1
|
Komninou MA, Egli S, Rossi A, Ernst J, Krauthammer M, Schuepbach RA, Delgado M, Bartussek J. Former smoking, but not active smoking, is associated with delirium in postoperative ICU patients: a matched case-control study. Front Psychiatry 2024; 15:1347071. [PMID: 38559401 PMCID: PMC10979642 DOI: 10.3389/fpsyt.2024.1347071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/27/2024] [Indexed: 04/04/2024] Open
Abstract
Objective To examine the relationship between current and former smoking and the occurrence of delirium in surgical Intensive Care Unit (ICU) patients. Methods We conducted a single center, case-control study involving 244 delirious and 251 non-delirious patients that were admitted to our ICU between 2018 and 2022. Using propensity score analysis, we obtained 115 pairs of delirious and non-delirious patients matched for age and Simplified Acute Physiology Score II (SAPS II). Both groups of patients were further stratified into non-smokers, active smokers and former smokers, and logistic regression was performed to further investigate potential confounders. Results Our study revealed a significant association between former smoking and the incidence of delirium in ICU patients, both in unmatched (adjusted odds ratio (OR): 1.82, 95% confidence interval (CI): 1.17-2.83) and matched cohorts (OR: 3.0, CI: 1.53-5.89). Active smoking did not demonstrate a significant difference in delirium incidence compared to non-smokers (unmatched OR = 0.98, CI: 0.62-1.53, matched OR = 1.05, CI: 0.55-2.0). Logistic regression analysis of the matched group confirmed former smoking as an independent risk factor for delirium, irrespective of other variables like surgical history (p = 0.010). Notably, also respiratory and vascular surgeries were associated with increased odds of delirium (respiratory: OR: 4.13, CI: 1.73-9.83; vascular: OR: 2.18, CI: 1.03-4.59). Medication analysis showed that while Ketamine and Midazolam usage did not significantly correlate with delirium, Morphine use was linked to a decreased likelihood (OR: 0.27, 95% CI: 0.13-0.55). Discussion Nicotine's complex neuropharmacological impact on the brain is still not fully understood, especially its short-term and long-term implications for critically ill patients. Although our retrospective study cannot establish causality, our findings suggest that smoking may induce structural changes in the brain, potentially heightening the risk of postoperative delirium. Intriguingly, this effect seems to be obscured in active smokers, potentially due to the recognized neuroprotective properties of nicotine. Our results motivate future prospective studies, the results of which hold the potential to substantially impact risk assessment procedures for surgeries.
Collapse
Affiliation(s)
- Maria Angeliki Komninou
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Simon Egli
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Aurelio Rossi
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Jutta Ernst
- Center of Clinical Nursing Sciences, University Hospital Zurich, Zurich, Switzerland
| | - Michael Krauthammer
- Department for Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | - Reto A. Schuepbach
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Marcos Delgado
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
- Department of Anesthesia and Intensive Care Medicine, Tiefenau Hospital, Insel Group. University of Bern, Bern, Switzerland
| | - Jan Bartussek
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
- Department for Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| |
Collapse
|
2
|
Trauzeddel RF, Nordine M, Fucini GB, Sander M, Dreger H, Stangl K, Treskatsch S, Habicher M. Feasibility of Goal-Directed Fluid Therapy in Patients with Transcatheter Aortic Valve Replacement - An Ambispective Analysis. Braz J Cardiovasc Surg 2024; 39:e20220470. [PMID: 38426709 PMCID: PMC10903543 DOI: 10.21470/1678-9741-2022-0470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 07/19/2023] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Goal-directed fluid therapy (GDFT) has been shown to reduce postoperative complications. The feasibility of GDFT in transcatheter aortic valve replacement (TAVR) patients under general anesthesia has not yet been demonstrated. We examined whether GDFT could be applied in patients undergoing TAVR in general anesthesia and its impact on outcomes. METHODS Forty consecutive TAVR patients in the prospective intervention group with GDFT were compared to 40 retrospective TAVR patients without GDFT. Inclusion criteria were age ≥ 18 years, elective TAVR in general anesthesia, no participation in another interventional study. Exclusion criteria were lack of ability to consent study participation, pregnant or nursing patients, emergency procedures, preinterventional decubitus, tissue and/or extremity ischemia, peripheral arterial occlusive disease grade IV, atrial fibrillation or other severe heart rhythm disorder, necessity of usage of intra-aortic balloon pump. Stroke volume and stroke volume variation were determined with uncalibrated pulse contour analysis and optimized according to a predefined algorithm using 250 ml of hydroxyethyl starch. RESULTS Stroke volume could be increased by applying GDFT. The intervention group received more colloids and fewer crystalloids than control group. Total volume replacement did not differ. The incidence of overall complications as well as intensive care unit and hospital length of stay were comparable between both groups. GDFT was associated with a reduced incidence of delirium. Duration of anesthesia was shorter in the intervention group. Duration of the interventional procedure did not differ. CONCLUSION GDFT in the intervention group was associated with a reduced incidence of postinterventional delirium.
Collapse
Affiliation(s)
- Ralf Felix Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine,
Charité - Universitätsmedizin Berlin, Corporate Member of Freie
Universität Berlin and Humboldt-Universität zu Berlin, Campus Benjamin
Franklin, Berlin, Germany
| | - Michael Nordine
- Department of Anesthesiology, Intensive Care Medicine, and Pain
Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt,
Hessen, Germany
| | - Giovanni B. Fucini
- Institute of Hygiene and Environmental Medicine and National
Reference Center for the Surveillance of Nosocomial Infections, Charité -
Universitätsmedizin Berlin, Corporate Member of Freie Universität
Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care Medicine,
and Pain Therapy, Justus Liebig University of Giessen, Hessen, Germany
| | - Henryk Dreger
- Department of Cardiology, Angiology, and Intensive Care Medicine,
Deutsches Herzzentrum der Charité - Medical Heart Center of Charité
and German Heart Institute Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Karl Stangl
- Department of Cardiology and Angiology, Deutsches Herzzentrum der
Charité - Medical Heart Center of Charité and German Heart Institute
Berlin, Campus Charité Mitte, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine,
Charité - Universitätsmedizin Berlin, Corporate Member of Freie
Universität Berlin and Humboldt-Universität zu Berlin, Campus Benjamin
Franklin, Berlin, Germany
| | - Marit Habicher
- Department of Anesthesiology, Operative Intensive Care Medicine,
and Pain Therapy, Justus Liebig University of Giessen, Hessen, Germany
| |
Collapse
|
3
|
Goettel N, Wueest AS. Diagnosing delirium in perioperative and intensive care medicine. Curr Opin Anaesthesiol 2023; 36:491-499. [PMID: 37427443 DOI: 10.1097/aco.0000000000001288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
PURPOSE OF REVIEW This article reviews the current literature on instruments used for screening and diagnosing delirium in perioperative and intensive care medicine. It summarizes recent findings to guide clinicians and researchers in choosing the most appropriate tools. RECENT FINDINGS The incidence of delirium in hospitalized patients ranges from 5% to over 50%, depending on the population of patients studied. Failure to diagnose delirium in a timely manner is associated with serious adverse outcomes, including death and institutionalization. Valid assessment tests are needed for delirium detection, as early identification and treatment of delirium may help to prevent complications. Currently, there are more than 30 available instruments, which have been developed to assist with the screening and diagnosis of delirium. However, these tools vary greatly in sensitivity, specificity, and administration time, and their overabundance challenges the selection of specific tool as well as direct comparisons and interpretation of results across studies. SUMMARY Overlooking or misdiagnosing delirium may result in poor patient outcomes. Familiarizing healthcare workers with the variety of delirium assessments and selecting the most appropriate tool to their needs is an important step toward improving awareness and recognition of delirium.
Collapse
Affiliation(s)
- Nicolai Goettel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Clinical Research, University of Basel
| | - Alexandra S Wueest
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel
- Memory Clinic, University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
| |
Collapse
|
4
|
Hori Y, Mihashi M. Relationship Between Delirium Development and Its Causative Factors in the Intensive Care Unit After Cardiac Surgery. Yonago Acta Med 2023; 66:214-222. [PMID: 37229376 PMCID: PMC10203640 DOI: 10.33160/yam.2023.05.003] [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: 11/08/2022] [Accepted: 03/10/2023] [Indexed: 05/27/2023]
Abstract
Background Delirium is a clinical symptom that can have serious side effects in patients, and it develops acutely and shows reversibility. Postoperative delirium is an important neuropsychological complication after surgery that directly or indirectly affects patients. Cardiac surgery increases the risk of delirium due to the complexity of surgical procedures, use of intraoperative and postoperative anesthetics and other pharmacologic agents, and possible postoperative complications. This study aims to determine the relationship between the development of delirium and its causative factors after cardiac surgery and its associated postoperative complications, and identify the high-relevance risk factors of postoperative delirium. Methods The participants comprised 730 patients who were admitted to the intensive care unit and underwent cardiac surgery. The collected data included 19 risk factors based on the patients' medical information records. As a delirium diagnostic tool, we used the Intensive Care Delirium Screening Checklist, with four or more points indicating delirium. For statistical analysis, the dependent variables were determined based on the presence or absence of delirium, while the independent variables were determined based on the risk factors of delirium. A t-test, χ2 test, and logistic regression analysis were performed on risk factors between the two groups-the delirium group and no delirium group. Results Postoperative delirium was observed in 126 (17.3%) of 730 patients after cardiac surgery. Postoperative complications were more common in the delirium group. Independent risk factors associated with postoperative delirium were identified in 7 of the 12 factors. Conclusion As cardiac surgery is invasive and affects the development and severity of delirium, efforts and intervention methods are necessary to predict the risk factors for the development of delirium before surgery, and to prevent its occurrence after surgery. In the future, it is necessary to further investigate factors associated with delirium that can be directly intervened.
Collapse
Affiliation(s)
- Yukio Hori
- Kurume University Graduate School of Medicine, Kurume 830-0003, Japan and
| | - Mutsuko Mihashi
- Kurume University School of Medicine, Nursing, Kurume 830-0003, Japan
| |
Collapse
|
5
|
Rengel KF, Boncyk CS, DiNizo D, Hughes CG. Perioperative Neurocognitive Disorders in Adults Requiring Cardiac Surgery: Screening, Prevention, and Management. Semin Cardiothorac Vasc Anesth 2023; 27:25-41. [PMID: 36137773 DOI: 10.1177/10892532221127812] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neurocognitive changes are the most common complication after cardiac surgery, ranging from acute postoperative delirium to prolonged postoperative neurocognitive disorder. Changes in cognition are distressing to patients and families and associated with worse outcomes overall. This review outlines definitions and diagnostic criteria, risk factors for, and mechanisms of Perioperative Neurocognitive Disorders and offers strategies for preoperative screening and perioperative prevention and management of neurocognitive complications.
