005959] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative delirium is frequent in older adults and is associated with postoperative neurocognitive disorder (PND). Studies evaluating perioperative medication use and delirium have generally evaluated medications in aggregate and been poorly controlled; the association between perioperative medication use and PND remains unclear. We sought to evaluate the association between medication use and postoperative delirium and PND in older adults undergoing major elective surgery. METHODS This is a secondary analysis of a prospective cohort study of adults ≥70 years without dementia undergoing major elective surgery. Patients were interviewed preoperatively to determine home medication use. Postoperatively, daily hospital use of 7 different medication classes listed in guidelines as risk factors for delirium was collected; administration before delirium was verified. While hospitalized, patients were assessed daily for delirium using the Confusion Assessment Method and a validated chart review method. Cognition was evaluated preoperatively and 1 month after surgery using a neurocognitive battery. The association between prehospital medication use and postoperative delirium was assessed using a generalized linear model with a log link function, controlling for age, sex, type of surgery, Charlson comorbidity index, and baseline cognition. The association between daily postoperative medication use (when class exposure ≥5%) and time to delirium was assessed using time-varying Cox models adjusted for age, sex, surgery type, Charlson comorbidity index, Acute Physiology and Chronic Health Evaluation (APACHE)-II score, and baseline cognition. Mediation analysis was utilized to evaluate the association between medication use, delirium, and cognitive change from baseline to 1 month. RESULTS Among 560 patients enrolled, 134 (24%) developed delirium during hospitalization. The multivariable analyses revealed no significant association between prehospital benzodiazepine (relative risk [RR], 1.44; 95% confidence interval [CI], 0.85-2.44), beta-blocker (RR, 1.38; 95% CI, 0.94-2.05), NSAID (RR, 1.12; 95% CI, 0.77-1.62), opioid (RR, 1.22; 95% CI, 0.82-1.82), or statin (RR, 1.34; 95% CI, 0.92-1.95) exposure and delirium. Postoperative hospital benzodiazepine use (adjusted hazard ratio [aHR], 3.23; 95% CI, 2.10-4.99) was associated with greater delirium. Neither postoperative hospital antipsychotic (aHR, 1.48; 95% CI, 0.74-2.94) nor opioid (aHR, 0.82; 95% CI, 0.62-1.11) use before delirium was associated with delirium. Antipsychotic use (either presurgery or postsurgery) was associated with a 0.34 point (standard error, 0.16) decrease in general cognitive performance at 1 month through its effect on delirium (P = .03), despite no total effect being observed. CONCLUSIONS Administration of benzodiazepines to older adults hospitalized after major surgery is associated with increased postoperative delirium. Association between inhospital, postoperative medication use and cognition at 1 month, independent of delirium, was not detected.
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Affiliation(s)
| | - John W. Devlin
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - John L. Griffith
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
| | - Thomas G. Travison
- Harvard Medical School, Boston, MA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Becky A. Briesacher
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
| | - Richard Jones
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Departments of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
| | - Eva M. Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sharon K. Inouye
- Harvard Medical School, Boston, MA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Avan R, Sahebnasagh A, Hashemi J, Monajati M, Faramarzi F, Henney NC, Montecucco F, Jamialahmadi T, Sahebkar A. Update on Statin Treatment in Patients with Neuropsychiatric Disorders. Life (Basel) 2021; 11:1365. [PMID: 34947895 PMCID: PMC8703562 DOI: 10.3390/life11121365] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/26/2021] [Accepted: 12/04/2021] [Indexed: 02/06/2023] Open
Abstract
Statins are widely accepted as first-choice agents for the prevention of lipid-related cardiovascular diseases. These drugs have both anti-inflammatory and anti-oxidant properties, which may also make them effective as potential treatment marked by perturbations in these pathways, such as some neuropsychiatric disorders. In this narrative review, we have investigated the effects of statin therapy in individuals suffering from major depressive disorder (MDD), schizophrenia, anxiety, obsessive-compulsive disorder (OCD), bipolar disorder (BD), delirium, and autism spectrum disorders using a broad online search of electronic databases. We also explored the adverse effects of these drugs to obtain insights into the benefits and risks associated with their use in the treatment of these disorders. Lipophilic statins (including simvastatin) because of better brain penetrance may have greater protective effects against MDD and schizophrenia. The significant positive effects of statins in the treatment of anxiety disorders without any serious adverse side effects were shown in numerous studies. In OCD, BD, and delirium, limitations, and contradictions in the available data make it difficult to draw conclusions on any positive effect of statins. The positive effects of simvastatin in autism disorders have been evaluated in only a small number of clinical trials. Although some studies showed positive effect of statins in some neuropsychiatric disorders, further prospective studies are needed to confirm this and define the most effective doses and treatment durations.
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Affiliation(s)
- Razieh Avan
- Department of Clinical Pharmacy, Medical Toxicology and Drug Abuse Research Center (MTDRC), School of Pharmacy, Birjand University of Medical Sciences, Birjand 9717853577, Iran;
| | - Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, North Khorasan University of Medical Sciences, Bojnurd 9453155166, Iran;
| | - Javad Hashemi
- Department of Pathobiology and Laboratory Sciences, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd 9453155166, Iran;
| | - Mahila Monajati
- Department of Internal Medicine, Golestan University of Medical Sciences, Gorgan 4934174515, Iran;
| | - Fatemeh Faramarzi
- Clinical Pharmacy Research Center, Iran University of Medical Sciences, Tehran 1445613131, Iran;
| | - Neil C. Henney
- Pharmacy & Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 5UX, UK;
| | - Fabrizio Montecucco
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, 10 Largo Benzi, 16132 Genoa, Italy;
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132 Genoa, Italy
| | - Tannaz Jamialahmadi
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad 9177948564, Iran;
| | - Amirhossein Sahebkar
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad 9177948564, Iran
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad 9177948954, Iran
- Department of Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad 9177948954, Iran
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Genet B, Lamy T, Cohen-Bittan J, Glasman P, Verny M, Riou B, Boddaert J, Zerah L. Lack of Association Between Perioperative Medication and Postoperative Delirium in Hip Fracture Patients in an Orthogeriatric Care Pathway. J Am Med Dir Assoc 2021; 23:623-630.e2. [PMID: 34653382 DOI: 10.1016/j.jamda.2021.09.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/07/2021] [Accepted: 09/20/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Units for perioperative geriatric care are playing a growing role in the care of older patients after hip fracture surgery. Postoperative delirium is one of the most common complications after hip fracture, but no study has assessed the impact of therapeutics received during a dedicated orthogeriatric care pathway on its incidence. Our main objective was to assess the association between drugs used in emergency, operating, and recovery departments and postoperative delirium during the acute stay. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS All patients ≥70 years old admitted for hip fracture to the emergency department and hospitalized in our unit for perioperative geriatric care after hip fracture surgery under general anesthesia between July 2009 and December 2019 in an academic hospital in Paris. METHODS Demographic, clinical, and biological data and all medications administered pre-, peri-, and postoperatively were prospectively collected by 3 geriatricians. Postoperative delirium in the unit for perioperative geriatric care was assessed by using the confusion assessment method scale. Logistic regression analysis was used to assess variables independently associated with postoperative delirium. RESULTS A total of 490 patients were included [mean (SD) age 87 (6) years]; 215 (44%) had postoperative delirium. The occurrence was not associated with therapeutics administered during the dedicated orthogeriatric care pathway. Probability of postoperative delirium was associated with advanced age [>90 years, odds ratio (OR) 2.03, 95% confidence interval (CI) 1.07-3.89], dementia (OR 3.51, 95% CI 2.14--5.82), depression (OR 1.85, 95% CI 1.14-3.01), and preoperative use of beta-blockers (OR 1.75, 95% CI 1.10-2.79). CONCLUSIONS AND IMPLICATIONS No emergency or anesthetic drugs were significantly associated with postoperative delirium. Further studies are needed to demonstrate a possible causal link between preoperative use of beta-blockers and postoperative delirium.
