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Paunikar S, Chakole V. Postoperative Delirium and Neurocognitive Disorders: A Comprehensive Review of Pathophysiology, Risk Factors, and Management Strategies. Cureus 2024; 16:e68492. [PMID: 39364454 PMCID: PMC11447296 DOI: 10.7759/cureus.68492] [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: 08/28/2024] [Accepted: 09/02/2024] [Indexed: 10/05/2024] Open
Abstract
Postoperative delirium (POD) and neurocognitive disorders (NCDs) are common and serious complications that can occur after surgery, particularly in older adults and those with preexisting cognitive impairments. These conditions are associated with significant morbidity, increased healthcare costs, and reduced quality of life. Understanding the underlying mechanisms, risk factors, and effective management strategies for POD and NCDs is critical for improving patient outcomes and reducing the burden on healthcare systems. This comprehensive review aims to synthesize current knowledge on the pathophysiology, risk factors, and management strategies for POD and NCDs. It explores the neurobiological and molecular mechanisms contributing to these conditions, identifies the patient-related, surgical, and environmental factors that increase risk, and evaluates pharmacological and non-pharmacological approaches to prevention and treatment. A thorough literature review was conducted using recent studies, clinical guidelines, and expert consensus to provide a detailed overview of the pathophysiology, risk factors, clinical presentation, prevention, and management of POD and NCDs. The pathophysiology of POD and NCDs involves complex interactions between neuroinflammatory processes, neurotransmitter imbalances, and brain network disruptions. Risk factors include advanced age, preexisting cognitive impairment, type and duration of surgery, and perioperative complications. Management strategies emphasize a multidisciplinary approach, incorporating preoperative optimization, careful intraoperative management, and postoperative interventions. Pharmacological treatments, such as antipsychotics, and non-pharmacological approaches, including environmental modifications and cognitive rehabilitation, play crucial roles in management. Postoperative delirium and NCDs are multifactorial conditions with significant impacts on surgical outcomes. Effective management requires a comprehensive understanding of their pathophysiology and risk factors and the implementation of targeted prevention and treatment strategies. Future research should focus on personalized approaches to prevention and treatment, further elucidation of mechanisms, and developing predictive models to enhance care for patients at risk of these neurocognitive complications.
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Affiliation(s)
- Sharayu Paunikar
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vivek Chakole
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Varpaei HA, Robbins LB, Farhadi K, Bender CM. Preoperative cognitive function as a risk factor of postoperative delirium in cancer surgeries: A systematic review and meta-analysis. J Surg Oncol 2024; 130:222-240. [PMID: 38865298 DOI: 10.1002/jso.27730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 05/24/2024] [Indexed: 06/14/2024]
Abstract
Postoperative delirium (POD) after cancer surgeries can be a result of chemo brain, anesthesia, surgery duration, and preoperative cognitive impairment. Although older age and preoperative cognitive dysfunction were reported to increase the risk of POD in noncardiac surgery, the role of preoperative cognitive function and age in the development of POD after all types of cancer surgeries is not clear. This study aimed to determine the relationship between preoperative cognitive function and likelihood of POD after cancer surgeries. This study used three main online databases and followed PRISMA guidelines. English language original articles that examined preoperative cognitive function before solid tumor cancer surgery and assessed patients for postoperative delirium were included. We employed the random effect meta-analysis method. The overall incidence of POD ranged from 8.7% to 50.9%. The confusion assessment method was the most common tool used to assess delirium. Mini-mental state evaluation (MMSE), Mini-cog, and Montreal cognitive assessment were the most common tools to assess cognitive function. The pooled (total observation = 4676) random effects SMD was estimated at -0.84 (95% confidence interval [CI]: -1.30 to -0.31), indicating that lower MMSE scores before surgery are associated with a higher risk of POD. The pooled (total observation = 2668) random effects OR was estimated at 5.17 (95% CI: 2.51 to -10.63), indicating preoperative cognitive dysfunction can significantly predict the occurrence of POD after cancer surgeries. In conclusion, preoperative cognitive function is an independent and significant predictor of POD after solid tumor cancer surgeries.
