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Dragoescu AN, Padureanu V, Stanculescu AD, Chiutu L, Padureanu R, Andrei M, Radu MA, Mitroi G, Dragoescu PO. The Role of Neutrophil-to-Lymphocyte Ratio (NLR) in Urosepsis-Associated Delirium. Cureus 2024; 16:e62110. [PMID: 38863776 PMCID: PMC11165295 DOI: 10.7759/cureus.62110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2024] [Indexed: 06/13/2024] Open
Abstract
Introduction Urosepsis is a systemic, dysregulated, inflammatory reaction to a urinary tract infection and can have severe effects on all systems, which can often lead to multi-organ failure and death. Sepsis-associated delirium is a common complication in critically ill patients, contributing to adverse outcomes and prolonged hospital stays. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a potential biomarker for sepsis severity and prognosis. Material and methods Our study investigates the utility of NLR in the diagnostic strategies for urosepsis-associated delirium in a cohort of 76 patients with sepsis and septic shock admitted to the Intensive Care Unit (ICU). We performed a single-centre retrospective observational study in the Craiova Clinical Emergency Hospital between June and October 2023. Results Patients with urological conditions that were diagnosed with urosepsis included 76 patients. These patients were clustered as follows: a group with delirium (37 patients, 48.7%) and another group without delirium (39 patients, 51.3%). Complete blood count parameters were obtained upon admission, and delirium was assessed using standardized diagnostic criteria. We identified a strong significant positive correlation between elevated NLR values on ICU admission and the development of delirium during hospitalization in urosepsis patients. Receiver operating characteristic (ROC) analysis showed similar diagnostic performance for NLR score. Conclusions The findings suggest that NLR may serve as a valuable biomarker for early detection, risk stratification, and guiding therapeutic interventions in urosepsis-associated delirium, thus improving outcomes in critically ill patients.
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Affiliation(s)
- Alice Nicoleta Dragoescu
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Vlad Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Andreea Doriana Stanculescu
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Luminita Chiutu
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Rodica Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Maria Andrei
- Department of Cardiology, Emergency Clinical County Hospital of Craiova, Craiova, ROU
| | - Mihai Alexandru Radu
- Department of Urology, Emergency Clinical County Hospital of Craiova, Craiova, ROU
| | - George Mitroi
- Department of Urology, University of Medicine and Pharmacy of Craiova, Craiova, ROU
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Hirayama T, Igarashi E, Wada S, Sadahiro R, Oshikiri H, Suzuka M, Sato Y, Utsumi Y, Sakuma A, Nakahara R, Imai T, Tomita H, Matsuoka H. Concomitant use of hydroxyzine and haloperidol did not worsen delirium in patients with cancer: A multicenter, retrospective, observational study. Palliat Support Care 2024:1-8. [PMID: 38409802 DOI: 10.1017/s1478951524000117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
OBJECTIVES There is concern that hydroxyzine exacerbates delirium, but a recent preliminary study suggested that the combination of haloperidol and hydroxyzine was effective against delirium. This study examined whether the concomitant use of hydroxyzine and haloperidol worsened delirium in patients with cancer. METHODS This retrospective, observational study was conducted at 2 general hospitals in Japan. The medical records of patients with cancer who received haloperidol for delirium from July to December 2020 were reviewed. The treatments for delirium included haloperidol alone or haloperidol combined with hydroxyzine. The primary outcome was the duration from the first day of haloperidol administration to the resolution of delirium, defined as its absence for 2 consecutive days. The time to delirium resolution was analyzed to compare the haloperidol group and hydroxyzine combination group using the log-rank test with the Kaplan-Meier method. Secondary outcomes were (1) the total dose of antipsychotic medications, including those other than haloperidol (measured in chlorpromazine-equivalent doses), and (2) the frequencies of detrimental incidents during delirium, specifically falls and self-removal of drip infusion lines. The unpaired t-test and Fisher's exact test were used to analyze secondary outcomes. RESULTS Of 497 patients who received haloperidol, 118 (23.7%) also received hydroxyzine. No significant difference in time to delirium resolution was found between the haloperidol group and the hydroxyzine combination group (log-rank test, P = 0.631). No significant difference between groups was found in either chlorpromazine-equivalent doses or the frequency of detrimental incidents. SIGNIFICANCE OF RESULTS This study showed that the concomitant use of hydroxyzine and haloperidol did not worsen delirium in patients with cancer.