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Affiliation(s)
- Bastien Genet
- Department of Geriatric Medicine, Unit of Peri-Operative Geriatric Care, Assistance Publique Hôpitaux de Paris (APHP), Hôpital la Pitié-Salpêtrière, Paris, France.
| | - Tina Lamy
- Department of Geriatric Medicine, Unit of Peri-Operative Geriatric Care, Assistance Publique Hôpitaux de Paris (APHP), Hôpital la Pitié-Salpêtrière, Paris, France
| | - Judith Cohen-Bittan
- Department of Geriatric Medicine, Unit of Peri-Operative Geriatric Care, Assistance Publique Hôpitaux de Paris (APHP), Hôpital la Pitié-Salpêtrière, Paris, France
| | - Pauline Glasman
- Department of Anesthesiology and Critical Care, Assistance Publique Hôpitaux de Paris (APHP), Hôpital la Pitié-Salpêtrière, Paris, France
| | - Marc Verny
- Department of Geriatric Medicine, Unit of Peri-Operative Geriatric Care, Assistance Publique Hôpitaux de Paris (APHP), Hôpital la Pitié-Salpêtrière, Paris, France; Team Neuronal Cell Biology and Pathology, Sorbonne Université, UMR CNRS 8256, Paris, France
| | - Bruno Riou
- Department of Emergency Medicine and Surgery, Sorbonne Université, UMRS INSERM 1166, IHU ICAN, APHP, Hôpital la Pitié-Salpêtrière, Paris, France
| | - Jacques Boddaert
- Department of Geriatric Medicine, Unit of Peri-Operative Geriatric Care, Assistance Publique Hôpitaux de Paris (APHP), Hôpital la Pitié-Salpêtrière, Paris, France; Sorbonne Université, UMR INSERM 1135, Paris, France
| | - Lorène Zerah
- Department of Geriatric Medicine, Unit of Peri-Operative Geriatric Care, Assistance Publique Hôpitaux de Paris (APHP), Hôpital la Pitié-Salpêtrière, Paris, France; Sorbonne Université, UMRS INSERM 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
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8
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Visser L, Prent A, Banning LBD, van Leeuwen BL, Zeebregts CJ, Pol RA. Risk Factors for Delirium after Vascular Surgery: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2021; 76:500-513. [PMID: 33905851 DOI: 10.1016/j.avsg.2021.03.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Vascular surgery is considered a risk factor for the development of postoperative delirium (POD). In this systematic review we provide a report on the incidence and risk-factors of POD after vascular surgery. METHODS A systematic literature search was conducted using Pubmed with the MeSH terms and key words "delirium" or "confusion", "vascular surgery procedures" and "risk factors or "risk assessment". Studies were selected for review after meeting the following inclusion criteria: vascular surgery, POD diagnosed using validated screening tools, and DSM-derived criteria to assess delirium. A meta-analysis was performed for each endpoint if at least two studies could be combined. RESULTS Sixteen articles met the abovementioned criteria. The incidence of delirium ranged from 5% to 39%. Various preoperative risk factors were identified that is, age (Random MD 3.96, CI 2.57-5.35), hypertension (Fixed OR 1.30, CI 1.05-1.59), diabetes mellitus (Random OR 2.15, CI 1.30-3.56), hearing impairment (Fixed OR 1.89, CI 1.28-2.81), history of cerebrovascular incident or transient ischemic attack (Fixed OR 2.20, CI 1.68-2.88), renal failure (Fixed OR 1.61, CI 1.19-2.17), and pre-operative low haemoglobin level (fixed MD -0.76, CI -1.04 to -0.47). Intra-operative risk factors were duration of surgery (Random MD 15.68; CI 2.79-28.57), open aneurysm repair (Fixed OR 4.99, CI 3.10-8.03), aortic cross clamping time (fixed MD 7.99, CI 2.56-13.42), amputation surgery (random OR 3.77, CI 2.13-6.67), emergency surgery (Fixed OR 4.84, CI 2.81-8.32) and total blood loss (Random MD 496.5, CI 84.51-908.44) and need for blood transfusion (Random OR 3.72, CI 1.57-8.80). Regional anesthesia on the other hand, had a protective effect. Delirium was associated with longer ICU and hospital length of stay, and more frequent discharge to a care facility. CONCLUSIONS POD after vascular surgery is a frequent complication and effect-size pooling supports the concept that delirium is a heterogeneous disorder. The risk factors identified can be used to either design a validated risk factor model or individual preventive strategies for high-risk patients.
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Affiliation(s)
- Linda Visser
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Anna Prent
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Louise B D Banning
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Department of Surgery, Division of Transplantation Surgery, University Medical Center Groningen, Groningen, The Netherlands
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Cojocariu SA, Maștaleru A, Sascău RA, Stătescu C, Mitu F, Leon-Constantin MM. Neuropsychiatric Consequences of Lipophilic Beta-Blockers. ACTA ACUST UNITED AC 2021; 57:medicina57020155. [PMID: 33572109 PMCID: PMC7914867 DOI: 10.3390/medicina57020155] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 12/21/2022]
Abstract
Beta-blockers are a class of drugs with important benefits in cardiovascular pathology. In this paper, we aim to highlight their adverse and therapeutic effects in the neuropsychiatric field. With respect to permeability, we would like to mention that most beta-blockers are lipophilic and can cross the blood–brain barrier. Observational studies show the presence of neuropsychiatric side effects when taking beta-blockers, and is the reason for which caution is recommended in their use in patients with depressive syndrome. From a therapeutic point of view, most current evidence is for the use of beta-blockers in migraine attacks, essential tremor, and akathisia. Beta-blockers appear to be effective in the treatment of aggressive behavior, beneficial in the prevention of posttraumatic stress syndrome and may play a role in the adjuvant treatment of obsessive–compulsive disorder, which is refractory to standard therapy. In conclusion, the relationship between beta-blockers and the central nervous system appears as a two-sided coin. Summarizing the neuropsychiatric side effects of beta-blockers, we suggest that clinicians pay special attention to the pharmacological properties of different beta-blockers.
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Affiliation(s)
- Sabina Alexandra Cojocariu
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
| | - Alexandra Maștaleru
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
- Clinical Rehabilitation Hospital–Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania
- Correspondence:
| | - Radu Andy Sascău
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
- Institute of Cardiovascular Disease “Prof. Dr. George. I.M. Georgescu”, Carol I Boulevard nr 50, 700503 Iasi, Romania
| | - Cristian Stătescu
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
- Institute of Cardiovascular Disease “Prof. Dr. George. I.M. Georgescu”, Carol I Boulevard nr 50, 700503 Iasi, Romania
| | - Florin Mitu
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
- Clinical Rehabilitation Hospital–Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania
| | - Maria Magdalena Leon-Constantin
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
- Clinical Rehabilitation Hospital–Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania
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Wu J, Gao S, Zhang S, Yu Y, Liu S, Zhang Z, Mei W. Perioperative risk factors for recovery room delirium after elective non-cardiovascular surgery under general anaesthesia. Perioper Med (Lond) 2021; 10:3. [PMID: 33531068 PMCID: PMC7856719 DOI: 10.1186/s13741-020-00174-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/28/2020] [Indexed: 12/31/2022] Open
Abstract
Background Although postoperative delirium is a frequent complication of surgery, little is known about risk factors for delirium occurring in the post-anaesthesia care unit (PACU). The aim of this study was to determine pre- and intraoperative risk factors for the development of recovery room delirium (RRD) in patients undergoing elective non-cardiovascular surgery. Methods RRD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We collected perioperative data in 228 patients undergoing elective non-cardiovascular surgery under general anaesthesia and performed univariate and multivariate logistic regression to identify risk factors related to RRD. PACU and postoperative events were recorded to assess the outcome of RRD. Results Fifty-seven patients (25%) developed RRD. On multivariate analysis, maintenance of anaesthesia with inhalation anaesthetic agents (OR = 6.294, 95% CI 1.4–28.8, corrected p = 0.03), malignant primary disease (OR = 3.464, 95% CI = 1.396–8.592, corrected p = 0.018), American Society of Anaesthesiologists Physical Status (ASA-PS) III–V (OR = 3.389, 95% CI = 1.401–8.201, corrected p = 0.018), elevated serum total or direct bilirubin (OR = 2.535, 95% CI = 1.006–6.388, corrected p = 0.049), and invasive surgery (OR = 2.431, 95% CI = 1.103–5.357, corrected p = 0.035) were identified as independent risk factors for RRD. RRD was associated with higher healthcare costs (31,428 yuan [17,872–43,674] versus 16,555 yuan [12,618–27,788], corrected p = 0.002), a longer median hospital stay (17 days [12–23.5] versus 11 days [9–17], corrected p = 0.002), and a longer postoperative stay (11 days [7–15] versus 7 days [5–10], corrected p = 0.002]). Conclusions Identifying patients at high odds for RRD preoperatively would enable the formation of more timely postoperative delirium management programmes.
