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Al-Qudah AM, Sivaguru S, Anetakis K, Crammond DJ, Balzer JR, Thirumala PD, Subramaniam K, Sadhasivam S, Shandal V. Role of Intraoperative Electroencephalography in Predicting Postoperative Delirium in Patients Undergoing Cardiovascular Surgeries. Clin Neurophysiol 2024; 164:40-46. [PMID: 38848665 DOI: 10.1016/j.clinph.2024.05.012] [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: 11/21/2023] [Revised: 04/30/2024] [Accepted: 05/21/2024] [Indexed: 06/09/2024]
Abstract
OBJECTIVE To determine the utility of electroencephalography (EEG) in predicting postoperative delirium (POD) in patients who underwent cardiovascular surgeries with EEG monitoring. METHODS A total of 1161 patients who underwent cardiovascular surgeries with EEG monitoring were included in the study, and their data were retrospectively reviewed. POD assessment was done utilizing Intensive Care Delirium Screening Checklist (ICDSC). Patients with a score of > 4 on ICDSC were diagnosed with POD. RESULTS Of 1161 patients, 131 patients had EEG changes and 56 (42.74%) of 131 patients experienced POD. Of 1030 patients without EEG changes, 219 (21.26%) experienced POD. EEG showed specificity of 91.5% and negative predictive value of 78.7% in detecting POD. On multivariable analysis, EEG changes showed a strong association with POD (ORadj 1.97 CI (1.30-2.99), p = 0.001) with persistent EEG changes showing even a higher risk of developing POD (ORadj 2.65 (1.43-4.92), p = 0.002). CONCLUSION EEG change has specificity of 91.5% emphasizing the need for its implementation as a diagnostic tool for predicting POD. Patients with POD are two times more likely to experience significant EEG changes, especially persistent EEG changes when undergoing cardiovascular surgeries. SIGNIFICANCE Intraoperative EEG can detect POD, and EEG changes based therapeutic interventions can mitigate POD.
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Affiliation(s)
- Abdullah M Al-Qudah
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh 15213-2582, Pennsylvania; UPMC Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sreeja Sivaguru
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh 15213-2582, Pennsylvania
| | - Katherine Anetakis
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh 15213-2582, Pennsylvania
| | - Donald J Crammond
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh 15213-2582, Pennsylvania
| | - Jeffrey R Balzer
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh 15213-2582, Pennsylvania
| | - Parthasarathy D Thirumala
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh 15213-2582, Pennsylvania
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh 15213-2582, Pennsylvania
| | - Senthil Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh 15213-2582, Pennsylvania
| | - Varun Shandal
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh 15213-2582, Pennsylvania.
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Guttenthaler V, Fidorra J, Wittmann M, Menzenbach J. Predictiveness of preoperative laboratory values for postoperative delirium. Health Sci Rep 2024; 7:e2219. [PMID: 38952405 PMCID: PMC11215531 DOI: 10.1002/hsr2.2219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 07/03/2024] Open
Abstract
Background Postoperative delirium (POD) is a common postoperative complication, especially in patients over 60 years, with an incidence ranging from 15% to 50%. In most cases, POD manifests in the first 5 days after surgery. Multiple contributing risk factors for POD have been detected. Besides the predisposing factors such as higher age, cognitive impairment, high blood pressure, atrial fibrillation, and past stroke, pathophysiological mechanisms like neuroinflammation are also considered as contributing factors. Methods In a subanalysis of the "PRe- Operative Prediction of postoperative DElirium by appropriate SCreening" (PROPDESC) study, the preoperative laboratory values of sodium, potassium, total protein, hemoglobin concentration (Hgb), and white blood cells as well as the biomarkers creatinine, HbA1c, NT-pro-BNP, high sensitive Troponin T (hsTnT), and C-reactive protein (CRP) were assessed to investigate a possible relationship to the occurrence of POD. Results After correction for age, physical status classification, surgery risk after Johns Hopkins, and operative discipline (cardiac surgery vs. noncardiac surgery), male patients with a Hgb <13 g/dL had significantly higher odds for POD (p = 0.025). Furthermore, patients with CRP ≥ 10 mg/L, HbA1c value ≥ 8.5% as well as patients with hypernatraemia (>145 mmol/L) presented significantly higher odds to develop POD (p = 0.011, p < 0.001, and p = 0.021, respectively). A raised (>14-52 ng/L) or high (>52 ng/L) hsTnT value was also associated with a significantly higher chance for POD compared to the patient group with hsTnT <14 ng/L (p < 0.001 and p = 0.016, respectively). Conclusions Preoperative Hgb, CRP, HbA1c, sodium, and hsTnT could be used to complement and refine the preoperative screening for patients at risk for POD. Further studies should track these correlations to investigate the potential of targeted POD protection and enabling hospital staff to initiate POD-preventing measures in time.
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Affiliation(s)
- Vera Guttenthaler
- Clinic of Anaesthesia and Intensive Care MedicineUniversity BonnBonnGermany
| | - Jacqueline Fidorra
- Clinic of Anaesthesia and Intensive Care MedicineUniversity BonnBonnGermany
- Asklepios Clinic North HeidbergClinic for Internal Medicine Department IHamburgGermany
| | - Maria Wittmann
- Clinic of Anaesthesia and Intensive Care MedicineUniversity BonnBonnGermany
| | - Jan Menzenbach
- Clinic of Anaesthesia and Intensive Care MedicineUniversity BonnBonnGermany
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Sadlonova M, Hansen N, Esselmann H, Celano CM, Derad C, Asendorf T, Chebbok M, Heinemann S, Wiesent A, Schmitz J, Bauer FE, Ehrentraut J, Kutschka I, Wiltfang J, Baraki H, von Arnim CAF. Preoperative Delirium Risk Screening in Patients Undergoing a Cardiac Surgery: Results from the Prospective Observational FINDERI Study. Am J Geriatr Psychiatry 2024; 32:835-851. [PMID: 38228452 DOI: 10.1016/j.jagp.2023.12.017] [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: 11/07/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE Postoperative delirium (POD) is a common complication of cardiac surgery that is associated with higher morbidity, longer hospital stay, cognitive decline, and mortality. Preoperative assessments may help to identify patients´ POD risk. However, a standardized screening assessment for POD risk has not been established. DESIGN Prospective observational FINd DElirium RIsk factors (FINDERI) study. PARTICIPANTS Patients aged ≥50 years undergoing cardiac surgery. MEASUREMENTS The primary aim was to analyze the predictive value of the Delirium Risk Screening Questionnaire (DRSQ) prior to cardiac surgery. Secondary aims are to investigate cognitive, frailty, and geriatric assessments, and to use data-driven machine learning (ML) in predicting POD. Predictive properties were assessed using receiver operating characteristics analysis and multivariate approaches (regularized LASSO regression and decision trees). RESULTS We analyzed a data set of 504 patients (68.3 ± 8.2 years, 21.4% women) who underwent cardiac surgery. The incidence of POD was 21%. The preoperatively administered DRSQ showed an area under the curve (AUC) of 0.68 (95% CI 0.62, 0.73), and the predictive OR was 1.25 (95% CI 1.15, 1.35, p <0.001). Using a ML approach, a three-rule decision tree prediction model including DRSQ (score>7), Trail Making Test B (time>118), and Montreal Cognitive Assessment (score ≤ 22) was identified. The AUC of the three-rule decision tree on the training set was 0.69 (95% CI 0.63, 0.75) and 0.62 (95% CI 0.51, 0.73) on the validation set. CONCLUSION Both the DRSQ and the three-rule decision tree might be helpful in predicting POD risk before cardiac surgery.
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Affiliation(s)
- Monika Sadlonova
- Department of Cardiovascular and Thoracic Surgery (MS, IK, HB), University of Göttingen Medical Center, Göttingen, Germany; Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany; Department of Psychosomatic Medicine and Psychotherapy (MS,), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany; Department of Psychiatry (MS, CMC), Massachusetts General Hospital, Boston, MA.
| | - Niels Hansen
- Department of Psychiatry and Psychotherapy (NH, HE, JW), University of Göttingen Medical Center, Göttingen, Germany
| | - Hermann Esselmann
- Department of Psychiatry and Psychotherapy (NH, HE, JW), University of Göttingen Medical Center, Göttingen, Germany
| | - Christopher M Celano
- Department of Psychiatry (MS, CMC), Massachusetts General Hospital, Boston, MA; Department of Psychiatry (CMC), Harvard Medical Schol, Boston, MA
| | - Carlotta Derad
- Department of Medical Statistics (CD, TA), University of Göttingen Medical Center, Göttingen, Germany
| | - Thomas Asendorf
- Department of Medical Statistics (CD, TA), University of Göttingen Medical Center, Göttingen, Germany
| | - Mohammed Chebbok
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany; Department of Cardiology and Pneumology (MC), University of Göttingen Medical Center, Göttingen, Germany
| | - Stephanie Heinemann
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Adriana Wiesent
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Jessica Schmitz
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Frederike E Bauer
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Julia Ehrentraut
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Ingo Kutschka
- Department of Cardiovascular and Thoracic Surgery (MS, IK, HB), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany
| | - Jens Wiltfang
- Department of Psychiatry and Psychotherapy (NH, HE, JW), University of Göttingen Medical Center, Göttingen, Germany; German Center for Neurodegenerative Diseases (DZNE) (JW), Göttingen, Germany; Neurosciences and Signaling Group (JW), Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Hassina Baraki
- Department of Cardiovascular and Thoracic Surgery (MS, IK, HB), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany
| | - Christine A F von Arnim
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany
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Elbakry AEA, El-Desoky IM, Saafan AG, Elsersy HE. The impact of melatonin on postoperative delirium in geriatric patients after colorectal surgery: a randomized placebo-controlled trial. Minerva Anestesiol 2024; 90:509-519. [PMID: 38869264 DOI: 10.23736/s0375-9393.24.17888-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
BACKGROUND The current study was designed to evaluate the role of prophylactic melatonin administration in reducing delirium occurrence in elderly patients undergoing colorectal cancer surgeries. METHODS One hundred patients of both genders undergoing elective colorectal cancer surgeries under general anesthesia were randomly allocated into two equal groups. A treatment group of patients (Melatonin group) received five mg of melatonin the night before surgery, twelve hours before the scheduled surgery time, and an additional five mg of melatonin two hours before surgery. The control group of patients received placebo tablets at the same time points. Delirium score, sedation score, pain score, hemodynamics, oxygen saturation, and blood requirements were recorded. RESULTS Twenty-eight patients (56%) in the control group versus 18 (36%) in the melatonin group developed delirium (P=0.045), OR=2.26, 95% CI: 1.013-5.05. Five patients (18%) in the control group versus six (33%) in the melatonin group developed delirium on discharge from the recovery room (P=0.749), OR=1.22, 95% CI: 0.34-4.31, while 23 patients (82%) in the control group versus 12 (66%) in the melatonin group developed delirium six hours postoperative (P=0.021), OR=1.705, 95% CI: 1.02-2.81 with higher nursing delirium screening score in the control group 2 (1, 4) versus 1 (0, 2) in the melatonin group (P=0.002), 95% CI: 1.77-2.71. CONCLUSIONS The prophylactic administration of melatonin may decrease the incidence of postoperative delirium in elderly patients undergoing colorectal surgeries under general anesthesia.