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Affiliation(s)
- Takatoshi Hirayama
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Emi Igarashi
- Department of Psychiatry, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Saho Wada
- Division of Quality Assurance Programs, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Ryoichi Sadahiro
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hanae Oshikiri
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
| | - Masato Suzuka
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
| | - Yuji Sato
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
| | - Yusuke Utsumi
- Department of Psychiatry, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Psychiatry, Tohoku University Hospital, Sendai, Japan
| | - Atsushi Sakuma
- Department of Psychiatry, Tohoku University Hospital, Sendai, Japan
| | - Rika Nakahara
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Toru Imai
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroaki Tomita
- Department of Psychiatry, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Psychiatry, Tohoku University Hospital, Sendai, Japan
| | - Hiromichi Matsuoka
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
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Khan SH, Perkins AJ, Jawaid S, Wang S, Lindroth H, Schmitt RE, Doles J, True JD, Gao S, Caplan GA, Twigg HL, Kesler K, Khan BA. Serum proteomic analysis in esophagectomy patients with postoperative delirium: A case-control study. Heart Lung 2024; 63:35-41. [PMID: 37748302 PMCID: PMC10843392 DOI: 10.1016/j.hrtlng.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/24/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Postoperative delirium occurs in up to 80% of patients undergoing esophagectomy. We performed an exploratory proteomic analysis to identify protein pathways that may be associated with delirium post-esophagectomy. OBJECTIVES Identify proteins associated with delirium and delirium severity in a younger and higher-risk surgical population. METHODS We performed a case-control study using blood samples collected from patients enrolled in a negative, randomized, double-blind clinical trial. English speaking adults aged 18 years or older, undergoing esophagectomy, who had blood samples obtained were included. Cases were defined by a positive delirium screen after surgery while controls were patients with negative delirium assessments. Delirium was assessed using Richmond Agitation Sedation Scale and Confusion Assessment Method for the Intensive Care Unit, and delirium severity was assessed by Delirium Rating Scale-Revised-98. Blood samples were collected pre-operatively and on post-operative day 1, and discovery proteomic analysis was performed. Between-group differences in median abundance ratios were reported using Wilcoxon-Mann-Whitney Odds (WMWodds1) test. RESULTS 52 (26 cases, 26 controls) patients were included in the study with a mean age of 64 (SD 9.6) years, 1.9% were females and 25% were African American. The median duration of delirium was 1 day (IQR: 1-2), and the median delirium/coma duration was 2.5 days (IQR: 2-4). Two proteins with greater relative abundance ratio in patients with delirium were: Coagulation factor IX (WMWodds: 1.89 95%CI: 1.0-4.2) and mannosyl-oligosaccharide 1,2-alpha-mannosidase (WMWodds: 2.4 95%CI: 1.03-9.9). Protein abundance ratios associated with mean delirium severity at postoperative day 1 were Complement C2 (Spearman rs = -0.31, 95%CI [-0.55, -0.02]) and Mannosyl-oligosaccharide 1,2-alpha-mannosidase (rs = 0.61, 95%CI = [0.29, 0.81]). CONCLUSIONS We identified changes in proteins associated with coagulation, inflammation, and protein handling; larger, follow-up studies are needed to confirm our hypothesis-generating findings.
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Affiliation(s)
- Sikandar H Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA; Indiana University Center of Health Innovation and Implementation Science, Indianapolis, Indiana, USA.
