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Gao S, Liu G, Wang J, Zhang Q, Wang J, Teng Y, Wang Q, Yan S, Bian L, Hu Q, Wang T, Yan W, Ji B. A modified low-priming cardiopulmonary bypass system in patients undergoing cardiac surgery with medium risk of transfusion: A randomized controlled trial. Heliyon 2024; 10:e31388. [PMID: 38832269 PMCID: PMC11145224 DOI: 10.1016/j.heliyon.2024.e31388] [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: 03/31/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 06/05/2024] Open
Abstract
Objectives The FUWAI-SAVE system is a modified low-priming cardiopulmonary bypass (CPB) system. The study aimed to explore whether the FUWAI-SAVE system can reduce the perioperative blood transfusion and its impact on other postoperative complications during cardiac surgery. Metohds This study was a single-center, single-blind, randomized controlled trial, registered at the Chinese Clinical Trial Registry (identifier: ChiCTR2100050488). Adult patients undergoing cardiac surgery with CPB and intermediate risk for transfusion risk stratification were randomly assigned to an intervention group (FUWAI-SAVE group) or a control group (conventional group). The primary endpoint of the study was the peri-CPB red blood cell transfusion (RBC) rate. The secondary endpoints included the transfusion rate of other blood products, the amount of blood products transfused, the incidence of major complications, in-hospital mortality, and others. Results 360 patients were randomized from December 9, 2021, to January 30, 2023. The rate of the primary endpoint was significantly lower in the FUWAI-SAVE group compared to the control group [ OR (95%CI): 0.649 (0.424-0.994)]. Meanwhile, the amount of RBC transfusion during the peri-CPB period was significantly lower in the FUWAI-SAVE group compared to the control group, with a mean difference of -0.626 (-1.176 to -0.076) units. The occurrence rate of major complications did not differ significantly between the two groups. Conclusions Among adult patients undergoing cardiac surgery with CPB, the application of the FUWAI-SAVE system significantly reduced RBC transfusion rate and amount. The FUWAI-SAVE system can be considered an important component of comprehensive blood management strategies in cardiac surgery.
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Affiliation(s)
- Sizhe Gao
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
- Department of Pain Management, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Jing Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Qiaoni Zhang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Jian Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Yuan Teng
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Qian Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Luyu Bian
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Qiang Hu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Tianlong Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Weidong Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
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Liu W, Jia M, Zhang K, Chen J, Zhu X, Li R, Xu Z, Zang Y, Wang Y, Pan J, Ma D, Yang J, Wang D. Increased A1 astrocyte activation-driven hippocampal neural network abnormality mediates delirium-like behavior in aged mice undergoing cardiac surgery. Aging Cell 2024; 23:e14074. [PMID: 38155547 DOI: 10.1111/acel.14074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 12/30/2023] Open
Abstract
Delirium is the most common neurological complication after cardiac surgery with adverse impacts on surgical outcomes. Advanced age is an independent risk factor for delirium occurrence but its underlying mechanisms are not fully understood. Although increased A1 astrocytes and abnormal hippocampal networks are involved in neurodegenerative diseases, whether A1 astrocytes and hippocampal network changes are involved in the delirium-like behavior of aged mice remains unknown. In the present study, a mice model of myocardial ischemia-reperfusion mimicking cardiac surgery and various assessments were used to investigate the different susceptibility of the occurrence of delirium-like behavior between young and aged mice and the underlying mechanisms. The results showed that surgery significantly increased hippocampal A1 astrocyte activation in aged compared to young mice. The high neuroinflammatory state induced by surgery resulted in glutamate accumulation in the extrasynaptic space, which subsequently decreased the excitability of pyramidal neurons and increased the PV interneurons inhibition through enhancing N-methyl-D-aspartate receptors' tonic currents in the hippocampus. These further induced the abnormal activities of the hippocampal neural networks and consequently contributed to delirium-like behavior in aged mice. Notably, the intraperitoneal administration of exendin-4, a glucagon-like peptide-1 receptor agonist, downregulated A1 astrocyte activation and alleviated delirium-like behavior in aged mice, while IL-1α, TNF-α, and C1q in combination administered intracerebroventricularly upregulated A1 astrocyte activation and induced delirium-like behavior in young mice. Therefore, our study suggested that cardiac surgery increased A1 astrocyte activation which subsequently impaired the hippocampal neural networks and triggered delirium development.
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Affiliation(s)
- Wenxue Liu
- Department of Cardio-Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Min Jia
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Keyin Zhang
- Department of Cardio-Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jiang Chen
- Ministry of Education Key Laboratory of Model Animal for Disease Study, Model Animal Research Center, Department of Neurology, Drum Tower Hospital, Medical School, Nanjing University, Nanjing, China
| | - Xiyu Zhu
- Department of Cardio-Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Ruisha Li
- Department of Cardio-Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhenjun Xu
- Department of Cardio-Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yanyu Zang
- Ministry of Education Key Laboratory of Model Animal for Disease Study, Model Animal Research Center, Nanjing University, Nanjing, China
| | - Yapeng Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
| | - Jun Pan
- Department of Cardio-Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Daqing Ma
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK
- Perioperative and Systems Medicine Laboratory, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jianjun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dongjin Wang
- Department of Cardio-Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Fadhlurrahman AF, Setiawan P, Sumartono C, Perdhana F, Husain TA. The effect of pectointercostal fascial block on stress response in open heart surgery. Saudi J Anaesth 2024; 18:70-76. [PMID: 38313701 PMCID: PMC10833016 DOI: 10.4103/sja.sja_349_23] [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: 04/27/2023] [Revised: 05/19/2023] [Accepted: 06/04/2023] [Indexed: 02/06/2024] Open
Abstract
Background Activation of the hypothalamus-pituitary-adrenal (HPA) axis and inflammatory processes are common forms of stress response. The increased stress response is associated with a higher chance of complications. Open hearth surgery is one of the procedures with a high-stress response. Pectointercostal fascial block (PIFB), as a new pain management option in sternotomy, has the potential to modulate the stress response. Objective To determine the effect of PIFB on stress response in open heart surgery. Methods This study was a Randomized Controlled Trial on 40 open heart surgery. Patients were divided into two groups, control (20 patients) and PIFB (20 patients). Primary parameters included basal and postoperative TNF-α, basal and post sternotomy ACTH, and basal, 0, and 24 hours postoperative NLR. Secondary parameters include the amount of opioid use, length of the post-operative ventilator, length of ICU stay, and Numeric Rating Scale (NRS) 6, 12, 24, and 48 hours postoperative. Results The PIFB group had a decrease in ACTH levels with an average change that was not significantly different from the control group (-57.71 ± 68.03 vs. -129.78 ± 140.98). The PIFB group had an average change in TNFα levels and an average increase in NLR 0 hours postoperative that was not significantly lower than the control group (TNFα: -0.52 ± 1.31 vs. 0.54 ± 1.76; NLR: 12.80 ± 3.51 vs. 14.82 ± 4.23). PIFB significantly reduced the amount of opioid use during surgery, NRS at 6, 12, and 24 hours, and the length of post-operative ventilator use (P < 0.05, CI: 95%). Conclusion PIFB has a good role in reducing the stress response of open heart surgery and producing good clinical outcomes.
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Affiliation(s)
- Ahmad Feza Fadhlurrahman
- Department of Anesthesiology and Intensive Therapy, Medical Faculty of Airlangga University, Surabaya, Indonesia
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Brawijaya University, Dr. Saiful Anwar General Hospital, Malang, Indonesia
| | - Philia Setiawan
- Division of Cardiovascular and Thoracic Anesthesia, Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Airlangga University, Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Christijogo Sumartono
- Division of Regional Anesthesia, Department of Anesthesiology and Intensive Theraoy, Faculty of Medicine, Airlangga University, Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Fajar Perdhana
- Division of Cardiovascular and Thoracic Anesthesia, Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Airlangga University, Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Teuku Aswin Husain
- Division of Cardiovascular and Thoracic Anesthesia, Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Airlangga University, Dr. Soetomo General Hospital, Surabaya, Indonesia
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Gonçalves M, Khera T, Otu HH, Narayanan S, Dillon ST, Shanker A, Gu X, Jung Y, Ngo LH, Marcantonio ER, Libermann TA, Subramaniam B. Multivariable model of postoperative delirium in cardiac surgery patients: proteomic and demographic contributions. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.30.23289741. [PMID: 37333093 PMCID: PMC10274980 DOI: 10.1101/2023.05.30.23289741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Background Delirium following cardiac surgery is common, morbid, and costly, but may be prevented with risk stratification and targeted intervention. Preoperative protein signatures may identify patients at increased risk for worse postoperative outcomes, including delirium. In this study, we aimed to identify plasma protein biomarkers and develop a predictive model for postoperative delirium in older patients undergoing cardiac surgery, while also uncovering possible pathophysiological mechanisms. Methods SOMAscan analysis of 1,305 proteins in the plasma from 57 older adults undergoing cardiac surgery requiring cardiopulmonary bypass was conducted to define delirium-specific protein signatures at baseline (PREOP) and postoperative day 2 (POD2). Selected proteins were validated in 115 patients using the ELLA multiplex immunoassay platform. Proteins were combined with clinical and demographic variables to build multivariable models that estimate the risk of postoperative delirium and bring light to the underlying pathophysiology. Results A total of 115 and 85 proteins from SOMAscan analyses were found altered in delirious patients at PREOP and POD2, respectively (p<0.05). Using four criteria including associations with surgery, delirium, and biological plausibility, 12 biomarker candidates (Tukey's fold change (|tFC|)>1.4, Benjamini-Hochberg (BH)-p<0.01) were selected for ELLA multiplex validation. Eight proteins were significantly altered at PREOP, and seven proteins at POD2 (p<0.05), in patients who developed postoperative delirium compared to non-delirious patients. Statistical analyses of model fit resulted in the selection of a combination of age, sex, and three proteins (angiopoietin-2 (ANGPT2); C-C motif chemokine 5 (CCL5); and metalloproteinase inhibitor 1 (TIMP1); AUC=0.829) as the best performing predictive model for delirium at PREOP. The delirium-associated proteins identified as biomarker candidates are involved with inflammation, glial dysfunction, vascularization, and hemostasis, highlighting the multifactorial pathophysiology of delirium. Conclusion Our study proposes a model of postoperative delirium that includes a combination of older age, female sex, and altered levels of three proteins. Our results support the identification of patients at higher risk of developing postoperative delirium after cardiac surgery and provide insights on the underlying pathophysiology. ClinicalTrials.gov ( NCT02546765 ).
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Vasunilashorn SM, Dillon ST, Marcantonio ER, Libermann TA. Application of Multiple Omics to Understand Postoperative Delirium Pathophysiology in Humans. Gerontology 2023; 69:1369-1384. [PMID: 37722373 PMCID: PMC10711777 DOI: 10.1159/000533789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 08/23/2023] [Indexed: 09/20/2023] Open
Abstract
Delirium, an acute change in cognition, is common, morbid, and costly, particularly among hospitalized older adults. Despite growing knowledge of its epidemiology, far less is known about delirium pathophysiology. Initial work understanding delirium pathogenesis has focused on assaying single or a limited subset of molecules or genetic loci. Recent technological advances at the forefront of biomarker and drug target discovery have facilitated application of multiple "omics" approaches aimed to provide a more complete understanding of complex disease processes such as delirium. At its basic level, "omics" involves comparison of genes (genomics, epigenomics), transcripts (transcriptomics), proteins (proteomics), metabolites (metabolomics), or lipids (lipidomics) in biological fluids or tissues obtained from patients who have a certain condition (i.e., delirium) and those who do not. Multi-omics analyses of these various types of molecules combined with machine learning and systems biology enable the discovery of biomarkers, biological pathways, and predictors of delirium, thus elucidating its pathophysiology. This review provides an overview of the most recent omics techniques, their current impact on identifying delirium biomarkers, and future potential in enhancing our understanding of delirium pathogenesis. We summarize challenges in identification of specific biomarkers of delirium and, more importantly, in discovering the mechanisms underlying delirium pathophysiology. Based on mounting evidence, we highlight a heightened inflammatory response as one common pathway in delirium risk and progression, and we suggest other promising biological mechanisms that have recently emerged. Advanced multiple omics approaches coupled with bioinformatics methodologies have great promise to yield important discoveries that will advance delirium research.