Collapse
Affiliation(s)
- Kimberly F Rengel
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniella DiNizo
- Scope Anesthesia of North Carolina, Charlotte, NC, USA.,Pulmonary and Critical Care Consultants, Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Christopher G Hughes
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| |
Collapse
|
6
|
Wueest AS, Berres M, Bettex DA, Steiner LA, Monsch AU, Goettel N. Independent External Validation of a Preoperative Prediction Model for Delirium After Cardiac Surgery: A Prospective Observational Cohort Study. J Cardiothorac Vasc Anesth 2023; 37:415-422. [PMID: 36567220 DOI: 10.1053/j.jvca.2022.11.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/09/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This investigation provided independent external validation of an existing preoperative risk prediction model. DESIGN A prospective observational cohort study of patients undergoing cardiac surgery covering the period between April 16, 2018 and January 18, 2022. SETTING Two academic hospitals in Switzerland. PARTICIPANTS Adult patients (≥60 years of age) who underwent elective cardiac surgery, including coronary artery bypass graft, mitral or aortic valve replacement or repair, and combined procedures. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome measure was the incidence of postoperative delirium (POD) in the intensive or intermediate care unit, diagnosed using the Intensive Care Delirium Screening Checklist. The prediction model contained 4 preoperative risk factors to which the following points were assigned: Mini-Mental State Examination (MMSE) score ≤23 received 2 points; MMSE 24-27, Geriatric Depression Scale (GDS) >4, prior stroke and/or transient ischemic attack (TIA), and abnormal serum albumin (≤3.5 or ≥4.5 g/dL) received 1 point each. The missing data were handled using multiple imputation. In total, 348 patients were included in the study. Sixty patients (17.4%) developed POD. For point levels in the prediction model of 0, 1, 2, and ≥3, the cumulative incidence of POD was 12.6%, 22.8%, 25.8%, and 35%, respectively. The validation resulted in a pooled area under the receiver operating characteristics curve of 0.60 (median CI, 0.525-0.679). CONCLUSIONS The evaluated predictive model for delirium after cardiac surgery in this patient cohort showed only poor discriminative capacity but fair calibration.
Collapse
Affiliation(s)
- Alexandra S Wueest
- Memory Clinic, University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland; Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Manfred Berres
- Department of Mathematics and Technology, University of Applied Sciences Koblenz, Germany
| | - Dominique A Bettex
- Division of Cardiovascular Anaesthesia, Institute of Anaesthesia, University Hospital Zurich, Zurich, Switzerland
| | - Luzius A Steiner
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland; Department of Clinical Research University of Basel, Basel, Switzerland
| | - Andreas U Monsch
- Memory Clinic, University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
| | - Nicolai Goettel
- Department of Clinical Research University of Basel, Basel, Switzerland; Department of Anaesthesiology, University of Florida College of Medicine, Gainesville, FL, USA.
| |
Collapse
|
7
|
Dahl TS, Lindblom RPF. Intermediate outcomes following arch reconstruction with frozen elephant trunk, a single centre study. J Cardiothorac Surg 2023; 18:44. [PMID: 36683042 PMCID: PMC9869602 DOI: 10.1186/s13019-023-02140-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 01/05/2023] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Surgery on the aortic arch and proximal descending thoracic aorta can be lifesaving but is also associated with significant morbidity, ranging from minor infections to severe neurological impairments as well as a substantial risk of mortality. The aim of this study is to clinically assess outcomes, with special regards to neurologic injury, as well as to seek to identify predictors of in-hospital mortality in two patient groups with different underlying aortic pathology, aneurysms and dissections, undergoing arch/descending aortic repair. METHODS 34 patients (17 aneurysms, 17 dissections) underwent surgery involving the arch and/or descending aorta, using the Thoraflex or E-Vita frozen elephant trunk graft. 40% were female. Subgroup analysis of aneurysms compared to dissections were performed. Mean follow-up time was 53.9 months and mean age 63.5 years. RESULTS In-hospital mortality was 18%. Survival was comparable between aneurysms and dissections. Incidence of spinal cord injury was 9% and stroke 9%. 67% suffered any form of neurological affection, when also cognitive afflictions were included. Perioperative reoperation rate was 29% (bleeding 21%, visceral ischemia 6%, infection 2%), the need for postoperative dialysis was 11% and a series of other minor complications such as atrial fibrillation and pleurocentesis were common. CONCLUSION Postoperative dialysis was found to be a predictor of in-hospital mortality, while both dialysis as well as reoperation due to bleeding and/or visceral ischemia increased the risk for overall mortality, irrespective of preoperative diagnosis. Previous or current smoking appeared to be associated with negative outcomes regarding both in-hospital and overall mortality during follow-up. Trial registration Retrospectively enrolled.
Collapse
Affiliation(s)
- Therese Schagerholm Dahl
- grid.8993.b0000 0004 1936 9457Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden
| | - Rickard P. F. Lindblom
- grid.8993.b0000 0004 1936 9457Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden ,grid.412354.50000 0001 2351 3333Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, 751 85 Uppsala, Sweden
| |
Collapse
|
8
|
Mukaida H, Matsushita S, Minami Y, Sato G, Usuba M, Kondo R, Asai T, Amano A. Risk factors for postoperative delirium on oxygen delivery-guided perfusion. J Cardiothorac Surg 2022; 17:193. [PMID: 35987682 PMCID: PMC9392930 DOI: 10.1186/s13019-022-01938-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Studies have demonstrated the efficacy of oxygen delivery-guided perfusion (ODGP) in preventing postoperative acute kidney injury, but the benefit of ODGP for delirium has not been confirmed. We retrospectively investigated the risk factors for postoperative delirium in patients who underwent ODGP (with oxygen delivery index [DO2i] > 300 mL/min/m2).
Methods
Consecutive patients who underwent on-pump cardiovascular surgery with ODGP from January 2018 to December 2020 were retrospectively analyzed. In addition to examining patients’ DO2i during cardiopulmonary bypass (CPB), we quantified the two primary DO2 components-hematocrit (Hct) and pump flow. Delirium was defined based on the Intensive Care Delirium Screening Checklist (ICDSC). Patients were divided into three groups: no delirium (ICDSC score = 0), subsyndromal delirium (ICDSC score = 1–3), and clinical delirium (ICDSC score ≥ 4).
Results
Multivariate analysis identified only the number of red blood cell (RBC) units transfused, intubation time, and the cumulative time below the Hct threshold of 25% as predictive factors of postoperative delirium. Although patients with higher ICDSC scores had greater hemodilution during CPB, ODGP resulted in a higher pump flow, and DO2i was maintained above 300 mL/min/m2, with no significant difference between the three groups.
Conclusions
A low Hct level during CPB with ODGP, the number of RBC units transfused, and intubation time were associated with postoperative delirium. Further investigations are needed to determine the ability of ODGP to prevent low Hct during CPB.
Collapse
|
9
|
Neerland BE, Busund R, Haaverstad R, Helbostad JL, Landsverk SA, Martinaityte I, Norum HM, Ræder J, Selbaek G, Simpson MR, Skaar E, Skjærvold NK, Skovlund E, Slooter AJ, Svendsen ØS, Tønnessen T, Wahba A, Zetterberg H, Wyller TB. Alpha-2-adrenergic receptor agonists for the prevention of delirium and cognitive decline after open heart surgery (ALPHA2PREVENT): protocol for a multicentre randomised controlled trial. BMJ Open 2022; 12:e057460. [PMID: 35725264 PMCID: PMC9214392 DOI: 10.1136/bmjopen-2021-057460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Postoperative delirium is common in older cardiac surgery patients and associated with negative short-term and long-term outcomes. The alpha-2-adrenergic receptor agonist dexmedetomidine shows promise as prophylaxis and treatment for delirium in intensive care units (ICU) and postoperative settings. Clonidine has similar pharmacological properties and can be administered both parenterally and orally. We aim to study whether repurposing of clonidine can represent a novel treatment option for delirium, and the possible effects of dexmedetomidine and clonidine on long-term cognitive trajectories, motor activity patterns and biomarkers of neuronal injury, and whether these effects are associated with frailty status. METHODS AND ANALYSIS This five-centre, double-blind randomised controlled trial will include 900 cardiac surgery patients aged 70+ years. Participants will be randomised 1:1:1 to dexmedetomidine or clonidine or placebo. The study drug will be given as a continuous intravenous infusion from the start of cardiopulmonary bypass, at a rate of 0.4 µg/kg/hour. The infusion rate will be decreased to 0.2 µg/kg/hour postoperatively and be continued until discharge from the ICU or 24 hours postoperatively, whichever happens first.Primary end point is the 7-day cumulative incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). Secondary end points include the composite end point of coma, delirium or death, in addition to delirium severity and motor activity patterns, levels of circulating biomarkers of neuronal injury, cognitive function and frailty status 1 and 6 months after surgery. ETHICS AND DISSEMINATION This trial is approved by the Regional Committee for Ethics in Medical Research in Norway (South-East Norway) and by the Norwegian Medicines Agency. Dissemination plans include publication in peer-reviewed medical journals and presentation at scientific meetings. TRIAL REGISTRATION NUMBER NCT05029050.
Collapse
Affiliation(s)
| | - Rolf Busund
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, UiT The Artic University of Norway, Tromsø, Norway
| | - Rune Haaverstad
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Jorunn L Helbostad
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Ieva Martinaityte
- Institute of Clinical Medicine, UiT The Artic University of Norway, Tromsø, Norway
- Department of Geriatric Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Hilde Margrethe Norum
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
- Department of Research and Development, Oslo University Hospital, Oslo, Norway
| | - Johan Ræder
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Geir Selbaek
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Norwegian National Advisory Unit on Ageing and Health, Tønsberg, Norway
| | - Melanie R Simpson
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elisabeth Skaar
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Nils Kristian Skjærvold
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Anesthesia and Intensive Care Medicine, Trondheim University Hospital, Trondheim, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arjen Jc Slooter
- Department of Intensive Care Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussel, Brussel, Belgium
| | - Øyvind Sverre Svendsen
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Theis Tønnessen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - Alexander Wahba
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Cardiothoracic Surgery, Trondheim University Hospital, Trondheim, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
- UK Dementia Research Institute, UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong, People's Republic of China
| | - Torgeir Bruun Wyller
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
10
|
Choi H, Park CS, Huh J, Koo J, Jeon J, Kim E, Jung S, Kim HW, Lim JY, Hwang W. Intraoperative Glycemic Variability and Mean Glucose are Predictors for Postoperative Delirium After Cardiac Surgery: A Retrospective Cohort Study. Clin Interv Aging 2022; 17:79-95. [PMID: 35153478 PMCID: PMC8827640 DOI: 10.2147/cia.s338712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/20/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose Postoperative delirium (POD) is a common but serious complication after cardiac surgery and is associated with various short- and long-term outcomes. In this study, we investigated the effects of intraoperative glycemic variability (GV) and other glycemic variables on POD after cardiac surgery. Patients and Methods A retrospective single-center cohort analysis was conducted using data from electronic medical record from 2018 to 2020. A total of 705 patients undergoing coronary artery bypass graft surgery and/or valve surgery, and/or aortic replacement surgery were included in the analysis. Intraoperative GV was assessed with a coefficient of variation (CV), which was defined as the standard deviation of five intraoperative blood glucose measurements divided by the mean. POD assessment was performed three times a day in the ICU and twice a day in the ward until discharge by trained medical staff. POD was diagnosed if any of the Confusion Assessment Method for the Intensive Care Unit was positive in the ICU, and the Confusion Assessment Method was positive in the ward. Multivariable logistic regression was used to identify associations between intraoperative GV and POD. Results POD occurred in 306 (43.4%) patients. When intraoperative glycemic CV was compared as a continuous variable, the delirium group had higher intraoperative glycemic CV than the non-delirium group (22.59 [17.09, 29.68] vs 18.19 [13.00, 23.35], p < 0.001), and when intraoperative glycemic CV was classified as quartiles, the incidence of POD increased as intraoperative glycemic CV quartiles increased (first quartile 29.89%; second quartile 36.67%; third quartile 44.63%; and fourth quartile 62.64%, p < 0.001). In the multivariable logistic regression model, patients in the third quartile of intraoperative glycemic CV were 1.833 times (OR 1.833, 95% CI: 1.132–2.967, p = 0.014), and patients in the fourth quartile of intraoperative glycemic CV were 3.645 times (OR 3.645, 95% CI: 2.235–5.944, p < 0.001) more likely to develop POD than those in the first quartile of intraoperative glycemic CV. Conclusion Intraoperative blood glucose fluctuation, manifested by intraoperative GV, is associated with POD after cardiac surgery. Patients with a higher intraoperative GV have an increased risk of POD.