| | - Anthony J Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Samreen Jawaid
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Heidi Lindroth
- Department of Nursing, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Rebecca E Schmitt
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jason Doles
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jason D True
- Department of Biology, Ball State University, Muncie, Indiana, USA
| | - Sujuan Gao
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gideon A Caplan
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Homer L Twigg
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kenneth Kesler
- Department of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Babar A Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA; Indiana University Center of Health Innovation and Implementation Science, Indianapolis, Indiana, USA
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Chen B, Wu L, Fang Z, Zheng J, Dong W, Hong X, Jin P. Association between preoperative on-site CCU visits and postoperative delirium in patients undergoing cardiac surgery: A retrospective cohort study. Nurs Crit Care 2023; 28:689-697. [PMID: 36404271 DOI: 10.1111/nicc.12862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 11/04/2022] [Accepted: 11/05/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is a common complication after cardiac surgery (CS), with symptoms like attention disorders and even delays patients' recovery. AIMS To evaluate the impact of preoperative on-site visits in the cardiac care unit (CCU) on POD after CS. STUDY DESIGN Patients admitted to the CCU with extracorporeal CS were included in the visiting or non-visiting group according to whether they were on visiting week. The visiting group received a preoperative visit from a nurse-led multidisciplinary visiting team (including CCU nurses and physicians) 1 week before surgery in addition to standard care. The non-visiting group received standard care like unstructured information from the CS team and anesthesiologists and so on. The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) were used to evaluate the POD severity. The incidence, occurrence and duration of POD, as well as the CCU length of stay, postoperative mechanical ventilation duration and length of hospital stay were compared between the two groups. RESULTS A total of 735 participants (369 in the visited group and 366 in the unvisited group) were included in this study. Preoperative on-site visits were associated with a decreased POD incidence (odds ratio [OR]: 0.524, 95% CI: 0.336-0.817), an improved POD severity (OR: 0.578, 95% CI: 0.359-0.932) and a shortening POD duration (OR: 0.972, 95% CI: 0.951-0.994). There was a significant difference between the visiting and non-visiting groups in the mechanical ventilation duration (OR: 0.987, 95% CI: 0.978-0.996). CONCLUSIONS Preoperative on-site visits are associated with a reduction in the incidence, duration, and severity of POD, as well as the mechanical ventilation duration of patients. RELEVANCE TO CLINICAL PRACTICE This study found that preoperative on-site visits were associated with the onset, duration, severity and duration of mechanical ventilation of POD. Although many factors influence the occurrence of POD, a multidisciplinary visiting team led by a nurse (including CCU nurses and physicians) can provide early nursing interventions through preoperative visits, better obtain postoperative cooperation from patients, establish a good nurse-patient relationship and provide better health services to patients. In a realistic CCU setting, nurses and physicians can act as educators, assessing patients before surgery, enhancing preoperative education, improving patient familiarity with the CCU environment and teaching sign language communication skills when patients are mechanically ventilated. These findings can therefore provide the basis for effective clinical care to prevent postoperative POD.
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Affiliation(s)
- Beibei Chen
- Department of Cardiac Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lina Wu
- Department of Cardiac Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhenhong Fang
- Department of Cardiac Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jing Zheng
- Department of Cardiac Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Weihua Dong
- Department of Cardiac Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xia Hong
- Department of Cardiac Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peifeng Jin
- Department of Cardiac Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Kappen PR, Mos MI, Jeekel J, Dirven CMF, Kushner SA, Osse RJ, Coesmans M, Poley MJ, van Schie MS, van der Holt B, Klimek M, Vincent AJPE. Music to prevent deliriUm during neuroSurgerY (MUSYC): a single-centre, prospective randomised controlled trial. BMJ Open 2023; 13:e069957. [PMID: 37369412 PMCID: PMC10410844 DOI: 10.1136/bmjopen-2022-069957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/11/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVES Delirium is a serious complication following neurosurgical procedures. We hypothesise that the beneficial effect of music on a combination of delirium-eliciting factors might reduce delirium incidence following neurosurgery and subsequently improve clinical outcomes. DESIGN Prospective randomised controlled trial. SETTING Single centre, conducted at the neurosurgical department of the Erasmus Medical Center, Rotterdam, the Netherlands. PARTICIPANTS Adult patients undergoing craniotomy were eligible. INTERVENTIONS Patients in the intervention group received preferred recorded music before, during and after the operation until day 3 after surgery. Patients in the control group were treated according to standard of clinical care. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was presence or absence of postoperative delirium within the first 5 postoperative days measured with the Delirium Observation Screening Scale (DOSS) and, in case of a daily mean score of 3 or higher, a psychiatric evaluation with the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Secondary outcomes included anxiety, heart rate variability (HRV), depth of anaesthesia, delirium severity and duration, postoperative complications, length of stay and location of discharge. RESULTS We enrolled 189 patients (music=95, control=94) from July 2020 through September 2021. Delirium, as assessed by the DOSS, was less common in the music (n=11, 11.6%) than in the control group (n=21, 22.3%, OR:0.49, p=0.048). However, after DSM-5 confirmation, differences in delirium were not significant (4.2% vs 7.4%, OR:0.47, p=0.342). Moreover, music increased the HRV (root mean square of successive differences between normal heartbeats, p=0.012). All other secondary outcomes were not different between groups. CONCLUSION Our results support the efficacy of music in reducing the incidence of delirium after craniotomy, as found with DOSS but not after DSM-5 confirmation, substantiated by the effect of music on preoperative autonomic tone. Delirium screening tools should be validated and the long-term implications should be evaluated after craniotomy. TRIAL REGISTRATION NUMBER Trialregister.nl: NL8503 and ClinicalTrials.gov: NCT04649450.
