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Ooms M, Schooß R, Puladi B, Steiner T, Hölzle F, Bickenbach J, Rieg A, Modabber A. Identification of risk factors for postoperative delirium in patients following intraoral reconstruction with microvascular free flaps: a matched-pair analysis. Int J Oral Maxillofac Surg 2023; 52:1127-1136. [PMID: 37045611 DOI: 10.1016/j.ijom.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 03/08/2023] [Accepted: 03/24/2023] [Indexed: 04/14/2023]
Abstract
Postoperative delirium (POD) following microvascular head and neck reconstruction negatively impacts patient outcomes, and only a few risk factors have been identified. The aim of this study was to identify additional risk factors for POD after intraoral reconstruction with microvascular free flaps. Data from 377 patients who underwent intraoral microvascular free flap reconstruction between 2011 and 2019 were analysed retrospectively. Preoperative, intraoperative, and postoperative variables were compared between 40 patients with POD and 40 patients without POD who were matched for previously identified risk factors (i.e., sex, age, American Society of Anesthesiologists class, preoperative arterial hypertension, tracheotomy, operation time, and blood transfusion). A multivariable regression analysis was then performed to identify risk factors associated with POD. POD occurred in 50 (13.3%) of the 377 cases studied; the median time of onset was postoperative day 2. Excessive preoperative alcohol consumption (odds ratio 9.22, 95% confidence interval 1.09-77.97; P = 0.041) and postoperative transplant revision (odds ratio 25.72, 95% confidence interval 1.26-525.43; P = 0.035) were identified as risk factors for POD. The identification of patients at high risk of POD based on these two risk factors may allow early adjustment of diagnostic and therapeutic modalities to improve outcomes and reduce healthcare costs.
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Affiliation(s)
- M Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany.
| | - R Schooß
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - B Puladi
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - T Steiner
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - F Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - J Bickenbach
- Department of Intensive Care Medicine, Uniklinik RWTH Aachen, Aachen, Germany
| | - A Rieg
- Department of Anaesthesiology, Uniklinik RWTH Aachen, Aachen, Germany
| | - A Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
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2
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Turner E, Robinson DM, Roaten K. Psychological Issues. Phys Med Rehabil Clin N Am 2023; 34:849-866. [PMID: 37806702 DOI: 10.1016/j.pmr.2023.05.005] [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] [Indexed: 10/10/2023]
Abstract
Psychological distress is common following a burn injury, and many burn survivors have pre-morbid psychiatric illnesses including mood and trauma-related disorders, and substance and alcohol use. This article is intended to be used by all interdisciplinary health care team members to improve the identification and treatment of common psychological concerns experienced by survivors and is organized to follow the general recovery timeline.
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Affiliation(s)
- Emma Turner
- The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Suite CS6.104B, Dallas, TX 75390, USA.
| | - Diana M Robinson
- The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Suite CS6.104B, Dallas, TX 75390, USA.
| | - Kimberly Roaten
- The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Suite CS6.104B, Dallas, TX 75390, USA.