Collapse
Affiliation(s)
- Hoon Choi
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Soo Park
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jaewon Huh
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jungmin Koo
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joonpyo Jeon
- Department of Anesthesia and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eunsung Kim
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sangmin Jung
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hwan Wook Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Yong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Wonjung Hwang
- Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Correspondence: Wonjung Hwang, Department of Anesthesia and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea, Tel +82-2-22586162, Fax +82-2-5371951, Email
| |
Collapse
|
11
|
Augoustides JG. Protecting the Central Nervous System During Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
12
|
He J, Ling Q, Chen Y. Construction and Application of a Model for Predicting the Risk of Delirium in Postoperative Patients With Type a Aortic Dissection. Front Surg 2021; 8:772675. [PMID: 34869569 PMCID: PMC8636852 DOI: 10.3389/fsurg.2021.772675] [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: 09/08/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Postoperative delirium (POD), an alteration in a patient's consciousness pattern, can affect the treatment and prognosis of a disease. Objective: To construct a prediction model for delirium in patients with type A aortic dissection after surgery and to validate its effectiveness. Methods: A retrospective cohort design was used to study 438 patients undergoing surgical treatment for type A aortic dissection from April 2019 to June 2020 in tertiary care hospitals. POD (n = 78) and non-delirium groups (n = 360) were compared and analyzed for each index in the perioperative period. A prediction model was established using multifactorial logistic regression, and 30 patients' perioperative data were collected for model validation. Results: Eight predictors were included in this study: smoking, diabetes, previous cardiovascular surgery, ejection fraction (EF), time to aortic block, acute kidney injury, low cardiac output syndrome, and pulmonary complications. The area under the receiver operating characteristic (ROC) curve of the constructed prediction model was 0.98 ± 0.005, and the Youden index was 0.91. The validation results showed 97% sensitivity, 100% specificity, and 93% accuracy. The expression of the model was Z = Smoking assignment* – 2.807 – 6.009*Diabetes assignment – 2.994*Previous cardiovascular surgery assignment – 0.129*Ejection fraction assignment + 0.071*Brain perfusion time assignment – 2.583*Acute kidney injury assignment – 2.916*Low cardiac output syndrome assignment – 3.461*Pulmonary related complications assignment + 20.576. Conclusion: The construction of an effective prediction model for the risk of delirium in patients after type A aortic stratification can help identify patients at high risk of POD early. It also provides a reference for healthcare professionals in the prevention and care of these patients.
Collapse
Affiliation(s)
- Junfeng He
- Department of Nursing, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Qing Ling
- Department of Nursing, Nanjing First Hospital, Nanjing, China
| | - Yuhong Chen
- Department of Nursing, Nanjing First Hospital, Nanjing, China
| |
Collapse
|
13
|
Cheng HW, Liu CY, Chen YS, Shih CC, Chen WY, Chiou AF. Assessment of preoperative frailty and identification of patients at risk for postoperative delirium in cardiac intensive care units: a prospective observational study. Eur J Cardiovasc Nurs 2021; 20:745-751. [PMID: 34472606 DOI: 10.1093/eurjcn/zvab076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/24/2021] [Accepted: 08/17/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Postoperative delirium (POD) is a common complication that may occur from 24 to 72 h after cardiac surgery. Frailty is a chronic syndrome that leads to a decline in physiological reserve and to disability. The associations between frailty and POD are unclear. AIMS To investigate associations between POD and frailty in patients undergoing cardiac surgery and to analyse predictors of POD. METHODS AND RESULTS Convenience sampling was used to recruit 152 patients who underwent cardiac surgery in two medical centres in northern Taiwan. Preoperative frailty in these patients was evaluated using Fried's frailty phenotype. Delirium in patients was assessed from postoperative day 1 to day 5 using the confusion assessment method for intensive care units. A total of 152 patients who underwent cardiac surgery included 68 (44.74%) prefrail patients and 21 (13.81%) patients with frailty after the surgery. Ten patients (6.58%) developed delirium after cardiac surgery. The occurrence of delirium peaked at postoperative day 2, and the average duration of delirium was 3 days. A case-control comparison revealed a significant correlation between preoperative frailty and POD. Significant predictors of POD in patients undergoing cardiac surgery included the European System for Cardiac Operative Risk Evaluation II, preoperative arrhythmia, and preoperative anxiety and depression. CONCLUSION Preoperative frailty was correlated with POD. Preoperative arrhythmia, anxiety, and depression are predictors of POD. Nurses should perform preoperative assessments of surgical risk and physiological and psychological conditions of patients undergoing cardiac surgery and monitor the occurrence of POD.
Collapse
Affiliation(s)
- Hsiao-Wei Cheng
- Department of Nursing, National Taiwan University Hospital, No.7, Chung Shan South Road, Zhongzheng Dist., Taipei 100, Taiwan
| | - Chieh-Yu Liu
- Biostatistical Consultant Lab, Department of Health Care Management, National Taipei University of Nursing and Health Sciences, No.365, Ming-te Road, Peitou District, Taipei 112, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, Cardiovascular Surgery & Ped Cardiovascular Surgery, National Taiwan University Hospital, and College of Medicine, National Taiwan University, No.7, Chung Shan South Road, Zhongzheng Dist., Taipei 100, Taiwan
| | - Chun-Che Shih
- Taipei Heart Institute, Taipei Medical University, No. 250 Wu-Hsing St. Taipei 110, Taiwan.,Division of Cardiovascular Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, No. 111, Sec.3, Xinglong Rd., Wenshan Dist., Taipei 116, Taiwan.,Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, No. 250 Wu-Hsing St. Taipei 110, Taiwan.,Institute of Clinical Medicine, Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Li-Nong St., Taipei 112, Taiwan
| | - Wei-Yi Chen
- Department of Nursing, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei 112, Taiwan
| | - Ai-Fu Chiou
- College of Nursing, Institute of Clinical Nursing, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Li-Nong St., Taipei 112, Taiwan
| |
Collapse
|
14
|
Association between perioperative hypotension and postoperative delirium and atrial fibrillation after cardiac surgery: A post-hoc analysis of the DECADE trial. J Clin Anesth 2021; 76:110584. [PMID: 34784557 DOI: 10.1016/j.jclinane.2021.110584] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To test the hypotheses that in adults having cardiac surgery with cardio-pulmonary bypass, perioperative hypotension increases the risk of delirium and atrial fibrillation during the initial five postoperative days. DESIGN Sub-analysis of the DECADE multi-center randomized trial. SETTING Patients who had cardiac surgery with cardiopulmonary bypass at the Cleveland Clinic. INTERVENTIONS In the underlying trial, patients were randomly assigned 1:1 to dexmedetomidine or normal saline placebo. MEASUREMENTS Intraoperative mean arterial pressures were recorded at 1-min intervals from arterial catheters or at 1-5-min intervals oscillometrically. Postoperative blood pressures were recorded every half-hour or more often. The co-primary outcomes were atrial fibrillation and delirium occurring between intensive care unit admission and the earlier of postoperative day 5 or hospital discharge. Delirium was assessed twice daily during the initial 5 postoperative days while patients remained hospitalized with the Confusion Assessment Method for the intensive care unit. Assessments were made by trained research fellows who were blinded to the dexmedetomidine administration. MAIN RESULTS There was no significant association between intraoperative hypotension and delirium, with an adjusted odds ratio of 0.94 (95% CI: 0.81, 1.09; P = 0.419) for a doubling in AUC of mean arterial pressure (MAP) <60 mmHg. An increase in intraoperative AUC of MAP <60 mmHg was not significantly associated with the odds of atrial fibrillation (adjusted odds ratio = 0.99; 95% CI: 0.87, 1.11; P = 0.819). Postoperative MAP <70 mmHg per hour 1.14 (97.5% CI: 1.04,1.26; P = 0.002) and MAP <80 mmHg per hour 1.05 (97.5%: 1.01, 1.10; P = 0.010) were significantly associated with atrial fibrillation. CONCLUSIONS In patients having cardiac surgery with cardio-pulmonary bypass, neither intraoperative nor postoperative hypotension were associated with delirium. Postoperative hypotension was associated with atrial fibrillation, although intraoperative hypotension was not.
Collapse
|
15
|
Shin HJ, Choi SL, Na HS. Prevalence of postoperative delirium with different combinations of intraoperative general anesthetic agents in patients undergoing cardiac surgery: A retrospective propensity-score-matched study. Medicine (Baltimore) 2021; 100:e26992. [PMID: 34414981 PMCID: PMC8376347 DOI: 10.1097/md.0000000000026992] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/11/2021] [Indexed: 01/04/2023] Open
Abstract
Postoperative delirium (PD) remains an issue in cardiac surgery despite the constant efforts to reduce its incidence. In this retrospective study, the incidence of PD was evaluated in patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) according to different primary anesthetic agents: sevoflurane and dexmedetomidine- versus propofol-based anesthesia.A total of 534 patients who underwent heart-valve surgery or coronary artery bypass graft surgery with CPB between January 2012 and August 2017 were divided into 2 groups according to the main anesthetic agent: sevoflurane with dexmedetomidine (sevo-dex group, n = 340) and propofol (propofol group, n = 194). The incidence of PD was evaluated as the primary outcome. Patient-, surgery-, and anesthesia-related factors and postoperative complications were investigated as secondary outcomes. To reduce the risk of confounding effects between the 2 groups, 194 patients were selected from the sevo-dex group after propensity-score matching.After propensity-score matching, the incidence of PD was not significantly different between the sevo-dex (6.2%) and propofol (10.8%) groups (P = .136). In comparisons of the incidence of each type of PD, only hyperactive PD occurred significantly less frequently in the sevo-dex group (P = .021). Older age, lower preoperative albumin levels, and emergency surgery were significant risk factors for PD.The overall incidence of PD after cardiac surgery with CPB did not differ between patients receiving sevoflurane and dexmedetomidine-based versus propofol-based anesthesia. Only hyperactive PD occurred less frequently in patients receiving sevoflurane and dexmedetomidine-based anesthesia.