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Affiliation(s)
- Pablo R Kappen
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M I Mos
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Steven A Kushner
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert-Jan Osse
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michiel Coesmans
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marten J Poley
- Institute for Medical Technology Assessment (iMTA), Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Paediatric Surgery and Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bronno van der Holt
- Department of Haematology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M Klimek
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Preoperative Risk Factors Associated with Increased Incidence of Postoperative Delirium: Systematic Review of Qualified Clinical Studies. Geriatrics (Basel) 2023; 8:geriatrics8010024. [PMID: 36826366 PMCID: PMC9956273 DOI: 10.3390/geriatrics8010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/20/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Postoperative delirium (POD) is an acute alteration of mental state, characterized by reduced awareness and attention, occurring up to five postoperative days after recovery from anesthesia. Several original studies and reviews have identified possible perioperative POD risk factors; however, there is no comprehensive review of the preoperative risk factors in patients diagnosed with POD using only validated diagnostic scales. The aim of this systematic review was to report the preoperative risk factors associated with an increased incidence of POD in patients undergoing non-cardiac and non-brain surgery. The reviewed studies included original research papers that used at least one validated diagnostic scale to identify POD occurrence for more than 24 h. A total of 6475 references were retrieved from the database search, with only 260 of them being suitable for further review. Out of the 260 reviewed studies, only 165 that used a validated POD scale reported one or more preoperative risk factors. Forty-one risk factors were identified, with various levels of statistical significance. The extracted risk factors could serve as a preoperative POD risk assessment workup. Future studies dedicated to the further evaluation of the specific preoperative risk factors' contributions to POD could help with the development of a weighted screening tool.
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Chang WJ, Hsieh CE, Hung YJ, Hsu YL, Lin KH, Chen YL. Length of Alcohol Abstinence Predicts Posttransplant Delirium in Living Donor Liver Transplant Recipients with Alcoholic Cirrhosis. EXP CLIN TRANSPLANT 2022; 20:750-756. [DOI: 10.6002/ect.2022.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kappen P, Jeekel J, Dirven CMF, Klimek M, Kushner SA, Osse RJ, Coesmans M, Poley MJ, Vincent AJPE. Music to prevent deliriUm during neuroSurgerY (MUSYC) Clinical trial: a study protocol for a randomised controlled trial. BMJ Open 2021; 11:e048270. [PMID: 34598983 PMCID: PMC8488750 DOI: 10.1136/bmjopen-2020-048270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Delirium is a neurocognitive disorder characterised by an acute and temporary decline of mental status affecting attention, awareness, cognition, language and visuospatial ability. The underlying pathophysiology is driven by neuroinflammation and cellular oxidative stress.Delirium is a serious complication following neurosurgical procedures with a reported incidence varying between 4% and 44% and has been associated with increased length of hospital stay, increased amount of reoperations, increased costs and mortality.Perioperative music has been reported to reduce preoperative anxiety, postoperative pain and opioid usage, and attenuates stress response caused by surgery. We hypothesize that this beneficial effect of music on a combination of delirium eliciting factors might reduce delirium incidence following neurosurgery and subsequently improve clinical outcomes. METHODS This protocol concerns a single-centred prospective randomised controlled trial with 6 months follow-up. All adult patients undergoing a craniotomy at the Erasmus Medical Center in Rotterdam are eligible. The music group will receive recorded music through an overear headphone before, during and after surgery until postoperative day 3. Patients can choose from music playlists, offered based on music importance questionnaires administered at baseline. The control group will receive standard of clinical careDelirium is assessed by the Delirium Observation Scale and confirmed by a delirium-expert psychiatrist according to the DSM-5 criteria. Risk factors correlated with the onset of delirium, such as cognitive function at baseline, preoperative anxiety, perioperative medication use, depth of anaesthesia and postoperative pain, and delirium-related health outcomes such as length of stay, daily function, quality of life (ie, EQ-5D, EORTC questionnaires), costs and cost-effectiveness are collected. ETHICS AND DISSEMINATION This study is being conducted in accordance with the Declaration of Helsinki. The Medical Ethics Review Board of Erasmus University Medical Center Rotterdam, The Netherlands, approved this protocol. Results will be disseminated via peer-reviewed scientific journals and conference presentations. TRIAL REGISTRATION NUMBERS NL8503 and NCT04649450.