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Affiliation(s)
- Jiayi Wu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shaojie Gao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shuang Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yao Yu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shangkun Liu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Zhiguo Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, China
| | - Wei Mei
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China.
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Maldonado JR, Sher YI, Benitez-Lopez MA, Savant V, Garcia R, Ament A, De Guzman E. A Study of the Psychometric Properties of the "Stanford Proxy Test for Delirium" (S-PTD): A New Screening Tool for the Detection of Delirium. PSYCHOSOMATICS 2019; 61:116-126. [PMID: 31926650 DOI: 10.1016/j.psym.2019.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Delirium is a prevalent neuropsychiatric disorder associated with increased morbidity and mortality. Half the cases remain misdiagnosed. OBJECTIVE Assess the effectiveness of the Stanford Proxy Test for Delirium (S-PTD) in detecting delirium in an inpatient setting. METHODS This is a comparison study. Daily assessment with S-PTD, by the patient's nurse, and a neuropsychiatric assessment by a psychiatrist. Assessments were blinded. Inclusion criteria included 18 years or older. Exclusion criteria included patient's or surrogate's unwillingness to participate, inability to consent if a surrogate was not available, and inability to communicate in English or Spanish. A total of 309 patients were approached: 27 declined participation, 4 were excluded, and 278 subjects were followed up throughout their hospital stay. In the end, 78 were excluded for lack of neuropsychiatric assessment, S-PTD, or both. One was excluded for lack of demographic data. The sensitivity and specificity of the S-PTD in detecting delirium when compared with a neuropsychiatric assessment. RESULTS Participants were on average 60.8 years old and 54.3% were male. Patients who developed delirium were, on average, older (15.12 y, confidence interval: 8.94-21.32). A total of 199 patients were analyzed; 43 patients (21.6%) met criteria for delirium. S-PTD detected 67 days with delirium (16.5%) of 405 hospital days, while neuropsychiatric evaluation identified 83 (20.5%). S-PTD had a sensitivity of 80.72% and a specificity of 90.37%. CONCLUSION S-PTD is an effective, comprehensive, and simple screening tool for delirium, which is robust despite fluctuating symptoms and lack of cooperation. The use of S-PTD may enhance early diagnosis of delirium.
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Affiliation(s)
- Jose R Maldonado
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA.
| | - Yelizaveta I Sher
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Mario Alberto Benitez-Lopez
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA; Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA
| | - Vidushi Savant
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Renee Garcia
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Andrea Ament
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Earl De Guzman
- Consultation-Liaison Psychiatry Service, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
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Beattie WS, Yang H. Perioperative beta-adrenergic antagonism: panacea or poison? Br J Anaesth 2019; 123:97-100. [PMID: 31248641 PMCID: PMC6676158 DOI: 10.1016/j.bja.2019.05.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 05/16/2019] [Accepted: 05/26/2019] [Indexed: 01/24/2023] Open
Affiliation(s)
- W Scott Beattie
- University Health Network Department of Anesthesia and Pain Medicine, University of Toronto Department of Anesthesia, Toronto, ON, Canada.
| | - Homer Yang
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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13
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Effectiveness and Safety of Ultrasound Guided Lower Extremity Nerve Blockade in Infragenicular Bypass Grafting for High Risk Patients With Chronic Limb Threatening Ischaemia. Eur J Vasc Endovasc Surg 2019; 58:206-213. [DOI: 10.1016/j.ejvs.2019.03.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 03/09/2019] [Accepted: 03/16/2019] [Indexed: 11/18/2022]
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14
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Smith PE, Hade EM, Tan Y, Pandya LK, Hundley AF, Hudson CO. Mode of anesthesia and major perioperative outcomes associated with vaginal surgery. Int Urogynecol J 2019; 31:181-189. [DOI: 10.1007/s00192-019-03908-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
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15
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Kang SY, Seo SW, Kim JY. Comprehensive risk factor evaluation of postoperative delirium following major surgery: clinical data warehouse analysis. Neurol Sci 2019; 40:793-800. [DOI: 10.1007/s10072-019-3730-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 01/16/2019] [Indexed: 12/19/2022]
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16
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The effect of preoperative cognitive impairment and type of vascular surgery procedure on postoperative delirium with associated cost implications. J Vasc Surg 2019; 69:201-209. [DOI: 10.1016/j.jvs.2018.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 05/01/2018] [Indexed: 11/17/2022]
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17
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Hajibandeh S, Hajibandeh S, Antoniou SA, Torella F, Antoniou GA. Effect of beta-blockers on perioperative outcomes in vascular and endovascular surgery: a systematic review and meta-analysis. Br J Anaesth 2018; 118:11-21. [PMID: 28039238 DOI: 10.1093/bja/aew380] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND To investigate the role of perioperative beta-blocker use in vascular and endovascular surgery. METHODS We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. The review protocol was registered with International Prospective Register of Systematic Reviews (registration number:CRD42016038111). We searched electronic databases to identify all randomized controlled trials and observational studies investigating outcomes of patients undergoing vascular and endovascular surgery with or without perioperative beta blockade. We used the Cochrane tool and the Newcastle-Ottawa scale to assess the risk of bias of trials and observational studies, respectively. Random-effects models were applied to calculate pooled outcome data. RESULTS We identified three randomized trials, five retrospective cohort studies, and three prospective cohort studies, enrolling a total of 32,602 patients. Our analyses indicated that perioperative use of beta-blockers did not reduce the risk of all-cause mortality [odds ratio (OR) 1.10, 95% confidence interval (CI) 0.59-2.04, P = 0.77], cardiac mortality (OR 2.62, 95% CI 0.86-8.05, P = 0.09), myocardial infarction (OR 0.89, 95% CI 0.59-1.35, P = 0.58), unstable angina (OR 1.34, 95% CI 0.41- 4.38, P = 0.63), stroke (OR 2.45, 95% CI 0.89-6.75, P = 0.08), arrhythmias (OR 0.76, 95% CI 0.41-1.43, P = 0.40), congestive heart failure (OR 1.12, 95% CI 0.77-1.63, P = 0.56), renal failure (OR 1.48, 95% CI 0.90-2.45, P = 0.13), composite cardiovascular events (OR 0.88, 95% CI 0.55-1.40, P = 0.58), rehospitalisation (OR 0.86, 95% CI 0.48-1.52, P = 0.60), and reoperation (OR 1.17, 95% CI 0.42-3.27, P = 0.77) in vascular surgery. CONCLUSIONS Beta-blockers do not improve perioperative outcomes in vascular and endovascular surgery.
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Affiliation(s)
- S Hajibandeh
- Department of General Surgery, Royal Blackburn Hospital, Blackburn, UK
| | - S Hajibandeh
- Department of General Surgery, Royal Blackburn Hospital, Blackburn, UK
| | - S A Antoniou
- Department of General Surgery, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - F Torella
- Department of Mathematical Sciences, School of Physical Sciences, University of Liverpool, Liverpool, UK
| | - G A Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK
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18
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Styra R, Lindsay TF. Reply. J Vasc Surg 2018; 68:1616-1617. [PMID: 30360853 DOI: 10.1016/j.jvs.2018.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 08/05/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Rima Styra
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Kassie GM, Nguyen TA, Kalisch Ellett LM, Pratt NL, Roughead EE. Do Risk Prediction Models for Postoperative Delirium Consider Patients' Preoperative Medication Use? Drugs Aging 2018; 35:213-222. [PMID: 29423780 DOI: 10.1007/s40266-018-0526-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medicines are potentially modifiable risk factors for postoperative delirium. However, the extent to which preoperative medicines are included in risk prediction models (RPMs) is unknown. OBJECTIVE This systematic review aimed to assess the extent of inclusion of preoperative medications in RPMs for postoperative delirium. METHODS Articles were systematically searched from MEDLINE, EMBASE and CINAHL using Medical Subject Headings (MeSH) where possible and keywords for postoperative delirium and prediction model. Studies published until May 2017 with a primary outcome of postoperative delirium that developed an RPM containing preoperative patient information were considered. Where a study had two cohorts, a derivation and a validation cohort, findings from the derivation cohort were extracted and reported. RESULTS Eighteen prospective and one retrospective cohort studies were included for review. Of the 19 studies, only nine considered preoperative medication data, with medications appearing as predictor variables in five models. There was wide variability in the factors included in the final models, with the most frequent predictors being age and cognitive impairment, appearing in 13 (68%) and 11 (58%) RPMs, respectively. CONCLUSION While medications are commonly cited risk factors for delirium, they are not adequately considered when developing RPMs. Future studies aiming to develop an RPM for postoperative delirium should include preoperative medication data as a potential predictor variable because of the modifiable nature of medication use and its impact on other factors commonly in models, such as cognition.