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Affiliation(s)
- Hesam A Varpaei
- College of Nursing Michigan State University, East Lansing, Michigan, USA
| | - Lorraine B Robbins
- College of Nursing Michigan State University, East Lansing, Michigan, USA
| | - Kousha Farhadi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Catherine M Bender
- Nursing and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Ron D, Deiner S. Postoperative Delirium and Neurocognitive Disorders: Updates for Providers Caring for Cancer Patients. Curr Oncol Rep 2024:10.1007/s11912-024-01584-9. [PMID: 39052230 DOI: 10.1007/s11912-024-01584-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 07/27/2024]
Abstract
PURPOSE OF REVIEW To provide up to date information on postoperative delirium and neurocognitive disorders in surgical cancer patients. RECENT FINDINGS Established risk factors such as age, psychosocial factors, comorbidities, frailty and preexisting cognitive decline continue to exhibit associations with perioperative neurocognitive disorders (PND); novel risk factors identified recently include microbiome composition and vitamin D deficiency. Prevention measures include cognitive prehabilitation, perioperative geriatric assessment and multidisciplinary care, dexmedetomidine and multimodal analgesic techniques. Studies investigating ciprofol, remimazolam, esketamine, ramelteon and suvorexant have shown encouraging results. Controversy remains regarding the use of inhalational versus intravenous general anesthesia. Innovative approaches to address PND are a rapidly developing area of research, but more studies are needed to identify effective prevention and management interventions. Despite challenges and controversy in the field, implementation of best practice can reduce the detrimental impact of PND on patients, caregivers, and society at large.
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Affiliation(s)
- Donna Ron
- Department of Community and Family Medicine, Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
| | - Stacie Deiner
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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Brattinga B, Plas M, Spikman JM, Rutgers A, de Haan JJ, van der Wal-Huisman H, Absalom AR, Nieuwenhuijs-Moeke GJ, van Munster BC, de Bock GH, van Leeuwen BL. The link between the early surgery-induced inflammatory response and postoperative cognitive dysfunction in older patients. J Am Geriatr Soc 2024; 72:1360-1372. [PMID: 38516716 DOI: 10.1111/jgs.18876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 01/14/2024] [Accepted: 02/25/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) is a common complication in older patients with cancer and is associated with decreased quality of life and increased disability and mortality rates. Systemic inflammation resulting in neuroinflammation is considered important in the pathogenesis of POCD. The aim of this study was to explore the association between the early surgery-induced inflammatory response and POCD within 3 months after surgery in older cancer patients. METHODS Patients ≥65 years in need of surgery for a solid tumor were included in a prospective cohort study. Plasma levels of C-reactive protein (CRP), interleukin-1 beta (IL-1β), IL-6, IL-10, and Neutrophil gelatinase-associated lipocalin (NGAL) were measured perioperatively. Cognitive performance was assessed preoperatively and 3 months after surgery. POCD was defined as a decline in cognitive test scores of ≥25% on ≥2 of five tests within the different cognitive domains of memory, executive functioning, and information processing speed. Logistic regression analysis was performed. RESULTS POCD was observed in 44 (17.7%) of 248 included patients. Age >75, preoperative Mini-Mental State Examination (MMSE) score ≤26 and major surgery were independent significant predictors for POCD. In multivariate logistic regression analysis, no significant associations were shown between the early surgery-induced inflammatory response and either POCD or decline within the different cognitive domains. CONCLUSIONS This study shows that one out of six older patients with cancer developed POCD within 3 months after surgery. The early surgery-induced inflammatory response was neither associated with POCD, nor with decline in the separate cognitive domains. Further research is necessary for better understanding of the complex etiology of POCD.