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Affiliation(s)
- Pablo Kappen
- Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Neuroscience, Erasmus MC, Rotterdam, The Netherlands
- Surgery, Erasmus MC, Rotterdam, The Netherlands
| | | | - M Klimek
- Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - Steven A Kushner
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert-Jan Osse
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michiel Coesmans
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marten J Poley
- Pediatric Surgery, Erasmus MC Sophia, Rotterdam, The Netherlands
- Medical Technology Assessment (iMTA), Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands
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Postoperative Delirium. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00445-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Xin X, Chen J, Hua W, Wang H. Intraoperative dexmedetomidine for prevention of postoperative delirium in elderly patients with mild cognitive impairment. Int J Geriatr Psychiatry 2021; 36:143-151. [PMID: 33411362 DOI: 10.1002/gps.5406] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 05/19/2020] [Accepted: 08/08/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Delirium is the most common postoperative neurological complication and some evidence suggests that dexmedetomidine is associated with a decreased incidence of delirium. This study is designed to assess the effect of dexmedetomidine on postoperative delirium (POD) in elderly patients with mild cognitive impairment (MCI). METHODS Sixty geriatric patients with MCI were enrolled and ramdomly divided into two groups by a computer-generated randomisation sequence: dexmedetomidine group (D group) and normal saline group (C group). Patients in D group received a loading dose of 0.5 μg/kg dexmedetomidine over 10 minutes before anesthesia induction, followed by a continuous infusion of 0.4 μg·kg-1·h-1 until 30 minutes before the end of surgery; equal volume of normal saline was given in C group. Blood samples were extracted to detect the concentration of cytokines, including tumor necrosis factor-α (TNF-α), interleukin-10 (IL-10), heme oxygenase-1 (HO-1), matrix metalloproteinase-9 (MMP-9), and glial fibrillary acidic protein (GFAP) before anesthesia induction (T1), before suture (T2), and 30 minutes after surgery (T3). Postoperative recovery times were recorded. Delirium was assessed with the 3-Minute Diagnostic Interview for confusion assessment method during the first 7 days postoperatively. RESULTS POD occurred in 10 (33.3%) of 30 patients in C group, and in 3 (10%) of 30 patients given dexmedetomidine (odds ratio [OR] 0.222, 95% CI 0.054-0.914; P = 0.028). The serum concentrations of TNF-α, MMP-9, and GFAP were significantly increased and IL-10 was decreased in the C group than in the D group at T2 and T3. No differences were observed between groups in the level of HO-1. Analysis using random-effect multivariable logistic regression indicated that POD was associated with GFAP (odds ratio [OR] 16.691, 95% CI 2.288-121.746; P = 0.005). The positive predictive ability of the multivariate logistic regression model tested by ROC analysis showed an area under the curve of 0.713 (95% CI, 0.584-0.842). CONCLUSIONS Dexmedetomidine can alleviate POD in elderly patients with MCI and may be related to reduce the neuroinflammation by lowering the permeability of blood-brain barrier.