Collapse
|
16
|
Falk A, Kåhlin J, Nymark C, Hultgren R, Stenman M. Depression as a predictor of postoperative delirium after cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2021; 32:371-379. [PMID: 33831217 PMCID: PMC8906754 DOI: 10.1093/icvts/ivaa277] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/07/2020] [Accepted: 10/13/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Depression is common in patients with cardiac disease. The importance of preoperative depression for development of postoperative delirium (POD) following cardiac surgery is not well known. The aim is to provide a summary estimate of depression as a predictor of POD following cardiac surgery. METHODS Systematic search of MEDLINE, EMBASE, Cochrane Library, Web of Science Core Collection and Psycinfo (Ovid) was performed from inception to October 2019, including cohort studies reporting odds ratios (ORs) and 95% confidence intervals (CIs) for POD following cardiac surgery in patients with preoperative depression compared to patients without depression. ORs and 95% CIs for POD were calculated using random-effects meta-analyses. Subgroup and sensitivity analyses were performed. RESULTS Seven studies were included with a combined study population of 2066 patients. The pooled prevalence of POD in the combined study population was 26% and preoperative depression was present in ∼9% of the total study population. All studies showed a positive association between preoperative depression and POD; and in 5 studies, the association was statistically significant. Patients with depression had a pooled OR of 2.31 (95% CI 1.37-3.90) for POD. CONCLUSIONS This systematic review and meta-analysis confirm the findings that the previous association between preoperative depression and increased risk for developing POD reported for other patient groups is found also in cardiac surgery. Depression screening prior to cardiac surgery may be effective in identifying patients at higher risk for POD.
Collapse
Affiliation(s)
- Anna Falk
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Jessica Kåhlin
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Carolin Nymark
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Stenman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
17
|
Tonna JE, Dalton A, Presson AP, Zhang C, Colantuoni E, Lander K, Howard S, Beynon J, Kamdar BB. The Effect of a Quality Improvement Intervention on Sleep and Delirium in Critically Ill Patients in a Surgical ICU. Chest 2021; 160:899-908. [PMID: 33773988 DOI: 10.1016/j.chest.2021.03.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 03/08/2021] [Accepted: 03/13/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Delirium is a deleterious condition affecting up to 60% of patients in the surgical ICU (SICU). Few SICU-focused delirium interventions have been implemented, including those addressing sleep-wake disruption, a modifiable delirium risk factor common in critically ill patients. RESEARCH QUESTION What is the effect on delirium and sleep quality of a multicomponent nonpharmacologic intervention aimed at improving sleep-wake disruption in patients in the SICU setting? STUDY DESIGN AND METHODS Using a staggered pre-post design, we implemented a quality improvement intervention in two SICUs (general surgery or trauma and cardiovascular) in an academic medical center. After a preintervention (baseline) period, a multicomponent unit-wide nighttime (ie, efforts to minimize unnecessary sound and light, provision of earplugs and eye masks) and daytime (ie, raising blinds, promotion of physical activity) intervention bundle was implemented. A daily checklist was used to prompt staff to complete intervention bundle elements. Delirium was evaluated twice daily using the Confusion Assessment Method for the Intensive Care Unit. Patient sleep quality ratings were evaluated daily using the Richards-Campbell Sleep Questionnaire (RCSQ). RESULTS Six hundred forty-six SICU admissions (332 baseline, 314 intervention) were analyzed. Median age was 61 years (interquartile range, 49-70 years); 35% of the cohort were women and 83% were White. During the intervention period, patients experienced fewer days of delirium (proportion ± SD of ICU days, 15 ± 27%) as compared with the preintervention period (20 ± 31%; P = .022), with an adjusted pre-post decrease of 4.9% (95% CI, 0.5%-9.2%; P = .03). Overall RCSQ-perceived sleep quality ratings did not change, but the RCSQ noise subscore increased (9.5% [95% CI, 1.1%-17.5%; P = .02). INTERPRETATION Our multicomponent intervention was associated with a significant reduction in the proportion of days patients experienced delirium, reinforcing the feasibility and effectiveness of a nonpharmacologic sleep-wake bundle to reduce delirium in critically ill patients in the SICU. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03313115; URL: www.clinicaltrials.gov.
Collapse
Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT; Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT.
| | - Anna Dalton
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Angela P Presson
- Division of Epidemiology, Department of Medicine, University of Utah Health, Salt Lake City, UT
| | - Chong Zhang
- Division of Epidemiology, Department of Medicine, University of Utah Health, Salt Lake City, UT
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Kirsten Lander
- Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City, UT
| | - Sullivan Howard
- Surgical Intensive Care Unit, Critical Care, University of Utah Health, Salt Lake City, UT
| | - Julia Beynon
- AirMed & Emergency Nursing, University of Utah Health, Salt Lake City, UT
| | - Biren B Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, School of Medicine, La Jolla, CA
| |
Collapse
|
18
|
Hamadnalla H, Sessler DI, Troianos CA, Fang J, Rivas E, Ma C, Mascha EJ, Turan A. Optimal interval and duration of CAM-ICU assessments for delirium detection after cardiac surgery. J Clin Anesth 2021; 71:110233. [PMID: 33706033 DOI: 10.1016/j.jclinane.2021.110233] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE Our goal was to determine when postoperative delirium first occurs, and to assess evaluation strategies that reliably detect delirium with lowest frequency of testing'. DESIGN This was a retrospective study that used a database from a five-center randomized trial. SETTING Postoperative cardiothoracic ICU and surgical wards. PARTICIPANT Adults scheduled for elective coronary artery bypass and/or valve surgery. INTERVENTION AND MEASUREMENTS Postoperative delirium was assessed using CAM-ICU questionnaires twice daily for 5 days or until hospital discharge. Data were analyzed using frequency tables and Kaplan-Meier time-to-event estimators, the latter being used to summarize time to first positive CAM-ICU over POD1-5 for all patients for various evaluation strategies, including all assessments, only morning assessment, and only afternoon assessments. Sensitivity for various strategies were compared using McNemar's test for paired proportions. MAIN RESULTS A total of 95 of 788 patients (12% [95% CI, 10% to 15%]) had at least 1 episode of delirium within the first 5 postoperative days. Among all patients with delirium, 65% were identified by the end of the first postoperative day. Delirium was detected more often in the mornings (10% of patients) than evenings (7% of patients). Compared to delirium assessments twice daily for five days, we found that twice daily assessments for 4 days detected an estimated 97% (95% CI 91%, 99%) of delirium. Measurements twice daily for three days detected 90% (82%, 95%) of delirium. CONCLUSIONS Postoperative delirium is common, and CAM-ICU assessments twice daily for 4 days, versus 5 days, detects nearly all delirium with 20% fewer assessments. Four days of assessment may usually be sufficient for clinical and research purposes.
Collapse
Affiliation(s)
- Hassan Hamadnalla
- Department of Outcomes Research, Cleveland Clinic, OH, United States; Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health System, MI, United States
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, OH, United States
| | | | - Jonathan Fang
- Department of Outcomes Research, Cleveland Clinic, OH, United States
| | - Eva Rivas
- Department of Outcomes Research, Cleveland Clinic, OH, United States; Department of Anesthesiology, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona Spain
| | - Chao Ma
- Department of Outcomes Research, Cleveland Clinic, OH, United States; Department of Quantitative Health Sciences, Cleveland Clinic, OH, United States
| | - Edward J Mascha
- Department of Outcomes Research, Cleveland Clinic, OH, United States; Department of Quantitative Health Sciences, Cleveland Clinic, OH, United States
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, OH, United States; Department of General Anesthesiology, Cleveland Clinic, OH, United States.
| |
Collapse
|
19
|
Xue B, Li D, Lu C, King CR, Wildes T, Avidan MS, Kannampallil T, Abraham J. Use of Machine Learning to Develop and Evaluate Models Using Preoperative and Intraoperative Data to Identify Risks of Postoperative Complications. JAMA Netw Open 2021; 4:e212240. [PMID: 33783520 PMCID: PMC8010590 DOI: 10.1001/jamanetworkopen.2021.2240] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Postoperative complications can significantly impact perioperative care management and planning. OBJECTIVES To assess machine learning (ML) models for predicting postoperative complications using independent and combined preoperative and intraoperative data and their clinically meaningful model-agnostic interpretations. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed 111 888 operations performed on adults at a single academic medical center from June 1, 2012, to August 31, 2016, with a mean duration of follow-up based on the length of postoperative hospital stay less than 7 days. Data analysis was performed from February 1 to September 31, 2020. MAIN OUTCOMES AND MEASURES Outcomes included 5 postoperative complications: acute kidney injury (AKI), delirium, deep vein thrombosis (DVT), pulmonary embolism (PE), and pneumonia. Patient and clinical characteristics available preoperatively, intraoperatively, and a combination of both were used as inputs for 5 candidate ML models: logistic regression, support vector machine, random forest, gradient boosting tree (GBT), and deep neural network (DNN). Model performance was compared using the area under the receiver operating characteristic curve (AUROC). Model interpretations were generated using Shapley Additive Explanations by transforming model features into clinical variables and representing them as patient-specific visualizations. RESULTS A total of 111 888 patients (mean [SD] age, 54.4 [16.8] years; 56 915 [50.9%] female; 82 533 [73.8%] White) were included in this study. The best-performing model for each complication combined the preoperative and intraoperative data with the following AUROCs: pneumonia (GBT), 0.905 (95% CI, 0.903-0.907); AKI (GBT), 0.848 (95% CI, 0.846-0.851); DVT (GBT), 0.881 (95% CI, 0.878-0.884); PE (DNN), 0.831 (95% CI, 0.824-0.839); and delirium (GBT), 0.762 (95% CI, 0.759-0.765). Performance of models that used only preoperative data or only intraoperative data was marginally lower than that of models that used combined data. When adding variables with missing data as input, AUROCs increased from 0.588 to 0.905 for pneumonia, 0.579 to 0.848 for AKI, 0.574 to 0.881 for DVT, 0.5 to 0.831 for PE, and 0.6 to 0.762 for delirium. The Shapley Additive Explanations analysis generated model-agnostic interpretation that illustrated significant clinical contributors associated with risks of postoperative complications. CONCLUSIONS AND RELEVANCE The ML models for predicting postoperative complications with model-agnostic interpretation offer opportunities for integrating risk predictions for clinical decision support. Such real-time clinical decision support can mitigate patient risks and help in anticipatory management for perioperative contingency planning.
