Environmental and Clinical Risk Factors for Delirium in a Neurosurgical Center: A Prospective Study

Music to prevent deliriUm during neuroSurgerY (MUSYC): a single-centre, prospective randomised controlled trial

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.

Physical Restraint Experiences of Family Caregivers of Patients With Stroke in Turkey: A Qualitative Study

The purpose of this study was to explore the experiences and needs of family caregivers of stroke patients who require physical restraints. The themes and sub-themes that emerged included "the reason for the use of PR" (disruptive behaviors of the patient and personal reasons of caregivers), "the turmoil of having to use PR" (inevitableness, comparing benefits and harms, the emotional effect of PR, and physical effects), and "unmet needs and suggestions" (unmeet needs and suggestions). Nurses should take the experiences of patient relatives into account in the process of PR application, organize training programs, and determine application standards for PR.

Dexmedetomidine administration during brain tumour resection for prevention of postoperative delirium: a randomised trial

BACKGROUND

Delirium is common, especially after neurosurgery. Dexmedetomidine might reduce delirium by improving postoperative analgesia and sleep quality. We tested the primary hypothesis that dexmedetomidine administration during intracerebral tumour resection reduces the incidence of postoperative delirium.

METHODS

This randomised, double-blind, placebo-controlled trial was conducted in two tertiary-care hospitals in Beijing. We randomised 260 qualifying patients to either dexmedetomidine (n=130) or placebo (n=130). Subjects assigned to dexmedetomidine were given a loading dose of 0.6 μg kg^-1 followed by continuous infusion at 0.4 μg kg^-1 h^-1 until dural closure; subjects in the placebo group were given comparable volumes of normal saline. The primary outcome was the incidence of delirium, which was assessed with the Confusion Assessment Method twice daily during the initial 5 postoperative days.

RESULTS

The average (standard deviation) age of participating patients was 45 (12) yr, duration of surgery was 4.2 (1.5) h, and patients assigned to dexmedetomidine were given an average of 126 (45) μg of dexmedetomidine. There was less delirium during the initial 5 postoperative days in patients assigned to dexmedetomidine (22%, 28 of 130 patients) than in those given placebo (46%, 60 of 130 patients) with a risk ratio of 0.51 (95% confidence interval: 0.36-0.74, P<0.001). Postoperative pain scores with movement, and recovery and sleep quality were improved by dexmedetomidine (P<0.001). The incidence of safety outcomes was similar in each group.

CONCLUSIONS

Prophylactic intraoperative dexmedetomidine infusion reduced by half the incidence of delirium during the initial 5 postoperative days in patients recovering from elective brain tumour resection.

CLINICAL TRIAL REGISTRATION

NCT04674241.

A Scoping Review of the Incidence, Predictors, and Outcomes of Delirium Among Critically Ill Stroke Patients

ABSTRACT

BACKGROUND: Delirium is a common, often iatrogenically induced syndrome that may impede the physical, cognitive, and psychological recovery of critically ill adults. The effect delirium has on outcomes of intensive care unit patients having acute neurologic injury remains unclear because previous studies frequently exclude this vulnerable population. The aim of this scoping review was to describe the incidence, predictors, and outcomes of delirium among adults admitted to an intensive care unit experiencing an acute ischemic stroke, intracerebral hemorrhage, or aneurysmal subarachnoid hemorrhage. METHODS: PubMed, CINAHL, Web of Science, EMBASE, and Scopus were searched with the terms (1) stroke, (2) critical care, and (3) delirium. Inclusion criteria were original peer-reviewed research reporting the incidence, outcomes, or predictors of delirium after acute stroke among critically ill adults. Editorials, reviews, posters, conference proceedings, abstracts, and studies in which stroke was not the primary reason for admission were excluded. Title and abstract screening, full-text review, and data extraction were performed by 2 authors, with disagreements adjudicated by a third author. RESULTS: The initial search yielded 1051 results. Eighteen studies met eligibility criteria and were included in the review. Stroke type was not mutually exclusive and included persons given a diagnosis of acute ischemic stroke (11), intracerebral hemorrhage (12), aneurysmal subarachnoid hemorrhage (8), and other (1) strokes. Incidence of delirium among stroke patients ranged from 12% to 75%. Predictors of delirium included older age, preexisting dementia, higher severity of illness, and physical restraint use. Outcomes associated with delirium included higher mortality, longer length of stay, worse cognition and quality of life, and lower functional status. CONCLUSIONS: Current findings are limited by heterogenous populations, assessments, and measurement parameters. Detection and management of delirium among critically ill stroke patients requires an approach with specific considerations to the complexities of acute neurological injury and concomitant critical illness.