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Affiliation(s)
- Xi Xin
- Department of Anesthesiology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Jing Chen
- Department of Anesthesiology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Department of Anesthesiology, Tianjin Baodi Hospital, Baodi Clinical College of Tianjin Medical University, Tianjin, China
| | - Wei Hua
- Department of Anesthesiology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Haiyun Wang
- Department of Anesthesiology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, China
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More medications, more problems: results from the Sedation Level after Emergent Exlap with Packing for TRAUMA (SLEEP-TRAUMA) study. Eur J Trauma Emerg Surg 2020; 48:943-952. [PMID: 33078257 PMCID: PMC7571531 DOI: 10.1007/s00068-020-01524-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 10/06/2020] [Indexed: 02/03/2023]
Abstract
Purpose Sedation management of trauma patients after damage control laparotomy (DCL) has not been optimized. We evaluated if shorter sedation exposure was associated with increased proportion of delirium-free/coma-free (DF/CF-ICU) days and change in time to definitive fascial closure (DFC). Methods We reviewed trauma DCL patients at an ACS-verified level I center over 5 years as shorter (SE) or longer than median (LE) sedation exposure. We compared demographics, injury patterns, hemodynamic parameters, and injury severity between groups. We calculated the propensity for each patient to achieve DFC using age, gender, ISS, red blood cell transfusion, bowel discontinuity, abdominal vascular injury, and time to first takeback; we then determined the effect of sedation exposure on rate of DFC by multivariate Cox regression, adjusted for propensity to achieve DFC. We used linear regression adjusted for age, ISS, head-AIS, bowel discontinuity, and vascular injury to determine the effect of sedation exposure on the proportion of DF/CF-ICU days. Results 65 patients (33.8% penetrating) had mean age 41.8 ± 16.0, ISS 27.1 ± 14.2, Head-AIS 1.2 ± 1.6 and median sedation exposure of 2.2 [IQR 0.78, 7.3] days (35 SE and 30 LE). Pattern and severity of solid organ injuries and proportion of small and large bowel and vascular injuries were similar between groups. LE had more abdominal sepsis (23.3% vs 0%, p = 0.003) and enterocutaneous fistula (16.7% vs 0%, p = 0.016), and more ventilator (17.3 ± 12.7 vs 6.1 ± 6.8, p < 0.001), ICU (20.8 ± 14.2 vs 7.2 ± 7.6, p < 0.001), and hospital days (29.6 ± 19.6 vs 13.9 ± 9.0, p < 0.001). DFC was achieved more rapidly in the SE group (2.0 ± 1.5 days vs 3.9 ± 3.7 days [unadjusted], p = 0.023) and SE had a higher proportion of unadjusted DF/CF-ICU days (33.0 ± 32.0% vs 18.1 ± 16.4%, p = 0.020). SE was associated with an increased proportion of adjusted DF/CF-ICU days by multivariate linear regression (13.1% [95% CI 1.4–24.8%], p = 0.029) and with faster adjusted rate of DFC by multivariate Cox regression (RR 2.28 [95% CI 1.25–4.15, p = 0.007]). Conclusions Shorter sedation exposure is associated with increased proportion of DF/CF-ICU days and more rapid DFC after DCL for trauma. Electronic supplementary material The online version of this article (10.1007/s00068-020-01524-9) contains supplementary material, which is available to authorized users.
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Silva AR, Regueira P, Albuquerque E, Baldeiras I, Cardoso AL, Santana I, Cerejeira J. Estimates of Geriatric Delirium Frequency in Noncardiac Surgeries and Its Evaluation Across the Years: A Systematic Review and Meta-analysis. J Am Med Dir Assoc 2020; 22:613-620.e9. [PMID: 33011097 DOI: 10.1016/j.jamda.2020.08.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/26/2020] [Accepted: 08/13/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Delirium is an acute neuropsychiatric syndrome associated with poor outcomes. Older adults undergoing surgery have a higher risk of manifesting perioperative delirium, particularly those having associated comorbidities. It remains unclear whether delirium frequency varies across surgical settings and if it has remained stable across the years. We conducted a systematic review to (1) determine the overall frequency of delirium in older people undergoing noncardiac surgery; (2) explore factors explaining the variability of the estimates; and (3) determine the changing of the estimates over the past 2 decades. DESIGN Systematic review and meta-analysis. Literature search was performed in MEDLINE, PubMed, ISI Web of Science, EBSCO, ISRCTN registry, ScienceDirect, and Embase in January 2020 for studies published from 1995 to 2020. SETTING Noncardiac surgical settings. PARTICIPANTS Forty-nine studies were included with a total of 26,865 patients screened for delirium. METHODS We included observational and controlled trials reporting incidence, prevalence, or proportion of delirium in adults aged ≥60 years undergoing any noncardiac surgery requiring hospitalization. Data extracted included sample size, reported delirium frequencies, surgery type, anesthesia type, delirium diagnosis method, length of hospitalization, and year of assessment. (PROSPERO registration no.: CRD42020160045). RESULTS We found an overall pooled frequency of preoperative delirium of 17.9% and postoperative delirium (POD) of 23.8%. The POD estimates increased between 1995 and 2020 at an average rate of 3% per year. Pooled estimates of POD were significantly higher in studies not excluding patients with lower cognitive performance before surgery (28% vs 16%) and when general anesthesia was used in comparison to local, spinal, or epidural anesthesia (28% vs 20%). CONCLUSIONS AND IMPLICATIONS Type of anesthesia and preoperative cognitive status were significant moderators of delirium frequency. POD in noncardiac surgery has been increasing across the years, suggesting that more resources should be allocated to delirium prevention and management.