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Affiliation(s)
- Gizat M Kassie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia.
| | - Tuan A Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia.,University of South Australia, GPO Box 2471 (CEA-18), Adelaide, SA, 5001, Australia
| | - Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Nicole L Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia.,University of South Australia, GPO Box 2471 (R3-17A), Adelaide, SA, 5001, Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
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Safavynia SA, Arora S, Pryor KO, García PS. An update on postoperative delirium: Clinical features, neuropathogenesis, and perioperative management. CURRENT ANESTHESIOLOGY REPORTS 2018; 8:252-262. [PMID: 30555281 PMCID: PMC6290904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE OF REVIEW We present a focused review on postoperative delirium for anesthesiologists, encompassing clinical features, neuropathogenesis, and clinical identification and management strategies based on risk factors and current delirium treatments. RECENT FINDINGS The literature on postoperative delirium is dominated by non-experimental studies. We review delirium phenotypes, diagnostic criteria, and present standard nomenclature based on current literature. Disruption of cortical integration of complex information (CICI) may provide a framework to understand the neuropathogenesis of postoperative delirium, as well as risk factors and clinical modifiers in the perioperative period. We further divide risk factors into patient factors, surgical factors, and medical/pharmacological factors, and present specific considerations for each in the preoperative, intraoperative, and postoperative periods. SUMMARY Postoperative delirium is prevalent, poorly understood, and often missed with current screening techniques. Proper identification of risk factors is useful for perioperative interventions and can help tailor patient-specific management strategies.
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Affiliation(s)
- Seyed A. Safavynia
- Department of Anesthesiology, Weill Cornell Medical
College, New York, NY, USA
| | - Sona Arora
- Department of Anesthesiology, Emory University, Atlanta,
GA, USA
| | - Kane O. Pryor
- Department of Anesthesiology, Weill Cornell Medical
College, New York, NY, USA
| | - Paul S. García
- Department of Anesthesiology, Emory University, Atlanta,
GA, USA
- Neuroanesthesia Laboratory, Atlanta VA Medical Center/Emory
University, Atlanta, GA, USA
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Safavynia SA, Arora S, Pryor KO, García PS. An Update on Postoperative Delirium: Clinical Features,
Neuropathogenesis, and Perioperative Management. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0282-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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22
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Lee DS, Lee MY, Park CM, Kim DI, Kim YW, Park YJ. Preoperative statins are associated with a reduced risk of postoperative delirium following vascular surgery. PLoS One 2018; 13:e0192841. [PMID: 29570715 PMCID: PMC5865715 DOI: 10.1371/journal.pone.0192841] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/31/2018] [Indexed: 12/13/2022] Open
Abstract
Delirium is a common complication of vascular surgery. The protective effect of preoperative statins on delirium after vascular surgery is controversial. The authors hypothesized that preoperative statin administration would decrease the incidence of delirium after vascular surgery. From May 2010 to May 2015, 1,132 patients underwent vascular surgery. Postoperative delirium was diagnosed from patients’ medical records. The incidence of delirium was 11.5%. The preoperative statin exposure was not associated with reduced delirium in the univariate analysis. After adjusting for covariates, preoperative statin exposure was associated with reduced delirium (OR, 0.54; 95% CI, 0.33–0.87; p = 0.011). This favor effect of statin for delirium was observed after propensity matching (OR, 0.59; 95% CI, 0.34–1.02; p = 0.060). However, the median hospital lengths of stay and in-hospital mortality were not statistically different between the two groups. CRP(C-reactive protein) levels in the unmatched population were lower in the preoperative statin group compared with the other group (p<0.001), however, there was only numerically different without statistical difference after matching (p = 0.083). Preoperative statin use was associated with a decreased incidence of postoperative delirium in patients who underwent vascular surgery. However, preoperative statin did not reduce mortality rate and hospital stay.
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Affiliation(s)
- Dae-Sang Lee
- Department of Trauma Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Mi Yeon Lee
- Department of Biostatistics, Kangbuk Samsung Hospital, Seoul, Republic of Korea
| | - Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong-Ik Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young-Wook Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yang-Jin Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- * E-mail:
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Kassie GM, Nguyen TA, Kalisch Ellett LM, Pratt NL, Roughead EE. Preoperative medication use and postoperative delirium: a systematic review. BMC Geriatr 2017; 17:298. [PMID: 29284416 PMCID: PMC5747155 DOI: 10.1186/s12877-017-0695-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/18/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of risk of postoperative delirium associated with preoperative medication use. METHODS A systematic search in Medline and EMBASE was conducted using MeSH terms and keywords for postoperative delirium and medication. Studies which included patients 18 years and older who underwent major surgery were included. The methodological quality of included studies was assessed independently by two authors using the Newcastle-Ottawa quality assessment scale for cohort studies. RESULTS Twenty-nine studies; 25 prospective cohort, three retrospective cohort and one post hoc analysis of RCT data were included. Only four specifically aimed to assess medicines as an independent predictor of delirium, all other studies included medicines among a number of potential predictors of delirium. Of the studies specifically testing the association with a medication class, preoperative use of beta-blockers (OR = 2.06[1.18-3.60]) in vascular surgery and benzodiazepines RR 2.10 (1.23-3.59) prior to orthopedic surgery were significant. However, evidence is from single studies only. Where medicines were included as one possible factor among many, hypnotics had a similar risk estimate to the benzodiazepine study, with one significant and one non-significant result. Nifedipine use prior to cardiac surgery was found to be significantly associated with delirium. The non-specific grouping of psychoactive medication use preoperatively was generally higher with an associated two-to-seven-fold higher risk of postoperative delirium, while only two studies included narcotics without other agents, with one significant and one non-significant result. CONCLUSIONS There was a limited number of high quality studies in the literature quantifying the direct association between preoperative medication use and postsurgical delirium. More studies are required to evaluate the association of specific preoperative medications on the risk of postoperative delirium so that comprehensive guidelines for medicine use prior to surgery can be developed to aid delirium prevention. TRIAL REGISTRATION This systematic review has been registered on PROSPERO International prospective register of systematic reviews (Registration number: CRD42016051245 ).
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Affiliation(s)
- Gizat M Kassie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, 5001, Australia.
| | - Tuan A Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, 5001, Australia
| | - Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, 5001, Australia
| | - Nicole L Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, 5001, Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, 5001, Australia
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O'Neal JB, Billings FT, Liu X, Shotwell MS, Liang Y, Shah AS, Ehrenfeld JM, Wanderer JP, Shaw AD. Effect of Preoperative Beta-Blocker Use on Outcomes Following Cardiac Surgery. Am J Cardiol 2017; 120:1293-1297. [PMID: 28826895 DOI: 10.1016/j.amjcard.2017.07.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/21/2017] [Accepted: 07/07/2017] [Indexed: 12/29/2022]
Abstract
Recent studies suggest that the use of preoperative β blockers in cardiac surgery may not provide improved mortality rates and may even contribute to negative clinical outcomes. We therefore assessed the role of β blockers on several outcomes after cardiac surgery (delirium, acute kidney injury [AKI], stroke, atrial fibrillation (AF), mortality, and hospital length of stay) in 4,076 patients who underwent elective coronary artery bypass grafting, coronary artery bypass grafting + valve, or valve cardiac surgery from November 1, 2009, to September 30, 2015, at Vanderbilt Medical Center. Clinical data from 2 prospectively collected datasets at our institution were reviewed: the Cardiac Surgery Perioperative Outcomes Database and the Society of Thoracic Surgeons Database. Preoperative β-blocker use was defined by Society of Thoracic Surgeons guidelines as patients receiving a β blocker within 24 hours preceding surgery. Of the included patients, 2,648 (65.0%) were administered a β blocker within 24 hours before surgery. Adjusting for possible confounders, preoperative β-blocker use was associated with increased odds of AKI stage 2 (odds ratio 1.96, 95% confidence interval 1.19 to 3.24, p <0.01). There was no evidence that β-blocker use had an independent association with postoperative delirium, AKI stages 1 and 3, stroke, AF, mortality, or prolonged length of stay. A secondary propensity score analysis did not show a marginal association between β-blocker use and any outcome. In conclusion, we did not find significant evidence that preoperative β-blocker use was associated with postoperative delirium, AF, AKI, stroke, or mortality.