Higher Grade Glioma Increases the Risk of Postoperative Delirium: Deficient Brain Compensation Might Be a Potential Mechanism of Postoperative Delirium

Objective

The brain compensation mechanism in postoperative delirium (POD) has not been reported. We uncovered the mechanism by exploring the association between POD and glioma grades, and the relationship between preoperative brain structural and functional compensation with POD in patients with frontal glioma.

Methods

A total of 335 adult patients with glioma were included. The multivariable analysis examined the association between tumor grade and POD. Then, 20 patients with left frontal lobe glioma who had presurgical structural and functional MRI data and Montreal Cognitive Assessment (MoCA) in this cohort were analyzed. We measured the gray matter volume (GMV) and functional connectivity (FC) in patients with (n = 8) and without (n = 12) POD and healthy controls (HCs, n = 29) to detect the correlation between the structural and functional alteration and POD.

Results

The incidence of POD was 37.3%. Multivariable regression revealed that high-grade glioma had approximately six times the odds of POD. Neuroimaging data showed that compared with HC, the patients with left frontal lobe glioma showed significantly increased GMV of the right dorsal lateral prefrontal cortex (DLPFC) in the non-POD group and decreased GMV of right DLPFC in the POD group, and the POD group exhibited significantly decreased FC of right DLPFC, and the non-POD group showed the increasing tendency. Partial correlation analysis showed that GMV in contralesional DLPFC were positively correlated with preoperative neurocognition, and the GMV and FC in contralesional DLPFC were negatively correlated with POD.

Conclusions

Our findings suggested that insufficient compensation for injured brain regions involving cognition might be more vulnerable to suffering from POD.

Music to prevent deliriUm during neuroSurgerY (MUSYC) Clinical trial: a study protocol for a randomised controlled trial

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.

Nurses' experiences of using restraint in neurosurgical care - A qualitative interview study

AIM AND OBJECTIVES

To describe nurses' experiences of using restraint in neurosurgical care.

BACKGROUND

Despite reports of negative consequences, and conflicts with key values in healthcare, restraint measures are still practised in somatic healthcare worldwide. When using restraint, basic principles of nursing collide, creating dilemmas known to be perceived as difficult for many nurses. Patients in neurosurgical care are at high risk of being subjected to restraint, but research on nurses' experiences of using restraint in neurosurgical care are scarce.

DESIGN

A qualitative, descriptive design guided by a naturalistic inquiry was used.

METHODS

Semi-structured interviews with 15 nurses working in three neurosurgical departments in Sweden were analysed with inductive qualitative content analysis. COREQ reporting guidelines were used as reporting checklist.

RESULTS

The analysis resulted in one overarching theme, The struggling professional, and two categories. The category Internal struggle describes nurses' conflicting emotions and internal struggle when engaging in restraint. The category The struggle in clinical practice, describes how nurses struggle with handling restraint in clinical practice, and how the use of restraint is based on individual assessment rather than guidelines.

CONCLUSION

Nurses' experience restraint in neurosurgical care as a multi-layered struggle, ranging from inner doubts to practical issues. In order to enhance patient safety, there is a need for policies and guidelines regarding the use of restraint, as well as structured discussions and reflections for nurses engaged in the practice.

RELEVANCE TO CLINICAL PRACTICE

The results highlight the importance of clear guidelines, openness, support and teamwork for nurses working with patients at risk to be subjected to restraint, in order to create a safer care for patients as well as healthcare personnel. When developing guidelines and policies concerning restraint in somatic care, both practical issues such as the decision-making process, and the emotional effect on nurses should be considered.