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Affiliation(s)
- Ana Rita Silva
- Centre for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal
| | - Patrícia Regueira
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Elisabete Albuquerque
- Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Inês Baldeiras
- Centre for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Ana Luísa Cardoso
- Centre for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal
| | - Isabel Santana
- Centre for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal; Faculty of Medicine, Coimbra University, Coimbra, Portugal; Department of Neurology, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Joaquim Cerejeira
- Centre for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal; Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, Coimbra University, Coimbra, Portugal.
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Abstract
BACKGROUND Delirium is a frequently encountered complication, which is associated with increased mortality. Suvorexant, an approved agent for the treatment of insomnia, is recently suggested to be also effective for prevention of delirium by some authors. However, a consensus has yet to be reached. The goal of this study was to perform a meta-analysis to overall estimate the effectiveness of suvorexant in preventing delirium and its related consequences. METHODS Eligible studies were identified by searching online databases of PubMed, EMBASE, and Cochrane Library. The pooled OR was calculated for binary outcomes (e.g., the incidence of delirium, mortality, or adverse events), while standardized mean difference (SMD) were expressed for continuous outcomes (e.g., time to delirium onset, length of stay in hospital and ICU, time on ventilation). RESULTS Seven studies which comprised 402 suvorexant treatment patients and 487 patients with control treatment were included in this meta-analysis. Overall, pooled analysis indicated the incidence of delirium could be significantly reduced (OR, 0.30; P < .001) and time to delirium onset was significantly lengthened (SMD, 0.44; P = .006) in patients undergoing suvorexant treatment compared with controls. Suvorexant had no beneficial effects on the secondary outcomes [length of stay in hospital (SMD, -0.65; P = .161) and ICU (SMD, 0.34; P = .297), time on ventilation (SMD, 1.09; P = .318), drug-related adverse events (OR, drug-related adverse events (OR, 1.66; P = .319) and mortality (OR, 2.21; P = .261)]. Subgroup analysis also confirmed the benefit of suvorexant on the development of delirium, which was significant in any subgroup. CONCLUSION Suvorexant should be recommended for the prevention of delirium in clinic.