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Affiliation(s)
- Baukje Brattinga
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthijs Plas
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jacoba M Spikman
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Abraham Rutgers
- Department of Rheumatology and Clinical Immunology, University Medical Center, Groningen, The Netherlands
| | - Jacco J de Haan
- Department of Medical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Barbara C van Munster
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Geertruida H de Bock
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
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Ma H, Ahrens E, Wachtendorf LJ, Suleiman A, Shay D, Munoz-Acuna R, Tartler TM, Teja B, Wagner S, Subramaniam B, Rhee J, Schaefer MS. Intraoperative Use of Phenylephrine versus Ephedrine and Postoperative Delirium: A Multicenter Retrospective Cohort Study. Anesthesiology 2024; 140:657-667. [PMID: 37725759 DOI: 10.1097/aln.0000000000004774] [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: 09/21/2023]
Abstract
BACKGROUND The treatment of intraoperative hypotension with phenylephrine may impair cerebral perfusion through vasoconstriction, which has been linked to postoperative delirium. The hypothesis was that intraoperative administration of phenylephrine, compared to ephedrine, is associated with higher odds of postoperative delirium. METHODS A total of 103,094 hospitalized adults undergoing general anesthesia for noncardiac, non-neurosurgical procedures between 2008 and 2020 at two tertiary academic healthcare networks in Massachusetts were included in this multicenter hospital registry study. The primary exposure was the administration of phenylephrine versus ephedrine during surgery, and the primary outcome was postoperative delirium within 7 days. Multivariable logistic regression analyses adjusted for a priori defined confounding variables including patient demographics, comorbidities, and procedural factors including magnitude of intraoperative hypotension were applied. RESULTS Between the two healthcare networks, 78,982 (76.6%) patients received phenylephrine, and 24,112 (23.4%) patients received ephedrine during surgery; 770 patients (0.8%) developed delirium within 7 days. The median (interquartile range) total intraoperative dose of phenylephrine was 1.0 (0.2 to 3.3) mg and 10.0 (10.0 to 20.0) mg for ephedrine. In adjusted analyses, the administration of phenylephrine, compared to ephedrine, was associated with higher odds of developing postoperative delirium within 7 days (adjusted odds ratio, 1.35; 95% CI, 1.06 to 1.71; and adjusted absolute risk difference, 0.2%; 95% CI, 0.1 to 0.3%; P = 0.015). A keyword and manual chart review-based approach in a subset of 45,465 patients further validated these findings (delirium incidence, 3.2%; adjusted odds ratio, 1.88; 95% CI, 1.49 to 2.37; P < 0.001). Fractional polynomial regression analysis further indicated a dose-dependent effect of phenylephrine (adjusted coefficient, 0.08; 95% CI, 0.02 to 0.14; P = 0.013, per each μg/kg increase in the cumulative phenylephrine dose). CONCLUSIONS The administration of phenylephrine compared to ephedrine during general anesthesia was associated with higher odds of developing postoperative delirium. Based on these data, clinical trials are warranted to determine whether favoring ephedrine over phenylephrine for treatment of intraoperative hypotension can reduce delirium after surgery. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Haobo Ma
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts; and Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Denys Shay
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts; and Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ricardo Munoz-Acuna
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tim M Tartler
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Bijan Teja
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Soeren Wagner
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Balachundhar Subramaniam
- Department of Anesthesia, Critical Care and Pain Medicine and Sadhguru Center for a Conscious Planet, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - James Rhee
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts; and Department of Anesthesiology, University Hospital Duesseldorf, Düsseldorf, Germany
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Stern M, Nieuwenhuijs-Moeke GJ, Absalom A, van Leeuwen B, van der Wal-Huisman H, Plas M, Bosch DJ. Association between anaesthesia-related factors and postoperative neurocognitive disorder: a post-hoc analysis. BMC Anesthesiol 2023; 23:368. [PMID: 37950163 PMCID: PMC10636964 DOI: 10.1186/s12871-023-02318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/23/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Postoperative neurocognitive disorder (pNCD) is common after surgery. Exposure to anaesthetic drugs has been implicated as a potential cause of pNCD. Although several studies have investigated risk factors for the development of cognitive impairment in the early postoperative phase, risk factors for pNCD at 3 months have been less well studied. The aim of this study was to identify potential anaesthesia-related risk factors for pNCD at 3 months after surgery. METHODS We analysed data obtained for a prospective observational study in patients aged ≥ 65 years who underwent surgery for excision of a solid tumour. Cognitive function was assessed preoperatively and at 3 months postoperatively using 5 neuropsychological tests. Postoperative NCD was defined as a postoperative decline of ≥ 25% relative to baseline in ≥ 2 tests. The association between anaesthesia-related factors (type of anaesthesia, duration of anaesthesia, agents used for induction and maintenance of anaesthesia and analgesia, the use of additional vasoactive medication, depth of anaesthesia [bispectral index] and mean arterial pressure) and pNCD was analysed using logistic regression analyses. Furthermore, the relation between anaesthesia-related factors and change in cognitive test scores expressed as a continuous variable was analysed using a z-score. RESULTS Of the 196 included patients, 23 (12%) fulfilled the criteria for pNCD at 3 months postoperatively. A low preoperative score on Mini-Mental State Examination (OR, 8.9 [95% CI, (2.8-27.9)], p < 0.001) and a longer duration of anaesthesia (OR, 1.003 [95% CI, (1.001-1.005)], p = 0.013) were identified as risk factors for pNCD. On average, patients scored higher on postoperative tests (mean z-score 2.35[± 3.13]). CONCLUSION In this cohort, duration of anaesthesia, which is probably an expression of the complexity of the surgery, was the only anaesthesia-related predictor of pNCD. On average, patients' scores on cognitive tests improved postoperatively.