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Affiliation(s)
- Abd-Elazeem A Elbakry
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Menoufia University, Shibin El Kom, Egypt
| | - Islam M El-Desoky
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Menoufia University, Shibin El Kom, Egypt
| | - Amal G Saafan
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Menoufia University, Shibin El Kom, Egypt
| | - Hazem E Elsersy
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Menoufia University, Shibin El Kom, Egypt -
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Rustenbach CJ, Reichert S, Berger R, Schano J, Nemeth A, Haeberle H, Charotte C, Caldonazo T, Saqer I, Saha S, Schnackenburg P, Djordjevic I, Krasivskyi I, Wendt S, Serna-Higuita LM, Doenst T, Hagl C, Wahlers T, Schlensak C, Sandoval Boburg R. Unraveling the Predictors for Delirium and ICU Stay Duration in Patients with Heart Failure and Reduced Ejection Fraction (HFrEF) Undergoing Coronary Artery Bypass Grafting-A Multicentric Analysis. Biomedicines 2024; 12:749. [PMID: 38672105 PMCID: PMC11048437 DOI: 10.3390/biomedicines12040749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Objective: This study assesses predictors for postoperative delirium (POD) and ICU stay durations in HFrEF patients undergoing CABG, focusing on ONCAB versus OPCAB surgical methods. Summary Background Data: In cardiac surgery, especially CABG, POD significantly impacts patient recovery and healthcare resource utilization. With varying incidences based on surgical techniques, this study provides an in-depth analysis of POD in the context of HFrEF patients, a group particularly susceptible to this complication. Methods: A retrospective analysis of 572 patients who underwent isolated CABG surgery with a preoperative ejection fraction under 40% was conducted at four German university hospitals. Patients were categorized into ONCAB and OPCAB groups for comparative analysis. Results: Age and Euro Score II were significant predictors of POD. The ONCAB group showed higher incidences of re-sternotomy (OR: 3.37), ECLS requirement (OR: 2.29), and AKI (OR: 1.49), whereas OPCAB was associated with a lower incidence of delirium. Statistical analysis indicated a significant difference in ICU stay durations between the two groups, influenced by surgical complexity and postoperative complications. Conclusions: This study underscores the importance of surgical technique in determining postoperative outcomes in HFrEF patients undergoing CABG. OPCAB may offer advantages in reducing POD incidence. These findings suggest the need for tailored surgical decisions and comprehensive care strategies to enhance patient recovery and optimize healthcare resources.
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Affiliation(s)
- Christian Jörg Rustenbach
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University of Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany; (S.R.); (J.S.); (A.N.); (C.S.); (R.S.B.)
| | - Stefan Reichert
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University of Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany; (S.R.); (J.S.); (A.N.); (C.S.); (R.S.B.)
| | - Rafal Berger
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University of Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany; (S.R.); (J.S.); (A.N.); (C.S.); (R.S.B.)
| | - Julia Schano
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University of Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany; (S.R.); (J.S.); (A.N.); (C.S.); (R.S.B.)
| | - Attila Nemeth
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University of Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany; (S.R.); (J.S.); (A.N.); (C.S.); (R.S.B.)
| | - Helene Haeberle
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls-University of Tuebingen, 72076 Tuebingen, Germany; (H.H.); (C.C.)
| | - Christophe Charotte
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls-University of Tuebingen, 72076 Tuebingen, Germany; (H.H.); (C.C.)
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, University Hospital of Jena, Friedrich-Schiller-University, 07747 Jena, Germany; (T.C.); (I.S.); (T.D.)
| | - Ibrahim Saqer
- Department of Cardiothoracic Surgery, University Hospital of Jena, Friedrich-Schiller-University, 07747 Jena, Germany; (T.C.); (I.S.); (T.D.)
| | - Shekhar Saha
- Department of Cardiac Surgery, Ludwig-Maximilians-University, 80539 Munich, Germany (P.S.); (C.H.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Philipp Schnackenburg
- Department of Cardiac Surgery, Ludwig-Maximilians-University, 80539 Munich, Germany (P.S.); (C.H.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, 50923 Köln, Germany; (I.D.); (I.K.); (S.W.); (T.W.)
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, 50923 Köln, Germany; (I.D.); (I.K.); (S.W.); (T.W.)
| | - Stefanie Wendt
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, 50923 Köln, Germany; (I.D.); (I.K.); (S.W.); (T.W.)
| | - Lina Maria Serna-Higuita
- Institute for Clinical Epidemiology and Applied Biostatistics, Eberhard-Karls-University of Tuebingen, 72074 Tuebingen, Germany;
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, University Hospital of Jena, Friedrich-Schiller-University, 07747 Jena, Germany; (T.C.); (I.S.); (T.D.)
| | - Christian Hagl
- Department of Cardiac Surgery, Ludwig-Maximilians-University, 80539 Munich, Germany (P.S.); (C.H.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, 50923 Köln, Germany; (I.D.); (I.K.); (S.W.); (T.W.)
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University of Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany; (S.R.); (J.S.); (A.N.); (C.S.); (R.S.B.)
| | - Rodrigo Sandoval Boburg
- Department of Thoracic and Cardiovascular Surgery, German Cardiac Competence Center, Eberhard-Karls-University of Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany; (S.R.); (J.S.); (A.N.); (C.S.); (R.S.B.)
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Othman SMA, Xu Q, Zhao K, Kafi L, Aziz MAA. Identification of early delirium and its outcomes after cardiopulmonary bypass among adult patients with cardiovascular disease: a prospective observational study. Indian J Thorac Cardiovasc Surg 2024; 40:151-158. [PMID: 38389776 PMCID: PMC10879051 DOI: 10.1007/s12055-023-01613-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 02/24/2024] Open
Abstract
Purpose To identify the incidence and outcomes of postoperative delirium after cardiopulmonary bypass machine in adult cardiac surgery patients. Method A prospective observational study was conducted in a single-center institution in the Republic of China. This study included 273 patients who underwent cardiac surgical procedures requiring cardiopulmonary bypass machine utilization. Results This study used the Confusion Assessment Method to screen for delirium. Univariate analysis identified advanced age, emergency surgery and prolonged aortic cross-clamping time as significant predisposing factors for delirium, which occurred in 19.8% (n = 54) of cases and typically developed in average of 4.8 ± 3.28 days after the surgery. The analysis also identified that delirium was associated with increased complications and external referrals. A total of 142 patients (52.1%) were discharged to their homes, wherein the discharge rate in the delirium group was notably lower, with only 35.2% (n = 19) of patients, than in the delirium-free group with 56.2% (n = 123) of patients. Conclusion Considering the increased probability of delirium-related complications following cardiac surgery, it is important to develop effective preventive strategies for patients with perioperative risk factors, such as advanced age, emergency surgery and prolonged cross-clamp time, by implementing practical measures to minimize the risk of delirium.
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Affiliation(s)
- Saleh Mohammed Alhaj Othman
- Nanjing Medical University School of Nursing, Longmian Avenue No.101Jiangning District, Nanjing, Jiangsu China
| | - Qin Xu
- Nanjing Medical University School of Nursing, Longmian Avenue No.101Jiangning District, Nanjing, Jiangsu China
| | - Kang Zhao
- Nanjing Medical University School of Nursing, Longmian Avenue No.101Jiangning District, Nanjing, Jiangsu China
| | - Lina Kafi
- Nanjing Medical University School of Nursing, Longmian Avenue No.101Jiangning District, Nanjing, Jiangsu China
| | - Mohammed Ali Ali Aziz
- Nanjing Medical University School of Nursing, Longmian Avenue No.101Jiangning District, Nanjing, Jiangsu China
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Wiredu K, O’Connor S, Naseem H, Brauer BL, Kettenbach AN, Frost HR, Shaefi S, Gerber SA. Intraoperative plasma proteomic changes in cardiac surgery: In search of biomarkers of post-operative delirium. Proteomics Clin Appl 2023; 17:e2200066. [PMID: 36567636 PMCID: PMC10290728 DOI: 10.1002/prca.202200066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/02/2022] [Accepted: 12/21/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE Delirium presents a significant healthcare burden. It complicates post-operative care in up to 50% of cardiac surgical patients with worse outcomes, longer hospital stays and higher cost of care. Moreover, the nature of delirium following cardiac surgery with cardiopulmonary bypass (CPB) remains unclear, the underlying pathobiology is poorly understood, status quo diagnostic methods are subjective, and diagnostic biomarkers are currently lacking. OBJECTIVE To identify diagnostic biomarkers of delirium and for insights into possible neuronal pathomechanisms. EXPERIMENTAL DESIGN Comparative proteomic analyses were performed on plasma samples from a nested matched cohort of patients who underwent cardiac surgery. Validation by targeted proteomics was performed in an independent set of samples. Biomarkers were assessed for biological functions and diagnostic accuracy. RESULTS Forty-seven percent of subjects demonstrated delirium. Of 3803 proteins identified from patient samples by multiplexed quantitative proteomics, 16 were identified as signatures of exposure to CPB, and 11 biomarkers distinguished delirium cases from non-cases (AuROC = 93%). Notable among these biomarkers are C-reactive protein, serum amyloid A-1 and cathepsin-B. CONCLUSIONS AND CLINICAL RELEVANCE The interplay of systemic and central inflammatory markers sheds new light on delirium pathogenesis. This work suggests that accurate identification of cases may be achievable using panels of biomarkers.
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Affiliation(s)
- Kwame Wiredu
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Anesthesia, Critical Care and Pain Medicine, Mass General Hospital, Boston MA
- Department of Anaesthesia, Harvard Medical School, Boston MA
| | - Sean O’Connor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Heba Naseem
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Brooke L. Brauer
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Arminja N. Kettenbach
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Hildreth R. Frost
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Shahzad Shaefi
- Department of Anaesthesia, Harvard Medical School, Boston MA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Scott A. Gerber
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
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Chang Y, Ragheb SM, Oravec N, Kent D, Nugent K, Cornick A, Hiebert B, Rudolph JL, MacLullich AMJ, Arora RC. Diagnostic accuracy of the "4 A's Test" delirium screening tool for the postoperative cardiac surgery ward. J Thorac Cardiovasc Surg 2023; 165:1151-1160.e8. [PMID: 34243932 DOI: 10.1016/j.jtcvs.2021.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 05/12/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward. METHODS This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study. RESULTS In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use. CONCLUSIONS The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.
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Affiliation(s)
- Yue Chang
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sandra M Ragheb
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nebojsa Oravec
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Kent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Kristina Nugent
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Alexandra Cornick
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Brett Hiebert
- Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, and Brown University, Providence, RI
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada.
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9
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Han Y, Tian Y, Wu J, Zhu X, Wang W, Zeng Z, Qin Z. Melatonin and Its Analogs for Prevention of Post-cardiac Surgery Delirium: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:888211. [PMID: 35665270 PMCID: PMC9157569 DOI: 10.3389/fcvm.2022.888211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/21/2022] [Indexed: 11/24/2022] Open
Abstract
Background The effectiveness of melatonin and its analogs in preventing postoperative delirium (POD) following cardiac surgery is controversial. The purpose of this systematic review and meta-analysis was to confirm the benefits of melatonin and its analogs on delirium prevention in adults who underwent cardiac surgery. Methods We systematically searched the PubMed, Cochrane Library, Web of Science, Embase, and EBSCOhost databases, the last search was performed in October 2021 and repeated before publication. The controlled studies were included if investigated the impact of melatonin and its analogs on POD in adults who underwent cardiac surgery. The primary outcome was the incidence of delirium. The Stata statistical software 17.0 was used to perform this study. Results This meta-analysis included eight randomized controlled trials (RCTs) and two cohort studies with a total of 1,714 patients. The results showed that melatonin and ramelteon administration were associated with a significantly lower incidence of POD in adults who underwent cardiac surgery (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.29–0.74; P = 0.001). The subgroup analyses confirmed that melatonin 3 mg (OR, 0.37; 95% CI, 0.18–0.76; P = 0.007) and 5 mg (OR, 0.34; 95% CI, 0.21–0.56; P < 0.001) significantly reduced the incidence of POD. Conclusion Melatonin at dosages of 5 and 3 mg considerably decreased the risk of delirium in adults who underwent cardiac surgery, according to our results. Cautious interpretation of our results is important owing to the modest number of studies included in this meta-analysis and the heterogeneity among them. Systematic Review Registration PROSPERO registration number: CRD42021246984.