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Affiliation(s)
- Jason B O'Neal
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Frederic T Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Xulei Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yafen Liang
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jesse M Ehrenfeld
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Oldroyd C, Scholz AFM, Hinchliffe RJ, McCarthy K, Hewitt J, Quinn TJ. A systematic review and meta-analysis of factors for delirium in vascular surgical patients. J Vasc Surg 2017; 66:1269-1279.e9. [PMID: 28942855 DOI: 10.1016/j.jvs.2017.04.077] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 04/30/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Delirium is a common syndrome responsible for a large burden of morbidity and mortality. In surgical settings, research into risk factors for postoperative delirium has largely focused on elective orthopedic patients. We performed a systematic review and meta-analysis to evaluate the evidence surrounding risk factors for delirium in vascular surgical populations. METHODS Two independent reviewers searched five databases (MEDLINE, Web of Science, Embase, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO) from January 1987 to December 2015. We included primary research studies for incident delirium that used validated delirium assessment tools in exclusively vascular surgical populations. RESULTS We identified 16 studies (3817 patients) that met the inclusion criteria. There was substantial clinical heterogeneity in the populations included under a heading of "vascular surgery." Studies were high quality, with an average Newcastle-Ottawa Scale score of 6.9. Summary incidence of delirium was 23.4% (range, 4.8%-39%). Across all studies, 157 separate risk factors were examined. Ten of the included studies used multivariable models in their analysis of risk factors. Meta-analysis of risk factors with data from more than three studies identified the following factors as conferring an increased risk of delirium: American Society of Anesthesiologists score >2 (odds ratio [OR], 3.44), renal failure (OR, 2.09), previous stroke (OR, 1.87), history of neurologic comorbidity (OR, 1.57), and male sex (OR, 1.30). Delirious patients were older (mean difference [MD], +4.99 years), had lower preoperative hemoglobin levels (MD, -0.66 g/dL), and stayed longer in intensive care units (MD, +1.06 days). CONCLUSIONS Delirium is common in vascular surgery settings. Meta-analysis has identified significant risk factors relating to the patient, the presentation, and the pathway of care. Better understanding of these risk factors may help in prediction, prevention, and early identification of delirium.
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Affiliation(s)
- Christopher Oldroyd
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom.
| | - Anna F M Scholz
- Department of Endocrinology and Diabetes, Cardiff and Vale NHS Trust, Cardiff, United Kingdom
| | - Robert J Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, United Kingdom
| | - Kathryn McCarthy
- Department of General Surgery, North Bristol NHS Trust, Bristol, United Kingdom
| | - Jonathan Hewitt
- Department of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - Terrence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
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Aitken SJ, Blyth FM, Naganathan V. Incidence, prognostic factors and impact of postoperative delirium after major vascular surgery: A meta-analysis and systematic review. Vasc Med 2017; 22:387-397. [DOI: 10.1177/1358863x17721639] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Although postoperative delirium is a common complication and increases patient care needs, little is known about the predictors and outcomes of delirium in patients having vascular surgery. This review aimed to determine the incidence, prognostic factors and impact of postoperative delirium in vascular surgical patients. MEDLINE and EMBASE were systematically searched for articles published between January 2000 and January 2016 on delirium after vascular surgery. The primary outcome was the incidence of delirium. Secondary outcomes were contributing prognostic factors and impact of delirium. Study quality and risk of bias was assessed using the QUIPS tool for systematic reviews of prognostic studies, and MOOSE guidelines for reviews of observational studies. Quantitative analyses of extracted data were conducted using meta-analysis where possible to determine incidence of delirium and prognostic factors. A qualitative review of outcomes was performed. Fifteen articles were eligible for inclusion. Delirium incidence ranged between 5% and 39%. Meta-analysis found that patients with delirium were older than those without delirium (OR 3.6, p<0.001). Prognostic factors predicting delirium included increased age (OR 1.04, p<0.001), pre-existing cognitive impairment (OR 9.8, p=0.01), hypertension, pre-existing depression and open aortic surgery. Delirious patients remained in hospital 6 days longer ( p<0.001) and had more complications than patients without delirium. Data were limited on the impact of procedure complexity, endovascular compared to open surgery or type of anaesthetic. Postoperative delirium occurs frequently, resulting in major morbidity for vascular patients. Improved quality of prognostic studies may identify modifiable peri-operative factors to improve quality of care for vascular surgical patients.
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Affiliation(s)
- Sarah Joy Aitken
- University of Sydney, Concord Clinical School, Sydney, NSW, Australia
- Concord Institute of Academic Surgery, Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Fiona M Blyth
- University of Sydney, Concord Clinical School, Sydney, NSW, Australia
- Centre for Education and Research in Ageing, Concord, Sydney, NSW, Australia
- Ageing and Alzheimers Institute, Concord, Sydney, NSW, Australia
| | - Vasi Naganathan
- University of Sydney, Concord Clinical School, Sydney, NSW, Australia
- Centre for Education and Research in Ageing, Concord, Sydney, NSW, Australia
- Ageing and Alzheimers Institute, Concord, Sydney, NSW, Australia
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Galyfos GC, Geropapas GE, Sianou A, Sigala F, Filis K. Risk factors for postoperative delirium in patients undergoing vascular surgery. J Vasc Surg 2017; 66:937-946. [PMID: 28583731 DOI: 10.1016/j.jvs.2017.03.439] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/22/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Postoperative delirium (PODE) remains a common complication after vascular surgery procedures although the exact pathogenesis remains unclear, mainly because of its multifactorial character. The aim of this systematic review was to evaluate pooled data on potential risk factors for PODE in patients undergoing vascular surgery procedures. METHODS A systematic literature review was conducted conforming to established criteria to identify eligible articles published from 1990 to 2016. Eligible studies evaluated potential risk factors for PODE after vascular surgery procedures, using both univariate and multivariate analysis. PODE was defined as a disturbance of consciousness with reduced ability to focus, sustain, or shift attention after vascular surgery procedures and was diagnosed in all studies using well-established criteria. Only risk factors reported in at least four studies were included in this review. Pooled results were calculated, and further multivariate regression analysis was conducted. RESULTS Overall, nine studies (published from 2003 to 2015) including 2388 patients in total were evaluated (457 with and 1931 without PODE). Patients with PODE were older (73.27 vs 69.87 years; P < .0001) and showed a higher male sex rate (78.1% vs 73.5%; P = .043). Open aortic surgery was the most frequent procedure in this analysis, followed by lower limb revascularization. Patients with PODE also showed higher rates of diabetes mellitus, hypertension, cardiac disease, and neurologic disease; lower hemoglobin level; larger duration of surgery; longer hospital and intensive care unit stay; and higher blood loss. Mean age (odds ratio [OR], 3.44; 95% confidence interval [CI], 2.933-4.034; P < .0001), hypertension (OR, 1.94; 95% CI, 1.469-2.554; P < .0001), cardiac disease (OR, 3.16; 95% CI, 2.324-4.284; P < .0001), open aortic surgery (OR, 1.74; 95% CI, 1.421-2.143; P < .0001), blood loss (OR, 1.01; 95% CI, 1.007-1.010; P < .0001), hospital stay (OR, 2.26; 95% CI, 1.953-2.614; P <. 0001), and intensive care unit stay (OR, 6.12; 95% CI, 4.699-7.957; P < .0001) were identified as the strongest risk predictors for PODE, followed by male sex, diabetes mellitus, neurologic disease, and history of smoking. However, body mass index, renal failure, preoperative hemoglobin level, and general anesthesia were not found to be risk factors for PODE in such patients. CONCLUSIONS This study has confirmed that PODE after vascular surgery procedures is a multifactorial disease, and several independent risk factors have been identified. However, pooled data regarding the effect of PODE on primary outcomes after vascular surgery procedures are still lacking. The results of this review could contribute to the designation of future prediction models and improve prevention of PODE in these patients.