Collapse
Affiliation(s)
- Bing Xue
- Department of Electrical and Systems Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, Missouri
| | - Dingwen Li
- Department of Computer Science and Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, Missouri
| | - Chenyang Lu
- Department of Electrical and Systems Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, Missouri
- Department of Computer Science and Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Christopher R. King
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Troy Wildes
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Thomas Kannampallil
- Institute for Informatics, Washington University in St Louis School of Medicine, St Louis, Missouri
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Joanna Abraham
- Institute for Informatics, Washington University in St Louis School of Medicine, St Louis, Missouri
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri
| |
Collapse
|
20
|
Ordóñez-Velasco LM, Hernández-Leiva E. Factors associated with delirium after cardiac surgery: A prospective cohort study. Ann Card Anaesth 2021; 24:183-189. [PMID: 33884974 PMCID: PMC8253013 DOI: 10.4103/aca.aca_43_20] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background: Delirium is a frequent complication after cardiac surgery and is associated with a higher incidence of morbidity and mortality and a prolonged hospital stay. However, knowledge of the variables involved in its occurrence is still limited; therefore, in this study, we evaluated the perioperative risk factors independently associated with this complication. Methods: This study was conducted in a referral tertiary care university hospital with a cardiovascular focus. A total of 311 consecutive adult patients undergoing any type of cardiac surgery were evaluated. The subjects were examined at regular intervals in the postoperative period using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) tool. Results: The incidence of postoperative delirium (PD) was 10%. Among the 18 pre-, intra- and postoperative variables evaluated, the logistic regression analysis showed that low education level, history of diabetes or stroke, type of surgery, prolonged extracorporeal circulation, or red blood cell transfusion in the intra- or postoperative period were independently associated with delirium after cardiac surgery. An increased body mass index was identified as a protective factor. Conclusions: The aforementioned risk factors are significantly and independently associated with the presentation of PD. Because some of these factors can be treated or avoided, the results of this study are highly relevant to reduce the risk of this complication and improve the care of patients undergoing cardiac surgery.
Collapse
Affiliation(s)
- Lina Maria Ordóñez-Velasco
- Intensivist at Cardiovascular Intensive Care Unit. Instituto de Cardiología - Fundación Cardioinfantil, Colombia
| | - Edgar Hernández-Leiva
- Department of Cardiology, Head of the Cardiac Surgical Intensive Care Unit, Instituto de Cardiología - Fundación Cardioinfantil, Colombia
| |
Collapse
|
21
|
Hollinger A, Rüst CA, Riegger H, Gysi B, Tran F, Brügger J, Huber J, Toft K, Surbeck M, Schmid HR, Rentsch K, Steiner L, Siegemund M. Ketamine vs. haloperidol for prevention of cognitive dysfunction and postoperative delirium: A phase IV multicentre randomised placebo-controlled double-blind clinical trial. J Clin Anesth 2020; 68:110099. [PMID: 33120302 DOI: 10.1016/j.jclinane.2020.110099] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/21/2020] [Accepted: 10/10/2020] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVE Delirium is frequently observed in the postoperative and intensive care unit (ICU) population. Due to the multifactorial origin of delirium and according to international guidelines (e.g., American Geriatrics Society; Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) guideline), there are several but no incontestable options for prevention and symptomatic treatment. The purpose of the Baden PRIDe (Prevention and Reduction of Incidence of postoperative Delirium) trial was to determine whether postoperative cognitive dysfunction and delirium could be prevented by the combination of possible preventive agents such as haloperidol and ketamine. In addition, pre- and postoperative levels of the biomarkers cortisol, neuron specific enolase (NSE) and S100β were measured to investigate their dynamics in delirious and non-delirious patients after surgery. DESIGN The Baden PRIDe Trial was an investigator-initiated, phase IV, two-centre, randomised, placebo-controlled, double-blind clinical trial. SETTING Perioperative care. PATIENTS 182 adult patients that underwent elective or emergency surgery under general or combined (i.e., general and regional) anaesthesia. INTERVENTIONS Pre-anaesthetic, pharmacologic prevention of postoperative brain dysfunction with haloperidol, ketamine, and the combination of both vs. placebo. MEASUREMENTS Assessment of cognitive performance pre- and postoperatively with the MMSE, the DOS, the Nursing Delirium Screening Scale (Nu-DESC) or the Intensive Care Delirium Screening Checklist (ICDSC) during ICU stay. MAIN RESULTS None of the three study arms - haloperidol, ketamine, or both drugs combined - was significantly superior to placebo for prevention of postoperative brain dysfunction and delirium (P = 0.39). Measured levels of postoperative cortisol were significantly higher in delirious patients. S-100β levels were significantly higher in all postoperative outcome groups (cognitive impairment, delirium, no cognitive decline), whereas postoperative NSE levels declined in all groups. CONCLUSIONS The study results offer no possibility for a novel recommendation for prevention of postoperative cognitive decline including delirium. Perioperative S-100β trajectories in patients with cognitive deterioration suggest affection of glial cells in particular. TRIAL REGISTRATION ClinicalTrials.govNCT02433041; registered on April 7, 2015.
Collapse
Affiliation(s)
- Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4031 Basel, Switzerland.
| | - Christoph A Rüst
- Institute of Primary Care, University of Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland.
| | - Harriet Riegger
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland.
| | - Bianca Gysi
- Intensive Care Unit, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland.
| | - Fabian Tran
- Intensive Care Unit, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland.
| | - Jonas Brügger
- Intensive Care Unit, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland.
| | - Jan Huber
- Intensive Care Unit, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland.
| | - Katharina Toft
- Department for Anaesthesia, Intensive Care and Emergency Medicine, See-Spital, Horgen and Kilchberg Branches, Asylstrasse 19, 8810 Horgen, Switzerland.
| | - Madlen Surbeck
- Intensive Care Unit, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland.
| | - Hans-Ruedi Schmid
- Central Laboratory, Cantonal Hospital Baden, Im Ergel 1, 5404 Baden, Switzerland.
| | - Katharina Rentsch
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4031 Basel, Switzerland; Department of Clinical Chemistry and Laboratory Medicine, Petersgraben 4, 4031 Basel, Switzerland.
| | - Luzius Steiner
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4031 Basel, Switzerland; Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland.
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4031 Basel, Switzerland.
| |
Collapse
|
22
|
Arai Y, Shioji S, Tanaka H, Kondo I, Sakamoto E, Suzuki M, Katagiri D, Tada M, Hinoshita F. Delirium is independently associated with early mortality in elderly patients starting hemodialysis. Clin Exp Nephrol 2020; 24:1077-1083. [PMID: 32748309 DOI: 10.1007/s10157-020-01941-5] [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: 12/09/2019] [Accepted: 07/21/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Delirium is an independent predictor of death in patients undergoing dialysis for end-stage renal disease (ESRD). However, it is unknown whether delirium during hospitalization at the start of hemodialysis (HD) in elderly populations is associated with early mortality. METHODS We conducted a retrospective cohort study to investigate the association between delirium and early mortality in the elderly after starting HD. The cohort consisted of patients ≥ 75 years who started dialysis for ESRD at the National Center for Global Health and Medicine from 2010 to 2017 and at Yokosuka Kyosai Hospital from 2007 to 2011. Delirium was defined as patients who showed new symptoms of transient confused thinking and reduced awareness of their environment and were prescribed antipsychotic medications. The primary outcome was death within 1 year. Data were analyzed using Cox proportional hazard models with adjustments for baseline characteristics. A multinomial logistic regression was used to identify the determinants of patients developing delirium. RESULTS We enrolled 259 patients (males, 60%); 33 patients were diagnosed with delirium. The primary outcome was observed in 19 patients with delirium (58%) and 24 patients without delirium (11%) (p < 0.01). Delirium was independently associated with all-cause mortality within 1 year after starting HD (hazard ratio 7.82, 95% confidence interval 4.26-14.3; adjusted hazard ratio 7.16, 95% confidence interval 3.49-14.7). Delirium was positively correlated with "cognitive impairment" as well as "the use of steroids." CONCLUSION Delirium is independently associated with early mortality in the elderly after starting HD.
Collapse
Affiliation(s)
- Yohei Arai
- Department of Nephrology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-3655, Japan. .,Department of Nephrology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Shingo Shioji
- Department of Nephrology, Yokosuka Kyosai Hospital, Kanagawa, Japan
| | - Hiroyuki Tanaka
- Department of Nephrology, Yokosuka Kyosai Hospital, Kanagawa, Japan
| | - Isao Kondo
- Department of Nephrology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-3655, Japan
| | - Emi Sakamoto
- Department of Nephrology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-3655, Japan
| | - Minami Suzuki
- Department of Nephrology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-3655, Japan
| | - Daisuke Katagiri
- Department of Nephrology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-3655, Japan
| | - Manami Tada
- Department of Nephrology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-3655, Japan
| | - Fumihiko Hinoshita
- Department of Nephrology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-3655, Japan
| |
Collapse
|
23
|
Szylińska A, Rotter I, Listewnik M, Lechowicz K, Brykczyński M, Dzidek S, Żukowski M, Kotfis K. Postoperative Delirium in Patients with Chronic Obstructive Pulmonary Disease after Coronary Artery Bypass Grafting. MEDICINA-LITHUANIA 2020; 56:medicina56070342. [PMID: 32660083 PMCID: PMC7404780 DOI: 10.3390/medicina56070342] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/06/2020] [Accepted: 07/06/2020] [Indexed: 11/16/2022]
Abstract
Background and Objectives: The incidence of postoperative delirium (POD) in patients with chronic obstructive pulmonary disease (COPD) is unclear. It seems that postoperative respiratory problems that may occur in COPD patients, including prolonged mechanical ventilation or respiratory-tract infections, may contribute to the development of delirium. The aim of the study was to identify a relationship between COPD and the occurrence of delirium after cardiac surgery and the impact of these combined disorders on postoperative mortality. Materials and Methods: We performed an analysis of data collected from 4151 patients undergoing isolated coronary artery bypass grafting (CABG) in a tertiary cardiac-surgery center between 2012 and 2018. We included patients with a clinical diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The primary endpoint was postoperative delirium; Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) was used for delirium assessment. Results: Final analysis included 283 patients with COPD, out of which 65 (22.97%) were diagnosed with POD. Delirious COPD patients had longer intubation time (p = 0.007), more often required reintubation (p = 0.019), had significantly higher levels of C-reactive protein (CRP) three days after surgery (p = 0.009) and were more often diagnosed with pneumonia (p < 0.001). The CRP rise on day three correlated positively with the occurrence of postoperative pneumonia (r = 0.335, p = 0.005). The probability of survival after CABG was significantly lower in COPD patients with delirium (p < 0.001). Conclusions: The results of this study confirmed the relationship between chronic obstructive pulmonary disease and the incidence of delirium after cardiac surgery. The probability of survival in COPD patients undergoing CABG who developed postoperative delirium was significantly decreased.
Collapse
Affiliation(s)
- Aleksandra Szylińska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University in Szczecin, Żołnierska 48, 71-210 Szczecin, Poland; (A.S.); (I.R.)
| | - Iwona Rotter
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University in Szczecin, Żołnierska 48, 71-210 Szczecin, Poland; (A.S.); (I.R.)
| | - Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (M.L.); (M.B.)
| | - Kacper Lechowicz
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (K.L.); (M.Ż.)
| | - Mirosław Brykczyński
- Department of Cardiac Surgery, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (M.L.); (M.B.)
| | - Sylwia Dzidek
- Student Science Club at the Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, 70-111 Szczecin, Poland;
| | - Maciej Żukowski
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (K.L.); (M.Ż.)
| | - Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (K.L.); (M.Ż.)