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Affiliation(s)
- Sarinnapha M. Vasunilashorn
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Simon T. Dillon
- Harvard Medical School, Boston, MA, USA
- Division of Interdisciplinary Medicine and Biotechnology, Department of Medicine, BIDMC, Boston, MA, USA
- Genomics, Proteomics, Bioinformatics and Systems Biology Center, BIDMC, Boston, MA, USA
| | - Edward R. Marcantonio
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Gerontology, Department of Medicine, BIDMC, Boston, MA, USA
| | - Towia A. Libermann
- Harvard Medical School, Boston, MA, USA
- Division of Interdisciplinary Medicine and Biotechnology, Department of Medicine, BIDMC, Boston, MA, USA
- Genomics, Proteomics, Bioinformatics and Systems Biology Center, BIDMC, Boston, MA, USA
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Maslov GO, Zabegalov KN, Demin KA, Kolesnikova TO, Kositsyn YM, de Abreu MS, Petersen EV, Kalueff AV. Towards experimental models of delirium utilizing zebrafish. Behav Brain Res 2023; 453:114607. [PMID: 37524203 DOI: 10.1016/j.bbr.2023.114607] [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: 05/25/2023] [Revised: 07/28/2023] [Accepted: 07/29/2023] [Indexed: 08/02/2023]
Abstract
Delirium is an acute neuropsychiatric condition characterized by impaired behavior and cognition. Although the syndrome has been known for millennia, its CNS mechanisms and risk factors remain poorly understood. Experimental animal models, especially rodent-based, are commonly used to probe various pathogenetic aspects of delirium. Complementing rodents, the zebrafish (Danio rerio) emerges as a promising novel model organism to study delirium. Zebrafish demonstrate high genetic and physiological homology to mammals, easy maintenance, robust behaviors in various sensitive behavioral tests, and the potential to screen for pharmacological agents relevant to delirium. Here, we critically discuss recent developments in the field, and emphasize the developing utility of zebrafish models for translational studies of delirium and deliriant drugs. Overall, the zebrafish represents a valuable and promising aquatic model species whose use may help understand delirium etiology, as well as develop novel therapies for this severely debilitating disorder.
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Affiliation(s)
- Gleb O Maslov
- Neurobiology Program, Sirius University of Science and Technology, Sochi, Russia; Ural Federal University, Ekaterinburg, Russia
| | | | - Konstantin A Demin
- Institute of Experimental Medicine, Almazov National Medical Research Centre, Ministry of Healthcare of Russian Federation, St. Petersburg, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia
| | - Tatiana O Kolesnikova
- Neurobiology Program, Sirius University of Science and Technology, Sochi, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia
| | - Yuriy M Kositsyn
- Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia
| | - Murilo S de Abreu
- Laboratory of Cell and Molecular Biology and Neurobiology, Moscow Institute of Physics and Technology, Moscow, Russia.
| | - Elena V Petersen
- Laboratory of Cell and Molecular Biology and Neurobiology, Moscow Institute of Physics and Technology, Moscow, Russia
| | - Allan V Kalueff
- Neurobiology Program, Sirius University of Science and Technology, Sochi, Russia; Institute of Experimental Medicine, Almazov National Medical Research Centre, Ministry of Healthcare of Russian Federation, St. Petersburg, Russia; Institute of Translational Biomedicine, St. Petersburg State University, St. Petersburg, Russia; Novosibirsk State University, Novosibirsk, Russia; Laboratory of Preclinical Bioscreening, Granov Russian Research Center of Radiology and Surgical Technologies, Ministry of Healthcare of Russian Federation, Pesochny, Russia; Ural Federal University, Ekaterinburg, Russia.
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Su LJ, Chen MJ, Yang R, Zou H, Chen TT, Li SL, Guo Y, Hu RF. Plasma biomarkers and delirium in critically ill patients after cardiac surgery: A prospective observational cohort study. Heart Lung 2023; 59:139-145. [PMID: 36801548 DOI: 10.1016/j.hrtlng.2023.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Delirium is common in postoperative critically ill patients and may affect by intraoperative events. Biomarkers are vital indicators in the development and prediction of delirium. OBJECTIVES This study aimed to investigate the associations between various plasma biomarkers and delirium. METHODS We performed a prospective cohort study on cardiac surgery patients. Delirium assessment was performed twice daily using the confusion assessment method for the intensive care unit (ICU), and the Richmond Agitation Sedation Scale was used to assess the depth of sedation and agitation. Blood samples were collected on the day after ICU admission, and the concentrations of cortisol, interleukin (IL)-1β, IL-6, tumor necrosis factor α, soluble tumor necrosis factor receptor-1 (sTNFR-1), and sTNFR-2 were measured. RESULTS Delirium in the ICU was noted in 93 (29.2%, 95% CI 24.2-34.3) out of 318 patients (mean age 52 years, SD 12.0). The longer duration of cardiopulmonary bypass, aortic clamping and surgery, and higher plasma, erythrocytes, and platelet transfusion requirements were among the significant differences in intraoperative events between patients with and without delirium. Median levels of IL-6 (p = 0.017), TNF-α (p = 0.048), sTNFR-1 (p < 0.001), and sTNFR-2 (p = 0.001) were significantly higher in patients with delirium than in those without it. After adjusting for demographic variables and intraoperative events, only sTNFR-1 (odds ratio 6.83, 95% CI: 1.14-40.90) was associated with delirium. CONCLUSIONS Plasma IL-6, TNF-α, sTNFR-1, and sTNFR-2 levels were higher in ICU-acquired delirium patients after cardiac surgery. sTNFR-1 was a potential indicator of the disorder.
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Affiliation(s)
- Li-Jing Su
- School of Nursing, Fujian Medical University, Fuzhou 350122, China
| | - Mei-Jing Chen
- School of Nursing, Fujian Medical University, Fuzhou 350122, China
| | - Rong Yang
- Follow-up Center, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hong Zou
- Department of Clinical Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ting-Ting Chen
- School of Nursing, Fujian Medical University, Fuzhou 350122, China
| | - Sai-Lan Li
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuan Guo
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Rong-Fang Hu
- School of Nursing, Fujian Medical University, Fuzhou 350122, China.
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Ormseth CH, LaHue SC, Oldham MA, Josephson SA, Whitaker E, Douglas VC. Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review. JAMA Netw Open 2023; 6:e2249950. [PMID: 36607634 PMCID: PMC9856673 DOI: 10.1001/jamanetworkopen.2022.49950] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups. OBJECTIVE To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting. EVIDENCE REVIEW A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium. FINDINGS A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity. CONCLUSIONS AND RELEVANCE In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.
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Affiliation(s)
- Cora H. Ormseth
- Department of Emergency Medicine, University of California, San Francisco
| | - Sara C. LaHue
- Department of Neurology, University of California, San Francisco
| | - Mark A. Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | | | - Evans Whitaker
- University of California, San Francisco, School of Medicine
| | - Vanja C. Douglas
- Department of Neurology, University of California, San Francisco
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Kaźmierski J, Miler P, Pawlak A, Jerczyńska H, Nowakowska K, Walkiewicz G, Woźniak K, Krejca M, Wilczyński M. Increased postoperative myeloperoxidase concentration associated with low baseline antioxidant capacity as the risk factor of delirium after cardiac surgery. Ann Med 2022; 54:610-616. [PMID: 35175161 PMCID: PMC8856092 DOI: 10.1080/07853890.2022.2039405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Though risk factors of postoperative delirium are well described, its pathophysiology is still undiscovered. The primary objective of the current study is to assess whether increased pre- and postoperative myeloperoxidase (MPO) levels are associated with postoperative delirium in the population of cardiac surgery patients. The secondary objective is to evaluate the correlation between MPO levels and serum antioxidant capacity (AC). METHODS The patients' cognitive status was assessed one day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of major depressive disorder and anxiety disorders was established based on DSM-5 criteria. Blood samples for MPO and AC levels were collected both pre- and postoperatively. The Confusion Assessment Method for the Intensive Care Unit was used to screen for a diagnosis of delirium. RESULTS Delirium occurred in 34% (61 of 177) of patients. Multivariable logistic regression analysis revealed that increased postoperative MPO concentration was independently associated with postoperative delirium development, and negatively correlated with lower baseline serum AC. CONCLUSIONS Cardiac surgery patients with less efficient antioxidative mechanisms experience a higher postoperative peak of serum MPO, which in turn may predispose to postoperative delirium development.KEY MESSAGESMPO is a lysosomal enzyme with strong pro-oxidative and pro-inflammatory properties.Cardiac surgery patients who have increased concentration of postoperative MPO are at significantly higher risk of postoperative delirium development.This higher level of postoperative MPO is negatively correlated with baseline antioxidant capacity (AC).It can be hypothesized that individuals with decreased baseline AC experience a higher peak of MPO post-surgery due to less efficient antioxidative mechanisms, which in turn contributes to postoperative delirium development.
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Affiliation(s)
- Jakub Kaźmierski
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Piotr Miler
- Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Agnieszka Pawlak
- Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Hanna Jerczyńska
- CoreLab Central Scientific Laboratory of Medical University of Lodz, Medical University of Lodz, Lodz, Poland
| | - Karina Nowakowska
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Grzegorz Walkiewicz
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Katarzyna Woźniak
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Michał Krejca
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Mirosław Wilczyński
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
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10
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Zhou Y, Ma Y, Yu C, Chen Y, Ding J, Yu J, Zhou R, Wang X, Fan T, Shi C. Detection Analysis of Perioperative Plasma and CSF Reveals Risk Biomarkers of Postoperative Delirium of Parkinson's Disease Patients Undergoing Deep Brain Stimulation of the Subthalamic Nuclei. Clin Interv Aging 2022; 17:1739-1749. [PMID: 36474580 PMCID: PMC9719687 DOI: 10.2147/cia.s388690] [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: 09/16/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022] Open
Abstract
Objective This study aimed to explore possible biomarkers of postoperative delirium (POD) of Parkinson's disease (PD) patients received deep brain stimulation (DBS) of the subthalamic nuclei. Materials and methods This nested case control study analyzed perioperative plasma and cerebral spinal fluid (CSF) of patients (n = 40) who developed POD undergone DBS surgery (n = 10) and those who did not (n = 30). Blood sample was collected before surgery and on the first day postoperative, CSF sample was collected at the beginning of the operation. POD was assessed by the Confusion Assessment Method (CAM) twice a day between 7:00 am and 7:00 pm after the surgery until discharge. Plasma and CSF sample from the two groups were analyzed to investigate possible biomarkers for POD in PD patients. Results There was no difference between POD and Non-POD groups on the concentration of Interleukin 6 and Tumor Necrosis Factor-α in CSF, preoperative plasma and postoperative plasma. There was no difference between POD and Non-POD groups on the concentration of S100 calcium-binding protein β protein (S100β) and Neurofilament light chain (NFL) in preoperative plasma and postoperative plasma. The concentration of C-reactive protein (CRP), NFL and S100β were significant higher in POD group than non-POD group in CSF. The concentration of CRP was significantly higher in POD group than non-POD group in preoperative plasma and postoperative plasma. CSF concentration of S100β might be a potential biomarker for POD via the receiver operating characteristic curve analysis and the area under the curve value of 0.973. Conclusion For PD patients received DBS surgery, CSF S100β might be a marker for aiding detection of high-risk patients with delirium. This requires further confirmation in clinical trials.
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Affiliation(s)
- Yongde Zhou
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, People’s Republic of China
| | - Yu Ma
- Department of Neurosurgery, Tsinghua University Yuquan Hospital, Beijing, People’s Republic of China
| | - Cuiping Yu
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, People’s Republic of China
| | - Yao Chen
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, People’s Republic of China
| | - Jian Ding
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, People’s Republic of China
| | - Jianfeng Yu
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, People’s Republic of China
| | - Rongsong Zhou
- Department of Neurosurgery, Tsinghua University Yuquan Hospital, Beijing, People’s Republic of China
| | - Xiaoxiao Wang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Ting Fan
- Department of Anesthesiology, Tsinghua University Yuquan Hospital, Beijing, People’s Republic of China
| | - Chengmei Shi
- Department of Anesthesiology, Peking University Third Hospital, Beijing, People’s Republic of China,Correspondence: Chengmei Shi; Ting Fan, Email ;
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11
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Zheng GZ, Chen XF, Chen LW, Luo ZR. Thyroid hormone, cortisol, interleukin-2, and procalcitonin regulate postoperative delirium in acute type A aortic dissection patients. BMC Cardiovasc Disord 2022; 22:503. [PMID: 36434500 PMCID: PMC9701024 DOI: 10.1186/s12872-022-02962-6] [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: 05/31/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND We assessed the relationships between levels of preoperative thyroid hormone (TH), cortisol, interleukin-2 (IL-2), and procalcitonin (PCT) and postoperative delirium (POD) in acute type A aortic dissection (ATAAD) patients receiving modified triple-branched stent-graft (MTBSG) implant surgeries. METHODS ATAAD patients received MTBSG implant surgeries in our hospital between February 2019 and December 2020 were recruited. We separated them into a POD and non-POD cohort and employed univariable and multivariable regression analysis to establish independent correlations between preoperative THs, cortisol, IL-2, and PCT and POD. In addition, we conducted stratification analyses to examine the link between pre-surgical THs and POD in normal TSH and lower TSH subgroups. RESULTS POD occurred in 78 of 224 patients (34.8%). POD patients exhibited markedly reduced preoperative free triiodothyronine (FT3) (P = 0.008) and free thyroxine (FT4) (P = 0.023) levels, while remarkably enhanced preoperative cortisol (P < 0.001), IL-2 (P < 0.001), and PCT (P < 0.001) levels. Based on multivariate regression analysis, reduced preoperative FT3 (P = 0.032), as well as augmented preoperative IL-2 (P = 0.001), cortisol (P < 0.001), and PCT (P = 0.016) were strong stand-alone risk factors for POD. Moreover, subgroup analysis found the association between FT3 (P = 0.029), FT4 (P = 0.042) and POD was both significant in patients with normal TSH levels. CONCLUSIONS Reduced preoperative FT3 and elevated preoperative cortisol, IL-2, and PCT were strong indicators of POD in ATAAD patients. Hence, we recommend that the thyroid function, cortisol, PCT, and IL-2 should be evaluated prior to surgery in ATAAD patients.