Delirium in neurosurgery: a systematic review and meta-analysis

Delirium is a frequent occurring complication in surgical patients. Nevertheless, a scientific work-up of the clinical relevance of delirium after intracranial surgery is lacking. We conducted a systematic review (CRD42020166656) to evaluate the current diagnostic work-up, incidence, risk factors and health outcomes of delirium in this population. Five databases (Embase, Medline, Web of Science, PsycINFO, Cochrane Central) were searched from inception through March 31st, 2021. Twenty-four studies (5589 patients) were included for qualitative analysis and twenty-one studies for quantitative analysis (5083 patients). Validated delirium screening tools were used in 70% of the studies, consisting of the Confusion Assessment Method (intensive care unit) (45%), Delirium Observation Screening Scale (5%), Intensive Care Delirium Screening Checklist (10%), Neelon and Champagne Confusion Scale (5%) and Nursing Delirium Screening Scale (5%). Incidence of post-operative delirium after intracranial surgery was 19%, ranging from 12 to 26% caused by variation in clinical features and delirium assessment methods. Meta-regression for age and gender did not show a correlation with delirium. We present an overview of risk factors and health outcomes associated with the onset of delirium. Our review highlights the need of future research on delirium in neurosurgery, which should focus on optimizing diagnosis and assessing prognostic significance and management.

Prevalence and Factors Affecting Postoperative Delirium in a Neurosurgical Intensive Care Unit

ABSTRACT

PURPOSE: The aim of this study was to identify the prevalence of, and factors affecting, postoperative delirium (POD) in patients in the neurosurgical intensive care unit. METHODS: A cross-sectional study of 127 Turkish neurosurgical intensive care unit patients admitted between May 2018 and May 2019 was conducted. Patients were assessed for the development of POD using the Intensive Care Delirium Screening Checklist. We collected other independent data variables daily. Data were analyzed using independent sample t test, χ2 test, and logistic regression. RESULTS: The prevalence rates of POD on the first and second postoperative days were 18.9% and 8.7%, respectively. Logistic regression analysis showed that the Glasgow Coma Scale score, albumin level, Spo2 level, hemoglobin values, undergoing cranial surgery, and having intra-arterial catheter were the independent risk factors for POD. CONCLUSION: These findings may contribute to identifying patients at risk for developing POD and developing strategies to improve patient outcomes.

Management of post-operative delirium following stereoelectroencephalography electrode placement for drug resistant epilepsy: Lessons learned from two case reports

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Post-operative delirium poses unique challenges in neurosurgical patients.

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Substance use is a modifiable risk factor for post-operative delirium after SEEG.

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SEEG patients have increased risk of harm when experiencing post-operative delirium.

Post-operative delirium (POD) represents a unique challenge in the care of any surgical patient but is especially challenging in neurosurgical inpatient management due to a host of potentially significant predisposing factors. Patients undergoing stereoencephalography (SEEG) for diagnosis of drug resistant epilepsy are at unique risk due to safety concerns, yet POD has been underdiscussed in this population. Patients should be counseled pre-operatively about their risk and subsequent steps be taken post-operatively. We present two cases of POD status-post SEEG and propose a mechanism by which future post-operative care be coordinated by the physician, patient, and patient’s family.

Neuropsychiatric symptoms associated with cerebral small vessel disease: a systematic review and meta-analysis

BACKGROUND

Cerebral small vessel disease, a common cause of vascular dementia, is often considered clinically silent before dementia or stroke become apparent. However, some individuals have subtle symptoms associated with acute MRI lesions. We aimed to determine whether neuropsychiatric and cognitive symptoms vary according to small vessel disease burden.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, EMBASE, and PsycINFO for articles published in any language from database inception to Jan 24, 2020. We searched for studies assessing anxiety, apathy, delirium, emotional lability, fatigue, personality change, psychosis, dementia-related behavioural symptoms or cognitive symptoms (including subjective memory complaints), and radiological features of cerebral small vessel disease. We extracted reported odds ratios (OR), standardised mean differences (SMD), and correlations, stratified outcomes by disease severity or symptom presence or absence, and pooled data using random-effects meta-analyses, reporting adjusted findings when possible. We assessed the bias on included studies using the Risk of Bias for Non-randomized Studies tool. This study is registered with PROSPERO, CRD42018096673.