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Affiliation(s)
- Yunyang Han
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yu Tian
- Department of Anesthesiology, Guangdong Women and Children Hospital, Guangzhou, China
| | - Jie Wu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoqin Zhu
- Department of Anesthesiology, Guangdong Women and Children Hospital, Guangzhou, China
| | - Wei Wang
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- *Correspondence: Zhenhua Zeng
| | - Zaisheng Qin
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Zaisheng Qin
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Choi H, Park CS, Huh J, Koo J, Jeon J, Kim E, Jung S, Kim HW, Lim JY, Hwang W. Intraoperative Glycemic Variability and Mean Glucose are Predictors for Postoperative Delirium After Cardiac Surgery: A Retrospective Cohort Study. Clin Interv Aging 2022; 17:79-95. [PMID: 35153478 PMCID: PMC8827640 DOI: 10.2147/cia.s338712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/20/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose Postoperative delirium (POD) is a common but serious complication after cardiac surgery and is associated with various short- and long-term outcomes. In this study, we investigated the effects of intraoperative glycemic variability (GV) and other glycemic variables on POD after cardiac surgery. Patients and Methods A retrospective single-center cohort analysis was conducted using data from electronic medical record from 2018 to 2020. A total of 705 patients undergoing coronary artery bypass graft surgery and/or valve surgery, and/or aortic replacement surgery were included in the analysis. Intraoperative GV was assessed with a coefficient of variation (CV), which was defined as the standard deviation of five intraoperative blood glucose measurements divided by the mean. POD assessment was performed three times a day in the ICU and twice a day in the ward until discharge by trained medical staff. POD was diagnosed if any of the Confusion Assessment Method for the Intensive Care Unit was positive in the ICU, and the Confusion Assessment Method was positive in the ward. Multivariable logistic regression was used to identify associations between intraoperative GV and POD. Results POD occurred in 306 (43.4%) patients. When intraoperative glycemic CV was compared as a continuous variable, the delirium group had higher intraoperative glycemic CV than the non-delirium group (22.59 [17.09, 29.68] vs 18.19 [13.00, 23.35], p < 0.001), and when intraoperative glycemic CV was classified as quartiles, the incidence of POD increased as intraoperative glycemic CV quartiles increased (first quartile 29.89%; second quartile 36.67%; third quartile 44.63%; and fourth quartile 62.64%, p < 0.001). In the multivariable logistic regression model, patients in the third quartile of intraoperative glycemic CV were 1.833 times (OR 1.833, 95% CI: 1.132–2.967, p = 0.014), and patients in the fourth quartile of intraoperative glycemic CV were 3.645 times (OR 3.645, 95% CI: 2.235–5.944, p < 0.001) more likely to develop POD than those in the first quartile of intraoperative glycemic CV. Conclusion Intraoperative blood glucose fluctuation, manifested by intraoperative GV, is associated with POD after cardiac surgery. Patients with a higher intraoperative GV have an increased risk of POD.
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Affiliation(s)
- Hoon Choi
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Soo Park
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jaewon Huh
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jungmin Koo
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joonpyo Jeon
- Department of Anesthesia and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eunsung Kim
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sangmin Jung
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hwan Wook Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Yong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Wonjung Hwang
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Correspondence: Wonjung Hwang, Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea, Tel +82-2-22586162, Fax +82-2-5371951, Email
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Andrási TB, Talipov I, Dinges G, Arndt C, Rastan AJ. Risk factors for postoperative delirium after cardiac surgical procedures with cardioplegic arrest. Eur J Cardiothorac Surg 2022; 62:6509257. [PMID: 35037042 DOI: 10.1093/ejcts/ezab570] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/30/2021] [Accepted: 12/05/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The pathophysiology of delirium after cardiac surgery is complex. The present study aims to determine perioperative risk factors and construct a scoring system for postoperative delirium based on the type of surgery. METHODS Three hundred patients undergoing coronary artery bypass grafting (CABG; n = 150) or valve and/or aortic surgery ± CABG (n = 150) were retrospectively evaluated. RESULTS The incidence of delirium (32%) was similar in subgroups (28.7% and 33.33%, P = 0.384). Delirium patients were older [71.3 (standard deviation: 8.5) vs 66.6 (standard deviation: 9.5), P < 0.001; 70.0 (standard deviation: 9.6) vs 62.5 (standard deviation: 12.6), P < 0.001] and required more packed red blood cell units [2.1 (standard deviation: 2.1) vs 4.2 (standard deviation: 4.0), P < 0.001; 2.4 (standard deviation: 3.3) vs 5.4 (standard deviation: 5.9), P < 0.001] and fresh frozen plasma units [6.1 (standard deviation: 2.9) vs. 8.0 (standard deviation: 4.2), P < 0.001; 6.3 (standard deviation: 3.4) vs 10.8 (standard deviation: 7.2), P < 0.001] in CABG and valve/aortic subgroups, respectively. Delirium was associated with longer operation time [298.3 (standard deviation: 98.4) vs 250.6 (standard deviation: 67.8) min, P < 0.001], cardiopulmonary bypass (CPB) time [171.5 (standard deviation: 54.9) vs 140.98 (standard deviation: 45.8) min, P < 0.001] and cardiac arrest time [112 (standard deviation: 35.9) vs 91.9 (standard deviation: 28.6), P < 0.001] only in the valve/aortic group (versus non-delirium). Multivariate regression analysis identified an association between delirium and age [odds ratio: 1.056 (95% confidence interval: 1.002-1.113), P = 0.041], CPB time [odds ratio: 1.1014 (95% confidence interval: 1.004-1.025), P = 0.007], fresh frozen plasma transfusion [odds ratio: 1.127 (95% confidence interval: 1.006-1.262), P = 0.039] and atrial fibrillation [odds ratio: 4.801 (95% confidence interval: 1.844-12.502), P < 0.001] after valve/aortic surgery (area under the curve 0.835, P < 0.001) and between delirium and age [odds ratio: 1.089 (95% confidence interval: 1.023-1.160), P = 0.007] and ventilation time [odds ratio: 1.068 (95% confidence interval: 1.026-1.113), P = 0.001] after isolated CABG (area under the curve 0.798, P < 0.001). The cross-validation of the results by k-fold logistic regression revealed for the entire patient cohort an overall average accuracy of the prediction model of 0.764, with a false-positive rate of 0.052 and a false-negative rate of 0.18. CONCLUSIONS Age, CPB time, ventilation, transfusion and atrial fibrillation are differently associated with delirium depending on the operative characteristics. Optimization of intraoperative parameters and use of risk calculators may enable early institution of pharmacotherapy and improve overall outcome after cardiac surgery.
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Affiliation(s)
- Terézia B Andrási
- Department of Cardiac Surgery, Philipps University of Marburg, Marburg, Germany
| | - Ildar Talipov
- Department of Cardiac Surgery, Philipps University of Marburg, Marburg, Germany
| | - Gerhard Dinges
- Department of Anesthesiology and Intensive Care Medicine, Phillips University of Marburg, Marburg, Germany
| | - Christian Arndt
- Department of Anesthesiology and Intensive Care Medicine, Phillips University of Marburg, Marburg, Germany
| | - Ardawan J Rastan
- Department of Cardiac Surgery, Philipps University of Marburg, Marburg, Germany
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12
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Arbabi M, Dezhdar Z, Amini B, Dehnavi AZ, Ghasemi M. Depression and anxiety increase the odds of developing delirium in ICU patients; a prospective observational study. Cogn Neuropsychiatry 2022; 27:1-10. [PMID: 34676803 DOI: 10.1080/13546805.2021.1991295] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delirium is prevalent among hospitalised patients, especially in critically ill patients. Preventing delirium by recognising its modifiable risk factors could improve life quality, decrease mortality and restrain its devastating consequences. METHOD We investigated 50 patients who had been hospitalised in the general ICU and monitored them for developing delirium. We employed CAM and CAM-ICU Scales to assess delirium, RASS score to determine the consciousness level, HADS questionnaire for anxiety and depression, and the demographic data questionnaire. RESULTS We found that 20% of ICU patients developed delirium and found a meaningful correlation between the incident delirium, older ages, visual impairment, and higher anxiety and depression scores (HADS) of first and second days of hospitalisation. By utilising logistic regression, we found that older ages, visual impairment, higher anxiety and depression scores (HADS) of the first day of hospitalisation were statistically significant to predict the risk model of developing delirium. CONCLUSION Depressive and anxiety symptoms were associated with higher odds of transitioning to delirium; so, at the admission time, it may be useful to screen patients for the symptoms of affective disorders, particularly, who are at higher risks for developing delirium.
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Affiliation(s)
- Mohammad Arbabi
- Brain & Spinal Cord Injury Research Centre, Tehran University of Medical Sciences, Tehran, Iran.,Psychosomatic Medicine Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Behnam Amini
- Tehran University of Medical Science, Tehran, Iran
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Association between perioperative hypotension and postoperative delirium and atrial fibrillation after cardiac surgery: A post-hoc analysis of the DECADE trial. J Clin Anesth 2021; 76:110584. [PMID: 34784557 DOI: 10.1016/j.jclinane.2021.110584] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To test the hypotheses that in adults having cardiac surgery with cardio-pulmonary bypass, perioperative hypotension increases the risk of delirium and atrial fibrillation during the initial five postoperative days. DESIGN Sub-analysis of the DECADE multi-center randomized trial. SETTING Patients who had cardiac surgery with cardiopulmonary bypass at the Cleveland Clinic. INTERVENTIONS In the underlying trial, patients were randomly assigned 1:1 to dexmedetomidine or normal saline placebo. MEASUREMENTS Intraoperative mean arterial pressures were recorded at 1-min intervals from arterial catheters or at 1-5-min intervals oscillometrically. Postoperative blood pressures were recorded every half-hour or more often. The co-primary outcomes were atrial fibrillation and delirium occurring between intensive care unit admission and the earlier of postoperative day 5 or hospital discharge. Delirium was assessed twice daily during the initial 5 postoperative days while patients remained hospitalized with the Confusion Assessment Method for the intensive care unit. Assessments were made by trained research fellows who were blinded to the dexmedetomidine administration. MAIN RESULTS There was no significant association between intraoperative hypotension and delirium, with an adjusted odds ratio of 0.94 (95% CI: 0.81, 1.09; P = 0.419) for a doubling in AUC of mean arterial pressure (MAP) <60 mmHg. An increase in intraoperative AUC of MAP <60 mmHg was not significantly associated with the odds of atrial fibrillation (adjusted odds ratio = 0.99; 95% CI: 0.87, 1.11; P = 0.819). Postoperative MAP <70 mmHg per hour 1.14 (97.5% CI: 1.04,1.26; P = 0.002) and MAP <80 mmHg per hour 1.05 (97.5%: 1.01, 1.10; P = 0.010) were significantly associated with atrial fibrillation. CONCLUSIONS In patients having cardiac surgery with cardio-pulmonary bypass, neither intraoperative nor postoperative hypotension were associated with delirium. Postoperative hypotension was associated with atrial fibrillation, although intraoperative hypotension was not.
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Ševčíková B, Matějovská Kubešová H, Šáteková L, Gurková E. The validation of the Czech version of the Delirium Observation Scale and the Nursing Delirium Screening Scale for delirium screening in patients with locomotive apparatus trauma. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2021. [DOI: 10.15452/cejnm.2021.12.0011] [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] Open
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Abstract
This review provides an overview for health care teams involved in the perioperative care of cardiac surgery patients. The intention is to summarize key determinants of delirium, its impact on short- and long-term outcomes as well as to discuss effective management strategies. The first component of this review examines the prevalence and the factors associated with an increased risk of postoperative delirium. A multitude of predisposing (eg, baseline vulnerability and comorbidities) and precipitating (eg, type of cardiac surgery and postoperative care) factors that contribute to the occurrence of delirium are discussed.