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Affiliation(s)
- Guo-Zhong Zheng
- grid.411176.40000 0004 1758 0478Department of Cardiovascular Surgery and Cardiac Disease Center, Union Hospital, Fujian Medical University, Fuzhou, 350001 People’s Republic of China ,grid.256112.30000 0004 1797 9307Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, People’s Republic of China
| | - Xing-Feng Chen
- grid.411176.40000 0004 1758 0478Department of Cardiovascular Surgery and Cardiac Disease Center, Union Hospital, Fujian Medical University, Fuzhou, 350001 People’s Republic of China ,grid.256112.30000 0004 1797 9307Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, People’s Republic of China
| | - Liang-Wan Chen
- grid.411176.40000 0004 1758 0478Department of Cardiovascular Surgery and Cardiac Disease Center, Union Hospital, Fujian Medical University, Fuzhou, 350001 People’s Republic of China ,grid.256112.30000 0004 1797 9307Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, People’s Republic of China
| | - Zeng-Rong Luo
- grid.411176.40000 0004 1758 0478Department of Cardiovascular Surgery and Cardiac Disease Center, Union Hospital, Fujian Medical University, Fuzhou, 350001 People’s Republic of China ,grid.256112.30000 0004 1797 9307Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, People’s Republic of China
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12
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Lin L, Zhang X, Xu S, Peng Y, Li S, Huang X, Chen L, Lin Y. Outcomes of postoperative delirium in patients undergoing cardiac surgery: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:884144. [PMID: 36017087 PMCID: PMC9395738 DOI: 10.3389/fcvm.2022.884144] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Postoperative delirium (POD) is an acute brain dysfunction that is frequently observed in patients undergoing cardiac surgery. Increasing evidence indicates POD is related to higher mortality among cardiac surgical patients, but the results remain controversial. Moreover, a quantitative evaluation of the influence of POD on hospital days, intensive care unit (ICU) time, and mechanical ventilation (MV) time has not been performed. Objective This study aimed to evaluate the correlation between POD and outcomes in patients undergoing cardiac surgery by a systematic review and meta-analysis. Materials and methods A total of 7 electronic databases (Cochrane Library, PubMed, EMBASE, CINAHL Complete, MEDLINE, Wan-fang database, and China National Knowledge Infrastructure) were searched from January 1980 to July 20, 2021, with language restrictions to English and Chinese, to estimate the impact of the POD on outcome in patients who underwent cardiac surgery. The meta-analysis was registered with PROSPERO (Registration: CRD42021228767). Results Forty-two eligible studies with 19785 patients were identified. 3368 (17.0%) patients were in the delirium group and 16417 (83%) were in the non-delirium group. The meta-analysis showed that compared to patients without POD, patients with POD had 2.77-fold higher mortality (OR = 2.77, 95% CI 1.86-4.11, P < 0.001), 5.70-fold higher MV (>24h) rate (OR = 5.70, 95% CI 2.93-11.09, P < 0.001); and longer MV time (SMD = 0.83, 95% CI 0.57-1.09, P < 0.001), ICU time (SMD = 0.91, 95% CI 0.60-1.22, P < 0.001), hospital days (SMD = 0.62, 95% CI 0.48-0.76, P < 0.001). Conclusion The synthesized evidence suggests that POD is causally related to the increased risk of mortality, prolonged length of ICU and hospital stay, and a longer duration of MV time. Future research should focus on the interventions for POD, to reduce the incidence. Systematic review registration [www.crd.york.ac.uk/PROSPERO], identifier [CRD42021228767].
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Affiliation(s)
- Lingyu Lin
- Department of Nursing, Fujian Medical University, Fuzhou, China
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xuecui Zhang
- Department of Nursing, Fujian Medical University, Fuzhou, China
| | - Shurong Xu
- Department of Nursing, Fujian Medical University, Fuzhou, China
| | - Yanchun Peng
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Sailan Li
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xizhen Huang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yanjuan Lin
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, China
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13
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Kaźmierski J, Miler P, Pawlak A, Woźniak J, Frankowska E, Nowakowska K, Kuchta K, Pazdrak M, Woźniak K, Magierski R, Krejca M, Wilczyński M. Lower Preoperative Verbal Memory Performance Is Associated with Delirium after Coronary Artery Bypass Graft Surgery: A Prospective Cohort Study. Arch Clin Neuropsychol 2022; 38:49-56. [PMID: 35915987 PMCID: PMC9868524 DOI: 10.1093/arclin/acac064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/22/2022] [Accepted: 07/07/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE Cognitive impairment constitutes one of the major risk factors of delirium after coronary artery bypass graft (CABG) surgery; however, it is unclear whether only patients with global cognitive decline are at increased risk for delirium or if individuals with preserved global cognitive functions but impairments in specific cognitive domains are also more vulnerable to developing delirium. Thus, this study aimed to analyze the neurocognitive status of patients scheduled for CABG surgery with the use of an advanced computerized cognitive battery (CNS Vital Signs) and to investigate possible associations between impaired performance in selective cognitive areas and the risk of postoperative delirium development. METHODS The study enrolled 127 participants with a median age of 67 years (IQR: 63-71). Postoperative delirium developed in 32 (25%) patients.Before surgery, the patients were screened for global cognitive impairment with the use of the Mini-Mental State Examination Test, and the individuals were asked to perform the CNS Vital Signs battery to investigate 12 specific cognitive domains. The Confusion Assessment Method and the Memorial Delirium Assessment Scale were used to screen for a diagnosis of delirium postoperatively. RESULTS In multivariate models, a lower score of verbal memory-assessed preoperatively was independently associated with the risk of postoperative delirium development. Other independent predictors of delirium included more advanced age, gender female, depression, postoperative pyrexia, and the presence of extracorporeal circulation. CONCLUSIONS As decreased verbal memory constitutes an independent risk factor for postoperative delirium, a verbal memory test may be a useful predictor of postoperative delirium development.
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Affiliation(s)
- Jakub Kaźmierski
- Corresponding author at: Department of Old Age Psychiatry and Psychotic Disorders, Faculty of Gerontology, Medical University of Lodz, Czechoslowacka 8/10, 92-216 Lodz, Poland. Tel.: 48 42 675 73 72; fax: 00 48 42 675 77 29. E-mail address: (J. Kaźmierski)
| | - Piotr Miler
- Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Agnieszka Pawlak
- Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Joanna Woźniak
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Emilia Frankowska
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Karina Nowakowska
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Katarzyna Kuchta
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Michał Pazdrak
- Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Katarzyna Woźniak
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Radosław Magierski
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Michał Krejca
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
| | - Mirosław Wilczyński
- Department of Cardiac Surgery, Central Clinical Hospital, Medical University of Lodz, Lodz, Poland
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14
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Zhu X, Yang M, Mu J, Wang Z, Zhang L, Wang H, Yan F. The Effect of General Anesthesia vs. Regional Anesthesia on Postoperative Delirium-A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:844371. [PMID: 35419373 PMCID: PMC8995788 DOI: 10.3389/fmed.2022.844371] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/01/2022] [Indexed: 01/10/2023] Open
Abstract
Background Postoperative delirium (POD) commonly occurs in patients following major surgeries and is associated with adverse prognosis. The modes of anesthesia may be associated with POD occurrence. General anesthesia (GA) causes loss of consciousness in the patient by altering the levels of some neurotransmitters as well as signaling pathways. We conducted this meta-analysis to investigate the effect of GA vs. regional anesthesia (RA) on POD incidence in surgical patients. Methods The databases of Pubmed, Embase, and Cochrane Library were searched till October 22, 2021. The eligible criteria were participants aged 18 years or older, patients undergoing surgery under GA and RA, and articles reporting the effect of GA vs. RA on POD incidence. RevMan 5.3 was used to perform statistical analyses. Results A total of 21 relevant trials with a total of 1,702,151 patients were included. The pooled result using random-effects model with OR demonstrated significant difference in POD incidence between patients with GA and RA (OR = 1.15, 95% CI: [1.02, 1.31], I2 = 83%, p for effect = 0.02). We did not obtain the consistent pooled result after sensitivity analysis (OR = 0.95, 95% CI: [0.83, 1.08], I2 =13%, p for effect = 0.44) and excluded the articles without the information on preoperative cognitive or neuropsychological assessment (OR = 1.12, 95% CI: [1.00, 1.25], I2 =80%, p for effect = 0.05), respectively. Conclusion This meta-analysis could not identify that GA was significantly associated with POD occurrence in surgical patients compared with RA.
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Affiliation(s)
- Xianlin Zhu
- Department of Anesthesiology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
| | - Min Yang
- Department of Anesthesiology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
| | - Junying Mu
- Department of Anesthesiology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
| | - Zaiping Wang
- Department of Anesthesiology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
| | - Liang Zhang
- Department of Anesthesiology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Hongbai Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuxia Yan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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15
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Khan SH, Lindroth H, Jawed Y, Wang S, Nasser J, Seyffert S, Naqvi K, Perkins AJ, Gao S, Kesler K, Khan B. Serum Biomarkers in Postoperative Delirium After Esophagectomy. Ann Thorac Surg 2022; 113:1000-1007. [PMID: 33774004 PMCID: PMC8582321 DOI: 10.1016/j.athoracsur.2021.03.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/09/2021] [Accepted: 03/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Esophagectomy is associated with postoperative delirium, but its pathophysiology is not well defined. We conducted this study to measure the relationship among serum biomarkers of inflammation and neuronal injury and delirium incidence and severity in a cohort of esophagectomy patients. METHODS Blood samples were obtained from patients preoperatively and on postoperative days 1 and 3 and were analyzed for S100 calcium-binding protein B, C-reactive protein (CRP), interleukin (IL) 8 and IL-10, tumor necrosis factor-α, and insulin-like growth factor 1. Delirium was assessed twice daily using the Richmond Agitation Sedation Scale and Confusion Assessment Method for Intensive Care Unit. Delirium severity was assessed once daily with the Delirium Rating Scale-Revised-98. RESULTS Samples from 71 patients were included. Preoperative biomarker concentrations were not associated with postoperative delirium. Significant differences in change in concentrations from preoperatively to postoperative day 1 were seen in IL-8 (delirium, 38.6; interquartile range [IQR], 29.3-69.8; no delirium, 24.8; IQR, 16.0-41.7, P = .022), and IL-10 (delirium, 26.1; IQR, 13.9-36.7; no delirium, 12.4; IQR, 7.7-25.7; P = .025). Greater postoperative increase in S100 calcium-binding protein B (Spearman r = 0.289, P = .020) and lower levels of insulin-like growth factor 1 were correlated with greater delirium severity (Spearman r = -0.27, P = .040). Greater CRP change quartiles were associated with higher delirium incidence adjusting for severity of illness (odds ratio, 1.68; 95% confidence interval, 1.03-2.75; P = .037) or comorbidities (odds ratio, 1.70; 95% confidence interval, 1.05-2.76, P = .030). CONCLUSIONS Differences in change in serum CRP, IL-8, and IL-10 concentrations were associated with postoperative delirium, suggesting biomarker measurement early in the postoperative course is associated with delirium.