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O'Brien A, Hopkins J, Boardman G, Stanley G, Daly P, Martin L, Wood F. A retrospective, cross-sectional analysis of delirium in burn injury compared to other surgical specialities. Burns 2023; 49:1676-1687. [PMID: 37821275 DOI: 10.1016/j.burns.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 04/12/2023] [Accepted: 05/06/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Delirium is an acute cerebral disorder characterised by a disturbance in cognition, attention, and awareness. Often, it's undiagnosed and associated with increased morbidity and mortality. For burn patients, the reported prevalence ranges from 16% to 39%, with a multifactorial aetiology, increasing when intensive care is required. A direct comparison of delirium between surgical specialities has not been made. AIM 1. To audit the use of the 4AT for those who become delirious during their stay. 2. Assess the proportion of patients diagnosed with delirium during hospitalisation by surgical specialities. 3. Identification of the factors associated with delirium in surgical patients. METHODS Investigators at a single centre conducted a two-phase study. An initial retrospective audit of delirious patients under burns, general, and orthopaedic specialities over 16months, as defined by ICD-10 coding, identified compliance screening with the 4 A's Test. This informed the design of a retrospective, observational cohort study to compare factors associated with delirium and statistical comparison between four specialities to identify delirium-associated factor, where an analysis corrects for age. RESULTS 37% of patients with an ICD-10 code indicating delirium had a 4AT test completed. Speciality, number of operations, LOS, ICU hours, age, and discharge destination were all statistically significant independent variables. When all other variables were equal, burns had the highest predicted probability of delirium diagnosis. CONCLUSIONS Further analysis to identify and diagnose across the specialties is required. From a patient viewpoint, their LOS, ICU hours, and operations are increased for patients coded as delirious compared to non-delirious across the specialities. On a hospital level, the mean difference in cost for a delirious compared to a non-delirious patient is AU$9317. Despite the low incidence of delirium amongst the observed specialities, burns patients were most likely to develop delirium when demographic and clinical profiles were the same, and were more likely to develop delirium at a younger age and if in ICU.
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Affiliation(s)
- Aoife O'Brien
- Burns Service of Western Australia, Fiona Stanley Hospital, Western Australia, Australia.
| | - Jane Hopkins
- Service 4, Fiona Stanley Fremantle Hospitals Group, Western Australia, Australia
| | - Glenn Boardman
- Research Support and Development Unit, Fiona Stanley Hospital, Western Australia, Australia
| | - Guy Stanley
- Burns Service of Western Australia, Fiona Stanley Hospital, Western Australia, Australia; Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia
| | - Patrick Daly
- Burns Service of Western Australia, Fiona Stanley Hospital, Western Australia, Australia
| | - Lisa Martin
- Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia
| | - Fiona Wood
- Burns Service of Western Australia, Fiona Stanley Hospital, Western Australia, Australia; Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia
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Ren Y, Zhang Y, Zhan J, Sun J, Luo J, Liao W, Cheng X. Machine learning for prediction of delirium in patients with extensive burns after surgery. CNS Neurosci Ther 2023; 29:2986-2997. [PMID: 37122154 PMCID: PMC10493655 DOI: 10.1111/cns.14237] [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: 01/03/2023] [Revised: 02/23/2023] [Accepted: 04/15/2023] [Indexed: 05/02/2023] Open
Abstract
AIMS Machine learning-based identification of key variables and prediction of postoperative delirium in patients with extensive burns. METHODS Five hundred and eighteen patients with extensive burns who underwent surgery were included and randomly divided into a training set, a validation set, and a testing set. Multifactorial logistic regression analysis was used to screen for significant variables. Nine prediction models were constructed in the training and validation sets (80% of dataset). The testing set (20% of dataset) was used to further evaluate the model. The area under the receiver operating curve (AUROC) was used to compare model performance. SHapley Additive exPlanations (SHAP) was used to interpret the best one and to externally validate it in another large tertiary hospital. RESULTS Seven variables were used in the development of nine prediction models: physical restraint, diabetes, sex, preoperative hemoglobin, acute physiological and chronic health assessment, time in the Burn Intensive Care Unit and total body surface area. Random Forest (RF) outperformed the other eight models in terms of predictive performance (ROC:84.00%) When external validation was performed, RF performed well (accuracy: 77.12%, sensitivity: 67.74% and specificity: 80.46%). CONCLUSION The first machine learning-based delirium prediction model for patients with extensive burns was successfully developed and validated. High-risk patients for delirium can be effectively identified and targeted interventions can be made to reduce the incidence of delirium.