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Affiliation(s)
- George C Galyfos
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece; Department of Vascular Surgery, "KAT" General Hospital, Athens, Greece.
| | | | - Argiri Sianou
- Department of Microbiology, University of Athens Medical School, Areteion Hospital, Athens, Greece
| | - Fragiska Sigala
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Konstantinos Filis
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
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Nazemi AK, Gowd AK, Carmouche JJ, Kates SL, Albert TJ, Behrend CJ. Prevention and Management of Postoperative Delirium in Elderly Patients Following Elective Spinal Surgery. Clin Spine Surg 2017; 30:112-119. [PMID: 28141603 DOI: 10.1097/bsd.0000000000000467] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This study is a systematic review. OBJECTIVE Propose an evidence-based algorithm for prevention, diagnosis, and management of postoperative delirium in geriatric patients undergoing elective spine surgery. SUMMARY OF BACKGROUND DATA Delirium is associated with longer stays after elective surgery, increased risk of readmission, and $6.9 billion annually in medical costs. Early diagnosis and treatment of delirium can reduce length of stay (LOS), in-hospital morbidity, and health care costs. After spinal surgery, postoperative delirium increases average LOS to >7 days and is diagnosed in 12.5%-24.3% of geriatric patients. Currently, studies for management of postoperative delirium after elective spinal procedures are not available. METHODS A literature review was performed for observational studies, randomized controlled trials, and systematic reviews between 1990 and 2015. RESULTS Risk factors for delirium after elective spinal surgery include age, functional impairment, preexisting dementia, general anesthesia, surgical duration >3 hours, intraoperative hypercapnia and hypotension, greater blood loss, low hematocrit and albumin, preoperative affective dysfunction, and postoperative sleep disorders. Postoperatively, decreasing the use of methylprednisolone and promoting movement with an appropriate orthosis can reduce delirium incidence (P=0.0091). Polypharmacy is an independent risk factor for delirium (P=0.01) and decreasing use of delirium-inducing medications may reduce incidence. The delirium observation screening scale diagnoses and monitors delirium and is rated by nurses as easier to use than the NEECHAM Confusion Scale (P<0.003). Haloperidol is used widely to treat postoperative delirium. Randomized controlled trials show that adding quetiapine results in delirium resolution an average of 3.5 days faster than haloperidol alone (P=0.001) and decreases agitation and LOS (P=0.02; P=0.05). CONCLUSIONS An evidence-based algorithm is proposed to prevent, diagnose, and manage postoperative delirium that can be used clinically for geriatric patients undergoing elective spine surgery. Prevention and diagnosis involve efforts from the anesthesiologist and postoperative clinical care team. Treatment may include a therapeutic regimen of low-dose neuroleptic medications as needed. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Alireza K Nazemi
- *Virginia Tech Carilion School of Medicine †Carilion Clinic, Institute for Orthopaedics and Neurosciences, Roanoke ‡Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA §Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
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Beta-blockers in vascular surgery patients: is the debate still going on? J Anesth 2016; 30:1031-1036. [DOI: 10.1007/s00540-016-2232-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 08/05/2016] [Indexed: 12/27/2022]
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Rosuvastatin versus placebo for delirium in intensive care and subsequent cognitive impairment in patients with sepsis-associated acute respiratory distress syndrome: an ancillary study to a randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2016; 4:203-12. [PMID: 26832963 DOI: 10.1016/s2213-2600(16)00005-9] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/19/2015] [Accepted: 12/23/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Delirium is common in mechanically ventilated patients and is associated with cognitive impairment lasting at least 1 year after hospital discharge. Preclinical and observational studies suggest that the use of statins might reduce delirium in intensive care. We assessed whether the pleiotropic effects of statins can reduce delirium in intensive care and decrease subsequent cognitive impairment in a randomised controlled trial. METHODS We did this ancillary study within the SAILS trial, a randomised controlled trial assessing mortality and ventilator-free days for rosuvastatin versus placebo for patients with sepsis-associated acute respiratory distress syndrome. This study was done at 35 hospitals in the USA. Patients were randomly assigned in permuted blocks of eight and stratified by hospital to receive either rosuvastatin (40 mg loading dose and then 20 mg daily until the earliest of 3 days after discharge from intensive care, study day 28, or death) or placebo. Patients and investigators were masked to treatment assignment. Delirium was assessed with the validated Confusion Assessment Method for intensive care. Cognitive function was assessed with tests for executive function, language, verbal reasoning and concept formation, and working, immediate, and delayed memory. We defined cognitive impairment as having one of these domains at least two SDs below population norms or at least two domains at least 1·5 SDs below norms. The primary endpoint was daily delirium status in intensive care up to 28 days in the intention-to-treat population and secondary endpoints were cognitive function at 6 months and 12 months. This trial is registered with ClinicalTrials.gov (NCT00979121 and NCT00719446). FINDINGS 272 patients were assessed for delirium daily in intensive care. The mean proportion of days with delirium was 34% (SD 30%) in the rosuvastatin group versus 31% (29%) in the placebo group; hazard ratio 1·14, 95% CI 0·92-1·41, p=0·22. At 6 months, 19 (36%) of 53 patients in the rosuvastatin group versus 29 (38%) of 77 in the placebo group had cognitive impairment, with no significant difference between groups (treatment effect 0·93, 95% CI 0·39-2·22; p=0·87). At 12 months, 20 (30%) of 67 patients versus 23 (28%) of 81 patients had cognitive impairment, with no significant difference between groups (treatment effect 1·1, 95% CI 0·5-2·6; p=0·82). INTERPRETATION Most patients had delirium, with around a third of survivors having cognitive impairment over 1 year of follow-up. Despite encouraging preclinical and observational studies, this trial shows no benefit of rosuvastatin in reducing delirium in intensive care or cognitive impairment during 12 months of follow-up although the study was not powered for superiority. Thus, there is continued need to evaluate interventions aimed at attenuating intensive care and post-intensive-care cognitive impairments commonly observed in this population. FUNDING National Heart, Lung and Blood Institute; Johns Hopkins Institute for Clinical and Translational Research; the SAILS trial was also supported by AstraZeneca.
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Hori D, Max L, Laflam A, Brown C, Neufeld KJ, Adachi H, Sciortino C, Conte JV, Cameron DE, Hogue CW, Mandal K. Blood Pressure Deviations From Optimal Mean Arterial Pressure During Cardiac Surgery Measured With a Novel Monitor of Cerebral Blood Flow and Risk for Perioperative Delirium: A Pilot Study. J Cardiothorac Vasc Anesth 2016; 30:606-12. [PMID: 27321787 DOI: 10.1053/j.jvca.2016.01.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate whether excursions of blood pressure from the optimal mean arterial pressure during and after cardiac surgery are associated with postoperative delirium identified using a structured examination. DESIGN Prospective, observational study. SETTING University hospital. PARTICIPANTS The study included 110 patients undergoing cardiac surgery. INTERVENTIONS Patients were monitored using ultrasound-tagged near-infrared spectroscopy to assess optimal mean arterial pressure by cerebral blood flow autoregulation monitoring during cardiopulmonary bypass and the first 3 hours in the intensive care unit. MEASUREMENTS AND MAIN RESULTS The patients were tested preoperatively and on postoperative days 1 to 3 with the Confusion Assessment Method or Confusion Assessment Method for the Intensive Care Unit, the Delirium Rating Scale-Revised-98, and the Mini Mental State Examination. Summative presence of delirium on postoperative days 1 through 3, as defined by the consensus panel following Diagnostic and Statistical Manual of Mental Disorders-IV-TR criteria, was the primary outcome. Delirium occurred in 47 (42.7%) patients. There were no differences in blood pressure excursions above and below optimal mean arterial pressure between patients with and without summative presence of delirium. Secondary analysis showed blood pressure excursions above the optimal mean arterial pressure to be higher in patients with delirium (mean±SD, 33.2±26.51 mmHgxh v 23.4±16.13 mmHgxh; p = 0.031) and positively correlated with the Delirium Rating Scale score on postoperative day 2 (r = 0.27, p = 0.011). CONCLUSIONS Summative presence of delirium was not associated with perioperative blood pressure excursions; but on secondary exploratory analysis, excursions above the optimal mean arterial pressure were associated with the incidence and severity of delirium on postoperative day 2.