FINDINGS

Of 7119 papers identified, 81 studies including 79 cohorts in total were eligible for inclusion (n=21 730 participants, mean age 69·2 years). Of these 81 studies, 45 (8120 participants) reported effect estimates. We found associations between worse white matter hyperintensity (WMH) severity and apathy (OR 1·41, 95% CI 1·05-1·89) and the adjusted SMD in apathy score between WMH severities was 0·38 (95% CI 0·15-0·61). Worse WMH severity was also associated with delirium (adjusted OR 2·9, 95% CI 1·12-7·55) and fatigue (unadjusted OR 1·63, 95% CI 1·20-2·22). WMHs were not consistently associated with subjective memory complaints (OR 1·34, 95% CI 0·61-2·94) and unadjusted SMD for WMH severity between these groups was 0·08 (95% CI -0·31 to 0·47). Anxiety, dementia-related behaviours, emotional lability, and psychosis were too varied or sparse for meta-analysis; these factors were reviewed narratively. Overall heterogeneity varied from 0% to 79%. Only five studies had a low risk of bias across all domains.

INTERPRETATION

Apathy, fatigue, and delirium associated independently with worse WMH, whereas subjective cognitive complaints did not. The association of anxiety, dementia-related behaviours, emotional lability, and psychosis with cerebral small vessel disease require further investigation. These symptoms should be assessed longitudinally to improve early clinical detection of small vessel disease and enable prevention trials to happen early in the disease course, long before cognition declines.

FUNDING

Chief Scientist Office of the Scottish Government, UK Dementia Research Institute, Fondation Leducq, Stroke Association Garfield-Weston Foundation, Alzheimer's Society, and National Health Service Research Scotland.

A gap existed between physicians' perceptions and performance of pain, agitation-sedation and delirium assessments in Chinese intensive care units

BACKGROUND

Pain, agitation-sedation and delirium management are crucial elements in the care of critically ill patients. In the present study, we aimed to present the current practice of pain, agitation-sedation and delirium assessments in Chinese intensive care units (ICUs) and investigate the gap between physicians' perception and actual clinical performance.

METHODS

We sent invitations to the 33 members of the Neuro-Critical Care Committee affiliated with the Chinese Association of Critical Care Physicians. Finally, 24 ICUs (14 general-, 5 neuroscience-, 3 surgical-, and 2 emergency-ICUs) from 20 hospitals participated in this one-day point prevalence study combined with an on-site questionnaire survey. We enrolled adult ICU admitted patients with a length of stay ≥24 h, who were divided into the brain-injured group or non-brain-injured group. The hospital records and nursing records during the 24-h period prior to enrollment were reviewed. Actual evaluations of pain, agitation-sedation and delirium were documented. We invited physicians on-duty during the 24 h prior to the patients' enrollment to complete a survey questionnaire, which contained attitude for importance of pain, agitation-sedation and delirium assessments.

RESULTS

We enrolled 387 patients including 261 (67.4%) brain-injured and 126 (32.6%) non-brain-injured patients. There were 19.9% (95% confidence interval [CI]: 15.9-23.9%) and 25.6% (95% CI: 21.2-29.9%) patients receiving the pain and agitation-sedation scale assessment, respectively. The rates of these two types of assessments were significantly lower in brain-injured patients than non-brain-injured patients (p = 0.003 and < 0.001). Delirium assessment was only performed in three patients (0.8, 95% CI: 0.1-1.7%). In questionnaires collected from 91 physicians, 70.3% (95% CI: 60.8-79.9%) and 82.4% (95% CI: 74.4-90.4%) reported routine use of pain and agitation-sedation scale assessments, respectively. More than half of the physicians (52.7, 95% CI: 42.3-63.2%) reported daily screening for delirium using an assessment scale.