- Correspondence: ; Tel.: +48-91-466-1144
| |
Collapse
|
24
|
Falk A, Eriksson M, Stenman M. Depressive and/or anxiety scoring instruments used as screening tools for predicting postoperative delirium after cardiac surgery: A pilot study. Intensive Crit Care Nurs 2020; 59:102851. [PMID: 32223922 DOI: 10.1016/j.iccn.2020.102851] [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: 08/02/2019] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Depression is common in patients with cardiac disease. Depression is a risk factor for developing postoperative delirium, a common and serious complication to cardiac surgery. OBJECTIVES The aim was to evaluate if screening tools for depression can be used to predict postoperative delirium after cardiac surgery. METHODS This was a prospective population-based pilot study including 26 patients between 23 and 80 years of age undergoing cardiac surgery in Sweden during 2018. The day before surgery the participants filled out the depression screening instruments Hospital Anxiety and Depression Scale and Patient Health Questionnaire. After discharge the patient charts were examined for documentation of symptoms of delirium. RESULTS Five (20%) patients screened positive regarding depression using the Hospital Anxiety and Depression Scale and 7 patients (27%) screened positive using The Patient Health Questionnaire. Four (22%) patients showed symptoms of postoperative delirium, none of them screened positive for depression prior to surgery. CONCLUSION We found no difference between the questionnaires PHQ-9 and HADS regarding identifying depressive symptoms. Moreover, we found that post-operative delirium, to a certain extent, can be detected by reading the patient́s charts postoperatively. However, this pilot study showed that screening tools for delirium need to be better implemented.
Collapse
Affiliation(s)
- Anna Falk
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden; Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Mats Eriksson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Malin Stenman
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| |
Collapse
|
25
|
|
26
|
Neurological Complications in Cardiac Surgery. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00344-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
27
|
Toft K, Tontsch J, Abdelhamid S, Steiner L, Siegemund M, Hollinger A. Serum biomarkers of delirium in the elderly: a narrative review. Ann Intensive Care 2019; 9:76. [PMID: 31263968 PMCID: PMC6603109 DOI: 10.1186/s13613-019-0548-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 06/20/2019] [Indexed: 12/17/2022] Open
Abstract
Delirium after surgery and in the intensive care unit (ICU) remains a challenge for patients, families, and caregivers. Over the years, many promising biomarkers have been investigated as potential instruments for risk stratification of delirium. This review aimed to identify and assess the clinical usefulness of candidate serum biomarkers associated with hospital delirium in patients aged 60 years and older. We performed a time-unlimited review of publications indexed in PubMed, Cochrane, Embase, and MEDLINE databases until June 2019 that evaluated baseline and/or longitudinal biomarker measurements in patients suffering from delirium at some point during their hospital stay. A total of 32 studies were included in this review reporting information on 7610 patients. Of these 32 studies, twenty-four studies reported data from surgical patients including four studies in ICU cohorts, five studies reported data from medical patients (1026 patients), and three studies reported data from a mixed cohort (1086 patients), including one study in an ICU cohort. Findings confirm restricted clinical usefulness to predict or diagnose delirium due to limited evidence on which biomarkers can be used and limited availability due to non-routine use.
Collapse
Affiliation(s)
- Katharina Toft
- Department for Anesthesia, Intensive Care and Emergency Medicine, See-Spital, Horgen, Kilchberg, Switzerland.,Institute for Anesthesia and Intensive Care, Hirslanden Klinik Zurich, Zurich, Switzerland
| | - Janna Tontsch
- Department for Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Salim Abdelhamid
- Department for Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Luzius Steiner
- Medical Faculty of the University of Basel, Basel, Switzerland.,Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Department for Intensive Care, University Hospital Basel, Basel, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Alexa Hollinger
- Department for Intensive Care, University Hospital Basel, Basel, Switzerland.
| |
Collapse
|
28
|
Shi Q, Mu X, Zhang C, Wang S, Hong L, Chen X. Risk Factors for Postoperative Delirium in Type A Aortic Dissection Patients: A Retrospective Study. Med Sci Monit 2019; 25:3692-3699. [PMID: 31102507 PMCID: PMC6540648 DOI: 10.12659/msm.913774] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common complication in cardiac surgery among adult patients. This retrospective study was designed to identify the risk factors associated with POD of type A aortic dissection patients. MATERIAL AND METHODS Clinical data of 148 patients with type A aortic dissection in the Department of Critical Care Medicine was retrospectively analyzed. All these patients underwent Sun's procedure with anesthetic treatment. The confusion assessment method for intensive care unit (CAM-ICU) was adapted to evaluate the delirium status of these patients. They were divided into 2 groups: the delirium group and the control group. Univariate analysis and multivariate logistic regression were performed in succession to determine the independent risk factors for POD. RESULTS The average age of these patients was 54.41±11.676 years old. Among the 148 patients, POD was detected in 68 patients, with an incidence of 45.95%. According to univariate analysis, age, irritability, alcohol use, extracorporeal circulation duration (cardiopulmonary bypass, CPB time), antegrade selective cerebral perfusion (ASCP) time, lowest partial pressure of oxygen (lowest PO2), mechanical ventilation time, blood loss, low PO₂ and oxygenation index, hemoglobin (Hb), Intensive Care Unit (ICU) stay, and dihydroxyphenylalanine (DEX) were associated with higher odds of POD among type A aortic dissection patients. According to further analysis of multivariate logistic regression, ASCP time and irritability were confirmed as the independent factors for POD of type A aortic dissection patients. CONCLUSIONS We determined 2 independent risk factors for POD: ASCP time and irritability. Identifying and adjusting these risk factors are very important in reducing the incidence of POD among type A aortic dissection patients.
Collapse
Affiliation(s)
- Qiankun Shi
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Xinwei Mu
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Cui Zhang
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Shu Wang
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Liang Hong
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| |
Collapse
|
29
|
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.
Collapse
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, ;
| |
Collapse
|
30
|
The effect of preoperative cognitive impairment and type of vascular surgery procedure on postoperative delirium with associated cost implications. J Vasc Surg 2019; 69:201-209. [DOI: 10.1016/j.jvs.2018.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 05/01/2018] [Indexed: 11/17/2022]
|
31
|
Kotfis K, Szylińska A, Listewnik M, Brykczyński M, Ely EW, Rotter I. Diabetes and elevated preoperative HbA1c level as risk factors for postoperative delirium after cardiac surgery: an observational cohort study. Neuropsychiatr Dis Treat 2019; 15:511-521. [PMID: 30863073 PMCID: PMC6388975 DOI: 10.2147/ndt.s196973] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common complication of cardiac surgery associated with increased mortality, morbidity, and long-term cognitive dysfunction. Diabetic patients, especially those with poor diabetes control and long-standing hyperglycemia, may be at risk of developing delirium. The aim of this study was to analyze whether the occurrence of POD in cardiac surgery is associated with diabetes or elevated preoperative glycated hemoglobin (HbA1c) level. MATERIALS AND METHODS We performed a cohort analysis of prospectively collected data from a register of cardiac surgery department of a university hospital. Delirium assessment was performed twice a day during the first 5 days after the operation based on Diagnostic Statistical Manual of Mental Disorders, fifth edition criteria. RESULTS We analyzed a cohort of 3,178 consecutive patients, out of which 1,010 (31.8%) were diabetic and 502 (15.8%) were diagnosed with POD. Patients with delirium were more often diabetic (42.03% vs 29.86%, P<0.001) and on oral diabetic medications (34.66% vs 24.07%, P<0.001), no difference was found in patients with insulin treatment. Preoperative HbA1c was elevated above normal (≥6%) in more delirious than nondelirious patients (44.54% vs 33.04%, P<0.001), but significance was reached only in nondiabetic patients (20.44% vs 14.86%, P=0.018). In univariate analysis, the diagnosis of diabetes was associated with an increased risk of developing POD (OR: 1.703, 95% CI: 1.401-2.071, P<0.001), but only for patients on oral diabetic medications (OR: 1.617, 95% CI: 1.319-1.983, P<0.001) and an association was noted between HbA1c and POD (OR: 1.269, 95% CI: 1.161-1.387, P<0.001). Multivariate analysis controlled for diabetes showed that POD was associated with age, heart failure, preoperative creatinine, extracardiac arteriopathy, and preoperative HbA1c level. CONCLUSION More diabetic patients develop POD after cardiac surgery than nondiabetic patients. Elevated preoperative HbA1c level is a risk factor for postcardiac surgery delirium regardless of the diagnosis of diabetes.
Collapse
Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Aleksandra Szylińska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin, Poland,
| | - Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland
| | | | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Iwona Rotter
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin, Poland,
| |
Collapse
|
32
|
Noss C, Prusinkiewicz C, Nelson G, Patel PA, Augoustides JG, Gregory AJ. Enhanced Recovery for Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 32:2760-2770. [DOI: 10.1053/j.jvca.2018.01.045] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Indexed: 12/13/2022]
|
33
|
Lindblom RPF, Shen Q, Axén S, Landegren U, Kamali-Moghaddam M, Thelin S. Protein Profiling in Serum and Cerebrospinal Fluid Following Complex Surgery on the Thoracic Aorta Identifies Biological Markers of Neurologic Injury. J Cardiovasc Transl Res 2018; 11:503-516. [PMID: 30367354 PMCID: PMC6294830 DOI: 10.1007/s12265-018-9835-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/10/2018] [Indexed: 12/19/2022]
Abstract
Surgery on the arch or descending aorta is associated with significant risk of neurological complications. As a consequence of intubation and sedation, early neurologic injury may remain unnoticed. Biomarkers to aid in the initial diagnostics could prove of great value as immediate intervention is critical. Twenty-three patients operated in the thoracic aorta with significant risk of perioperative neurological injury were included. Cerebrospinal fluid (CSF) and serum were obtained preoperatively and in the first and second postoperative days and assessed with a panel of 92 neurological-related proteins. Three patients suffered spinal cord injury (SCI), eight delirium, and nine hallucinations. There were markers in both serum and CSF that differed between the affected and non-affected patients (SCI; IL6, GFAP, CSPG4, delirium; TR4, EZH2, hallucinations; NF1). The study identifies markers in serum and CSF that reflect the occurrence of neurologic insults following aortic surgery, which may aid in the care of these patients.