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Affiliation(s)
- Sikandar H Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Center for Aging Research, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Heidi Lindroth
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN,IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN,Indiana University School of Nursing, Indianapolis, Indiana
| | - Yameena Jawed
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - Jason Nasser
- IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN,Lebanese American University, School of Medicine, Byblos, Lebanon
| | - Sarah Seyffert
- Department of Internal Medicine, Indiana University School of Medicine
| | - Kiran Naqvi
- IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
| | - Anthony J. Perkins
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Sujuan Gao
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Kenneth Kesler
- Department of Cardiothoracic Surgery, Indiana University
| | - Babar Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN,IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
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16
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Wang S, Greene R, Song Y, Chan C, Lindroth H, Khan S, Rios G, Sanders RD, Khan B. Postoperative delirium and its relationship with biomarkers for dementia: a meta-analysis. Int Psychogeriatr 2022; 34:1-14. [PMID: 35034675 PMCID: PMC9288560 DOI: 10.1017/s104161022100274x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This study seeks to identify Alzheimer's and related dementias (ADRD) biomarkers associated with postoperative delirium (POD) via meta-analysis. DESIGN A comprehensive search was conducted. Studies met the following inclusion criteria: >18 years of age, identified POD with standardized assessment, and biomarker measured in the AT(N)-X (A = amyloid, T = tau, (N)=neurodegeneration, X-Other) framework. Exclusion criteria: focus on prediction of delirium, delirium superimposed on dementia, other neurologic or psychiatric disorders, or terminal delirium. Reviewers extracted and synthesized data for the meta-analysis. SETTING Meta-analysis. PARTICIPANTS Patients with POD. MEASUREMENTS Primary outcome: association between POD and ATN-X biomarkers. Secondary outcomes involved sample heterogeneity. RESULTS 28 studies were included in this meta-analysis. Studies focused on inflammatory and neuronal injury biomarkers; there were an insufficient number of studies for amyloid and tau biomarker analysis. Two inflammatory biomarkers (IL-6, and CRP) showed a significant relationship with POD (IL-6 n = 10, standardized mean difference (SMD): 0.53, 95% CI: 0.36-0.70; CRP n = 14, SMD: 0.53, 95% CI: 0.33-0.74). Two neuronal injury biomarkers (blood-based S100B and NfL) were positively associated with POD (S100B n = 5, SMD: 0.40, 95% CI: 0.11-0.69; NFL n = 2, SMD: 0.93, 95% CI: 0.28-1.57). Of note, many analyses were impacted by significant study heterogeneity. CONCLUSIONS This meta-analysis identified an association between certain inflammatory and neuronal injury biomarkers and POD. Future studies will need to corroborate these relationships and include amyloid and tau biomarkers in order to better understand the relationship between POD and ADRD.
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Affiliation(s)
- Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
- Indiana Alzheimer’s Disease Research Center, Indiana University School of Medicine, Indianapolis, IN
| | - Ryan Greene
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - Yiqing Song
- Fairbanks School of Public Health, Indiana University, Indianapolis, IN
| | - Carol Chan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD
| | - Heidi Lindroth
- Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN
| | - Sikandar Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
- IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
- Center for Health Innovation and Implementation Science
| | - Gabriel Rios
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN
| | - Robert D. Sanders
- Specialty of Anaesthetics, University of Sydney, Sydney Medical School/Central Clinical School, Sydney, Australia; Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital
| | - Babar Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
- IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
- Center for Health Innovation and Implementation Science
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17
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Fernández-Jiménez E, Muñoz-Sanjose A, Mediavilla R, Martínez-Alés G, Louzao II, Andreo J, Cebolla S, Bravo-Ortiz MF, Bayón C. Prospective Analysis Between Neutrophil-to-Lymphocyte Ratio on Admission and Development of Delirium Among Older Hospitalized Patients With COVID-19. Front Aging Neurosci 2021; 13:764334. [PMID: 34887744 PMCID: PMC8650500 DOI: 10.3389/fnagi.2021.764334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022] Open
Abstract
Objective: To examine any prospective association between neutrophil-to-lymphocyte ratio (NLR) at hospital admission and subsequent delirium in older COVID-19 hospitalized patients comparing by sex and age groups. Methods: The sample consisted of 1,785 COVID-19 adult inpatients (minimum sample size required of 635 participants) admitted to a public general hospital in Madrid (Spain) between March 16th and April 15th, 2020. Variables were obtained from electronic health records. Binary logistic regression models were performed between baseline NLR and delirium adjusting for age, sex, medical comorbidity, current illness severity, serious mental illness history and use of chloroquine and dexamethasone. An NLR cut-off was identified, and stratified analyses were performed by age and sex. Also, another biomarker was tested as an exposure (the systemic immune-inflammation index -SII). Results: 55.3% of the patients were men, with a mean age of 66.8 years. Roughly 13% of the patients had delirium during hospitalization. NLR on admission predicted subsequent delirium development (adjusted OR = 1.02, 95 percent CI: 1.00-1.04, p = 0.024). Patients between 69 and 80 years with NLR values > 6.3 presented a twofold increased risk for delirium (p = 0.004). There were no sex differences in the association between baseline NLR and delirium (p > 0.05) nor SII predicted delirium development (p = 0.341). Conclusion: NLR is a good predictor of delirium during hospitalization, especially among older adults, independently of medical comorbidity, illness severity, and other covariates. Routine blood tests on admission might provide valuable information to guide the decision-making process to be followed with these especially vulnerable patients.
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Affiliation(s)
- Eduardo Fernández-Jiménez
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Ainoa Muñoz-Sanjose
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Roberto Mediavilla
- Department of Psychiatry, Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBERSAM), Madrid, Spain
| | - Gonzalo Martínez-Alés
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBERSAM), Madrid, Spain.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Iker I Louzao
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain
| | - Jorge Andreo
- Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Susana Cebolla
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - María-Fe Bravo-Ortiz
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.,Department of Psychiatry, Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBERSAM), Madrid, Spain
| | - Carmen Bayón
- Department of Psychiatry, Clinical Psychology and Mental Health, La Paz University Hospital, Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.,Department of Psychiatry, Universidad Autónoma de Madrid (UAM), Madrid, Spain
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18
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Ghezzi ES, Ross TJ, Sharman R, Davis D, Boord MS, Thanabalan T, Thomas J, Keage HAD. The neuropsychological profile of delirium vulnerability: A systematic review and meta-analysis. Neurosci Biobehav Rev 2021; 132:248-259. [PMID: 34863781 DOI: 10.1016/j.neubiorev.2021.11.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 12/17/2022]
Abstract
Delirium is a common neurocognitive disorder in hospitalised older adults with substantial negative consequences. Impaired global cognition is a well-established delirium risk factor. However, poor performance on attention tests and higher intra-subject variability may be more sensitive delirium risk factors, given the disorder is characterised by a fluctuating course and attentional deficits. We systematically searched databases (Embase, PsycINFO, MEDLINE) and 44 studies satisfied inclusion criteria. Random-effects meta-analysis models showed poor performance in all cognitive domains except perception was significantly associated with incident delirium. Largest effects were for orientation (g=-1.20) and construction and motor performance (g=-0.60). These effects were no longer significant in the subgroup without pre-existing cognitive impairment, where executive functions and verbal functions and language skills were associated with incident delirium. A small, non-significant association between intra-subject variability and incident delirium was found (g=0.42). Cognitive domain specific tests may be quicker and more sensitive predictors of incident delirium. This pattern of neuropsychological findings supports the proposition that vulnerability for delirium manifests as a dysfunction of whole-brain information integration.
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Affiliation(s)
- Erica S Ghezzi
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia.
| | - Tyler J Ross
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Rhianna Sharman
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing Unit at UCL, London, United Kingdom
| | - Monique S Boord
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Thivina Thanabalan
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Jessica Thomas
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
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19
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Liu W, Wang Y, Wang J, Shi J, Pan J, Wang D. Effects of Glucocorticoids on Postoperative Delirium in Adult Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis. Clin Ther 2021; 43:1608-1621. [PMID: 34548175 DOI: 10.1016/j.clinthera.2021.07.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 07/05/2021] [Accepted: 07/26/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE Delirium is a common neurologic complication after cardiac surgery and is associated with a poor prognosis. Several studies have explored the effects of glucocorticoids on postoperative delirium (POD). However, conclusion have been inconsistent. The purpose of this systematic review and meta-analysis is to evaluate the effects of glucocorticoids on POD in adult patients undergoing cardiac surgery. METHODS A systematic literature search was conducted using PubMed/MEDLINE, Embase, Cochrane Library/Central, and Web of Science from inception to January 28, 2021. Randomized controlled trials evaluating the effects of perioperative glucocorticoids administration on the incidence of POD in adults (≥18 years of age) undergoing cardiac surgery were included. The primary outcome of incidence of POD was assessed using the risk ratio (RR) with a fixed-effects model. Secondary analyses included the severity or duration of delirium, mortality at 30 days, length of hospital and intensive care unit (ICU) stay, duration of mechanical ventilatory support, the incidence of myocardial injury, new atrial fibrillation, renal and respiratory failure, postoperative infection and stroke, and the level of glucose and inflammatory factors. FINDINGS A total 4 trials (n = 8448 patients) were included. Glucocorticoids did not significantly reduce the incidence of POD (RR = 0.99; 95% CI, 0.86-1.14) but increased the risk of myocardial injury (RR = 1.22; 95% CI, 1.08-1.38), decreased the duration of mechanical ventilatory support (mean difference, -0.83; 95% CI, -1.32 to -0.34), and led to a tendency toward short length of ICU stay (mean difference, -0.22; 95% CI, -0.47 to -0.03). No significant differences were observed in other secondary outcomes. IMPLICATIONS The perioperative administration of glucocorticoids did not reduce the incidence of POD in adult patients undergoing cardiac surgery but might be associated with shorter duration of mechanical ventilatory support and a tendency toward a shorter length of ICU stay. Furthermore, we found that glucocorticoids may increase the rate of myocardial injury but have no effects on other clinical outcomes. International Prospective Register of Systematic Reviews identifier: CRD42021233458.
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Affiliation(s)
- Wenxue Liu
- Department of Thoracic and Cardiovascular Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing China
| | - Yali Wang
- Department of Thoracic and Cardiovascular Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing China
| | - Junxia Wang
- Department of Thoracic and Cardiovascular Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing China
| | - Jian Shi
- Department of Thoracic and Cardiovascular Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing China
| | - Jun Pan
- Department of Thoracic and Cardiovascular Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing China.
| | - Dongjin Wang
- Department of Thoracic and Cardiovascular Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing China.
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20
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CheheiliSobbi S, Peters van Ton AM, Wesselink EM, Looije MF, Gerretsen J, Morshuis WJ, Slooter AJC, Abdo WF, Pickkers P, van den Boogaard M. Case-control study on the interplay between immunoparalysis and delirium after cardiac surgery. J Cardiothorac Surg 2021; 16:239. [PMID: 34425856 PMCID: PMC8381527 DOI: 10.1186/s13019-021-01627-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 08/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background Delirium occurs frequently following cardiothoracic surgery, and infectious disease is an important risk factor for delirium. Surgery and cardiopulmonary bypass induce suppression of the immune response known as immunoparalysis. We aimed to investigate whether delirious patients had more pronounced immunoparalysis following cardiothoracic surgery than patients without delirium, to explain this delirium-infection association. Methods A prospective matched case–control study was performed in two university hospitals. Cytokine production (tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-8 and IL-10) of ex vivo lipopolysaccharide (LPS)-stimulated whole blood was analyzed in on-pump cardiothoracic surgery patients preoperatively, and at 5 timepoints up to 3 days after cardiothoracic surgery. Delirium was assessed by trained staff using two validated delirium scales and chart review. Results A total of 89 patients were screened of whom 14 delirious and 52 non-delirious patients were included. Ex vivo-stimulated production of TNF-α, IL-6, IL-8, and IL-10 was severely suppressed following cardiothoracic surgery compared to pre-surgery. Postoperative release of cytokines in non-delirious patients was attenuated by 84% [IQR: 13–93] for TNF-α, 95% [IQR: 78–98] for IL-6, and 69% [IQR: 55–81] for IL-10. The attenuation in ex vivo-stimulated production of these cytokines was not significantly different in patients with delirium compared to non-delirious patients (p > 0.10 for all cytokines). Conclusions The post-operative attenuation of ex vivo-stimulated production of pro- and anti-inflammatory cytokines was comparable between patients that developed delirium and those who remained delirium-free after on-pump cardiothoracic surgery. This finding suggests that immunoparalysis is not more common in cardiothoracic surgery patients with delirium compared to those without.
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Affiliation(s)
- Shokoufeh CheheiliSobbi
- Department of Intensive Care Medicine, IP 707, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annemieke M Peters van Ton
- Department of Intensive Care Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Esther M Wesselink
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marjolein F Looije
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jelle Gerretsen
- Department of Intensive Care Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim J Morshuis
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wilson F Abdo
- Department of Intensive Care Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, IP 707, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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21
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Dunne SS, Coffey JC, Konje S, Gasior S, Clancy CC, Gulati G, Meagher D, Dunne CP. Biomarkers in delirium: A systematic review. J Psychosom Res 2021; 147:110530. [PMID: 34098376 DOI: 10.1016/j.jpsychores.2021.110530] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delirium is a common neuropsychiatric disorder associated with prolonged hospital stays, and increased morbidity and mortality. Diagnosis is frequently missed due to varying disease presentation and lack of standardized testing. We examined biomarkers as diagnostic or prognostic indicators of delirium, and provide a rational basis for future studies. METHOD Systematic review of literature published between Jan 2000 and June 2019. Searches included: PubMed; Web of Science; CINAHL; EMBASE; COCHRANE and Medline. Additional studies were identified by searching bibliographies of eligible articles. RESULTS 2082 relevant papers were identified from all sources. Seventy-three met the inclusion criteria, all of which were observational. These assessed a range of fourteen biomarkers. All papers included were in the English language. Assessment methods varied between studies, including: DSM criteria; Confusion Assessment Method (CAM) or CAM-Intensive Care Unit (ICU). Delirium severity was measured using the Delirium Rating Scale (DRS). Delirium was secondary to post-operative dysfunction or acute medical conditions. CONCLUSION Evidence does not currently support the use of any one biomarker. However, certain markers were associated with promising results and may warrant evaluation in future studies. Heterogeneity across study methods may have contributed to inconclusive results, and more clarity may arise from standardization of methods of clinical assessment. Adjusting for comorbidities may improve understanding of the pathophysiology of delirium, in particular the role of confounders such as inflammation, cognitive disorders and surgical trauma. Future research may also benefit from inclusion of other diagnostic modalities such as EEG as well as analysis of genetic or epigenetic factors.