CONCLUSIONS

The actual prevalence of pain, agitation-sedation and delirium assessment, especially delirium screening, was suboptimal in Chinese ICUs. There is a gap between physicians' perceptions and actual clinical practice in pain, agitation-sedation and delirium assessments. Our results will prompt further quality improvement projects to optimize the practice of pain, agitation-sedation and delirium management in China.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT03975751 . Retrospectively registered on 2 June 2019.

Utility of the Hijdra Sum Score in Predicting Risk of Aneurysm in Patients With Subarachnoid Hemorrhage: A Single-Center Experience With 550 Patients

BACKGROUND

Subarachnoid hemorrhage (SAH) is most commonly caused by a ruptured vascular lesion. A significant number of patients presenting with SAH have no identifiable cause despite extensive cerebrovascular imaging at presentation. Significant neurological morbidity or mortality can result from misdiagnosis of aneurysm.

OBJECTIVE

To generate a model to assist in predicting the risk of aneurysm in this patient population.

METHODS

We conducted a retrospective study of all patients aged ≥18 yr admitted to a single center from March 2008 to March 2018 with nontraumatic SAH (n = 550). Patient information was compared between those with and without aneurysm to identify potential predictors. Odds ratios obtained from a logistic regression model were converted into scores which were summed and tested for predictive ability.

RESULTS

Female sex, higher modified Fisher or Hijdra score, nonperimesencephalic location, presence of intracerebral hemorrhage, World Federation of Neurosurgical Societies (WFNS) score ≥3, need for cerebrospinal fluid diversion on admission, and history of tobacco use were all entered into multivariable analysis. Greater modified Fisher, greater Hijdra score, WFNS ≥3, and hydrocephalus present on admission were significantly associated with the presence of an aneurysm. A model based on the Hijdra score and SAH location was generated and validated.

CONCLUSION

We show for the first time that the Hijdra score, in addition to other factors, may assist in identifying patients at risk for aneurysm on cerebrovascular imaging. A simple scoring tool based on patient sex, SAH location, and SAH burden can assist in predicting the presence of an aneurysm in patients with nontraumatic SAH.

White Matter Lesions as Brain Frailty and Age are Risk Factors for Surgical Clipping of Unruptured Intracranial Aneurysms in the Elderly

INTRODUCTION

We aimed to identify the risk factors for surgical treatment of unruptured intracranial aneurysms (UIAs) in individuals aged >60 years, particularly focusing on white matter lesions (WMLs).

MATERIAL AND METHODS

We investigated a total of 214 patients with UIAs. The patient group comprised 53 males and 151 females with an average age of 68.2 years. UIA size ranged from 2.7 to 26 (mean: 7.3) mm. The primary endpoint of the study was patient prognosis evaluated at the time of discharge using the modified Rankin Scale. We examined the risk factors for poor outcome and WMLs using magnetic resonance imaging.

RESULTS

Poor outcome was observed in 23 (10.7%) patients. Significant correlations were observed between poor outcome and UIA size (P < 0.0001), UIAs located posteriorly (P = 0.0204), UIA thrombosis (P = 0.0002), and presence of WMLs (P < 0.0001) in univariate regression analysis. However, no significant correlations were noted between poor outcome and age (P = 0.1438). Multivariate logistic regression analyses showed significant correlations between poor outcome and UIA size (P < 0.0001), presence of WMLs (P = 0.001). Severe WMLs based on the Fazekas classification was correlated to age (P < 0.0001) and atherosclerosis (P = 0.0001). Severe WMLs were associated with ischemia (P < 0.001) and epilepsy (P = 0.0502) as well as length of hospitalization (P < 0.0001).

CONCLUSION

Severe WMLs are risk factors for surgical treatment of UIAs in the elderly. Surgical indications must be considered and caution should be taken when managing patients with severe WMLs.

The prevalence rates and adversities of delirium: Too common and disadvantageous

Objective

The prevalence rates and adversities of delirium have not yet been systematically evaluated and are based on selected populations, limited sample sizes, and pooled studies. Therefore, this study assesses the prevalence rates and outcome of and odds ratios for managing services for delirium.