Collapse
Affiliation(s)
- Rickard P F Lindblom
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, SE-751 85, Uppsala, Sweden. .,Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden.
| | - Qiujin Shen
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Sofie Axén
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
| | - Ulf Landegren
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Masood Kamali-Moghaddam
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Stefan Thelin
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, SE-751 85, Uppsala, Sweden.,Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden
| |
Collapse
|
34
|
Flükiger J, Hollinger A, Speich B, Meier V, Tontsch J, Zehnder T, Siegemund M. Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis. Ann Intensive Care 2018; 8:92. [PMID: 30238227 PMCID: PMC6148680 DOI: 10.1186/s13613-018-0437-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 09/06/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND To determine the preventive and therapeutic effect of dexmedetomidine on intensive care unit (ICU) delirium. METHODS The literature search using PubMed and the Cochrane Central Register of Controlled Trials was performed (August 1, 2018) to detect all randomized controlled trials (RCTs) of adult ICU patients receiving dexmedetomidine. Articles were included if they assessed the influence of dexmedetomidine compared to a sedative agent on incidence of ICU delirium or treatment of this syndrome. Accordingly, relevant articles were allocated to the following two groups: (1) articles that assessed the delirium incidence (incidence comparison) or articles that assessed the treatment of delirium (treatment comparison). Incidence of delirium and delirium resolution were the primary outcomes. We combined treatment effects comparing dexmedetomidine versus (1) placebo, (2) standard sedatives, and (3) opioids in random-effects meta-analyses. Risk of bias for each included RCT was assessed following Cochrane standards. RESULTS The literature search resulted in 28 articles (25 articles/4975 patients for the incidence comparison and three articles/166 patients for the treatment comparison). In the incidence comparison, heterogeneity was present in different subgroups. Administration of dexmedetomidine was associated with significantly lower overall incidence of delirium when compared to placebo (RR 0.52; 95% CI 0.39-0.70; I2 = 37%), standard sedatives (RR 0.63; 95% CI 0.46-0.86; I2 = 69%), as well as to opioids (RR 0.61; 95% CI 0.44-0.83; I2 = 0%). Use of dexmedetomidine significantly increased the risks of bradycardia and hypotension. Limited data were available on circulatory insufficiency and mortality. In the treatment comparison, the comparison drugs in the three RCTs were placebo, midazolam, and haloperidol. The resolution of delirium was measured differently in each study. Two out of the three studies indicated clear favorable effects for dexmedetomidine (i.e., compared to placebo and midazolam). The study comparing dexmedetomidine with haloperidol was a pilot study (n = 20) with high variability in the results. CONCLUSION Findings suggest that dexmedetomidine reduces incidence and duration of ICU delirium. Furthermore, our systematic searches show that there is limited evidence if a delirium shall be treated with dexmedetomidine.
Collapse
Affiliation(s)
- Julian Flükiger
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Alexa Hollinger
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland. .,Department of Anaesthesiology, Burn and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue Ambroise Paré, 75010, Paris, France. .,Inserm 942 Paris, Biomarqueurs et maladies cardiaques, Hôpital Lariboisière - Bâtiment Viggo Petersen, 41, boulevard de la Chapelle, 75475, Paris Cedex 10, France.
| | - Benjamin Speich
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Basel, Switzerland.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Vera Meier
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Janna Tontsch
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Tatjana Zehnder
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Martin Siegemund
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| |
Collapse
|
35
|
Leenders J, Overdevest E, van Straten B, Golab H. The influence of oxygen delivery during cardiopulmonary bypass on the incidence of delirium in CABG patients; a retrospective study. Perfusion 2018; 33:656-662. [PMID: 29956559 PMCID: PMC6201164 DOI: 10.1177/0267659118783104] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Introduction: Postoperative delirium is the most common neurological complication of
cardiac surgery. Hypoxia has been shown to increase the risk of
postoperative delirium. The possibility to continuously monitor oxygen
delivery (DO2) during cardiopulmonary bypass (CPB) offers an
adequate approximation of the oxygen status in a patient. This study
investigates the role of oxygen delivery during cardiopulmonary bypass in
the incidence of postoperative delirium. Methods: Three hundred and fifty-seven adult patients who underwent normothermic
coronary artery bypass grafting (CABG) surgery were included in this
retrospective study. The nadir indexed DO2 (DO2i)
value on bypass, the total time under the critical DO2i level and
the area under the curve (AUC) for critical DO2i were determined.
Delirium was identified by the postoperative administration of
haloperidol. Results: The mean nadir DO2i significantly differed, comparing the group of
patients with postoperative delirium to the group without. Multivariate
analysis only identified age, pre-existing cognitive impairment,
preoperative kidney dysfunction and cross-clamp time as independent risk
factors for delirium. The results also indicated that patients of older age
were more sensitive to a declined DO2i. Conclusion: A low DO2i during cardiopulmonary bypass is significantly
associated with the incidence of postoperative delirium in CABG patients.
However, the role of DO2 as an independent predictor of delirium
could not be proven.
Collapse
|
36
|
Simeone S, Pucciarelli G, Perrone M, Teresa R, Gargiulo G, Guillari A, Castellano G, Tommaso LD, Niola M, Iannelli G. Delirium in ICU patients following cardiac surgery: An observational study. J Clin Nurs 2018; 27:1994-2002. [DOI: 10.1111/jocn.14324] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Silvio Simeone
- Department of Cardiology, Cardiac Surgery and Emergency; University of Naples Federico II; Naples Italy
| | - Gianluca Pucciarelli
- Department of Biomedicine and Prevention; University of Rome Tor Vergata; Rome Italy
| | - Marco Perrone
- Department of Cardiology, Cardiac Surgery and Emergency; University of Naples Federico II; Naples Italy
| | - Rea Teresa
- Department of Hygiene; University of Naples Federico II; Naples Italy
| | - Gianpaolo Gargiulo
- Pediatric Cardiac Surgery; University of Naples Federico II; Naples Italy
| | - Assunta Guillari
- Department of Hygiene; University of Naples Federico II; Naples Italy
| | - Gaetano Castellano
- Department of Clinical Neuroscience, Anaesthesiology; University of Naples Federico II; Naples Italy
| | - Luigi Di Tommaso
- Department of Cardiac Surgery; University of Naples Federico II; Naples Italy
| | - Massimo Niola
- Department of Advanced Biomedical Sciences; University of Naples Federico II; Naples Italy
| | - Gabriele Iannelli
- Department of Cardiology, Cardiac Surgery and Cardiovascular Emergency; University of Naples Federico II; Naples Italy
| |
Collapse
|
37
|
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]
|
38
|
Riegger H, Hollinger A, Seifert B, Toft K, Blum A, Zehnder T, Siegemund M. Baden Prevention and Reduction of Incidence of Postoperative Delirium Trial (PRIDe): a phase IV multicenter, randomized, placebo-controlled, double-blind clinical trial of ketamine versus haloperidol for prevention of postoperative delirium. Trials 2018; 19:142. [PMID: 29482596 PMCID: PMC5828327 DOI: 10.1186/s13063-018-2498-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/24/2018] [Indexed: 12/13/2022] Open
Abstract
Background Delirium is a neurobehavioural syndrome that frequently develops in the postoperative setting. The incidence of elderly patients who develop delirium during hospital stay ranges from 10-80%. Delirium was first described more than half a century ago in the cardiac surgery population, where it was already discovered as a state that might be accompanied by serious complications such as prolonged ICU and hospital stay, reduced quality of life and increased mortality. Furthermore, the duration of delirium is associated with worse long-term cognitive function in the general ICU population. This long-term experience with delirium suggests a high socioeconomic burden and has been a focus of many studies. Due to the multifactorial origin of delirium, we have several but no incontestable options for prevention and symptomatic treatment. Overall, delirium represents a high burden not only for patient and family members, but also for the medical care team that aims to prevent postoperative delirium to avoid serious consequences associated with it. The purpose of this study is to determine whether postoperative delirium can be prevented by the combination of established preventive agents. In addition, measured levels of pre- and postoperative cortisol, neuron specific enolase (NSE) and S-100β will be used to investigate dynamics of these parameters in delirious and non-delirious patients after surgery. Methods/design The Baden PRIDe Trial is an investigator-initiated, phase IV, two-centre, randomised, placebo-controlled, double-blind clinical trial for the prevention of delirium with haloperidol, ketamine, and the combination of both vs. placebo in 200 patients scheduled for surgery. We would like to investigate superiority of one of the three treatment arms (i.e., haloperidol, ketamine, combined treatment) to placebo. Discussion There is limited but promising evidence that haloperidol and ketamine can be used to prevent delirium. Clinical care for patients might improve as the results of this study may lead to better algorithms for the prevention of delirium. Trial registration ClinicalTrials.gov, NCT02433041. Registered on 7 April 2015. Swiss National Clinical Trial Portal, SNCTP000001628. Registered on 9 December 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2498-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Harriet Riegger
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Alexa Hollinger
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
| | - Burkhardt Seifert
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Katharina Toft
- Department for Anesthesia, Intensive Care and Emergency Medicine, See-Spital, Horgen and Kilchberg branches, Horgen and Kilchberg, Switzerland
| | - Andrea Blum
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Tatjana Zehnder
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
39
|
Ogawa M, Izawa KP, Satomi-Kobayashi S, Tsuboi Y, Komaki K, Gotake Y, Sakai Y, Tanaka H, Okita Y. Impact of delirium on postoperative frailty and long term cardiovascular events after cardiac surgery. PLoS One 2017; 12:e0190359. [PMID: 29287124 PMCID: PMC5747483 DOI: 10.1371/journal.pone.0190359] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 12/13/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common and critical complication after cardiac surgery. However, the relationship between POD and postoperative physical frailty and the effect of both on long-term clinical outcomes have not been fully explored. OBJECTIVE We aimed to examine the associations among POD, postoperative frailty, and major adverse cardiac events (MACE). DESIGN This was a prospective cohort study. METHODS We studied 329 consecutive patients undergoing elective cardiac surgery. The intensive care delirium screening checklist was used to assess POD. Postoperative frailty was defined by handgrip strength and walking speed. Patients were subsequently followed-up to detect MACE. RESULTS POD was present in 13.2%, while the incidence of postoperative frailty was 27.0%. POD was independently associated with development of postoperative frailty (adjusted odds ratio = 2.98). During follow-up, MACE occurred in 14.1% of all participants. On multivariate Cox proportional hazard analysis, POD (adjusted hazard ratio (HR) = 3.36), postoperative frailty (HR = 2.21), postoperative complications (HR = 1.54), and left ventricular ejection fraction (HR = 0.95) were independently associated with increased risk of MACE. LIMITATIONS It is a single-center study with a risk of bias. We did not investigate follow up cognitive function. CONCLUSIONS POD was a predictor of postoperative frailty after cardiac surgery. Both postoperative frailty and POD were associated with the incidence of MACE, while POD was the stronger predictor of MACE. Thus, POD and frailty play critical roles in the risk stratification of patients undergoing cardiac surgery.