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Fatehi Hassanabad A, Bahrami N, Novick RJ, Ali IS. Delirium and depression in cardiac surgery: A comprehensive review of risk factors, pathophysiology, and management. J Card Surg 2021; 36:2876-2889. [PMID: 34120376 DOI: 10.1111/jocs.15610] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Mental health and wellbeing continue to gain more attention as they are inextricably associated with clinical outcomes, particularly quality of life. Many medical ailments and major surgeries affect patients' mental health, including depression and delirium. AIMS The objective of this manuscript was to comprehensively review and critically examine the literature pertaining to cardiac surgery, depression, and delirium. METHODS This is a narrative review article. We performed our search analysis by using the following key words: "Cardiac Surgery", "Depression", "Delirium", "Clinical outcomes", and "Mental Health". Search analysis was done on MedLine PubMed, accessing indexed peer-reviewed publications. RESULTS Cardiac Surgery is a life-altering intervention indicated to improve morbidity and mortality in patients with cardiovascular diseases. Psychiatric conditions before and after cardiac surgery worsen patient prognosis and increase mortality rate. Specifically, preoperative depression increases postoperative depression and is associated with impaired functional status, slow physical recovery, and an increased readmission rate. DISCUSSION Although the exact pathophysiology between depression and cardiovascular disease (CVD) is unknown, several pathways have been implicated. Unmanaged depression can also lead to other psychological conditions such as delirium. Like depression, the exact association between delirium and CVD is not well understood, but believed to be multifactorial. CONCLUSION Herein, we provide a comprehensive review of the links between depression, delirium, and cardiovascular surgery. We critically examine the current data that pertains to the pathophysiology of these debilitating mental health issues in the context of cardiac surgery. Finally, we summarize the various treatment options available for managing depression and delirium in the cardiac surgery patient population.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Nabila Bahrami
- Department of Medicine, Department of Medicine, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Richard J Novick
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Imtiaz S Ali
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
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Ince I, Chiu A, Sagir A, Chahar P, Lin J, Douglas A, Adi A, Fang J, Mao G, Turan A. Association of Pain With Atrial Fibrillation and Delirium After Cardiac Surgery: A DECADE Sub-Study. J Cardiothorac Vasc Anesth 2021; 35:3021-3026. [PMID: 34148803 DOI: 10.1053/j.jvca.2021.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to evaluate the effects of postoperative pain on the incidence of atrial fibrillation and delirium in patients having surgery with cardiopulmonary bypass (CPB). DESIGN Post hoc analysis of the (An investigator-initiated, multicentre, double-blind trial (ClinicalTrials NCT02004613) (DECADE)), a randomized, placebo-controlled trial. SETTING Tertiary, academic hospital. PARTICIPANTS Six hundred five adults from the DECADE enrolled at Cleveland Clinic Main Campus, who had had surgery with CPB. INTERVENTIONS Dexmedetomidine versus placebo started before surgical incision and postoperatively was maintained until 24 hours. MEASUREMENTS Primary outcomes were atrial fibrillation, diagnosed by clinicians in the intensive care unit (ICU), presence of delirium assessed with the Confusion Assessment Method for the ICU, data on pain scores, and opioid consumption, occurring between ICU admission and the earlier of postoperative day five or hospital discharge. RESULTS Postoperative pain levels were similar among patients with or without atrial fibrillation. Two hundred six (34%) patients had atrial fibrillation and ninety-two (15%) had delirium before hospital discharge within the first five postoperative days. The risk of atrial fibrillation was not significantly different between groups (hazard ratio: 1.09; 97.5% confidence interval [CI]: 0.99, 1.20, p = 0.039); there were no associations between postoperative pain and the risk of postoperative delirium (hazard ratio: 0.96; 97.5% CI: 0.84-1.11; p = 0.57). Postoperative opioid consumption was neither significantly associated with postoperative atrial fibrillation nor delirium. CONCLUSIONS Atrial fibrillation and delirium was not associated with pain after cardiac surgery. Opioid use was not associated with atrial fibrillation and delirium. Because both atrial fibrillation and delirium have a multifactorial nature, further studies should be focused on other plausible mechanisms.
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Affiliation(s)
- Ilker Ince
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Andrew Chiu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Afrin Sagir
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Praveen Chahar
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Jia Lin
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Aaron Douglas
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Ahmad Adi
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Jonathan Fang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Guangmei Mao
- Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH.
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Kaźmierski J, Miler P, Pawlak A, Jerczyńska H, Woźniak J, Frankowska E, Brzezińska A, Woźniak K, Krejca M, Wilczyński M. Elevated Monocyte Chemoattractant Protein-1 as the Independent Risk Factor of Delirium after Cardiac Surgery. A Prospective Cohort Study. J Clin Med 2021; 10:jcm10081587. [PMID: 33918634 PMCID: PMC8070441 DOI: 10.3390/jcm10081587] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The pathogenesis of postoperative delirium is largely unknown. The primary objective of this study is to assess whether increased levels of monocyte chemoattractant protein-1 (MCP-1) and high-sensitivity C-reactive protein (hsCRP) are associated with postoperative delirium in patients who have undergone cardiac surgery. The secondary objective is to investigate whether any association between raised inflammatory biomarkers levels and delirium is related to surgical and anesthetic procedures or mediated by pre-existing psychiatric conditions associated with raised pro-inflammatory markers levels. METHODS The patients were screened for cognitive impairment one day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of major depressive disorder (MDD) and anxiety disorders was established on the basis of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Blood samples were collected pre- and postoperatively for hsCRP and chemokine levels. RESULTS Postoperative delirium developed in 34% (61 of 177) of patients. Both pre- and postoperative hsCRP, and preoperative MCP-1 levels were associated with postoperative delirium in univariate comparisons; p = 0.001; p < 0.001; p < 0.001, respectively. However, according to a multivariable logistic regression analysis, only a raised MCP-1 concentration before surgery was independently associated with postoperative delirium, and related to advancing age, preoperative anxiety disorders and prolonged intubation. CONCLUSIONS The present study suggests that an elevated preoperative MCP-1 concentration is associated with delirium after cardiac surgery. Monitoring of this inflammatory marker may reveal the cardiovascular disease (CVD) patients who are at risk of neuropsychiatric syndromes development.
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Affiliation(s)
- Jakub Kaźmierski
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, 92-216 Lodz, Poland; (J.W.); (E.F.)
- Correspondence: ; Tel.: +48-42-675-7372
| | - Piotr Miler
- Central Clinical Hospital of Medical University of Lodz, 92-216 Lodz, Poland; (P.M.); (A.P.); (A.B.)
| | - Agnieszka Pawlak
- Central Clinical Hospital of Medical University of Lodz, 92-216 Lodz, Poland; (P.M.); (A.P.); (A.B.)
| | - Hanna Jerczyńska
- CoreLab Central Scientific Laboratory of Medical University of Lodz, Medical University of Lodz, 92-215 Lodz, Poland;
| | - Joanna Woźniak
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, 92-216 Lodz, Poland; (J.W.); (E.F.)
| | - Emilia Frankowska
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, 92-216 Lodz, Poland; (J.W.); (E.F.)
| | - Agnieszka Brzezińska
- Central Clinical Hospital of Medical University of Lodz, 92-216 Lodz, Poland; (P.M.); (A.P.); (A.B.)
| | - Katarzyna Woźniak
- Department of Cardiac Surgery, Medical University of Lodz, 92-213 Lodz, Poland; (K.W.); (M.K.); (M.W.)
| | - Michał Krejca
- Department of Cardiac Surgery, Medical University of Lodz, 92-213 Lodz, Poland; (K.W.); (M.K.); (M.W.)
| | - Mirosław Wilczyński
- Department of Cardiac Surgery, Medical University of Lodz, 92-213 Lodz, Poland; (K.W.); (M.K.); (M.W.)
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Lim L, Nam K, Lee S, Cho YJ, Yeom CW, Jung S, Moon JY, Jeon Y. The relationship between intraoperative cerebral oximetry and postoperative delirium in patients undergoing off-pump coronary artery bypass graft surgery: a retrospective study. BMC Anesthesiol 2020; 20:285. [PMID: 33189145 PMCID: PMC7666484 DOI: 10.1186/s12871-020-01180-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 10/01/2020] [Indexed: 12/18/2022] Open
Abstract
Background Cerebral oximetry has been widely used to measure regional oxygen saturation in brain tissue, especially during cardiac surgery. Despite its popularity, there have been inconsistent results on the use of cerebral oximetry during cardiac surgery, and few studies have evaluated cerebral oximetry during off pump coronary artery bypass graft surgery (OPCAB). Methods To evaluate the relationship between intraoperative cerebral oximetry and postoperative delirium in patients who underwent OPCAB, we included 1439 patients who underwent OPCAB between October 2004 and December 2016 and among them, 815 patients with sufficient data on regional cerebral oxygen saturation (rSO2) were enrolled in this study. We retrospectively analyzed perioperative variables and the reduction in rSO2 below cut-off values of 75, 70, 65, 60, 55, 50, 45, 40, and 35%. Furthermore, we evaluated the relationship between the reduction in rSO2 and postoperative delirium. Results Delirium occurred in 105 of 815 patients. In both univariable and multivariable analyses, the duration of rSO2 reduction was significantly longer in patients with delirium at cut-offs of < 50 and 45% (for every 5 min, adjusted odds ratio (OR) 1.007 [95% Confidence interval (CI) 1.001 to 1.014] and adjusted OR 1.012 [1.003 to 1.021]; p = 0.024 and 0.011, respectively). The proportion of patients with a rSO2 reduction < 45% was significantly higher among those with delirium (adjusted OR 1.737[1.064 to 2.836], p = 0.027). Conclusions In patients undergoing OPCAB, intraoperative rSO2 reduction was associated with postoperative delirium. Duration of rSO2 less than 50% was 40% longer in the patients with postoperative delirium. The cut-off value of intraoperative rSO2 that associated with postoperative delirium was 50% for the total patient population and 55% for the patients younger than 68 years. Supplementary information Supplementary information accompanies this paper at 10.1186/s12871-020-01180-x.
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Affiliation(s)
- Leerang Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Chan-Woo Yeom
- Department of Neuropsychiatry, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Sanghyup Jung
- Department of Neuropsychiatry, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Jung Yoon Moon
- Department of Neuropsychiatry, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea, 03080.
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Rao A, Shi SM, Afilalo J, Popma JJ, Khabbaz KR, Laham RJ, Guibone K, Marcantonio ER, Kim DH. Physical Performance and Risk of Postoperative Delirium in Older Adults Undergoing Aortic Valve Replacement. Clin Interv Aging 2020; 15:1471-1479. [PMID: 32921993 PMCID: PMC7455771 DOI: 10.2147/cia.s257079] [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] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/01/2020] [Indexed: 12/15/2022] Open
Abstract
Background Delirium is a major risk factor for poor recovery after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). It is unclear whether preoperative physical performance tests improve delirium prediction. Objective To examine whether physical performance tests can predict delirium after SAVR and TAVR, and adapt an existing delirium prediction rule for cardiac surgery, which includes Mini-Mental State Examination (MMSE), depression, prior stroke, and albumin level. Design Prospective cohort, 2014-2017. Setting Single academic center. Subjects A total of 187 patients undergoing SAVR (n=77) or TAVR (n=110). Methods The Short Physical Performance Battery (SPPB) score was calculated based on gait speed, balance, and chair stands (range: 0-12 points, lower scores indicate poor performance). Delirium was assessed using the Confusion Assessment Method. We fitted logistic regression to predict delirium using SPPB components and risk factors of delirium. Results Delirium occurred in 35.8% (50.7% in SAVR and 25.5% in TAVR). The risk of delirium increased for lower SPPB scores: 10-12 (28.2%), 7-9 (34.5%), 4-6 (37.5%) and 0-3 (44.1%) (p-for-trend=0.001). A model that included gait speed <0.46 meter/second (OR, 2.7; 95% CI, 1.2-6.4), chair stands time ≥11.2 seconds (OR, 3.5; 95% CI, 1.0-12.4), MMSE <24 points (OR, 2.9; 95% CI, 1.3-6.4), isolated SAVR (OR, 5.4; 95% CI, 2.1-13.8), and SAVR and coronary artery bypass grafting (OR, 15.8; 95% CI, 5.5-45.7) predicted delirium better than the existing prediction rule (C statistics: 0.71 vs 0.61; p=0.035). Conclusion Assessing physical performance, in addition to cognitive function, can help identify high-risk patients for delirium after SAVR and TAVR.