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Affiliation(s)
- Suzanne S Dunne
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - J Calvin Coffey
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Swiri Konje
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Sara Gasior
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Conor C Clancy
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - Gautam Gulati
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland
| | - David Meagher
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland; Cognitive Impairment Research Group, School of Medicine, University of Limerick, Limerick, Ireland
| | - Colum P Dunne
- Centre for Interventions in Infection, Inflammation and Immunity (4i) and School of Medicine, University of Limerick, Limerick, Ireland; Cognitive Impairment Research Group, School of Medicine, University of Limerick, Limerick, Ireland.
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22
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Zhao Y, Yue J, Lei P, Lin T, Peng X, Xie D, Gao L, Shu X, Wu C. Neutrophil-lymphocyte ratio as a predictor of delirium in older internal medicine patients: a prospective cohort study. BMC Geriatr 2021; 21:334. [PMID: 34034650 PMCID: PMC8147036 DOI: 10.1186/s12877-021-02284-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 05/11/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUNDS Delirium is a common neuropsychiatric syndrome in older hospitalized patients. Previous studies have suggested that inflammation and oxidative stress contribute to the pathophysiology of delirium. However, it remains unclear whether neutrophil-lymphocyte ratio (NLR), an indicator of systematic inflammation, is associated with delirium. This study aimed to investigate the value of NLR as an independent risk factor for delirium among older hospitalized patients. METHODS We conducted a prospective study of 740 hospitalized patients aged ≥ 70 years in the geriatric ward of West China Hospital of Sichuan University. Neutrophil and lymphocyte counts were collected within 24 h after hospital admission. Delirium was assessed on admission and every 48 h thereafter. We used the receiver operating characteristic analysis to assess the ability of the NLR for predicting delirium. The optimal cut-point value of the NLR was determined based on the highest Youden index (sensitivity + specificity - 1). Patients were categorized according to the cut-point value and quartiles of NLR, respectively. We then used logistic regression to identify the unadjusted and adjusted associations between NLR as a categorical variable and delirium. RESULTS The optimal cut-point value of NLR for predicting delirium was 3.626 (sensitivity: 75.2 %; specificity: 63.4 %; Youden index: 0.386). The incidence of delirium was significantly higher in patients with NLR > 3.626 than NLR ≤ 3.626 (24.5 % vs. 5.8 %; P < 0.001). Significantly fewer patients in the first quartile of NLR experienced delirium than in the third (4.3 % vs. 20.0 %; P < 0.001) and fourth quartiles of NLR (4.3 % vs. 24.9 %; P < 0.001). Results from the multivariable logistic regression models showed that NLR was independently associated with delirium. CONCLUSIONS NLR is a simple and practical marker that can predict the development of delirium in older internal medicine patients.
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Affiliation(s)
- Yanli Zhao
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Jirong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China.
| | - Peng Lei
- Department of Neurology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Taiping Lin
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Xuchao Peng
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Dongmei Xie
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Langli Gao
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Xiaoyu Shu
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Chenkai Wu
- Global Health Research Center, Duke Kunshan University, 215300, Kunshan, Jiangsu Province, China
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Perioperative Vascular Biomarker Profiling in Elective Surgery Patients Developing Postoperative Delirium: A Prospective Cohort Study. Biomedicines 2021; 9:biomedicines9050553. [PMID: 34063403 PMCID: PMC8155907 DOI: 10.3390/biomedicines9050553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 02/06/2023] Open
Abstract
Background: Postoperative delirium (POD) ranks among the most common complications in surgical patients. Blood-based biomarkers might help identify the patient at risk. This study aimed to assess how serum biomarkers with specificity for vascular and endothelial function and for inflammation are altered, prior to or following surgery in patients who subsequently develop POD. Methods: This was a study on a subcohort of consecutively recruited elective non-cardiac as well as cardiac surgery patients (age > 60 years) of the single-center PROPDESC trial at a German tertiary care hospital. Serum was sampled prior to and following surgery, and the samples were subjected to bead-based multiplex analysis of 17 serum proteins (IL-3, IL-8, IL-10, Cripto, CCL2, RAGE, Resistin, ANGPT2, TIE2, Thrombomodulin, Syndecan-1, E-Selectin, VCAM-1, ICAM-1, CXCL5, NSE, and uPAR). Development of POD was assessed during the first five days after surgery, using the Confusion Assessment Method for ICU (CAM-ICU), the CAM, the 4-‘A’s test (4AT), and the Delirium Observation Scale (DOS). Patients were considered positive if POD was detected at least once during the visitation period by any of the applied methods. Non-parametric testing, as well as propensity score matching were used for statistical analysis. Results: A total of 118 patients were included in the final analysis; 69% underwent non-cardiac surgery, median overall patient age was 71 years, and 59% of patients were male. In the whole cohort, incidence of POD was 28%. The male gender was significantly associated with the development of POD (p = 0.0004), as well as a higher ASA status III (p = 0.04). Incidence of POD was furthermore significantly increased in cardiac surgery patients (p = 0.002). Surgery induced highly significant changes in serum levels of almost all biomarkers except uPAR. In preoperative serum samples, none of the analyzed parameters was significantly altered in subsequent POD patients. In postoperative samples, CCL2 was significantly increased by a factor of 1.75 in POD patients (p = 0.03), as compared to the no-POD cohort. Following propensity score matching, CCL2 remained the only biomarker that showed significant differences in postoperative values (p = 0.01). In cardiac surgery patients, postoperative CCL2 serum levels were more than 3.5 times higher than those following non-cardiac surgery (p < 0.0001). Moreover, after cardiac surgery, Syndecan-1 serum levels were significantly increased in POD patients, as compared to no-POD cardiac surgery patients (p = 0.04). Conclusions: In a mixed cohort of elective non-cardiac as well as cardiac surgery patients, preoperative serum biomarker profiling with specificity for vascular dysfunction and for systemic inflammation was not indicative of subsequent POD development. Surgery-induced systemic inflammation—as evidenced by the significant increase in CCL2 release—was associated with POD, particularly following cardiac surgery. In those patients, postoperative glycocalyx injury might furthermore contribute to POD development.
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24
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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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25
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Greaves D, Psaltis PJ, Davis DHJ, Ross TJ, Ghezzi ES, Lampit A, Smith AE, Keage HAD. Risk Factors for Delirium and Cognitive Decline Following Coronary Artery Bypass Grafting Surgery: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e017275. [PMID: 33164631 PMCID: PMC7763731 DOI: 10.1161/jaha.120.017275] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Coronary artery bypass grafting (CABG) is known to improve heart function and quality of life, while rates of surgery‐related mortality are low. However, delirium and cognitive decline are common complications. We sought to identify preoperative, intraoperative, and postoperative risk or protective factors associated with delirium and cognitive decline (across time) in patients undergoing CABG. Methods and Results We conducted a systematic search of Medline, PsycINFO, EMBASE, and Cochrane (March 26, 2019) for peer‐reviewed, English publications reporting post‐CABG delirium or cognitive decline data, for at least one risk factor. Random‐effects meta‐analyses estimated pooled odds ratio for categorical data and mean difference or standardized mean difference for continuous data. Ninety‐seven studies, comprising data from 60 479 patients who underwent CABG, were included. Moderate to large and statistically significant risk factors for delirium were as follows: (1) preoperative cognitive impairment, depression, stroke history, and higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) score, (2) intraoperative increase in intubation time, and (3) postoperative presence of arrythmia and increased days in the intensive care unit; higher preoperative cognitive performance was protective for delirium. Moderate to large and statistically significant risk factors for acute cognitive decline were as follows: (1) preoperative depression and older age, (2) intraoperative increase in intubation time, and (3) postoperative presence of delirium and increased days in the intensive care unit. Presence of depression preoperatively was a moderate risk factor for midterm (1–6 months) post‐CABG cognitive decline. Conclusions This meta‐analysis identified several key risk factors for delirium and cognitive decline following CABG, most of which are nonmodifiable. Future research should target preoperative risk factors, such as depression or cognitive impairment, which are potentially modifiable. Registration URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42020149276.
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Affiliation(s)
- Danielle Greaves
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society Academic Unit University of South Australia Adelaide Australia
| | - Peter J Psaltis
- Vascular Research Centre Lifelong Health Theme South Australian Health and Medical Research Institute Adelaide Australia.,Adelaide Medical School University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Central Adelaide Local Health Network Adelaide Australia
| | - Daniel H J Davis
- Medical Reasearch Council Unit for Lifelong Health and Ageing Unit at UCL London United Kingdom
| | - Tyler J Ross
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society Academic Unit University of South Australia Adelaide Australia
| | - Erica S Ghezzi
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society Academic Unit University of South Australia Adelaide Australia
| | - Amit Lampit
- Academic Unit for Psychiatry of Old Age Department of Psychiatry University of Melbourne Melbourne Australia.,Department of Neurology Charité-Universitätsmedizin Berlin Berlin Germany
| | - Ashleigh E Smith
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society Academic Unit University of South Australia Adelaide Australia.,Alliance for Research in Exercise, Nutrition and Activity Allied Health and Human Performance Academic Unit University of South Australia Adelaide Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society Academic Unit University of South Australia Adelaide Australia
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Current Evidence Regarding Biomarkers Used to Aid Postoperative Delirium Diagnosis in the Field of Cardiac Surgery-Review. ACTA ACUST UNITED AC 2020; 56:medicina56100493. [PMID: 32987655 PMCID: PMC7598630 DOI: 10.3390/medicina56100493] [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: 08/13/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/16/2022]
Abstract
Postoperative cognitive disorders after cardiac surgery may manifest as postoperative delirium (POD) or later as postoperative cognitive dysfunction (POCD). The incidence of POD after cardiac surgery ranges from 16% to 73%. In contrast to POD, POCD is usually diagnosed after the discharge from hospital, with an incidence of 30 to 70% of cases, very often noticed only by close relative or friends, decreasing after six (20–30%) and twelve (15–25%) months after surgery. Perioperative cognitive disorders are associated with adverse short- and long-term effects, including increased morbidity and mortality. Due to the complexity of delirium pathomechanisms and the difficulties in the diagnosis, researchers have not yet found a clear answer to the question of which patient will be at a higher risk of developing delirium. The risk for POD and POCD in older patients with numerous comorbidities like hypertension, diabetes, and previous ischemic stroke is relatively high, and the predisposing cognitive profile for both conditions is important. The aim of this narrative review was to identify and describe biomarkers used in the diagnosis of delirium after cardiac surgery by presenting a search through studies regarding this subject, which have been published during the last ten years. The authors discussed brain-derived biomarkers, inflammation-related biomarkers, neurotransmitter-based biomarkers, and others. Work based on inflammation-related biomarkers, which are characterized by the low cost of implementation and the effectiveness of delirium diagnosis, seems to be the closest to the goal of discovering an inexpensive and effective marker. Currently, the use of a panel of tests, and not a single biomarker, brings us closer to the discovery of a test, or rather a set of tests ideal for the diagnosis of delirium after cardiac surgery.
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Nomograms Predicting the Occurrence of Sepsis in Patients following Major Hepatobiliary and Pancreatic Surgery. Gastroenterol Res Pract 2020; 2020:9761878. [PMID: 32802049 PMCID: PMC7416249 DOI: 10.1155/2020/9761878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 06/21/2020] [Accepted: 07/13/2020] [Indexed: 01/31/2023] Open
Abstract
Purpose Sepsis is a severe complication in patients following major hepatobiliary and pancreatic surgery. The purpose of this study was to develop and validate a nomogram based on inflammation biomarkers and clinical characteristics. Methods Patients who underwent major hepatobiliary and pancreatic surgery between June 2015 and April 2017 were retrospectively collected. Multivariate logistic regression was used to identify the independent risk factors associated with postoperative sepsis. A training cohort of 522 patients in an earlier period was used to develop the prediction models, and a validation cohort of 136 patients thereafter was used to validate the nomograms. Results Sepsis developed in 55 of 522 patients of the training cohort and 19 of 136 patients in the validation cohort, respectively. In the training cohort, one nomogram based on clinical characteristics was developed. The clinical independent risk factors for postoperative sepsis include perioperative blood transfusion, diabetes, operative time, direct bilirubin, and BMI. Another nomogram was based on both clinical characteristics and inflammation biomarkers. Multivariate regression analyses showed that previous clinical risk factors, PCT, and CRP were independent risk factors for postoperative sepsis. The last nomogram showed a good C-index of 0.844 (95% CI, 0.787-0.900) compared with the previous one of 0.777 (95% CI, 0.713-0.840). Patients with a total score more than 109 in the second model are at high risk. The positive predictive value and negative predictive value of the second nomogram were 27% and 97%, respectively. Conclusion The nomogram achieved good performances for predicting postoperative sepsis in patients by combining clinical and inflammation risk factors. This model can provide the early risk estimation of sepsis for patients following major hepatobiliary and pancreatic surgery.