Methods

In this prospective cohort study, based on the Diagnostic and Statistical Manual (DSM) 5, the Delirium Observation Screening (DOS) scale, and the Intensive Care Delirium Screening Checklist (ICDSC) construct, 28,118 patients from 35 managing services were included, and the prevalence rates and adverse outcomes were determined by simple logistic regressions and their corresponding odds ratios (ORs).

Results

Delirious patients were older, admitted from institutions (OR 3.44–5.2), admitted as emergencies (OR 1.87), hospitalized twice longer, and discharged, transferred to institutions (OR 5.47–6.6) rather than home (OR 0.1), or deceased (OR 43.88). The rate of undiagnosed delirium was 84.2%. The highest prevalence rates were recorded in the intensive care units (47.1–84.2%, pooled 67.9%); in the majority of medical services, rates ranged from 20% to 40% (pooled 26.2%), except, at both ends, palliative care (55.9%), endocrinology (8%), and rheumatology (4.4%). Conversely, in surgery and its related services, prevalence rates were lower (pooled 13.1%), except for cardio- and neurosurgical services (53.3% and 46.4%); the lowest prevalence rate was recorded in obstetrics (2%).

Significance of results

Delirium remains underdiagnosed, and novel screening approaches are required. Furthermore, this study identified the impact of delirium on patients, determined the prevalence rates for 32 services, and elucidated the association between individual services and delirium.

The Incidence and Predictors of Postoperative Delirium After Brain Tumor Resection in Adults: A Cross-Sectional Survey

BACKGROUND

Postoperative delirium (POD) describes a multifactorial disease process occurring after surgery. However, few studies have focused on patients undergoing brain tumor resection, and its influencing factors are unclear.

METHODS

We performed a 1-year, single-center, cross-sectional, retrospective survey at Huashan Hospital. Patients were screened using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Confusion Assessment Method, and Richmond Agitation Sedation Scale by trained bedside nurses. Perioperative data were collected using demographic and disease-related questionnaires. The primary outcome measures were the incidence of POD and subtype of POD. Independent predictors of POD were estimated from multivariate logistic regression models, and receiver operating characteristic analysis was used to compare the predictive performance of the models.

RESULTS

Of the 916 patients included in the study, 893 were analyzed. The overall incidence was 14.78%, 67 had hyperactive delirium (50.76%), 55 had hypoactive delirium (41.67%), and 10 had mixed delirium (7.57%). Age, sex, working status, tobacco use history, comorbidities, physical restraint, axillary temperature (>38.5°C), electrolyte disturbances, duration of anesthesia, pathologic diagnosis, tumor site, length of disease, and duration of operation were risk factors for POD. Conversely, saddle area mass was a protective factor. Age, tobacco use history, electrolyte disturbances, physical restraint, and duration of operation were included in the model.

CONCLUSIONS

POD is harmful to patients undergoing brain tumor resection, increasing length of stay in the intensive care unit and hospitalization costs. Intraoperative factors and postoperative factors, in addition to older age and tobacco use history, are associated with POD.

Restraint in a Neurosurgical Setting: A Mixed-Methods Study

OBJECTIVE

To investigate the extent to which restraint is used in neurosurgical care, under what circumstances, and how it is documented.

METHODS

A cross-sectional study with a mixed-methods approach was used to identify neurosurgical inpatients subjected to restraint. The data were collected in 2 phases: (1) a study-specific questionnaire was distributed to nurses in which they identified if restraints had occurred during their shifts, and if so, which restraint and to which patient; and (2) scrutinizing of electronic medical records of patients identified by the questionnaires. Numeric data were analyzed using descriptive and analytic statistical methods, and textual data were analyzed using qualitative content analysis. The findings from the different data sources were compared and merged.