Collapse
Affiliation(s)
- Masato Ogawa
- Division of Rehabilitation Medicine, Kobe University Hospital, Kobe, Japan
- Department of International Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Kazuhiro P. Izawa
- Department of International Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
- * E-mail:
| | - Seimi Satomi-Kobayashi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasunori Tsuboi
- Division of Rehabilitation Medicine, Kobe University Hospital, Kobe, Japan
| | - Kodai Komaki
- Division of Rehabilitation Medicine, Kobe University Hospital, Kobe, Japan
| | - Yasuko Gotake
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshitada Sakai
- Division of Rehabilitation Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Tanaka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| |
Collapse
|
40
|
O'Neal JB, Billings FT, Liu X, Shotwell MS, Liang Y, Shah AS, Ehrenfeld JM, Wanderer JP, Shaw AD. Effect of Preoperative Beta-Blocker Use on Outcomes Following Cardiac Surgery. Am J Cardiol 2017; 120:1293-1297. [PMID: 28826895 DOI: 10.1016/j.amjcard.2017.07.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/21/2017] [Accepted: 07/07/2017] [Indexed: 12/29/2022]
Abstract
Recent studies suggest that the use of preoperative β blockers in cardiac surgery may not provide improved mortality rates and may even contribute to negative clinical outcomes. We therefore assessed the role of β blockers on several outcomes after cardiac surgery (delirium, acute kidney injury [AKI], stroke, atrial fibrillation (AF), mortality, and hospital length of stay) in 4,076 patients who underwent elective coronary artery bypass grafting, coronary artery bypass grafting + valve, or valve cardiac surgery from November 1, 2009, to September 30, 2015, at Vanderbilt Medical Center. Clinical data from 2 prospectively collected datasets at our institution were reviewed: the Cardiac Surgery Perioperative Outcomes Database and the Society of Thoracic Surgeons Database. Preoperative β-blocker use was defined by Society of Thoracic Surgeons guidelines as patients receiving a β blocker within 24 hours preceding surgery. Of the included patients, 2,648 (65.0%) were administered a β blocker within 24 hours before surgery. Adjusting for possible confounders, preoperative β-blocker use was associated with increased odds of AKI stage 2 (odds ratio 1.96, 95% confidence interval 1.19 to 3.24, p <0.01). There was no evidence that β-blocker use had an independent association with postoperative delirium, AKI stages 1 and 3, stroke, AF, mortality, or prolonged length of stay. A secondary propensity score analysis did not show a marginal association between β-blocker use and any outcome. In conclusion, we did not find significant evidence that preoperative β-blocker use was associated with postoperative delirium, AF, AKI, stroke, or mortality.
Collapse
Affiliation(s)
- Jason B O'Neal
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Frederic T Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Xulei Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yafen Liang
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jesse M Ehrenfeld
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
41
|
Hollinger A, Ledergerber K, von Felten S, Sutter R, Rüegg S, Gantner L, Zimmermann S, Blum A, Steiner LA, Marsch S, Siegemund M. Comparison of propofol and dexmedetomidine infused overnight to treat hyperactive and mixed ICU delirium: a protocol for the Basel ProDex clinical trial. BMJ Open 2017; 7:e015783. [PMID: 28710219 PMCID: PMC5726074 DOI: 10.1136/bmjopen-2016-015783] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/OBJECTIVES Delirium is a neurobehavioural disturbance that frequently develops particularly in the intensive care unit (ICU) population. It was first described more than half a century ago, where it was already discovered as a state that might come along with serious complications such as prolonged ICU and hospital stay, reduced quality of life and increased mortality. However, in most cases, there is still lack of proof for causal relationship. Its presence frequently remains unrecognised due to suggested predominance of the hypoactive form. Furthermore, in the general ICU population, it has been shown that the duration of delirium is associated with worse long-term cognitive function. Due to the multifactorial origin of delirium, we have several but no incontestable treatment options. Nonetheless, delirium bears a high burden for patient, family members and the medical care team.The Basel ProDex Study targets improvement of hyperactive and mixed delirium therapy in critically ill patients. We will focus on reducing the duration and severity of delirium by implementing dexmedetomidine into the treatment plan. Dexmedetomidine compared with other sedatives shows fewer side effects representing a better risk profile for delirium treatment in general. This could further contribute to higher patient safety.The aim of the BaProDex Trial is to assess the superiority of dexmedetomidine to propofol for treatment of hyperactive and mixed delirium in the ICU. We hypothesise that dexmedetomidine, compared with propofol administered at night, shortens both the duration and severity of delirium. METHODS/DESIGN The Basel ProDex Study is an investigator-initiated, one-institutional, two-centre randomised controlled clinical trial for the treatment of delirium with dexmedetomidine versus propofol in 316 critically ill patients suffering from hyperactive and mixed delirium. The primary outcome measure is delirium duration in hours. Secondary outcomes include delirium-free days at day 28, death at day 28, delirium severity, amount of ventilator days, amount of rescue sedation with haloperidol, length of ICU and hospital stay, and pharmaceutical economic analysis of the treatments. Sample size was estimated to be able to show the superiority of dexmedetomidine compared with propofol regarding the duration of delirium in hours. The trial will be externally monitored according to good clinical practice (GCP) requirements. There are no interim analyses planned for this trial. ETHICS AND DISSEMINATION This study will be conducted in compliance with the protocol, the current version of the Declaration of Helsinki, the International Conference on Harmonization- Good Clinical Practice (ICH-GCP) or Europäische Norm International Organization for Standardization (ISO EN 14155; as far as applicable) as well as all national legal and regulatory requirements. Only the study team will have access to trial specific data. Anonymisation will be achieved by a unique patient identification code. Trial data will be archived for a minimum of 10 years after study termination. We plan to publish the data in a major peer-reviewed clinical journal. TRIALS REGISTRATION ClinicalTrials.gov Identifier: NCT02807467 PROTOCOL VERSION: Clinical Study Protocol Version 2, 16.08.2016.
Collapse
Affiliation(s)
- Alexa Hollinger
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Katrin Ledergerber
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Stefanie von Felten
- Department for Clinical Neurophysiology, Epilepsy and Movement Disorders, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Stephan Rüegg
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Lukas Gantner
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Sibylle Zimmermann
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Andrea Blum
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | | | - Stephan Marsch
- Medical Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
42
|
Development of a nomogram for predicting the probability of postoperative delirium in patients undergoing free flap reconstruction for head and neck cancer. Eur J Surg Oncol 2017; 43:683-688. [DOI: 10.1016/j.ejso.2016.09.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 09/29/2016] [Indexed: 11/21/2022] Open
|
43
|
Cereghetti C, Siegemund M, Schaedelin S, Fassl J, Seeberger MD, Eckstein FS, Steiner LA, Goettel N. Independent Predictors of the Duration and Overall Burden of Postoperative Delirium After Cardiac Surgery in Adults: An Observational Cohort Study. J Cardiothorac Vasc Anesth 2017; 31:1966-1973. [PMID: 28711314 DOI: 10.1053/j.jvca.2017.03.042] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Postoperative delirium (POD) is a common complication after cardiac surgery and is associated with increased patient morbidity and mortality. The objective of this study was to identify risk factors for long duration and overall burden of POD after cardiac surgery. DESIGN One-year, single-center, retrospective, observational cohort study. SETTING University hospital. PARTICIPANTS Adult patients undergoing cardiac surgery with cardiopulmonary bypass in 2013. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were screened for POD using the Intensive Care Delirium Screening Checklist. The primary outcome measure was the incidence of POD. Secondary outcome measures were the duration of POD and the area under the curve determined using the Intensive Care Delirium Screening Checklist score over time. Independent predictors of POD were estimated in multivariable logistic regression models. Hospital length of stay, medications, and outcome data also were analyzed. Among the 656 patients included in the cohort, 618 were analyzed. The overall incidence of POD was 39%. Older patient age (odds ratio [95% confidence interval]) 1.06 [1.04-1.09] for an increase of 1 year, p < 0.001); low preoperative serum albumin (1.08 [1.03-1.13] for a decrease of 1 g/L, p < 0.001); a history of atrial fibrillation (2.30 [1.30-4.09], p = 0.004); perioperative stroke (6.27 [1.54-43.64], p = 0.008); ascending aortic replacement surgery (2.99 [1.50-6.05], p = 0.002); longer duration of procedure (1.37 [1.16-1.63] for an increase of 1 hour, p < 0.001); and increased postoperative C-reactive protein concentration (2.16 [1.49-3.16] for a 2-fold increase, p < 0.001) were associated with higher odds of POD. Among patients affected by POD, older age, perioperative stroke, longer procedure time, and increased postoperative C-reactive protein were consistently predictive of longer duration of POD and greater area under the curve. CONCLUSIONS Known risk factors for the development of POD after cardiac surgery also are predictive of prolonged duration and high overall burden of POD.
Collapse
Affiliation(s)
- Christian Cereghetti
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Martin Siegemund
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Sabine Schaedelin
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Jens Fassl
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Manfred D Seeberger
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Friedrich S Eckstein
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luzius A Steiner
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Nicolai Goettel
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland.
| |
Collapse
|
44
|
Liao Y, Flaherty JH, Yue J, Wang Y, Deng C, Chen L. The incidence of delirium after cardiac surgery in the elderly: protocol for a systematic review and meta-analysis. BMJ Open 2017; 7:e014726. [PMID: 28360251 PMCID: PMC5372073 DOI: 10.1136/bmjopen-2016-014726] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Delirium is one of the most common complications after cardiac surgery in the elderly. Future studies aimed at preventing postoperative delirium will need an accurate estimate of incidence. However, there are no available systematic reviews on the incidence, and reports of incidence of postoperative delirium after a cardiac operation vary widely with significant heterogeneity. Therefore, we aim to perform a systematic review and meta-analysis to determine the most accurate incidence possible of postoperative delirium in individuals aged >65 years after cardiac surgery. METHODS AND ANALYSES We will undertake a comprehensive literature search among PubMed, EMBASE, the Cochrane Library, PsycINFO and CINAHL, from their inception to January 2017. Prospective cohort and cross sectional studies that described the incidence of delirium will be eligible for inclusion. The primary outcome will be the incidence of delirium. Risk of bias and methodological quality for the included studies will be assessed using a risk of bias tool for prevalence studies and the Cochrane guidelines. Heterogeneity of the estimates across studies will be assessed. Incidence data will be pooled by selective or emergency surgery. This systematic review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). ETHICS AND DISSEMINATION This proposed systematic review and meta-analysis is based on published data, and thus there is no requirement for ethics approval. The study will provide an up to date and accurate incidence of postoperative delirium among the older population after cardiac surgery, which is necessary for future research in this area. The findings of this study will be presented at conferences and disseminated through publication in a peer reviewed journal. TRIAL REGISTRATION NUMBER CRD42016047773.
Collapse
Affiliation(s)
- Yulin Liao
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Joseph H Flaherty
- Division of Geriatrics, Department of Internal Medicine, Saint Louis University, St Louis, Missouri, USA
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, The National Center for Geriatric Clinical Research in West China Hospital, Chengdu, Sichuan, China
| | - Yanyan Wang
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chuanyao Deng
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ling Chen
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
45
|
Evans AS, Mazzeffi M, Ivascu NS, Dickerson S, Gutsche JT. Noteworthy Articles in 2015 for Cardiothoracic Critical Care. Semin Cardiothorac Vasc Anesth 2016; 20:24-33. [PMID: 26759154 DOI: 10.1177/1089253215626004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In 2015, the demand for the presence of cardiothoracic anesthesiologists outside of the cardiac operating rooms continues to expand. Most notably, cardiothoracic anesthesiologists now find themselves called on to care for patients postoperatively in the cardiothoracic surgical intensive care unit. This article is the first in this annual series to review relevant contributions in postoperative cardiac critical care that may influence the cardiac anesthesiologist. We explore the use of extracorporeal membrane oxygenation, management of postoperative atrial fibrillation and coagulopathy, metabolic support of the critically ill cardiothoracic surgical patient, and new insights into delirium and acute kidney injury.
Collapse
Affiliation(s)
- Adam S Evans
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | |
Collapse
|