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Hasan TF, Kelley RE, Cornett EM, Urman RD, Kaye AD. Cognitive impairment assessment and interventions to optimize surgical patient outcomes. Best Pract Res Clin Anaesthesiol 2020; 34:225-253. [PMID: 32711831 DOI: 10.1016/j.bpa.2020.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/20/2020] [Indexed: 12/22/2022]
Abstract
For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.
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Affiliation(s)
- Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Roger E Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, Massachussetts, 02115, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
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Amgarth-Duff I, Hosie A, Caplan G, Agar M. A systematic review of the overlap of fluid biomarkers in delirium and advanced cancer-related syndromes. BMC Psychiatry 2020; 20:182. [PMID: 32321448 PMCID: PMC7178636 DOI: 10.1186/s12888-020-02584-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 04/05/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Delirium is a serious and distressing neurocognitive disorder of physiological aetiology that is common in advanced cancer. Understanding of delirium pathophysiology is largely hypothetical, with some evidence for involvement of inflammatory systems, neurotransmitter alterations and glucose metabolism. To date, there has been limited empirical consideration of the distinction between delirium pathophysiology and that of the underlying disease, for example, cancer where these mechanisms are also common in advanced cancer syndromes such as pain and fatigue. This systematic review explores biomarker overlap in delirium, specific advanced cancer-related syndromes and prediction of cancer prognosis. METHODS A systematic review (PROSPERO CRD42017068662) was conducted, using MEDLINE, PubMed, Embase, CINAHL, CENTRAL and Web of Science, to identify body fluid biomarkers in delirium, cancer prognosis and advanced cancer-related syndromes of interest. Studies were excluded if they reported delirium tremens only; did not measure delirium using a validated tool; the sample had less than 75% of participants with advanced cancer; measured tissue, genetic or animal biomarkers, or were conducted post-mortem. Articles were screened for inclusion independently by two authors, and data extraction and an in-depth quality assessment conducted by one author, and checked by two others. RESULTS The 151 included studies were conducted in diverse settings in 32 countries between 1985 and 2017, involving 28130 participants with a mean age of 69.3 years. Seventy-one studies investigated delirium biomarkers, and 80 studies investigated biomarkers of an advanced cancer-related syndrome or cancer prognosis. Overall, 41 biomarkers were studied in relation to both delirium and either an advanced cancer-related syndrome or prognosis; and of these, 24 biomarkers were positively associated with either delirium or advanced cancer syndromes/prognosis in at least one study. The quality assessment showed large inconsistency in reporting. CONCLUSION There is considerable overlap in the biomarkers in delirium and advanced cancer-related syndromes. Improving the design of delirium biomarker studies and considering appropriate comparator/controls will help to better understanding the discrete pathophysiology of delirium in the context of co-existing illness.
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Affiliation(s)
- Ingrid Amgarth-Duff
- University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW, Australia.
| | - Annmarie Hosie
- grid.117476.20000 0004 1936 7611University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW Australia
| | - Gideon Caplan
- grid.1005.40000 0004 4902 0432Prince of Wales Clinical School, University of New South Wales, Sydney, NSW Australia ,grid.415193.bDepartment of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW Australia
| | - Meera Agar
- grid.117476.20000 0004 1936 7611University of Technology Sydney, Faculty of Health, IMPACCT -Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Sydney, NSW Australia ,grid.1005.40000 0004 4902 0432South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales Australia ,grid.429098.eClinical Trials, Ingham Institute of Applied Medical Research, Liverpool, New South Wales Australia
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Zhang H, Meng F, Lu S. Risk factors of sepsis following pancreaticoduodenectomy based on inflammation markers and clinical characteristics. ANZ J Surg 2020; 90:1428-1433. [DOI: 10.1111/ans.15791] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/11/2020] [Accepted: 02/16/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Haoyun Zhang
- Department of Hepatobiliary Surgery, First Medical Center of Chinese People's Liberation Army (PLA) General HospitalChinese PLA Medical School Beijing China
| | - Fanyu Meng
- Department of Hepatobiliary Surgery, First Medical Center of Chinese People's Liberation Army (PLA) General HospitalChinese PLA Medical School Beijing China
| | - Shichun Lu
- Department of Hepatobiliary Surgery, First Medical Center of Chinese People's Liberation Army (PLA) General HospitalChinese PLA Medical School Beijing China
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Knaak C, Vorderwülbecke G, Spies C, Piper SK, Hadzidiakos D, Borchers F, Brockhaus W, Radtke FM, Lachmann G. C-reactive protein for risk prediction of post-operative delirium and post-operative neurocognitive disorder. Acta Anaesthesiol Scand 2019; 63:1282-1289. [PMID: 31283835 DOI: 10.1111/aas.13441] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/12/2019] [Accepted: 06/12/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Post-operative delirium (POD) and post-operative neurocognitive disorder (NCD) are frequently seen in the elderly. Development of biomarkers for pre-operative risk prediction is of major relevance. As inflammation present before surgery might predispose to POD and post-operative NCD development, we aim to determine associations between pre-operative C-reactive protein (CRP) and the incidence of POD and post-operative NCD. METHODS In this observational study, we analyzed 314 patients enrolled in the SuDoCo trial, who had a pre-operative CRP measurement the day before surgery. Primary outcomes were POD assessed according DSM-4 from day 1 until day 7 after surgery and post-operative NCD assessed 3 months after surgery. We conducted multivariable logistic regression analysis adjusted for age, sex, randomization, body mass index, MMSE, ASA status, infection/autoimmune disease/malignoma and types of surgery to determine associations between CRP with POD and post-operative NCD, respectively. RESULTS Pre-operative CRP was independently associated with POD [OR 1.158 (95% CI 1.040, 1.291); P = .008]. Patients with CRP values ≥5 mg/dL had a 4.8-fold increased POD risk [OR 4.771 (95% CI 1.765, 12.899; P = .002)] compared to patients with lower CRP values. However, no association was seen between pre-operative CRP and post-operative NCD [OR 0.552 (95% CI 0.193, 1.581); P = .269]. CONCLUSIONS Pre-operative CRP levels were independently associated with POD but not post-operative NCD after three months. Moreover, higher pre-operative CRP levels showed higher risk for POD. This strengthens the role of inflammation in the development of POD. Assessment of CRP before surgery might allow risk stratification of POD. TRIAL REGISTRATION This study was registered with ISRCTN Register 36437985 on 02 March 2009.
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Affiliation(s)
- Cornelia Knaak
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Gerald Vorderwülbecke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Sophie K. Piper
- Institute of Biometry and Clinical Epidemiology Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
- Berlin Institute of Health (BIH) Berlin Germany
| | - Daniel Hadzidiakos
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Friedrich Borchers
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Wolf‐Rüdiger Brockhaus
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | | | - Gunnar Lachmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
- Berlin Institute of Health (BIH) Berlin Germany
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Egberts A, Osse RJ, Fekkes D, Tulen JHM, van der Cammen TJM, Mattace-Raso FUS. Differences in potential biomarkers of delirium between acutely ill medical and elective cardiac surgery patients. Clin Interv Aging 2019; 14:271-281. [PMID: 30799917 PMCID: PMC6369845 DOI: 10.2147/cia.s193605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND/AIMS The pathophysiology of delirium is poorly understood. Increasing evidence suggests that different pathways might be involved in the pathophysiology depending on the population studied. The aim of the present study was to investigate potential differences in mean plasma levels of neopterin, amino acids, amino acid ratios and homovanillic acid between two groups of patients with delirium. METHODS Data from acutely ill medical patients aged 65 years and older, and patients aged 70 years and older undergoing elective cardiac surgery, were used. Differences in biomarker levels between the groups were investigated using univariate ANOVA with adjustments for age, sex, comorbidities, C-reactive protein (CRP) and the estimated glomerular filtration rate (eGFR), where appropriate. Linear regression analysis was used to identify potential determinants of the investigated biochemical markers. RESULTS Eighty patients with delirium were included (23 acutely ill medical patients and 57 elective cardiac surgery patients). After adjustment, higher mean neopterin levels (93.1 vs 47.3 nmol/L, P=0.001) and higher phenylalanine/tyrosine ratios (1.39 vs 1.15, P=0.032) were found in acutely ill medical patients when compared to elective cardiac surgery patients. CRP levels were positively correlated with neopterin levels in acutely ill medical patients, explaining 28.4% of the variance in neopterin levels. eGFR was negatively correlated with neopterin in elective cardiac surgery patients, explaining 53.7% of the variance in neopterin levels. CONCLUSION In this study, we found differences in mean neopterin levels and phenylalanine/tyrosine ratios between acutely ill medical and elective cardiac surgery patients with delirium. Moreover, our findings may suggest that in acutely ill medical patients, neopterin levels are mainly determined by inflammation/oxidative stress whereas in elective cardiac surgery patients, neopterin levels are mainly driven by renal function/fluid status. These findings suggest that the markers and pathways that might be involved in the pathophysiology of delirium may differ between specific groups of patients.
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Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands, ;
| | - Robert J Osse
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Durk Fekkes
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Joke H M Tulen
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Tischa J M van der Cammen
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands, ;
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands, ;
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Natanov R, Gueler F, Falk CS, Kühn C, Maus U, Boyle EC, Siemeni T, Knoefel AK, Cebotari S, Haverich A, Madrahimov N. Blood cytokine expression correlates with early multi-organ damage in a mouse model of moderate hypothermia with circulatory arrest using cardiopulmonary bypass. PLoS One 2018; 13:e0205437. [PMID: 30308065 PMCID: PMC6181365 DOI: 10.1371/journal.pone.0205437] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/25/2018] [Indexed: 12/12/2022] Open
Abstract
Cardiopulmonary bypass (CPB) with moderate hypothermic cardiac arrest (MHCA) is essential for prolonged complex procedures in cardiac surgery and is associated with postoperative complications. Although cytokine release provoked through MHCA under CPB plays a pivotal role in postoperative organ damage, the pathomechanisms are unclear. Here, we investigated the cytokine release pattern and histological organ damage after MHCA using a recently described mouse CPB model. Eight BALB/c mice underwent 60 minutes of circulatory arrest under CPB, were successively rewarmed and reperfused. Blood cytokine concentrations and liver and kidney function parameters were measured and histological changes to these organs were compared to control animals. Our results showed a marked increase in proinflammatory cytokines and histological changes in the kidney, lung, and liver after CPB. Furthermore, clinical chemistry showed signs of hemolysis and acute kidney injury. These results suggest early onset of solid organ injury which correlates with increased leukocyte infiltration. A better understanding of the interplay between pro-inflammatory cytokine activation and solid organ injury in this model of CBP with MHCA will inform strategies to reduce organ damage during cardiac surgeries in the clinic.
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Affiliation(s)
- Ruslan Natanov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Faikah Gueler
- Department of Nephrology, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Christine S. Falk
- Institute of Transplant Immunology, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Ulrich Maus
- Department of Pneumology, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Erin C. Boyle
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Ann-Katrin Knoefel
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Serghei Cebotari
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Nodir Madrahimov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
- * E-mail:
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Wang BJ, Li CJ, Hu J, Li HJ, Guo C, Wang ZH, Zhang QC, Mu DL, Wang DX. Impact of dexmedetomidine infusion during general anaesthesia on incidence of postoperative delirium in elderly patients after major non-cardiac surgery: study protocol of a randomised, double-blinded and placebo-controlled trial. BMJ Open 2018; 8:e019549. [PMID: 29680809 PMCID: PMC5914899 DOI: 10.1136/bmjopen-2017-019549] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Delirium is a common complication in the elderly after surgery and is associated with worse outcomes. Multiple risk factors are related with postoperative delirium, such as exposure to general anaesthetics, pain and postoperative inflammatory response. Preclinical and clinical studies have shown that dexmedetomidine attenuated neurotoxicity induced by general anaesthetics, improved postoperative analgesia and inhibited inflammatory response after surgery. Several studies found that intraoperative use of dexmedetomidine can prevent postoperative delirium, but data were inconsistent. This study was designed to investigate the impact of dexmedetomidine administered during general anaesthesia in preventing delirium in the elderly after major non-cardiac surgery. METHODS AND ANALYSIS This is a randomised, double-blinded and placebo-controlled trial. 620 elderly patients (age ≥60 years) who are scheduled to undertake elective major non-cardiac surgery (with an expected duration ≥2 hours) are randomly divided into two groups. For patients in the dexmedetomidine group, a loading dose dexmedetomidine (0.6 µg/kg) will be administered 10 min before anaesthesia induction, followed by a continuous infusion at a rate of 0.5 µg/kg/hour until 1 hour before the end of surgery. For patients in the control group, normal saline will be administered with an identical rate as in the dexmedetomidine group. The primary endpoint is the incidence of delirium during the first five postoperative days. The secondary endpoints include pain intensity, cumulative opioid consumption and subjective sleep quality during the first three postoperative days, as well as the incidence of non-delirium complications and all-cause mortality within 30 days after surgery. ETHICS AND DISSEMINATION The study protocol was approved by the Clinical Research Ethics Committee of Peking University First Hospital (2015-987) and registered at Chinese Clinical Trial Registry (http://www.chictr.org.cn) with identifier ChiCTR-IPR-15007654. The results of the study will be presented at academic conferences and submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCRR-IPR-15007654; Pre-results.