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Affiliation(s)
- Aarti Rao
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sandra M Shi
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Jonathan Afilalo
- Division of Cardiology and Centre for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeffrey J Popma
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kamal R Khabbaz
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Roger J Laham
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kimberly Guibone
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Edward R Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Dae Hyun Kim
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
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Yoon U, Topper J, Goldhammer J. Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 36:1429-1448. [PMID: 32891522 DOI: 10.1053/j.jvca.2020.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/30/2020] [Accepted: 08/09/2020] [Indexed: 12/13/2022]
Abstract
Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.
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Affiliation(s)
- Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA.
| | - James Topper
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jordan Goldhammer
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
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Abstract
Better ways to manage preoperative, intraoperative and postoperative care of surgical patients is the bailiwick of anesthesiologists. Although we care for patients of all ages, protecting the cognitive capacity of elderly patients more frequently requires procedures and practices that go beyond routine care for nonelderly adults. This narrative review will consider current understanding of the reasons that elderly patients need enhanced care, and recommendations for that care based on established and recent empirical research. In that latter regard, unless and until we are able to classify anesthetic neurotoxicity as a rare complication, the first-do-no-harm approach should: (1) add anesthesia to surgical intervention on the physiological cost side of the cost/benefit ratio when making decisions about whether and when to proceed with surgery; (2) minimize anesthetic depth and periods of electroencephalographic suppression; (3) limit the duration of continuous anesthesia whenever possible; (4) consider the possibility that regional anesthesia with deep sedation may be as neurotoxic as general anesthesia; and (5) when feasible, use regional anesthesia with light or no sedation.
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Kang T, Park SY, Lee JH, Lee SH, Park JH, Kim SK, Suh SW. Incidence & Risk Factors of Postoperative Delirium After Spinal Surgery in Older Patients. Sci Rep 2020; 10:9232. [PMID: 32513956 PMCID: PMC7280299 DOI: 10.1038/s41598-020-66276-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 01/03/2020] [Indexed: 01/03/2023] Open
Abstract
Although postoperative delirium is a common complication in older patients, few papers have described risk factors after of spinal surgery. The purpose of this study was to analyze various perioperative risk factors for delirium after spinal surgery in older patients. This study was performed on retrospective data collection with prospective design. We analyzed 138 patients over 65 years of age who underwent spinal surgery. Preoperative factors were cognitive function (Mini-Mental State Examination-Korean (MMSE-K) and the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS 98)), age, sex, type of admission, American Society of Anesthesiologist classification, metabolic equivalents, laboratory findings, visual analog scale, and Oswestry Disability Index. Intraoperative factors were operation time, blood loss, and type of procedure. Postoperative factors were blood transfusion and type of postoperative pain control. Postoperative delirium developed in 25 patients (18.16%). Patients were divided into two groups: Group with delirium (group A) and group without delirium (group B). MMSE-K scores in Group A were significantly lower than in Group B (p < 0.001). K-DRS 98 scores were significantly higher in Group A than Group B (p < 0.001). The operation time was longer in Group A than Group B (p = 0.059). On multivariate regression analysis, the odds ratio of K-DRS 98 was 2.43 (p = 0.010). After correction for the interaction between age and MMSE-K, patients younger than 73 years old had a significantly lower incidence of delirium with higher MMSE-K score (p = 0.0014). Older age, low level of preoperative cognitive function, long duration of surgery, and transfusion were important risk factors of postoperative delirium after spinal surgery. It is important to recognize perioperative risk factors and manage appropriately.
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Affiliation(s)
- Taewook Kang
- Department of Orthopaedics, Korea University College of Medicine, Anam Hospital, Seoul, Korea
| | - Si Young Park
- Department of Orthopaedics, Korea University College of Medicine, Anam Hospital, Seoul, Korea.
| | - Jin Hyeok Lee
- Department of Orthopaedics, Korea University College of Medicine, Anam Hospital, Seoul, Korea
| | - Soon Hyuck Lee
- Department of Orthopaedics, Korea University College of Medicine, Anam Hospital, Seoul, Korea
| | - Jong Hoon Park
- Department of Orthopaedics, Korea University College of Medicine, Anam Hospital, Seoul, Korea
| | - Seul Ki Kim
- Department of Orthopaedics, Korea University College of Medicine, Anam Hospital, Seoul, Korea
| | - Seung Woo Suh
- Department of Orthopaedics, Korea University College of Medicine, Anam Hospital, Seoul, Korea
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Singh M, Spertus JA, Gharacholou SM, Arora RC, Widmer RJ, Kanwar A, Sanjanwala RM, Welle GA, Al-Hijji MA. Comprehensive Geriatric Assessment in the Management of Older Patients With Cardiovascular Disease. Mayo Clin Proc 2020; 95:1231-1252. [PMID: 32498778 DOI: 10.1016/j.mayocp.2019.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/29/2019] [Accepted: 09/04/2019] [Indexed: 12/30/2022]
Abstract
Cardiovascular disease (CVD) disproportionately affects older adults. It is expected that by 2030, one in five people in the United States will be older than 65 years. Individuals with CVD now live longer due, in part, to current prevention and treatment approaches. Addressing the needs of older individuals requires inclusion and assessment of frailty, multimorbidity, depression, quality of life, and cognition. Despite the conceptual relevance and prognostic importance of these factors, they are seldom formally evaluated in clinical practice. Further, although these constructs coexist with traditional cardiovascular risk factors, their exact prevalence and prognostic impact remain largely unknown. Development of the right decision tools, which include these variables, can facilitate patient-centered care for older adults. These gaps in knowledge hinder optimal care use and underscore the need to rigorously evaluate the optimal constructs for providing care to older adults. In this review, we describe available tools to examine the prognostic role of age-related factors in patients with CVD.
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Affiliation(s)
- Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, MO
| | | | - Rakesh C Arora
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Amrit Kanwar
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Rohan M Sanjanwala
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
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Abstract
PURPOSE OF REVIEW The present review aims to describe the clinical impact and assessment tools capable of identifying delirium in cardiac arrest survivors and providing strategies aimed at preventing and treating delirium. RECENT FINDINGS Patient factors leading to a cardiac arrest, initial resuscitation efforts, and postresuscitation management all influence the potential for recovery and the risk for development of delirium. Data suggest that delirium in cardiac arrest survivors is an independent risk factor for morbidity and mortality. Recognizing delirium in postcardiac arrest patients can be challenging; however, detection is not only achievable, but important as it may aid in predicting adverse outcomes. Serial neurologic examinations and delirium assessments, targeting light sedation when possible, limiting psychoactive medications, and initiating patient care bundles are important care aspects for not only allowing early identification of primary and secondary brain injury, but in improving patient morbidity and mortality. SUMMARY Developing delirium after cardiac arrest is associated with increased morbidity and mortality. The importance of addressing modifiable risk factors, recognizing symptoms early, and initiating coordinated treatment strategies can help to improve outcomes within this high risk population.
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Li Y, Ma J, Jin Y, Li N, Zheng R, Mu W, Wang J, Si JH, Chen J, Shang HC. Benzodiazepines for treatment of patients with delirium excluding those who are cared for in an intensive care unit. Cochrane Database Syst Rev 2020; 2:CD012670. [PMID: 32108325 PMCID: PMC7047222 DOI: 10.1002/14651858.cd012670.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Delirium is a very common condition associated with significant morbidity, mortality, and costs. Current critical care guidelines recommend first and foremost the use of nonpharmacological strategies in both the prevention and treatment of delirium. Pharmacological interventions may augment these approaches and they are currently used widely in clinical practice to manage the symptoms of delirium. Benzodiazepines are currently used in clinical practice to treat behavioural disturbances associated with delirium but current guidelines do not recommend their use for this indication. The use of these medicines is controversial because there is uncertainty about whether they are effective for patients or have the potential to harm them. OBJECTIVES To assess the effectiveness and safety of benzodiazepines in the treatment of delirium (excluding delirium related to withdrawal from alcohol or benzodiazepines) in any healthcare settings other than intensive care units (ICU). SEARCH METHODS We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register up to 10 April 2019. ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases (including MEDLINE, Embase, PsycINFO, CINAHL, LILACS), numerous trial registries (including national, international and pharmaceutical registries), and grey literature sources. SELECTION CRITERIA We included randomised controlled trials (RCTs) conducted in healthcare settings that ranged from nursing homes and long-term care facilities to any hospital setting except for ICUs, involving adult patients with delirium excluding those with delirium related to alcohol or benzodiazepine withdrawal. Included RCTs had to assess the effect of benzodiazepines, at any dose and given by any route, compared with placebo or another drug intended to treat delirium. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data, and assessed the risk of bias of included studies. We decided whether or not to pool data on the basis of clinical heterogeneity between studies. We used GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods to assess the quality of evidence. MAIN RESULTS We identified only two trials that satisfied the selection criteria. We did not pool the data because of the substantial clinical differences between the trials. In one trial, participants (n = 58) were patients in an acute palliative care unit with advanced cancer who had a mean age of 64 years. All of the participants had delirium, were treated with haloperidol, and were randomised to receive either lorazepam or placebo in combination with it. Due to very serious imprecision, all evidence was of low certainty. We were unable to determine whether there were clinically important differences in the severity of delirium (mean difference (MD) 2.10, 95% CI -0.96 to 5.16; n = 50), length of hospital admission (MD 0.00, 95% CI -3.45 to 3.45; n = 58), mortality from all causes (risk ratio (RR) 0.33, 95% CI 0.04 to 3.02; participants = 58) or any of a number of adverse events. Important effects could not be confirmed or excluded. The study authors did not report the length of the delirium episode. In the other trial, participants (n = 30) were patients in general medical wards with acquired immune deficiency syndrome (AIDS) who had a mean age of 39.2 years. Investigators compared three drug treatments: all participants had delirium, and were randomised to receive lorazepam, chlorpromazine, or haloperidol. Very low-certainty evidence was identified, and we could not determine whether lorazepam differed from either of the other treatments in the effect on severity of delirium, any adverse event, or mortality from all causes. The study authors did not report the length of the delirium episode or the length of hospital admission. AUTHORS' CONCLUSIONS There is no enough evidence to determine whether benzodiazepines are effective when used to treat patients with delirium who are cared for in non-ICU settings. The available evidence does not support their routine use for this indication. Because of the scarcity of data from randomised controlled trials, further research is required to determine whether or not there is a role for benzodiazepines in the treatment of delirium in non-ICU settings.