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Affiliation(s)
- Yujie Ren
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Yu Zhang
- Medical Innovation CenterThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Jianhua Zhan
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Junfeng Sun
- Medical Center of Burns and PlasticGanzhou People's HospitalGanzhouChina
| | - Jinhua Luo
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Wenqiang Liao
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Xing Cheng
- Medical Center of Burn Plastic and Wound RepairThe First Affiliated Hospital of Nanchang UniversityNanchangChina
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Williams EC, Estime S, Kuza CM. Delirium in trauma ICUs: a review of incidence, risk factors, outcomes, and management. Curr Opin Anaesthesiol 2023; 36:137-146. [PMID: 36607823 DOI: 10.1097/aco.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE OF REVIEW This article reviews the impact and importance of delirium on patients admitted to the ICU after trauma, including the latest work on prevention and treatment of this condition. As the population ages, the incidence of geriatric trauma will continue to increase with a concomitant rise in the patient and healthcare costs of delirium in this population. RECENT FINDINGS Recent studies have further defined the risk factors for delirium in the trauma ICU patient population, as well as better demonstrated the poor outcomes associated with the diagnosis of delirium in these patients. Recent trials and meta-analysis offer some new evidence for the use of dexmedetomidine and quetiapine as preferred agents for prevention and treatment of delirium and add music interventions as a promising part of nonpharmacologic bundles. SUMMARY Trauma patients requiring admission to the ICU are at significant risk of developing delirium, an acute neuropsychiatric disorder associated with increased healthcare costs and worse outcomes including increased mortality. Ideal methods for prevention and treatment of delirium are not well established, especially in this population, but recent research helps to clarify optimal prevention and treatment strategies.
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Affiliation(s)
- Elliot C Williams
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Stephen Estime
- Department of Anesthesiology and Critical Care, University of Chicago Medicine, Chicago, Illinois
| | - Catherine M Kuza
- Department of Anesthesiology and Critical Care, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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Stanley GHM, Barber ARJ, O'Brien AM, Hamill C, Boardman G, Frear CC, Edgar DW, Seymour H, Wood FM. Delirium in hospitalised adults with acute burns - A systematic review. Burns 2022; 48:1040-1054. [PMID: 35701326 DOI: 10.1016/j.burns.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/09/2022] [Accepted: 05/24/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Delirium is a potentially modifiable, acutely altered mental state, commonly characterised as a hospital-acquired complication. Studies of adult inpatients with acute burns with and without delirium identify causative risks related to the injury or treatment and outcomes related to the patient and healthcare system. We compare patients with and without delirium, providing a high-level quantitative synthesis of delirium risks and outcomes to inform guidelines and future research. METHODS A systematic review, meta-analysis and GRADE evaluation of risks and outcomes associated with delirium in adults with acute burns was conducted using PRISMA guidelines and PROSPERO protocol CRD42021283055. The Newcastle-Ottawa Scale was used to assess quality. RESULTS Investigators reviewed ten studies. ASA score ≥ 3, Total Body Surface Area Percentage (TBSA)> 10%, surgery done, ICU admission, hospital and also Intensive Care Unit (ICU) lengths of stay all had statistically significant associations with delirium, with low-very low certainty on GRADE evaluation. Limitations were heterogeneous studies, review methodology and study bias. CONCLUSION Delirium represents a significant risk to comorbid patients with burns that are hospitalised, receive ICU care, and surgery. Further research is indicated to precisely categorise delirium along the clinical journey to identify modifiable factors, prevention, and proactive therapy.
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Affiliation(s)
- Guy H M Stanley
- Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia; State Adult Burn Unit, Fiona Stanley Hospital, SMHS, Western Australia, Australia.