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Affiliation(s)
- Daijiro Hori
- Division of Cardiac Surgery, Department of Surgery
| | - Laura Max
- Department of Anesthesiology & Critical Care Medicine
| | - Andrew Laflam
- Department of Anesthesiology & Critical Care Medicine
| | - Charles Brown
- Department of Anesthesiology & Critical Care Medicine
| | - Karin J Neufeld
- Department of Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hideo Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | | | - John V Conte
- Division of Cardiac Surgery, Department of Surgery
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Tse L, Schwarz SK, Bowering JB, Moore RL, Barr AM. Incidence of and Risk Factors for Delirium After Cardiac Surgery at a Quaternary Care Center: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2015; 29:1472-9. [DOI: 10.1053/j.jvca.2015.06.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Indexed: 11/11/2022]
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Gosselt AN, Slooter AJ, Boere PR, Zaal IJ. Risk factors for delirium after on-pump cardiac surgery: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:346. [PMID: 26395253 PMCID: PMC4579578 DOI: 10.1186/s13054-015-1060-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 09/04/2015] [Indexed: 12/13/2022]
Abstract
Introduction As evidence-based effective treatment protocols for delirium after cardiac surgery are lacking, efforts should be made to identify risk factors for preventive interventions. Moreover, knowledge of these risk factors could increase validity of etiological studies in which adjustments need to be made for confounding variables. This review aims to systematically identify risk factors for delirium after cardiac surgery and to grade the evidence supporting these associations. Method A prior registered systematic review was performed using EMBASE, CINAHL, MEDLINE and Cochrane from 1990 till January 2015 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007371). All studies evaluating patients for delirium after cardiac surgery with cardiopulmonary bypass (CPB) using either randomization or multivariable data analyses were included. Data was extracted and quality was scored in duplicate. Heterogeneity impaired pooling of the data; instead a semi-quantitative approach was used in which the strength of the evidence was graded based on the number of investigations, the quality of studies, and the consistency of the association reported across studies. Results In total 1462 unique references were screened and 34 were included in this review, of which 16 (47 %) were graded as high quality. A strong level of evidence for an association with the occurrence of postoperative delirium was found for age, previous psychiatric conditions, cerebrovascular disease, pre-existent cognitive impairment, type of surgery, peri-operative blood product transfusion, administration of risperidone, postoperative atrial fibrillation and mechanical ventilation time. Postoperative oxygen saturation and renal insufficiency were supported by a moderate level of evidence, and there is no evidence that gender, education, CPB duration, pre-existent cardiac disease or heart failure are risk factors. Conclusion Of many potential risk factors for delirium after cardiac surgery, for only 11 there is a strong or moderate level of evidence. These risk factors should be taken in consideration when designing future delirium prevention strategies trials or when controlling for confounding in future etiological studies. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1060-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alex Nc Gosselt
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Arjen Jc Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Pascal Rq Boere
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Irene J Zaal
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Visser L, Prent A, van der Laan MJ, van Leeuwen BL, Izaks GJ, Zeebregts CJ, Pol RA. Predicting postoperative delirium after vascular surgical procedures. J Vasc Surg 2015; 62:183-9. [PMID: 25752688 DOI: 10.1016/j.jvs.2015.01.041] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 01/27/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine the incidence of and specific preoperative and intraoperative risk factors for postoperative delirium (POD) in electively treated vascular surgery patients. METHODS Between March 2010 and November 2013, all vascular surgery patients were included in a prospective database. Various preoperative, intraoperative, and postoperative risk factors were collected during hospitalization. The primary outcome variable was the incidence of POD. Secondary outcome variables were any surgical complication, hospital length of stay, and mortality. RESULTS In total, 566 patients were prospectively evaluated; 463 patients were 60 years or older at the time of surgery and formed our study cohort. The median age was 72 years (interquartile range, 66-77), and 76.9% were male. Twenty-two patients (4.8%) developed POD. Factors that differed significantly by univariate analysis included current smoking (P = .001), increased comorbidity (P = .001), hypertension (P = .003), diabetes mellitus (P = .001), cognitive impairment (P < .001), open aortic surgery or amputation surgery (P < .001), elevated C-reactive protein level (P < .001), and blood loss (P < .001). Multivariate logistic regression analysis revealed preoperative cognitive impairment (odds ratio [OR], 16.4; 95% confidence interval [CI], 4.7-57.0), open aortic surgery or amputation surgery (OR, 14.0; 95% CI, 3.9-49.8), current smoking (OR, 10.5; 95% CI, 2.8-40.2), hypertension (OR, 7.6; 95% CI, 1.9-30.5) and age ≥80 years (OR, 7.3; 95% CI, 1.8-30.1) to be independent predictors of the occurrence of POD. The combination of these parameters allows us to predict delirium with a sensitivity of 86% and a specificity of 92%. The area under the curve of the corresponding receiver operating characteristics was 0.93. Delirium was associated with longer hospital length of stay (P < .001), more frequent and increased intensive care unit stays (P = .008 and P = .003, respectively), more surgical complications (P < .001), more postdischarge institutionalization (P < .001), and higher 1-year mortality rates (P = .0026). CONCLUSIONS In vascular surgery patients, preoperative cognitive impairment and open aortic or amputation surgery were highly significant risk factors for the occurrence of POD. In addition, POD was significantly associated with a higher mortality and more institutionalization. Patients with these risk factors should be considered for high-standard delirium care to improve these outcomes.
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Affiliation(s)
- Linda Visser
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anna Prent
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten J van der Laan
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gerbrand J Izaks
- Division of Geriatric Medicine, University Center of Geriatric Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Do Postoperative Pain Management Techniques Influence Postoperative Delirium? CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0089-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schenning KJ, Deiner SG. Postoperative Delirium: A Review of Risk Factors and Tools of Prediction. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0086-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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van Meenen LCC, van Meenen DMP, de Rooij SE, ter Riet G. Risk Prediction Models for Postoperative Delirium: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2014; 62:2383-90. [DOI: 10.1111/jgs.13138] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Sophia E. de Rooij
- Geriatrics Section; Department of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Gerben ter Riet
- Department of General Practice; Academic Medical Center; University of Amsterdam; Amsterdam the Netherlands
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Singh S, Maldonado Y, Taylor MA. Optimal perioperative medical management of the vascular surgery patient. Anesthesiol Clin 2014; 32:615-637. [PMID: 25113724 DOI: 10.1016/j.anclin.2014.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Perioperative medical management of patients undergoing vascular surgery can be challenging because they represent the surgical population at highest risk. β-Blockers should be continued perioperatively in patients already taking them preoperatively. Statins may be used in the perioperative period in patients who are not on statin therapy preoperatively. Institutional guidelines should be used to guide insulin replacement. Recent research suggests that measurement of troponins may provide some risk stratification in clinically stable patients following vascular surgery. Multimodal pain therapy including nonopioid strategies is necessary to improve the efficacy of pain relief and decrease the risk of side effects and complications.
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Affiliation(s)
- Saket Singh
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA.
| | - Yasdet Maldonado
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA
| | - Mark A Taylor
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA
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Beta-blockers are the old BLACK. Can J Anaesth 2014; 61:787-93. [DOI: 10.1007/s12630-014-0199-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/17/2014] [Indexed: 02/02/2023] Open
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Ellard L, Katznelson R, Wasowicz M, Ashworth A, Carroll J, Lindsay T, Djaiani G. Type of anesthesia and postoperative delirium after vascular surgery. J Cardiothorac Vasc Anesth 2014; 28:458-61. [PMID: 24680130 DOI: 10.1053/j.jvca.2013.12.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate the association between general (GA), regional (RA), and local (LA) anesthetic techniques with respect to the development of delirium after vascular surgery. The authors hypothesized that patients undergoing GA for vascular surgery would have a higher incidence of postoperative delirium. The role of LA with respect to postoperative delirium in vascular surgery patients previously has not been reported. DESIGN Retrospective review. SETTING Tertiary referral center, university hospital. PARTICIPANTS 500 patients undergoing vascular surgical procedures. INTERVENTIONS Based on the chosen anesthetic technique, all patients were divided into GA, RA, and LA groups, respectively. Exclusion criteria were patients with preoperative dementia or abnormal level of consciousness, patients undergoing open abdominal aneurysm repair surgery, and patients undergoing carotid endarterectomy. All anesthetic techniques were conducted according to routine institutional practices. Patients in both the RA and LA groups received intravenous sedation. MEASUREMENTS AND MAIN RESULTS Three hundred ninety-six (79%) patients received GA, 73 (15%) RA, and 31 (6%) LA. The overall incidence of delirium was 19.4% and rates were similar among the 3 groups, with 73 (18.4%) patients in the GA group, 17 (23.2%) in the RA group, and 7 (22.5%) in the LA group (p = 0.56). Patients in the LA group were more likely to have emergency surgery and also had a higher incidence of previous cerebrovascular accidents or transient ischemic attacks. There was no significant difference with respect to either onset or duration of delirium among the 3 groups. Median length of hospital stay and in-hospital mortality were similar among the 3 groups. CONCLUSIONS Delirium rates after vascular surgery were similar with local, regional, or general anesthesia techniques. The presence of risk factors for the development of postoperative delirium should not influence the type of anesthesia provided.