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Affiliation(s)
- Yan Li
- Beijing Anzhen Hospital, Capital Medical UniversityCenter for AnesthesiologyNo.2 Anzhen RoadChaoyang DistrictBeijingBeijingChina100029
| | - Jun Ma
- Beijing Anzhen Hospital, Capital Medical UniversityCenter for AnesthesiologyNo.2 Anzhen RoadChaoyang DistrictBeijingBeijingChina100029
| | - Yinghui Jin
- Tianjin University of Traditional Chinese MedicineNursing#312 West Anshan RoadTianjinChina
| | - Nan Li
- Tianjin University of Traditional Chinese MedicineTianjin Insititute of Clinical Evaluation#88 Yuquan RoadNankai DistrictTianjinTianjinChina300193
| | - Rui Zheng
- Tianjin University of Traditional Chinese MedicineTianjin Insititute of Clinical Evaluation#88 Yuquan RoadNankai DistrictTianjinTianjinChina300193
| | - Wei Mu
- The 2nd Affiliated Hospital of Tianjin University of traditional Chinese MedicineClinical pharmacology861 Zhenli RoadHebei DistrictTianjinTianjinChina300150
| | - Jiaying Wang
- The Affiliated Wuxi People’s Hospital of Nanjing Medical UniversityRehabilitation and AcupunctureNo.299, Qingyang Road, Liangxi DistrictWuxiJiangsuChina214000
| | - Jin Hua Si
- Tianjin University of Traditional Chinese MedicineLibrary#88 Yuquan RoadNankai DistrictTianjinTianjinChina300193
| | - Jing Chen
- Tianjin University of Traditional Chinese MedicineBaokang Hospital#88 Yuquan RoadNankai DistrictTianjinTianjinChina300193
| | - Hong Cai Shang
- Dongzhimen Hospital, Beijing University of Chinese MedicineKey Laboratory of Chinese Internal Medicine of Ministry of EducationHaiyuncang Lane, Dongcheng DistrictBeijingChina100700
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Ford AH, Flicker L, Kelly R, Patel H, Passage J, Wibrow B, Anstey M, Edwards M, Almeida OP. The Healthy Heart‐Mind Trial: Randomized Controlled Trial of Melatonin for Prevention of Delirium. J Am Geriatr Soc 2019; 68:112-119. [DOI: 10.1111/jgs.16162] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/13/2019] [Accepted: 08/13/2019] [Indexed: 01/06/2023]
Affiliation(s)
- Andrew H. Ford
- Medical SchoolUniversity of Western Australia Perth Western Australia Australia
- WA Centre for Health & AgeingUniversity of Western Australia Perth Western Australia Australia
| | - Leon Flicker
- Medical SchoolUniversity of Western Australia Perth Western Australia Australia
- WA Centre for Health & AgeingUniversity of Western Australia Perth Western Australia Australia
| | - Rachael Kelly
- Medical SchoolUniversity of Western Australia Perth Western Australia Australia
| | - Hema Patel
- Medical SchoolUniversity of Western Australia Perth Western Australia Australia
| | - Jurgen Passage
- School of MedicineUniversity of Notre Dame and Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital Perth Western Australia Australia
| | - Bradley Wibrow
- Medical SchoolUniversity of Western Australia Perth Western Australia Australia
- Intensive Care Unit, Sir Charles Gairdner Hospital Perth Western Australia Australia
| | - Matthew Anstey
- Medical SchoolUniversity of Western Australia Perth Western Australia Australia
- Intensive Care Unit, Sir Charles Gairdner Hospital Perth Western Australia Australia
| | - Mark Edwards
- Department of Cardiothoracic SurgeryFiona Stanley Hospital Perth Western Australia Australia
| | - Osvaldo P. Almeida
- Medical SchoolUniversity of Western Australia Perth Western Australia Australia
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Reducing Delirium and Improving Patient Satisfaction With a Perioperative Mindfulness Intervention: A Mixed-Methods Pilot Study. Holist Nurs Pract 2019; 33:163-176. [PMID: 30973436 DOI: 10.1097/hnp.0000000000000321] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postoperative delirium (incidence estimated up to 82%) can be ameliorated with nonpharmacologic methods. Mindfulness has not yet been incorporated into these methods, although mindfulness has been demonstrated to help patients adapt to illness and hospitalization. To reduce postoperative delirium incidence and increase patient satisfaction, this study employs a program of thought exercises based on Langerian mindfulness. Preoperatively, cardiac surgical patients listened to a mindfulness or informational audio; mindfulness subjects were also guided by the principal investigator through mindfulness exercises. Postoperatively, mindfulness subjects were visited twice daily for mindfulness exercises. For all patients, delirium screening was performed twice daily. Before discharge, affective status and satisfaction with hospital stay were assessed. No patients who completed the study screened positive for delirium. Trends include (1) lower (improved) median anxiety and depression scores postoperatively when considering both study groups together; (2) both groups rated the hospital more favorably on global satisfaction measures; (3) both groups shared generally positive comments regarding the audio files (qualitative data). Audio files and mindfulness exercises are associated with patient satisfaction among cardiothoracic surgery patients. The absence of delirium precludes determination of the effectiveness of the intervention in reducing delirium incidence.
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Jovin DG, Katlaps KG, Ellis BK, Dharmaraj B. Neuroprotection against stroke and encephalopathy after cardiac surgery. Interv Med Appl Sci 2019; 11:27-37. [PMID: 32148901 PMCID: PMC7044570 DOI: 10.1556/1646.11.2019.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Cerebral ischemia in the perioperative period is a major risk factor for stroke, encephalopathy, and cognitive decline after cardiothoracic surgery. After coronary artery bypass grafting, both stroke and encephalopathy can result in poor patient outcomes and increased mortality. Neuroprotection aims to lessen the severity and occurrence of further injury mediated by stroke and encephalopathy and to aid the recovery of conditions already present. Several pharmacological and non-pharmacological methods of neuroprotection have been investigated in experimental studies and in animal models, and, although some have shown effectiveness in protection of the central nervous system, for most, clinical research is lacking or did not show the expected results. This review summarizes the value and need for neuroprotection in the context of cardiothoracic surgery and examines the use and effectiveness of several agents and methods with an emphasis on clinical trials and clinically relevant neuroprotectants.
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Affiliation(s)
- Daniel G Jovin
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Karl G Katlaps
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Ben K Ellis
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Benita Dharmaraj
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
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The effect of preoperative cognitive impairment and type of vascular surgery procedure on postoperative delirium with associated cost implications. J Vasc Surg 2019; 69:201-209. [DOI: 10.1016/j.jvs.2018.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 05/01/2018] [Indexed: 11/17/2022]
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Perioperative dexmedetomidine reduces delirium after cardiac surgery: A meta-analysis of randomized controlled trials. J Clin Anesth 2018; 50:33-42. [DOI: 10.1016/j.jclinane.2018.06.045] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/19/2018] [Accepted: 06/21/2018] [Indexed: 11/19/2022]
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Berger M, Terrando N, Smith SK, Browndyke JN, Newman MF, Mathew JP. Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms. Anesthesiology 2018; 129:829-851. [PMID: 29621031 PMCID: PMC6148379 DOI: 10.1097/aln.0000000000002194] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.
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Affiliation(s)
- Miles Berger
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Niccolò Terrando
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - S. Kendall Smith
- Critical Care Fellow, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jeffrey N. Browndyke
- Assistant Professor, Division of Geriatric Behavioral Health, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Mark F. Newman
- Merel H. Harmel Professor of Anesthesiology, and President of the Private Diagnostic Clinic, Duke University Medical Center, Durham, NC
| | - Joseph P. Mathew
- Jerry Reves, MD Professor and Chair, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Karamnov S, Brovman EY, Greco KJ, Urman RD. Risk Factors and Outcomes Associated With Sepsis After Coronary Artery Bypass and Open Heart Valve Surgeries. Semin Cardiothorac Vasc Anesth 2018; 22:359-368. [PMID: 29992859 DOI: 10.1177/1089253218785362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Sepsis causes significant morbidity and mortality after cardiac surgery and carries a significant burden on health care costs. There is a general association of increased risk of post-cardiac surgery sepsis in patients with postoperative complications. We sought to investigate significant patient and procedural risk factors and outcomes associated with sepsis after cardiac surgery. MATERIALS AND METHODS In this retrospective study, we analyzed 531 coronary artery bypass grafting and open heart valve surgery cases that developed postoperative sepsis in the National Surgical Quality Improvement Program database between 2007 and 2014. Patient-based and surgery-based parameters were analyzed for risk factors and outcomes reported in the 30 days postoperatively. The association between sepsis and patient outcomes was assessed in a propensity-matched cohort using univariable logistic regression. RESULTS Modifiable and nonmodifiable patient characteristics, including age >80, poor preoperative functional status, chronic diseases such as diabetes mellitus, congestive heart failure, chronic kidney disease with serum creatinine ⩾1.5, as well as serum albumin <3.5 and emergent nature of the case were associated with post-cardiac surgery sepsis. Surgical outcomes associated with sepsis included mortality (15.4% vs 4.5%), unplanned intubation (29.8% vs 8.2%), transfusion (53.4% vs 48.4%), acute kidney injury (7.1% vs 1.4%), postoperative dialysis (18.8% vs 3.5%), and return to the operating room (29.8% vs 8.2%). CONCLUSIONS We identified multiple patient and surgical characteristics as well as postoperative outcomes associated with postoperative sepsis development in the high-risk population of patients undergoing cardiac surgery. Early identification of patients who are at high risk for postoperative sepsis can facilitate early treatment interventions.
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Affiliation(s)
- Sergey Karamnov
- 1 Brigham and Women's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Ethan Y Brovman
- 1 Brigham and Women's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Katherine J Greco
- 1 Brigham and Women's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- 1 Brigham and Women's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
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Delirium after cardiac surgery. Incidence, phenotypes, predisposing and precipitating risk factors, and effects. Heart Lung 2018; 47:408-417. [PMID: 29751986 DOI: 10.1016/j.hrtlng.2018.04.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 04/08/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND In cardiac surgical patients little is known about different phenotypes of delirium and how the symptoms fluctuate over time. OBJECTIVES Evaluate risk factors, incidence, fluctuations, phenotypic characteristics and impact on patients' outcomes of delirium. METHODS Prospective longitudinal study. In postoperative intensive care unit 199 patient were assessed three-times a day through an adapted versions of the Intensive Care Delirium Screening Checklist. RESULTS Delirium and subsyndromal delirium incidence were 30.7% and 31.2%, respectively. Delirium manifested mostly in the hypoactive form and showed a fluctuating trend for several days. Atrial fibrillation, benzodiazepine/opioids dosages, hearing impairment, extracorporeal circulation length, SAPS-II and mean arterial pressure were independent predictors for delirium. Delirium was a statistically significant predictor of chemical/physical restraint use and hospital length of stay. CONCLUSIONS Given the fluctuating and phenotypic characteristics, delirium screening should be a systematic/intentional activity. Multidisciplinary prevention strategies should be implemented to identify and treat the modifiable risk factors.
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Simeone S, Pucciarelli G, Perrone M, Teresa R, Gargiulo G, Guillari A, Castellano G, Tommaso LD, Niola M, Iannelli G. Delirium in ICU patients following cardiac surgery: An observational study. J Clin Nurs 2018; 27:1994-2002. [DOI: 10.1111/jocn.14324] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Silvio Simeone
- Department of Cardiology, Cardiac Surgery and Emergency; University of Naples Federico II; Naples Italy
| | - Gianluca Pucciarelli
- Department of Biomedicine and Prevention; University of Rome Tor Vergata; Rome Italy
| | - Marco Perrone
- Department of Cardiology, Cardiac Surgery and Emergency; University of Naples Federico II; Naples Italy
| | - Rea Teresa
- Department of Hygiene; University of Naples Federico II; Naples Italy
| | - Gianpaolo Gargiulo
- Pediatric Cardiac Surgery; University of Naples Federico II; Naples Italy
| | - Assunta Guillari
- Department of Hygiene; University of Naples Federico II; Naples Italy
| | - Gaetano Castellano
- Department of Clinical Neuroscience, Anaesthesiology; University of Naples Federico II; Naples Italy
| | - Luigi Di Tommaso
- Department of Cardiac Surgery; University of Naples Federico II; Naples Italy
| | - Massimo Niola
- Department of Advanced Biomedical Sciences; University of Naples Federico II; Naples Italy
| | - Gabriele Iannelli
- Department of Cardiology, Cardiac Surgery and Cardiovascular Emergency; University of Naples Federico II; Naples Italy
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Stachon P, Kaier K, Zirlik A, Reinöhl J, Heidt T, Bothe W, Hehn P, Zehender M, Bode C, von Zur Mühlen C. Risk factors and outcome of postoperative delirium after transcatheter aortic valve replacement. Clin Res Cardiol 2018; 107:756-762. [PMID: 29654435 DOI: 10.1007/s00392-018-1241-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/09/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND POD is associated with a worse postoperative course in patients after cardiac surgery, but its incidence and effects after TAVR are not well-understood. The aim of the present study was to analyze incidence, risk factors, and in-hospital outcomes of postoperative delirium (POD) after transfemoral (TF-AVR) and transapical (TA-AVR) transcatheter aortic valve replacement (TAVR) in a nationwide cohort. METHODS AND RESULTS Administrative data on all patients undergoing isolated TAVR in Germany in 2014 were analyzed. 9038 TF-AVR and 2522 TA-AVR procedures were performed. POD incidence was 7% after TF-AVR and 12% after TA-AVR. Atrial fibrillation (TF: OR 1.35, p < 0.001; TA: OR 1.53, p = 0.001) and NYHA III/IV (TF: OR 1.23, p = 0.017, TA: OR 1.51, p = 0.001) were independent risk factors for POD. Dementia was a risk factor only in TF-AVR (OR 3.04, p < 0.001). Female sex was protective (TF: OR 0.56, p < 0.001, TA: OR 0.51, p < 0.001). We found the occurrence of POD to be associated with more postoperative complications such as stroke and bleeding. Consequently, patients with POD were ventilated and hospitalized longer and suffered an increased risk of in-hospital mortality (unadjusted OR TF: 1.83, p = 0.001, TA: 1.82, p = 0.01). After adjusting for postoperative events and comorbidities, POD's effect on in-hospital mortality disappeared. In contrast, stroke and bleeding remained independent predictors for mortality irrespective of POD. CONCLUSIONS Patients with POD after TAVR are at increased risk for in-hospital mortality. However, after adjusting for postoperative events and comorbidities, stroke and bleeding, but not POD, are independent mortality predictors.