| | | | - Aoife M O'Brien
- State Adult Burn Unit, Fiona Stanley Hospital, SMHS, Western Australia, Australia
| | - Cheryl Hamill
- Library & Information Service, SMHS, Western Australia, Australia
| | - Glenn Boardman
- Research support & development, SMHS, Western Australia, Australia
| | - Cody C Frear
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Dale W Edgar
- State Adult Burn Unit, Fiona Stanley Hospital, SMHS, Western Australia, Australia; The Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Hannah Seymour
- Department of Geriatric Medicine, SMHS, Western Australia, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, University of Western Australia, Crawley, Western Australia, Australia; State Adult Burn Unit, Fiona Stanley Hospital, SMHS, Western Australia, Australia
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Ren Y, Zhang Y, Luo J, Liao W, Cheng X, Zhan J. Research progress on risk factors of delirium in burn patients: A narrative review. Front Psychiatry 2022; 13:989218. [PMID: 36405924 PMCID: PMC9666388 DOI: 10.3389/fpsyt.2022.989218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Delirium, an acute brain dysfunction, is a common and serious complication in burn patients. The occurrence of delirium increases the difficulty of patient treatment, is associated with various adverse outcomes, and increases the burden on the patient's family. Many scholars have studied the factors that cause delirium, but the causes, pathogenesis, and treatment of delirium in burn patients have not been fully revealed. There is no effective pharmacological treatment for delirium, but active preventive measures can effectively reduce the incidence of delirium in burn patients. Therefore, it is necessary to study the relevant factors affecting the occurrence of delirium in burn patients. This study was conducted on December 20, 2021 by searching the PubMed database for a narrative review of published studies. The search strategy included keywords related to "burns," "delirium," and "risk factors." We reviewed the characteristics of delirium occurrence in burn patients and various delirium assessment tools, and summarized the risk factors for the development of delirium in burn patients in terms of personal, clinical, and environmental factors, and we found that although many risk factors act on the development of delirium in burn patients, some of them, such as clinical and environmental factors, are modifiable, suggesting that we can estimate the exposure of burn patients to risk factors by assessing their likelihood of delirium occurring and to make targeted interventions that provide a theoretical basis for the prevention and treatment of burn delirium.
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Affiliation(s)
- Yujie Ren
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yu Zhang
- Medical Innovation Center, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jinhua Luo
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wenqiang Liao
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xing Cheng
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jianhua Zhan
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Addition of admission lactate levels to Baux score improves mortality prediction in severe burns. Sci Rep 2021; 11:18038. [PMID: 34508143 PMCID: PMC8433150 DOI: 10.1038/s41598-021-97524-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/23/2021] [Indexed: 12/15/2022] Open
Abstract
Risk adjustment and mortality prediction models are central in optimising care and for benchmarking purposes. In the burn setting, the Baux score and its derivatives have been the mainstay for predictions of mortality from burns. Other well-known measures to predict mortality stem from the ICU setting, where, for example, the Simplified Acute Physiology Score (SAPS 3) models have been found to be instrumental. Other attempts to further improve the prediction of outcome have been based on the following variables at admission: Sequential Organ Failure Assessment (aSOFA) score, determinations of aLactate or Neutrophil to Lymphocyte Ratio (aNLR). The aim of the present study was to examine if estimated mortality rate (EMR, SAPS 3), aSOFA, aLactate, and aNLR can, either alone or in conjunction with the others, improve the mortality prediction beyond that of the effects of age and percentage total body surface area (TBSA%) burned among patients with severe burns who need critical care. This is a retrospective, explorative, single centre, registry study based on prospectively gathered data. The study included 222 patients with median (25th–75th centiles) age of 55.0 (38.0 to 69.0) years, TBSA% burned was 24.5 (13.0 to 37.2) and crude mortality was 17%. As anticipated highest predicting power was obtained with age and TBSA% with an AUC at 0.906 (95% CI 0.857 to 0.955) as compared with EMR, aSOFA, aLactate and aNLR. The largest effect was seen thereafter by adding aLactate to the model, increasing AUC to 0.938 (0.898 to 0.979) (p < 0.001). Whereafter, adding EMR, aSOFA, and aNLR, separately or in combinations, only marginally improved the prediction power. This study shows that the prediction model with age and TBSA% may be improved by adding aLactate, despite the fact that aLactate levels were only moderately increased. Thereafter, adding EMR, aSOFA or aNLR only marginally affected the mortality prediction.
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