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Affiliation(s)
- Louise Ellard
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - Rita Katznelson
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - Marcin Wasowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - Alan Ashworth
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - Jo Carroll
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - Thomas Lindsay
- Division of Vascular Surgery, University of Toronto, Toronto, Canada
| | - George Djaiani
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada.
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Neuropsychiatric adverse events associated with statins: epidemiology, pathophysiology, prevention and management. CNS Drugs 2014; 28:249-72. [PMID: 24435290 DOI: 10.1007/s40263-013-0135-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Statins, or 3-hydroxy-3-methyl-glutaryl coenzyme A reductase inhibitors, such as lovastatin, atorvastatin, simvastatin, pravastatin, fluvastatin, rosuvastatin and pitavastatin, are cholesterol-lowering drugs used in clinical practice to prevent coronary heart disease. These drugs are generally well tolerated and have been rarely associated with severe adverse effects (e.g. rhabdomyolysis). Over the years, case series and data from national registries of spontaneous adverse drug reaction reports have demonstrated the occurrence of neuropsychiatric reactions associated with statin treatment. They include behavioural alterations (severe irritability, homicidal impulses, threats to others, road rage, depression and violence, paranoia, alienation, antisocial behaviour); cognitive and memory impairments; sleep disturbance (frequent awakenings, shorter sleep duration, early morning awakenings, nightmares, sleepwalking, night terrors); and sexual dysfunction (impotence and decreased libido). Studies designed to investigate specific neuropsychiatric endpoints have yielded conflicting results. Several mechanisms, mainly related to inhibition of cholesterol biosynthesis, have been proposed to explain the detrimental effects of statins on the central nervous system. Approaches to prevent and manage such adverse effects may include drug discontinuation and introduction of dietary restrictions; maintenance of statin treatment for some weeks with close patient monitoring; switching to a different statin; dose reduction; use of ω-3 fatty acids or coenzyme Q10 supplements; and treatment with psychotropic drugs. The available information suggests that neuropsychiatric effects associated with statins are rare events that likely occur in sensitive patients. Additional data are required, and further clinical studies are needed.
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Cudennec T, Goëau-Brissonnière O, Coscas R, Capdevila C, Moulias S, Coggia M, Teillet L. Delirium in elderly vascular surgery patients. Ann Vasc Surg 2013; 28:781-6. [PMID: 24216404 DOI: 10.1016/j.avsg.2013.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 08/22/2013] [Accepted: 08/23/2013] [Indexed: 11/28/2022]
Abstract
The elderly represent a large percentage of patients seen in departments of vascular surgery. Delirium is a frequent perioperative complication in this population and contributes to increased morbidity and mortality. Prevention of problems associated with mental confusion rests in identifying comorbidities, their severity, and the risk factors associated with delirium syndrome. The aging of our population implies management of increasing numbers of older patients who often have concomitant pathologies and, consequently, polypharmacy. Optimization of their management rests on collaboration between surgeons, anesthetists, and geriatrists.
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Affiliation(s)
- Tristan Cudennec
- Department of Geriatrics, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt (92), and Versailles Saint-Quentin en Yvelines University, Versailles, France.
| | - Olivier Goëau-Brissonnière
- Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt (92), and Versailles Saint-Quentin en Yvelines University, Versailles, France
| | - Raphaël Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt (92), and Versailles Saint-Quentin en Yvelines University, Versailles, France
| | - Clément Capdevila
- Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt (92), and Versailles Saint-Quentin en Yvelines University, Versailles, France
| | - Sophi Moulias
- Department of Geriatrics, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt (92), and Versailles Saint-Quentin en Yvelines University, Versailles, France
| | - Marc Coggia
- Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt (92), and Versailles Saint-Quentin en Yvelines University, Versailles, France
| | - Laurent Teillet
- Department of Geriatrics, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt (92), and Versailles Saint-Quentin en Yvelines University, Versailles, France
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Sasajima Y, Sasajima T, Azuma N, Akazawa K, Saito Y, Inaba M, Uchida H. Factors related to postoperative delirium in patients with lower limb ischaemia: a prospective cohort study. Eur J Vasc Endovasc Surg 2012; 44:411-5. [PMID: 22863895 DOI: 10.1016/j.ejvs.2012.06.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 06/29/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To preoperatively determine candidates at definitive risk of postoperative delirium (POD), we identified relevant factors in patients with arteriosclerosis obliterans who underwent bypass surgery. DESIGN A prospective cohort study. PATIENTS AND METHODS 299 patients (age ≥ 60 years) who underwent bypasses in 1995-2006 were enrolled. Cognitive impairment was assessed by the Revised Hasegawa Dementia Scale, the Confusion Assessment Method was also used, and severity was graded as Grade I-III (mild to severe) based on the Delirium Rating Scale. All patients were followed for 3 years. RESULTS POD occurred in 88 patients (29%), with a median age of 75 (10) years (IQR). Onset was 2 (1) days postoperatively, and a duration of 2 (2) days was observed. POD was hyperactive in 89% and was Grade I, II, and III in 11%, 68%, and 21% respectively. Multiple logistic regression analysis identified the following risk factors for POD: age ≥ 72 years (<0.0001), end-stage renal failure (0.001), multiple occlusive lesions (<0.0001), cognitive impairment (0.003), and critical limb ischaemia (0.034). The 3-year survival rate was similar when comparing POD and non-POD patients (84% vs. 88%, NS). CONCLUSIONS This study identified 5 risk factors for POD in patients undergoing bypasses for limb ischaemia. Long-term outcomes were similar when comparing the patients who experienced POD with those who did not.
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Affiliation(s)
- Y Sasajima
- Asahikawa College, Hokkaido Educational University, Asahikawa, Japan.
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Endovascular versus open approach to aortic aneurysm repair surgery: rates of postoperative delirium. Can J Anaesth 2012; 59:556-61. [DOI: 10.1007/s12630-012-9695-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 03/13/2012] [Indexed: 12/25/2022] Open
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Koebrugge B, van Wensen RJ, Bosscha K, Dautzenberg PL, Koning OH. Delirium after Emergency/Elective Open and Endovascular Aortoiliac Surgery at a Surgical Ward with a High-standard Delirium Care Protocol. Vascular 2010; 18:279-87. [DOI: 10.2310/6670.2010.00052] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Delirium is a common problem in elderly patients undergoing surgery. Standard delirium care is not available at all surgical wards. We determined the incidence, risk factors, and outcomes of postoperative delirium among patients undergoing elective/emergency aortoiliac surgery at a surgical ward with high-standard delirium care. A prospective descriptive survey in 107 patients was conducted. High-standard delirium care was given to patients above age 65, consisting of an extended focus on risk factors and intensive screening. The Delirium Observation Scale was used as a screening instrument for delirium. Patients were classified as having delirium if they met the DSM-IV criteria. The overall incidence of delirium was 23%. The incidence was 14% after elective surgery. Delirium occurred in 59% after emergency surgery and more often after open than after endovascular aneurysm repair ( p < .01). Delirium was associated with age ( p < .01) and emergency surgery ( p = .01) and is an important and frequent complication after aortoiliac surgery.
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Affiliation(s)
- Boukje Koebrugge
- Departments of *Surgery and †Geriatrics, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Remco J.A. van Wensen
- Departments of *Surgery and †Geriatrics, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Koop Bosscha
- Departments of *Surgery and †Geriatrics, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Paul L.J. Dautzenberg
- Departments of *Surgery and †Geriatrics, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Olivier H.J. Koning
- Departments of *Surgery and †Geriatrics, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
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Hospital administrative database underestimates delirium rate after cardiac surgery. Can J Anaesth 2010; 57:898-902. [DOI: 10.1007/s12630-010-9355-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 07/01/2010] [Indexed: 10/19/2022] Open
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