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Affiliation(s)
- Bo-Jie Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Chun-Jing Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Jian Hu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Huai-Jin Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Chao Guo
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Zhen-Han Wang
- Department of Anesthesiology, Dongping People’s Hospital, Dongping, China
| | - Qiao-Chu Zhang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Dong-Liang Mu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
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Reduced ex vivo release of pro-inflammatory cytokines and elevated plasma interleukin-6 are inflammatory signatures of post-stroke delirium. J Neuroinflammation 2018; 15:111. [PMID: 29669581 PMCID: PMC5907192 DOI: 10.1186/s12974-018-1156-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/09/2018] [Indexed: 11/10/2022] Open
Abstract
Background Experimental studies suggest that systemic inflammation contributes to the pathophysiology of delirium. The aim of our study was to determine blood-derived inflammatory signatures of post-stroke delirium. Methods We included 144 ischemic stroke patients. We assessed delirium on a daily basis during the first 7 days of hospitalization. Venous blood was collected at day 3 after the onset of stroke and stimulated ex vivo with lipopolysaccharide (LPS). We measured LPS-induced cytokine concentration (TNFα, IP-10, IL-1β, IL-6, IL-8, IL-10, and IL-12p70) as well as plasma levels of IL-6 and TNFα. Results Delirium was diagnosed in 21.5% of patients. After correction for monocyte count, patients with delirium had reduced LPS-induced TNFα, IP-10, IL-1β, IL-6, and IL-12 release. The plasma IL-6 level was higher in delirious patients compared to patients without delirium. After adjusting for stroke severity and infections, higher ex vivo TNFα (OR 0.29, 95%CI 0.11–0.72, P = 0.01), IP-10 (OR 0.25, 95%CI 0.08–0.73, P = 0.01), IL-1β (OR 0.42, 95%CI 0.20–0.89, P = 0.02), and IL-12 (OR 0.07, 95%CI 0.01–0.70, P = 0.02) release was associated with the reduced risk of delirium. In multivariate analysis, the higher plasma IL-6 was associated with the increased risk of delirium (OR 1.61, 95%CI 1.00–2.58, P = 0.04). Conclusions Reduced ex vivo release of pro-inflammatory cytokines after LPS stimulation and the elevated plasma IL-6 are signatures of post-stroke delirium.
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Liu X, Yu Y, Zhu S. Inflammatory markers in postoperative delirium (POD) and cognitive dysfunction (POCD): A meta-analysis of observational studies. PLoS One 2018; 13:e0195659. [PMID: 29641605 PMCID: PMC5895053 DOI: 10.1371/journal.pone.0195659] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/27/2018] [Indexed: 11/19/2022] Open
Abstract
Background The aim of this study was to summarize and discuss the similarities and differences in inflammatory biomarkers in postoperative delirium (POD) and cognitive dysfunction (POCD). Methods A systematic retrieval of literature up to June 2017 in PubMed, Embase, the Cochrane Library, the China National Knowledge Infrastructure database, and the Wanfang database was conducted. Extracted data were analyzed with STATA (version 14). The standardized mean difference (SMD) and the 95% confidence interval (95% CI) of each indicator were calculated using a random effect model. We also performed tests of heterogeneity, sensitivity analysis, assessments of bias, and meta-regression in this meta-analysis. Results A total of 54 observational studies were included. By meta-analysis we found significantly increased C-reactive protein (CRP) (9 studies, SMD 0.883, 95% CI 0.130 to 1.637, P = 0.022 in POD; 10 studies, SMD -0.133, 95% CI -0.512 to 0.246, P = 0.429 in POCD) and interleukin (IL)-6 (7 studies, SMD 0.386, 95% CI 0.054 to 0.717, P = 0.022 in POD; 16 studies, SMD 0.089, 95% CI -0.133 to 0.311, P = 0.433 in POCD) concentrations in both POD and POCD patients. We also found that the SMDs of CRP and IL-6 from POCD patients were positively correlated with surgery type in the meta-regression (CRP: Coefficient = 1.555365, P = 0.001, 10 studies; IL-6: Coefficient = -0.6455521, P = 0.086, 16 studies). Conclusion Available evidence from medium-to-high quality observational studies suggests that POD and POCD are indeed correlated with the concentration of peripheral and cerebrospinal fluid (CSF) inflammatory markers. Some of these markers, such as CRP and IL-6, play roles in both POD and POCD, while others are specific to either one of them.
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Affiliation(s)
- Xuling Liu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Yang Yu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Shengmei Zhu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
- * E-mail:
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Smulter N, Lingehall HC, Gustafson Y, Olofsson B, Engström KG, Appelblad M, Svenmarker S. Disturbances in Oxygen Balance During Cardiopulmonary Bypass: A Risk Factor for Postoperative Delirium. J Cardiothorac Vasc Anesth 2018; 32:684-690. [DOI: 10.1053/j.jvca.2017.08.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Indexed: 12/12/2022]
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Giménez-Milà M, Vuylsteke A. Oxygen, Cardiac Surgery, and Delirium. J Cardiothorac Vasc Anesth 2018; 32:691. [DOI: 10.1053/j.jvca.2017.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Indexed: 12/21/2022]
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Anderson BJ, Chesley CF, Theodore M, Christie C, Tino R, Wysoczanski A, Ramphal K, Oyster M, Kalman L, Porteous MK, Bermudez CA, Cantu E, Kolson DL, Christie JD, Diamond JM. Incidence, risk factors, and clinical implications of post-operative delirium in lung transplant recipients. J Heart Lung Transplant 2018; 37:755-762. [PMID: 29477456 DOI: 10.1016/j.healun.2018.01.1295] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/22/2017] [Accepted: 01/18/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Delirium significantly affects post-operative outcomes, but the incidence, risk factors, and long-term impact of delirium in lung transplant recipients have not been well studied. METHODS We analyzed 155 lung transplant recipients enrolled in the Lung Transplant Outcomes Group (LTOG) cohort at a single center. We determined delirium incidence by structured chart review, identified risk factors for delirium, determined whether plasma concentrations of 2 cerebral injury markers (neuron-specific enolase [NSE] and glial fibrillary acidic protein [GFAP]) were associated with delirium, and determined the association of post-operative delirium with 1-year survival. RESULTS Fifty-seven (36.8%) patients developed post-operative delirium. Independent risk factors for delirium included pre-transplant benzodiazepine prescription (relative risk [RR] 1.82; 95% confidence interval [CI] 1.08 to 3.07; p = 0.025), total ischemic time (RR 1.10 per 30-minute increase; 95% CI 1.01 to 1.21; p = 0.027), duration of time with intra-operative mean arterial pressure <60 mm Hg (RR 1.07 per 15-minute increase; 95% CI 1.00 to 1.14; p = 0.041), and Grade 3 primary graft dysfunction (RR 2.13; 95% CI 1.27 to 3.58; p = 0.004). Ninety-one (58.7%) patients had plasma available at 24 hours. Plasma GFAP was inconsistently detected, whereas NSE was universally detectable, with higher NSE concentrations associated with delirium (risk difference 15.1% comparing 75th and 25th percentiles; 95% CI 2.5 to 27.7; p = 0.026). One-year mortality appeared higher among delirious patients, 12.3% compared with 7.1%, but the difference was not significant (p = 0.28). CONCLUSIONS Post-operative delirium is common in lung transplant recipients, and several potentially modifiable risk factors deserve further study to determine their associated mechanisms and predictive values.
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Affiliation(s)
- Brian J Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | | | - Miranda Theodore
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Colin Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan Tino
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alex Wysoczanski
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kristy Ramphal
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle Oyster
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laurel Kalman
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary K Porteous
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dennis L Kolson
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Diamond
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Si MS. Delirium postcardiac surgery: Intellectual insufficiency and insufficiently understood. J Thorac Cardiovasc Surg 2017; 155:276-277. [PMID: 28987744 DOI: 10.1016/j.jtcvs.2017.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/08/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Ming-Sing Si
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich; C.S. Mott Children's Hospital, Ann Arbor, Mich.
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A Prospective Evaluation of Systemic Biomarkers and Cognitive Function Associated with Carotid Revascularization. Ann Surg 2017; 264:659-65. [PMID: 27433899 DOI: 10.1097/sla.0000000000001853] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To determine factors affecting cognition and identify predictors of long-term cognitive impairment following carotid revascularization procedures. BACKGROUND Cognitive impairment is common in older patients with carotid occlusive diseases. METHODS Patients undergoing carotid intervention for severe occlusive diseases were prospectively recruited. Patients received neurocognitive testing before, 1, and 6 months after carotid interventions. Plasma samples were also collected within 24 hours after carotid intervention and inflammatory cytokines were analyzed. Univariate and multivariate logistic regressions were performed to identify risk factors associated with significant cognitive deterioration (>10% decline). RESULTS A total of 98 patients (48% symptomatic) were recruited, including 55 patients receiving carotid stenting and 43 receiving endarterectomy. Mean age was 69 (range 54-91 years). Patients had overall improvement in cognitive measures 1 month after revascularization. When compared with carotid stenting, endarterectomy patients demonstrated postoperative improvement in cognition at 1 and 6 months compared with baseline. Carotid stenting (odds ratio 6.49, P = 0.020) and age greater than 80 years (odds ratio 12.6, P = 0.023) were associated with a significant long-term cognitive impairment. Multiple inflammatory cytokines also showed significant changes after revascularization. On multivariate analysis, after controlling for procedure and age, IL-12p40 (P = 0.041) was associated with a higher risk of significant cognitive impairment at 1 month; SDF1-α (P = 0.004) and tumor necrosis factor alpha (P = 0.006) were independent predictors of cognitive impairment, whereas interleukin-6 (P = 0.019) demonstrated cognitive protective effects at 6 months after revascularization. CONCLUSIONS Carotid interventions affect cognitive function. Systemic biomarkers can be used to identify patients at risk of significant cognitive decline postprocedures that benefit from targeted cognitive training.
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Bhamidipati D, Goldhammer JE, Sperling MR, Torjman MC, McCarey MM, Whellan DJ. Cognitive Outcomes After Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2017; 31:707-718. [DOI: 10.1053/j.jvca.2016.09.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Indexed: 12/17/2022]
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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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Dillon ST, Vasunilashorn SM, Ngo L, Otu HH, Inouye SK, Jones RN, Alsop DC, Kuchel GA, Metzger ED, Arnold SE, Marcantonio ER, Libermann TA. Higher C-Reactive Protein Levels Predict Postoperative Delirium in Older Patients Undergoing Major Elective Surgery: A Longitudinal Nested Case-Control Study. Biol Psychiatry 2017; 81:145-153. [PMID: 27160518 PMCID: PMC5035711 DOI: 10.1016/j.biopsych.2016.03.2098] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Delirium is a common, morbid, and costly postoperative complication. We aimed to identify blood-based postoperative delirium markers in a nested case-control study of older surgical patients using a proteomics approach followed by enzyme-linked immunosorbent assay (ELISA) validation. METHODS The Successful Aging after Elective Surgery study enrolled dementia-free adults ≥70 years old undergoing major scheduled noncardiac surgery (N = 566; 24% delirium). Plasma was collected at four time points: preoperative, postanesthesia care unit, postoperative day 2, and 1 month postoperative. Matched pairs were selected for the independent discovery (39 pairs) and replication cohorts (36 pairs), which were subsequently combined into the pooled cohort (75 pairs). Isobaric tags for relative and absolute quantitation-based relative quantitation mass spectrometry proteomics were performed to identify the strongest delirium-related protein, which was selected for ELISA validation. Using the ELISA results, statistical analyses using nonparametric signed rank tests were performed in all cohorts examining the association between the identified protein and delirium. RESULTS C-reactive protein emerged from the proteomics analysis as the strongest delirium-related protein. Validation by ELISA confirmed that compared with controls, cases had significantly higher C-reactive protein levels in the discovery, replication, and pooled cohorts at the preoperative (median paired difference [MPD] 1.97 mg/L [p < .05], 0.29 mg/L, 1.56 mg/L [p < .01]), postanesthesia care unit (MPD 2.83 mg/L, 2.22 mg/L [p < .05], 2.53 mg/L [p < .01]) and postoperative day 2 (MPD 71.97 mg/L [p < .01], 35.18 mg/L [p < .05], 63.76 mg/L [p < .01]) time points, but not 1 month postoperative (MPD 2.72 mg/L, -0.66 mg/L, 1.10 mg/L). CONCLUSIONS Elevated preoperative and postoperative plasma levels of C-reactive protein were associated with delirium, suggesting that a preinflammatory state and heightened inflammatory response to surgery are potential pathophysiologic mechanisms of delirium.