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Affiliation(s)
| | | | - Jinhua Shen
- Intensive Care Unit, Huashan Hospital Affiliated to Fudan University, Shanghai, China
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Kijima E, Kayama T, Saito M, Kurosaka D, Ikeda R, Hayashi H, Kubota D, Hyakutake T, Marumo K. Pre-operative hemoglobin level and use of sedative-hypnotics are independent risk factors for post-operative delirium following total knee arthroplasty. BMC Musculoskelet Disord 2020; 21:279. [PMID: 32359366 PMCID: PMC7196215 DOI: 10.1186/s12891-020-03206-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/11/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Delirium is a well-known complication following surgery, especially with the increasing age of patients undergoing surgery. The increasing demands resulting from a prolonged healthy life expectancy has resulted in more arthroplasties despite their age and existing comorbidities. The purpose of this study is to explore the various risk factors that may contribute to delirium in unilateral and bilateral total knee arthroplasties in the elderly population. METHODS 170 patients who underwent unilateral or bilateral total knee arthroplasties were analyzed retrospectively for delirium. Age, sex, comorbidities, use of sedative-hypnotics, peri-operative blood loss, pre- and post-operative laboratory blood test results were investigated and analyzed. RESULTS The incidence of post-operative delirium was 6.5% (11 out of 170 patients) with a mean age of 79.5 (± 6.9) years, compared to 73.0 (± 9.0) years in the non-delirium group. Higher age, use of sedative-hypnotics, low pre-operative Hb and Ht, low post-operative Hb, Ht and BUN were observed in the delirium group. Multivariate logistic regression analysis identified that the use of sedative-hypnotics and pre-operative Hb level were independent risk factors for post-operative delirium after TKA. The odds ratios for the use of sedative-hypnotics and pre-operative Hb level were 4.6 and 0.53, respectively. Receiver operating characteristic curve analysis showed that pre-operative Hb of less than 11.1 g/dL was a predictor for the development of delirium, with a sensitivity of 54.6% and a specificity of 91.6%. CONCLUSION Patients with a pre-operative Hb level of < 11.1 g/dL or those using sedative-hypnotics are associated with post-operative delirium. Peri-operative management and preventative measures are therefore needed to reduce the risks of post-operative delirium in such patients.
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Affiliation(s)
- Eiji Kijima
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Tomohiro Kayama
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Daisaburo Kurosaka
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Ryo Ikeda
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroteru Hayashi
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Daisuke Kubota
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takashi Hyakutake
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Keishi Marumo
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
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Plyler SS, Muckler VC, Titch JF, Gupta DK, Rice AN. Low-Dose Ketamine Infusion to Decrease Postoperative Delirium for Spinal Fusion Patients. J Perianesth Nurs 2019; 34:779-788. [DOI: 10.1016/j.jopan.2018.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/20/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
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Vahdat Shariatpanahi M, Velayati A, Jamalian SA, Babevaynejad M, Vahdat Shariatpanahi Z. The relationship between serum cobalamin, folic acid, and homocysteine and the risk of post-cardiac surgery delirium. Neuropsychiatr Dis Treat 2019; 15:1413-1419. [PMID: 31190843 PMCID: PMC6536132 DOI: 10.2147/ndt.s201620] [Citation(s) in RCA: 5] [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: 01/15/2019] [Accepted: 03/25/2019] [Indexed: 12/04/2022] Open
Abstract
Purpose: It has been reported that cobalamin and folate deficiency is related to delirium in persons with dementia. We evaluated the association of admission serum levels of cobalamin, folic acid, and homocysteine with the occurrence of acute delirium after coronary artery bypass surgery. Methods: In this prospective cohort study, serum levels of cobalamin, folic acid, and homocysteine were measured for 296 patients upon admission. Delirium was defined by the confusion assessment method for the intensive care unit. Results: Postoperative delirium was detected in 23% (n=68) of patients. Cobalamin deficiency, folate deficiency, and hyperhomocysteinemia were observed in 29% (n=86), 6% (n=18), and 68% (n=200) of patients, respectively. The mean ± SD serum levels of folic acid were 10.77±5.39 ng/mL and 12.86±6.51 ng/mL in delirium and non-delirium patients, respectively (P=0.008). The median (interquartile range [IQR]) serum levels of cobalamin were 280 (216-351) and 247 (195.5-336) in delirium and non-delirium patients, respectively (P=0.09). The median (IQR) serum levels of homocysteine were 18.5 (14.5-22.1) µmol/L and 17.33 (14.2-23.2) µmol/L in delirium and non-delirium patients, respectively (P=0.94). Multivariate regression analysis adjusted by other risk factors indicated that serum homocysteine, folate, and cobalamin levels had no association with the occurrence of delirium. Conclusion: There was no relationship between the preoperative levels of cobalamin, folate, and homocysteine, and acute occurrence of delirium observed after cardiac surgery.
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Affiliation(s)
- Maryam Vahdat Shariatpanahi
- Department of Psychiatry, Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Aynaz Velayati
- National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Ali Jamalian
- Department of Cardiology, Shahid Lavasani Hospital, Islamic Azad University, Tehran, Iran
| | - Mehdi Babevaynejad
- Department of Cardiac Surgery, Shahid Lavasani Hospital, Islamic Azad University, Tehran, Iran
| | - Zahra Vahdat Shariatpanahi
- National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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