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Affiliation(s)
- Peter Stachon
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Medical Faculty, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Klaus Kaier
- Faculty of Medicine and Medical Center-University of Freiburg, Institute of Medical Biometry and Statistics, Freiburg, Germany
| | - Andreas Zirlik
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Medical Faculty, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Jochen Reinöhl
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Medical Faculty, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Timo Heidt
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Medical Faculty, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Wolfgang Bothe
- University Heart Center Freiburg, Department of Cardiovascular Surgery, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Philip Hehn
- Faculty of Medicine and Medical Center-University of Freiburg, Institute of Medical Biometry and Statistics, Freiburg, Germany
| | - Manfred Zehender
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Medical Faculty, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Christoph Bode
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Medical Faculty, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Constantin von Zur Mühlen
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Medical Faculty, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
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Oliveira FR, Oliveira VH, Oliveira ÍM, Lima JW, Calderaro D, Gualandro DM, Caramelli B. Hypertension, mitral valve disease, atrial fibrillation and low education level predict delirium and worst outcome after cardiac surgery in older adults. BMC Anesthesiol 2018; 18:15. [PMID: 29390969 PMCID: PMC5796436 DOI: 10.1186/s12871-018-0481-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 01/23/2018] [Indexed: 12/02/2022] Open
Abstract
Background Delirium is a common complication after cardiac surgery in older adult patients. However, risk factors and the influence of delirium on patient outcomes are not well established. We aimed to determine the incidence, predisposing and triggering factors of delirium following cardiac surgery. Methods One hundred seventy-three consecutive patients aged ≥60 years were studied. Patients’ characteristics and two cognitive function assessment tests were recorded preoperatively. Perioperative variables were blood transfusion, orotracheal intubation time (OIT), renal dysfunction, and hypoxemia. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit. The composite outcome consisted of death, infection, and perioperative myocardial infarction until hospital discharge or 30 days after surgery, and for up to 18 months. Results One hundred six patients (61.27%) were men and the age was 69.5 ± 5.8 years. EuroSCORE II index was 4.06 ± 3.86. Hypertension was present in 75.14%, diabetes in 39.88%, and 30.06% were illiterate. Delirium occurred in 59 patients (34.1%). Education level (OR 0.81, 0.71–0.92), hypertension (OR 2.73, 1.16–6.40), and mitral valve disease (OR 2.93, 1.32–6.50) were independent predisposing factors for delirium, and atrial fibrillation after surgery (OR 2.49, 1.20–5.20) represented the potential triggering factor. Delirium (OR 2.35, 1.20–4.58) and OIT ≥ 900 min (OR 2.50; 1.30–4.80) were independently associated with the composite outcome. Conclusions In older adult patients submitted to cardiac surgery, delirium is a frequent complication that is associated with worst outcome. Independent risk factors for delirium included education level, hypertension, mitral valve disease, and atrial fibrillation after cardiac surgery.
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Affiliation(s)
- Fátima R Oliveira
- Heart Institute (InCor), University of Sao Paulo, Brazil. Av. Dr. Enéas Carvalho de Aguiar 44, Sao Paulo, CEP, São Paulo, 05403-000, Brazil.,Hospital de Messejana Dr. Carlos Alberto Studart Gomes SESA, Fortaleza, Ceará, Brazil
| | - Victor H Oliveira
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes SESA, Fortaleza, Ceará, Brazil
| | - Ítalo M Oliveira
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes SESA, Fortaleza, Ceará, Brazil
| | - José W Lima
- Universidade Estadual do Ceará, Fortaleza, Brazil
| | - Daniela Calderaro
- Heart Institute (InCor), University of Sao Paulo, Brazil. Av. Dr. Enéas Carvalho de Aguiar 44, Sao Paulo, CEP, São Paulo, 05403-000, Brazil
| | - Danielle M Gualandro
- Heart Institute (InCor), University of Sao Paulo, Brazil. Av. Dr. Enéas Carvalho de Aguiar 44, Sao Paulo, CEP, São Paulo, 05403-000, Brazil
| | - Bruno Caramelli
- Heart Institute (InCor), University of Sao Paulo, Brazil. Av. Dr. Enéas Carvalho de Aguiar 44, Sao Paulo, CEP, São Paulo, 05403-000, Brazil.
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Nguyen Q, Uminski K, Hiebert BM, Tangri N, Arora RC. Midterm outcomes after postoperative delirium on cognition and mood in patients after cardiac surgery. J Thorac Cardiovasc Surg 2018; 155:660-667.e2. [DOI: 10.1016/j.jtcvs.2017.09.131] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/16/2017] [Accepted: 09/28/2017] [Indexed: 12/21/2022]
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Soundhar A, Udesh R, Mehta A, Schindler J, Jeevanantham V, Gleason T, Thirumala PD. Delirium Following Transcatheter Aortic Valve Replacement: National Inpatient Sample Analysis. J Cardiothorac Vasc Anesth 2017; 31:1977-1984. [DOI: 10.1053/j.jvca.2017.03.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Indexed: 12/14/2022]
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Impact of Modified Transesophageal Echocardiography on Mortality and Stroke after Cardiac Surgery: A Large Cohort Study. Int J Vasc Med 2017; 2017:1857069. [PMID: 29085679 PMCID: PMC5611872 DOI: 10.1155/2017/1857069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/27/2017] [Accepted: 07/18/2017] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to investigate the impact of perioperative screening with modified transesophageal echocardiography (A-View method). We compared, in consecutive patients who underwent cardiac surgery between 2006 and 2014, 30-day mortality and in-hospital stroke incidence, operated either with perioperative modified TEE screening (intervention group) or only with conventional TEE screening (control group). Of the 8,605 study patients, modified TEE was applied in 1,391 patients (16.2%). Patients in the intervention group were on average older (71 versus 68 years, p < 0.001) and more often females (31.0% versus 28.0%, p < 0.001) and had a higher predicted mortality (EuroSCORE I: 5.9% versus 4.0%, p < 0.001). The observed 30-day mortality was 2.2% and 2.5% in both groups, respectively, with multivariable and propensity-score adjusted relative risks (RRs) of 0.70 (95% CI: 0.50–1.00, p = 0.05) and 0.67 (95% CI: 0.45–0.98, p = 0.04). In-hospital stroke was 2.9% and 2.1% in both groups, respectively, with adjusted RRs of 1.03 (95% CI: 0.73–1.45) and 1.01 (95% CI: 0.71–1.43). In patients undergoing cardiac surgery, use of perioperative screening for aortic atherosclerosis with modified TEE was associated with lower postoperative mortality, but not stroke, as compared to patients operated on without such screening.
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Rieß FC, Behrendt CA, Amin W, Heller S, Hansen L, Winkel S, Stripling J, Rieß HC. Complete arterial revascularization using bilateral internal mammary artery in T-graft technique for multivessel coronary artery disease in on- or off-pump approach: does gender lose its historical impact on clinical outcome? Eur J Cardiothorac Surg 2017; 52:917-923. [DOI: 10.1093/ejcts/ezx287] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 07/16/2017] [Indexed: 11/13/2022] Open
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Mufti HN, Hirsch GM. Perioperative prediction of agitated (hyperactive) delirium after cardiac surgery in adults - The development of a practical scorecard. J Crit Care 2017; 42:192-199. [PMID: 28772221 DOI: 10.1016/j.jcrc.2017.07.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 07/08/2017] [Accepted: 07/25/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Delirium is a temporary mental disorder that occurs frequently among hospitalized patients. In this study we sought to develop a user-friendly scorecard based on perioperative features to identify patients at risk of developing agitated delirium after cardiac surgery. METHODS Retrospective analysis was performed on adult patients undergoing cardiac surgery in a single center. A parsimonious predictive model was created, with subsequent internal validation. Then a simple scorecard was developed that can be used to predict the probability of agitated delirium. RESULTS Among the 5584 patients who met the study criteria, 614 (11.4%) developed postoperative agitated delirium. Independent predictors of postoperative agitated delirium were age, male gender, history of cerebrovascular disease, procedure other than isolated Coronary Arteries Bypass Surgery, transfusion of blood products within the first 48h, mechanical ventilation for >24h, length of stay in the Intensive Care Unit. The scorecard stratified patients into 4 categories at risk of postoperative agitated delirium ranging from <5% to >30%. CONCLUSION Using a large cohort of adult patient's undergoing cardiac surgery, a user-friendly scorecard was developed and validated, which will facilitate the implementation of timely interventions to mitigate adverse effects of agitated delirium in this high risk population.
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Affiliation(s)
- Hani N Mufti
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada; Division of Cardiac Surgery, Department of Cardiac Sciences, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Jeddah, Saudi Arabia.
| | - Gregory M Hirsch
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Risk factors for delirium after cardiac surgery: a historical cohort study outlining the influence of cardiopulmonary bypass. Can J Anaesth 2017; 64:1129-1137. [PMID: 28718100 DOI: 10.1007/s12630-017-0938-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 06/17/2017] [Accepted: 07/06/2017] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Cardiopulmonary bypass (CPB) induces a significant inflammatory response that may increase the risk for delirium. We hypothesized that exposure to CPB during coronary artery bypass grafting (CABG) surgery would correlate with an increased risk of delirium. METHODS We reviewed clinical data from two databases at our medical centre - the Cardiac Surgery Perioperative Outcomes Database and the Society of Thoracic Surgeons Database. Patients undergoing elective CABG surgery (on-pump and off-pump) from November 1, 2009 to September 30, 2015 were included in the study. Delirium was defined as any postoperative positive Confusion Assessment Method for the Intensive Care Unit exam during the intensive care unit stay. We performed logistic regression to isolate the association between CPB exposure and delirium adjusted for predetermined risk factors and potential confounders. RESULTS During the study period, 2,280 patients underwent elective CABG surgery, with 384 patients (16.9%) exposed to CPB. Delirium was diagnosed in 451 patients (19.8%). Exposure to CPB showed a significant independent association with delirium. Patients exposed to CPB for 142 min (90th percentile of CPB duration) vs those exposed for 54 min (10th percentile) had an adjusted relative risk (RR) of delirium of 2.18 (95% confidence interval [CI], 1.39 to 3.07; P = 0.002) vs a RR of 1.51 (95% CI, 0.92 to 2.29; P = 0.10), respectively. CONCLUSIONS The use and duration of cardiopulmonary bypass were associated with an increased risk of delirium in patients undergoing CABG surgery. TRIAL REGISTRATION www.clinicaltrials.gov , NCT02548975. Registered 4 September 2015.