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Affiliation(s)
- Simon T Dillon
- Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics and Systems Biology Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Sarinnapha M Vasunilashorn
- Division of Interdisciplinary Medicine and Biotechnology, Division of General Medicine and Primary Care, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.
| | - Long Ngo
- Division of Interdisciplinary Medicine and Biotechnology, Division of General Medicine and Primary Care, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Hasan H Otu
- Department of Electrical and Computer Engineering, University of Nebraska-Lincoln, Lincoln, Nebraska
| | - Sharon K Inouye
- Division of Gerontology, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Richard N Jones
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts; Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - David C Alsop
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - George A Kuchel
- University of Connecticut Center on Aging, University of Connecticut Health Center, Farmington, Connecticut
| | - Eran D Metzger
- Division of Interdisciplinary Medicine and Biotechnology, Division of General Medicine and Primary Care, Boston, Massachusetts; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Steven E Arnold
- Harvard Medical School, Boston, Massachusetts; Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Edward R Marcantonio
- Division of Interdisciplinary Medicine and Biotechnology, Division of General Medicine and Primary Care, Boston, Massachusetts; Division of Gerontology, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Towia A Libermann
- Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics and Systems Biology Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Hennessy E, Gormley S, Lopez-Rodriguez AB, Murray C, Murray C, Cunningham C. Systemic TNF-α produces acute cognitive dysfunction and exaggerated sickness behavior when superimposed upon progressive neurodegeneration. Brain Behav Immun 2017; 59:233-244. [PMID: 27633985 PMCID: PMC5176008 DOI: 10.1016/j.bbi.2016.09.011] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 09/01/2016] [Accepted: 09/12/2016] [Indexed: 12/13/2022] Open
Abstract
Inflammation influences chronic neurodegeneration but its precise roles are not yet clear. Systemic inflammation caused by infection, trauma or co-morbidity can alter the brain's inflammatory status, produce acute cognitive impairments, such as delirium, and drive new pathology and accelerated decline. Consistent with this, elevated systemic TNF-α is associated with more rapid cognitive decline over 6months in Alzheimer's disease patients. In the current study we challenged normal animals and those with existing progressive neurodegeneration (ME7 prion disease) with TNF-α (i.p.) to test the hypothesis that this cytokine has differential effects on cognitive function, sickness behavior and features of underlying pathology contingent on the animals' baseline condition. TNF-α (50μg/kg) had no impact on performance of normal animals (normal brain homogenate; NBH) on working memory (T-maze) but produced acute impairments in ME7 animals similarly challenged. Plasma TNF-α and CCL2 levels were equivalent in NBH and ME7 TNF-challenged animals but hippocampal and hypothalamic transcription of IL-1β, TNF-α and CCL2 and translation of IL-1β were higher in ME7+TNF-α than NBH+TNF-α animals. TNF-α produced an exaggerated sickness behavior response (hypothermia, weight loss, inactivity) in ME7 animals compared to that in NBH animals. However a single challenge with this dose was not sufficient to produce de novo neuronal death, synaptic loss or tau hyperphosphorylation that was distinguishable from that arising from ME7 alone. The data indicate that acutely elevated TNF-α has robust acute effects on brain function, selectively in the degenerating brain, but more sustained levels may be required to significantly impact on underlying neurodegeneration.
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Affiliation(s)
| | | | | | | | | | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin 2, Ireland.
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O'Neal JB, Shaw AD. Predicting, preventing, and identifying delirium after cardiac surgery. Perioper Med (Lond) 2016; 5:7. [PMID: 27119013 PMCID: PMC4845390 DOI: 10.1186/s13741-016-0032-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 03/29/2016] [Indexed: 02/07/2023] Open
Abstract
Delirium after cardiac surgery is a major problem. The exact mechanisms behind delirium are not understood. Potential pathways of delirium include neurotransmitter interference, global cognitive disorder, and neuroinflammation. Several predisposing and precipitating risk factors have been identified for postoperative delirium. The development of delirium following cardiac surgery is associated with worse outcomes in the perioperative period. Multiple interventions are being explored for the prevention and treatment of delirium. Studies investigating the potential roles of biomarkers in delirium as well as pharmacological interventions to reduce the incidence and duration of delirium are necessary to mitigate this negative outcome.
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Affiliation(s)
- Jason B O'Neal
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
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Zhang W, Hu W, Shen M, Ye X, Huang Y, Sun Y. Profiles of delirium and the clinical outcomes of patients who underwent coronary artery bypass grafting: a prospective study from China. J Clin Nurs 2016; 25:631-41. [PMID: 26814370 DOI: 10.1111/jocn.13089] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Weiying Zhang
- Department of Cardiothoracic Surgery; Changhai Hospital; Second Military Medical University; Shanghai China
| | - Wenlin Hu
- Department of Cardiothoracic Surgery; Changhai Hospital; Shanghai China
| | - Meifang Shen
- Department of Cardiothoracic Surgery; Changhai Hospital; Shanghai China
| | - Xiaofei Ye
- Department of Health Statistics; Second Military Medical University; Shanghai China
| | - Yan Huang
- Department of Cardiothoracic Surgery; Changhai Hospital; Shanghai China
| | - Yan Sun
- Department of Cardiothoracic Surgery; Changhai Hospital; Shanghai China
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Yilmaz S, Aksoy E, Diken AI, Yalcinkaya A, Erol ME, Cagli K. Dopamine Administration is a Risk Factor for Delirium in Patients Undergoing Coronary Artery Bypass Surgery. Heart Lung Circ 2015; 25:493-8. [PMID: 26546094 DOI: 10.1016/j.hlc.2015.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 06/27/2015] [Accepted: 09/20/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Delirium is an important morbidity following heart surgery. We sought to determine whether dopamine infusion is associated with increased risk of delirium in patients undergoing coronary artery bypass grafting. METHODS A total of 137 patients (mean age; 61.02±7.83, 105 males) were included in the study. Patients undergoing isolated coronary artery bypass grafting were considered eligible and those with preoperative neurological deficit or significant neurocognitive disorders, dementia or psychiatric disorders were excluded. Primary outcome measure was occurrence of delirium within 72 hours after operation. The diagnosis of delirium was made using confusion assessment method for the intensive care unit questionnaire. Both administration of dopamine as a dichotomised variable and the total amount of dopamine per kg body-weight were included in two different logistic regression models. RESULTS Delirium occurred in 18 (13.1%) patients. Age adjusted Mantel-Haenszel relative risk for delirium with receiving dopamine was 4.62. Relative risk was 2.37 (0.18 to 31.28, 95% CI, p=0.51) in total doses over 10mg whereas it was 3.55 (1.16 to 10.89 95% CI, p=0.02) in total doses over 30 mg per kg body-weight. Older age (p=0.03), dopamine administration (OR: 9.227 95% CI, 2.688-32.022, p<0.001) and the amount of dopamine administered (OR: 1.072, 95% CI, 1.032-1.115, p<0.001) were independent predictors for delirium 72 hours after surgery. CONCLUSION Along with older age, dopamine infusion--even in low doses but more probably in higher doses--emerged as an independent risk factor for delirium in patients undergoing CABG. Further study is needed to confirm the validity of results presented.
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Affiliation(s)
- Seyhan Yilmaz
- Hitit University Corum Education and Research Hospital, Department of Cardiovascular Surgery, Turkey
| | - Eray Aksoy
- Hitit University Corum Education and Research Hospital, Department of Cardiovascular Surgery, Turkey.
| | - Adem Ilkay Diken
- Hitit University Corum Education and Research Hospital, Department of Cardiovascular Surgery, Turkey
| | - Adnan Yalcinkaya
- Hitit University Corum Education and Research Hospital, Department of Cardiovascular Surgery, Turkey
| | - Mehmet Emir Erol
- Hitit University Corum Education and Research Hospital, Department of Cardiovascular Surgery, Turkey
| | - Kerim Cagli
- Hitit University Corum Education and Research Hospital, Department of Cardiovascular Surgery, Turkey
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Gosselt AN, Slooter AJ, Boere PR, Zaal IJ. Risk factors for delirium after on-pump cardiac surgery: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:346. [PMID: 26395253 PMCID: PMC4579578 DOI: 10.1186/s13054-015-1060-0] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 09/04/2015] [Indexed: 12/13/2022]
Abstract
Introduction As evidence-based effective treatment protocols for delirium after cardiac surgery are lacking, efforts should be made to identify risk factors for preventive interventions. Moreover, knowledge of these risk factors could increase validity of etiological studies in which adjustments need to be made for confounding variables. This review aims to systematically identify risk factors for delirium after cardiac surgery and to grade the evidence supporting these associations. Method A prior registered systematic review was performed using EMBASE, CINAHL, MEDLINE and Cochrane from 1990 till January 2015 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007371). All studies evaluating patients for delirium after cardiac surgery with cardiopulmonary bypass (CPB) using either randomization or multivariable data analyses were included. Data was extracted and quality was scored in duplicate. Heterogeneity impaired pooling of the data; instead a semi-quantitative approach was used in which the strength of the evidence was graded based on the number of investigations, the quality of studies, and the consistency of the association reported across studies. Results In total 1462 unique references were screened and 34 were included in this review, of which 16 (47 %) were graded as high quality. A strong level of evidence for an association with the occurrence of postoperative delirium was found for age, previous psychiatric conditions, cerebrovascular disease, pre-existent cognitive impairment, type of surgery, peri-operative blood product transfusion, administration of risperidone, postoperative atrial fibrillation and mechanical ventilation time. Postoperative oxygen saturation and renal insufficiency were supported by a moderate level of evidence, and there is no evidence that gender, education, CPB duration, pre-existent cardiac disease or heart failure are risk factors. Conclusion Of many potential risk factors for delirium after cardiac surgery, for only 11 there is a strong or moderate level of evidence. These risk factors should be taken in consideration when designing future delirium prevention strategies trials or when controlling for confounding in future etiological studies. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1060-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alex Nc Gosselt
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Arjen Jc Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Pascal Rq Boere
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Irene J Zaal
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Wesselink EM, Kappen TH, van Klei WA, Dieleman JM, van Dijk D, Slooter AJC. Intraoperative hypotension and delirium after on-pump cardiac surgery. Br J Anaesth 2015. [PMID: 26209856 DOI: 10.1093/bja/aev256] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Delirium is a common complication after cardiac surgery and may be as a result of inadequate cerebral perfusion. We studied delirium after cardiac surgery in relation to intraoperative hypotension (IOH). METHODS This observational single-centre, cohort study was nested in a randomized trial, on a single intraoperative dose of dexamethasone vs placebo during cardiac surgery. During the first four postoperative days, patients were screened for delirium based on the Confusion Assessment Method (CAM) for Intensive Care Unit on the intensive care unit, CAM on the ward, and by inspection of medical records. To combine depth and duration of IOH, we computed the area under the curve for four blood pressure thresholds. Logistic regression analyses were performed to investigate the association between IOH and the occurrence of postoperative delirium, adjusting for confounding and using a 99% confidence interval to correct for multiple testing. RESULTS Of the 734 included patients, 99 patients (13%) developed postoperative delirium. The adjusted Odds Ratio for the Mean Arterial Pressure <60 mm Hg threshold was 1.04 (99% confidence interval: 0.99-1.10) for each 1000 mm Hg(2) min(2) AUC(2) increase. IOH, as defined according to the other three definitions, was not associated with postoperative delirium either. Deep and prolonged IOH seemed to increase the risk of delirium, but this was not statistically significant. CONCLUSIONS Independent of the applied definition, IOH was not associated with the occurrence of delirium after cardiac surgery.
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Affiliation(s)
- E M Wesselink
- Department of Anesthesiology, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
| | - T H Kappen
- Department of Anesthesiology, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
| | - W A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
| | - J M Dieleman
- Department of Anesthesiology, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
| | - D van Dijk
- Department of Intensive Care Medicine, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
| | - A J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508 GA, the Netherlands
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