RESULTS

Of the 517 patients admitted to the studied department during the study period, 58 (11%) were reported to have been subjected to restraint and most of the restraining events occurred in the neurointensive care unit. Most restraint measures were not documented in the electronic medical records. The identified patients were predominantly diagnosed with traumatic brain injury or subarachnoid hemorrhage. The qualitative content analysis showed the circumstances when restraints were used: when patients were considered a danger to self or others (theme) and which symptoms and behaviors (categories) were observed in relation to the use of restraint.

CONCLUSIONS

Restraint in neurosurgical care is mostly used to prevent patients from harming themselves or others. Because of the lack of documentation, restraint measures cannot be openly assessed, thus putting patients' safety at risk.

The predisposing and precipitating risk factors for delirium in neurosurgery: a prospective cohort study of 949 patients

BACKGROUND

Delirium is the most common neuropsychiatric presentation during hospitalization. In neurosurgery, studies on predisposing and precipitating risk factors for the development of delirium are rare but required for the individual risk estimation.

METHODS

Prospective cohort study in a tertiary university center. In total, 949 neurosurgical patients, 307 with and 642 without delirium, were included. Demographic factors, neurosurgery-related, neurological, and medical clusters were tested as predictors of delirium in multiple logistic regression analyses.

RESULTS

The incidence of delirium in this cohort of neurosurgical patients was 32.4%. Compared to patients without delirium, those with delirium were significantly older, more cognitively and neurologically impaired, transferred from hospitals and nursing homes, admitted as emergencies, longer hospitalized (16.2 vs. 9.5 days; p < 0.001), in greater need of intensive care management, and more frequently transferred to rehabilitation. Predisposing factors of delirium were stroke (OR 5.45, CI 2.12-14.0, p < 0.001), cardiac insufficiency (OR 4.59, CI 1.09-19.26, p = 0.038), cerebral neoplasm (OR 1.53, CI 0.92-2.54, p = 0.019), and age ≥ 65 years (OR 1.47, CI 1.03-2.09, p = 0.030). Precipitating factors of delirium were acute cerebral injury (OR 3.91, CI 2.24-6.83, p < 0.001), hydrocephalus (OR 3.10, CI 1.98-4.87, p < 0.001), and intracranial hemorrhage (OR 1.90, CI 1.23-2.94, p = 0.004).

CONCLUSIONS

Delirium in acute neurosurgical patients was associated with longer hospitalization. Whereas common etiologies of delirium like infections and dementia, did not predict delirium, pre-existing neurovascular and traumatic diseases, as well as surgery-related events seem important risk factors contributing to delirium in neurosurgery.

Delirium Risk Factors and Associated Outcomes in a Neurosurgical Cohort: A Case-Control Study

OBJECTIVE

There are limited reports examining delirium in cohorts of neurosurgical patients across inpatient settings without separation based on subspecialty distinction. It is of interest to identify consistent delirium risk factors across various cranial pathologies and inpatient settings that will inform future interventional studies.

METHODS

Delirium rates, patient and hospitalization risk factors, and clinical outcomes in 235 patients undergoing a cranial procedure were examined in a retrospective fashion.

RESULTS

Fifty-two (22.1%) patients experienced delirium during their hospital stay. Patient factors predictive of delirium on univariate logistic regression were older age, a diagnosis of hydrocephalus or intracranial infection, transfer from an outside hospital, and admission through the emergency department. Hospitalization factors predictive of delirium included longer length of intensive care unit (ICU) stay, abnormal sodium values preceding delirium, a new postoperative infection, and the presence of a neurologic deficit. Using recursive partitioning, age ≥72.56 years and ICU length of stay ≥5 days were identified as critical thresholds for predicting delirium (odds ratio [OR] 4.61 and 18.2, respectively). On multivariate logistic regression analysis, age (unit OR 1.05), length of ICU stay (unit OR 1.2), and a neurologic deficit (OR 5.4) were predictive of delirium. Furthermore, delirium was also significantly associated with a longer length of admission as well as decreased likelihood for discharge home.

CONCLUSIONS

Delirium is a frequent occurrence after neurosurgery with older age, longer ICU stay, and a neurologic deficit being consistent risk factors across inpatient settings. These results help identify at-risk patients for delirium on a neurosurgical service to enact interventions preemptively.