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Jin YH, Li N, Zheng R, Mu W, Lei X, Si JH, Chen J, Shang HC. Benzodiazepines for treatment of delirium in non-ICU settings. Hippokratia 2017. [DOI: 10.1002/14651858.cd012670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Ying Hui Jin
- Tianjin University of Traditional Chinese Medicine; Nursing; #312 West Anshan Road Tianjin China
| | - Nan Li
- Tianjin University of Traditional Chinese Medicine; Tianjin Insititute of Clinical Evaluation; #88 Yuquan Road Nankai District Tianjin Tianjin China 300193
| | - Rui Zheng
- Tianjin University of Traditional Chinese Medicine; Tianjin Insititute of Clinical Evaluation; #88 Yuquan Road Nankai District Tianjin Tianjin China 300193
| | - Wei Mu
- The 2nd Affiliated Hospital of Tianjin University of traditional Chinese Medicine; Clinical pharmacology; 861 Zhenli Road Hebei District Tianjin Tianjin China 300150
| | - Xiang Lei
- Dongzhimen Hospital, Beijing University of Chinese Medicine; Key Laboratory of Chinese Internal Medicine of Ministry of Education; Haiyuncang Lane, Dongcheng District Beijing Beijing China 100700
| | - Jin Hua Si
- Tianjin University of Traditional Chinese Medicine; Library; #88 Yuquan Road Nankai District Tianjin Tianjin China 300193
| | - Jing Chen
- Tianjin University of Traditional Chinese Medicine; Baokang Hospital; #88 Yuquan Road Nankai District Tianjin Tianjin China 300193
| | - Hong Cai Shang
- Dongzhimen Hospital, Beijing University of Chinese Medicine; Key Laboratory of Chinese Internal Medicine of Ministry of Education; Haiyuncang Lane, Dongcheng District Beijing Beijing China 100700
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European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34:192-214. [DOI: 10.1097/eja.0000000000000594] [Citation(s) in RCA: 491] [Impact Index Per Article: 70.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Kumar AK, Jayant A, Arya VK, Magoon R, Sharma R. Delirium after cardiac surgery: A pilot study from a single tertiary referral center. Ann Card Anaesth 2017; 20:76-82. [PMID: 28074801 PMCID: PMC5290701 DOI: 10.4103/0971-9784.197841] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Advances in cardiac surgery has shifted paradigm of management to perioperative psychological illnesses. Delirium is a state of altered consciousness with easy distraction of thoughts. The pathophysiology of this complication is not clear, but identification of risk factors is important for positive postoperative outcomes. The goal of the present study was to prospectively identify the incidence, motoric subtypes, and risk factors associated with development of delirium in cardiac surgical patients admitted to postoperative cardiac intensive care, using a validated delirium monitoring instrument. MATERIALS AND METHODS This is a prospective, observational study. This study included 120 patients of age 18-80 years, admitted to undergo cardiac surgery after applying inclusion and exclusion criteria. Specific preoperative, intraoperative, and postoperative data for possible risk factors were obtained. Once in a day, assessment of delirium was done. Continuous variables were measured as mean ± standard deviation, whereas categorical variables were described as proportions. Differences between groups were analyzed using Student's t-test, Mann-Whitney U-test, or Chi-square test. Variables with a P < 0.1 were then used to develop a predictive model using stepwise logistic regression with bootstrapping. RESULTS Delirium was seen in 17.5% patients. The majority of cases were of hypoactive delirium type (85.72%). Multiple risk factors were found to be associated with delirium, and when logistic regression with bootstrapping applied to these risk factors, five independent variables were detected. History of hypertension (relative risk [RR] =6.7857, P = 0.0003), carotid artery disease (RR = 4.5000, P < 0.0001) in the form of stroke or hemorrhage, noninvasive ventilation (NIV) use (RR = 5.0446, P < 0.0001), Intensive Care Unit (ICU) stay more than 10 days (RR = 3.1630, P = 0.0021), and poor postoperative pain control (RR = 2.4958, P = 0.0063) was associated with postcardiac surgical delirium. CONCLUSIONS Patients who developed delirium had systemic disease in the form of hypertension and cerebrovascular disease. Delirium was seen in patients who had higher postoperative pain scores, longer ICU stay, and NIV use. This study can be used to develop a predictive tool for diagnosing postcardiac surgical delirium.
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Affiliation(s)
- Ashok K Kumar
- Department of Anaesthesia, Postgraduate Institute for Medical Education and Research, Chandigarh, India
| | - Aveek Jayant
- Department of Anaesthesia, Postgraduate Institute for Medical Education and Research, Chandigarh, India
| | - V K Arya
- Department of Anaesthesia, Postgraduate Institute for Medical Education and Research, Chandigarh, India
| | - Rohan Magoon
- Department of Anaesthesia, Postgraduate Institute for Medical Education and Research, Chandigarh, India
| | - Ridhima Sharma
- Department of Anaesthesia, Postgraduate Institute for Medical Education and Research, Chandigarh, India
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Zhang W, Sun Y, Liu Y, Qiu W, Ye X, Zhang G, Zhang L. A nursing protocol targeting risk factors for reducing postoperative delirium in patients following coronary artery bypass grafting: Results of a prospective before-after study. Int J Nurs Sci 2017; 4:81-87. [PMID: 31406724 PMCID: PMC6626138 DOI: 10.1016/j.ijnss.2017.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 02/24/2017] [Indexed: 12/17/2022] Open
Abstract
Objective The results of postoperative delirium (POD) warrant testing for prevention. The purpose of this study was to determine whether a nursing intervention targeting risk factors could decrease the incidence of POD among patients who had coronary artery bypass grafting (CABG) in China. Methods A prospective before-after study was conducted between April 2014 and April 2015. A nursing delirium intervention protocol targeting risk factors for delirium was performed for 141 patients undergoing CABG in a cardiothoracic ICU from November 2014 to April 2015. Intervention consisted of screening for delirium risk factors, followed by targeted risk factor modification, including pain control, early catheter removal, patient orientation using the 5W1H procedure, increased family visits, minimizing care-related interruptions, comfortable nursing and monitoring for sleeping difficulties. Outcomes of the Intervention Group were compared with those of the Control Group for 137 CABG patients from April 2014 to October 2014. Delirium was assessed using the confusion assessment method for the intensive care unit (CAM-ICU). The sample size was justified by PASS2000, based on previous data of delirium incidence in our institution (30%). Main results Delirium incidence during the first seven postoperative days was significantly lower in the Intervention Group at 13.48% (19/141) vs. 29.93% (41/137) for the Control Group (χ2 = 11.112, P = 0.001). In addition, POD in the Intervention Group occurred between the 3rd and 6th postoperative days, while POD in the Control Group mainly occurred on the first three days postoperatively. Delirium in the Intervention Group occurred later than delirium in the Control Group (χ2 = 12.743, P < 0.001). Length of ICU stay was reduced significantly (Z = −6.026, P < 0.001). Conclusion The application of a nursing protocol targeting risk factors in this study seems to be associated with a lower incidence of POD in patients after CABG. This finding suggests that managing the predictors properly is one of the effective strategies to prevent delirium. A nursing intervention program of postoperative delirium was cultivated for CABG patients. The study estimated the efficacy of the intervention through a before-after study. The risk-targeted nursing intervention may decrease delirium incidence in CABG patients.
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Affiliation(s)
- Weiying Zhang
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yan Sun
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yang Liu
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Wenjuan Qiu
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xiaofei Ye
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Guihong Zhang
- Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Lingjuan Zhang
- Department of Nursing, Changhai Hospital, Second Military Medical University, Shanghai, China
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van der Zanden V, Beishuizen SJ, Swart LM, de Rooij SE, van Munster BC. The Effect of Treatment of Anemia with Blood Transfusion on Delirium: A Systematic Review. J Am Geriatr Soc 2017; 65:728-737. [PMID: 28205243 DOI: 10.1111/jgs.14564] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Treating the precipitating factors of delirium is the mainstay of the prevention and treatment of delirium. We aim to investigate the role of anemia and blood transfusion within the multicomponent prevention and treatment strategy of delirium. DESIGN Systematic review. SETTING We included cohort studies or Randomized Controlled Trials (RCTs) that considered blood transfusion as treatment for delirium or risk factor, and had delirium as outcome. PARTICIPANTS Hospitalized patients above 55 years old. MEASUREMENTS We searched MEDLINE from 1946 through November 2014. Quality assessment and data extraction were performed systematically. RESULTS We included 23 studies (n = 29,471). The majority of the studies (n = 22) had a limited quality and for one study quality was uncertain. Two studies evaluated the association between transfusion strategy and postoperative delirium and found no association. Twenty-one studies investigated blood transfusion as a risk factor for delirium. In four of the 21 studies it could be assumed that delirium occurred after transfusion. One of these studies stated that transfusion was a significant risk factor for subsequent delirium (odds ratio (OR) = 3.68, 95% confidence interval (CI) = 1.32-10.94). The other three studies found no association between transfusion and delirium. In the remaining 17 studies, it was not clear whether delirium occurred before or after transfusion, so no conclusion could be drawn on the role of transfusion in delirium development. CONCLUSION The majority of the included studies was not suited to answer the research question properly as the time course of the beginning of delirium as to transfusion was lacking. Our review shows that there is no good quality evidence available for blood transfusion to be a risk factor for delirium or to be a preventive or treatment option.
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Affiliation(s)
- Vera van der Zanden
- Geriatrics Section, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sara J Beishuizen
- Geriatrics Section, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Lieke M Swart
- Geriatrics Section, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sophia E de Rooij
- Geriatrics Section, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Internal Medicine, University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Barbara C van Munster
- Department of Internal Medicine, University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands.,Department of Geriatrics, Gelre Hospitals, Apeldoorn, The Netherlands
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Li X, Yang J, Nie XL, Zhang Y, Li XY, Li LH, Wang DX, Ma D. Impact of dexmedetomidine on the incidence of delirium in elderly patients after cardiac surgery: A randomized controlled trial. PLoS One 2017; 12:e0170757. [PMID: 28182690 PMCID: PMC5300174 DOI: 10.1371/journal.pone.0170757] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/03/2017] [Indexed: 02/04/2023] Open
Abstract
Background Delirium is a frequent complication after cardiac surgery and its occurrence is associated with poor outcomes. The purpose of this study was to investigate the impact of perioperative dexmedetomidine administration on the incidence of delirium in elderly patients after cardiac surgery. Methods This randomized, double-blinded, and placebo-controlled trial was conducted in two tertiary hospitals in Beijing between December 1, 2014 and July 19, 2015. Eligible patients were randomized into two groups. Dexmedetomidine (DEX) was administered during anesthesia and early postoperative period for patients in the DEX group, whereas normal saline was administered in the same rate for the same duration for patients in the control (CTRL) group. The primary endpoint was the incidence of delirium during the first five days after surgery. Secondary endpoints included the cognitive function assessed on postoperative days 6 and 30, the overall incidence of non-delirium complications within 30 days after surgery, and the all-cause 30-day mortality. Results Two hundred eighty-five patients were enrolled and randomized. Dexmedetomidine did not decrease the incidence of delirium (4.9% [7/142] in the DEX group vs 7.7% [11/143] in the CTRL group; OR 0.62, 95% CI 0.23 to 1.65, p = 0.341). Secondary endpoints were similar between the two groups; however, the incidence of pulmonary complications was slightly decreased (OR 0.51, 95% CI 0.26 to 1.00, p = 0.050) and the percentage of early extubation was significantly increased (OR 3.32, 95% CI 1.36 to 8.08, p = 0.008) in the DEX group. Dexmedetomidine decreased the required treatment for intraoperative tachycardia (21.1% [30/142] in the DEX group vs 33.6% [48/143] in the CTRL group, p = 0.019), but increased the required treatment for postoperative hypotension (84.5% [120/142] in the DEX group vs 69.9% [100/143] in the CTRL group, p = 0.003). Conclusions Dexmedetomidine administered during anesthesia and early postoperative period did not decrease the incidence of postoperative delirium in elderly patients undergoing elective cardiac surgery. However, considering the low delirium incidence, the trial might have been underpowered. Trial Registration ClinicalTrials.gov NCT02267538
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Affiliation(s)
- Xue Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Jing Yang
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Lu Nie
- Center for Clinical Epidemiology & Evidence-Based Medicine, Beijing Children’s Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Xue-Ying Li
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Li-Huan Li
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
- * E-mail:
| | - Daqing Ma
- Section of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom
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