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Affiliation(s)
- Manon Stern
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Gertrude J Nieuwenhuijs-Moeke
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Anthony Absalom
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Barbara van Leeuwen
- Department of Surgery/ Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hanneke van der Wal-Huisman
- Department of Surgery/ Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Matthijs Plas
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dirk J Bosch
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
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Sadeghirad B, Dodsworth BT, Schmutz Gelsomino N, Goettel N, Spence J, Buchan TA, Crandon HN, Baneshi MR, Pol RA, Brattinga B, Park UJ, Terashima M, Banning LBD, Van Leeuwen BL, Neerland BE, Chuan A, Martinez FT, Van Vugt JLA, Rampersaud YR, Hatakeyama S, Di Stasio E, Milisen K, Van Grootven B, van der Laan L, Thomson Mangnall L, Goodlin SJ, Lungeanu D, Denhaerynck K, Dhakharia V, Sampson EL, Zywiel MG, Falco L, Nguyen ALV, Moss SJ, Krewulak KD, Jaworska N, Plotnikoff K, Kotteduwa-Jayawarden S, Sandarage R, Busse JW, Mbuagbaw L. Perioperative Factors Associated With Postoperative Delirium in Patients Undergoing Noncardiac Surgery: An Individual Patient Data Meta-Analysis. JAMA Netw Open 2023; 6:e2337239. [PMID: 37819663 PMCID: PMC10568362 DOI: 10.1001/jamanetworkopen.2023.37239] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/21/2023] [Indexed: 10/13/2023] Open
Abstract
Importance Postoperative delirium (POD) is a common and serious complication after surgery. Various predisposing factors are associated with POD, but their magnitude and importance using an individual patient data (IPD) meta-analysis have not been assessed. Objective To identify perioperative factors associated with POD and assess their relative prognostic value among adults undergoing noncardiac surgery. Data Sources MEDLINE, EMBASE, and CINAHL from inception to May 2020. Study Selection Studies were included that (1) enrolled adult patients undergoing noncardiac surgery, (2) assessed perioperative risk factors for POD, and (3) measured the incidence of delirium (measured using a validated approach). Data were analyzed in 2020. Data Extraction and Synthesis Individual patient data were pooled from 21 studies and 1-stage meta-analysis was performed using multilevel mixed-effects logistic regression after a multivariable imputation via chained equations model to impute missing data. Main Outcomes and Measures The end point of interest was POD diagnosed up to 10 days after a procedure. A wide range of perioperative risk factors was considered as potentially associated with POD. Results A total of 192 studies met the eligibility criteria, and IPD were acquired from 21 studies that enrolled 8382 patients. Almost 1 in 5 patients developed POD (18%), and an increased risk of POD was associated with American Society of Anesthesiologists (ASA) status 4 (odds ratio [OR], 2.43; 95% CI, 1.42-4.14), older age (OR for 65-85 years, 2.67; 95% CI, 2.16-3.29; OR for >85 years, 6.24; 95% CI, 4.65-8.37), low body mass index (OR for body mass index <18.5, 2.25; 95% CI, 1.64-3.09), history of delirium (OR, 3.9; 95% CI, 2.69-5.66), preoperative cognitive impairment (OR, 3.99; 95% CI, 2.94-5.43), and preoperative C-reactive protein levels (OR for 5-10 mg/dL, 2.35; 95% CI, 1.59-3.50; OR for >10 mg/dL, 3.56; 95% CI, 2.46-5.17). Completing a college degree or higher was associated with a decreased likelihood of developing POD (OR 0.45; 95% CI, 0.28-0.72). Conclusions and Relevance In this systematic review and meta-analysis of individual patient data, several important factors associated with POD were found that may help identify patients at high risk and may have utility in clinical practice to inform patients and caregivers about the expected risk of developing delirium after surgery. Future studies should explore strategies to reduce delirium after surgery.
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Affiliation(s)
- Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Canada
| | | | | | - Nicolai Goettel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jessica Spence
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Canada
| | - Tayler A. Buchan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Holly N. Crandon
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Canada
| | - Mohammad R. Baneshi
- The University of Queensland, Australian Women and Girls’ Health Research Centre, School of Public Health, Herston Road, Herston, Queensland, Australia
| | - Robert A. Pol
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Baukje Brattinga
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ui Jun Park
- Transplant & Vascular Surgery, School of Medicine, Keimyung University, Dongsan Hospital, Daegu, South Korea
| | - Masanori Terashima
- Division of Gastric Surgery, Shizuoka Cancer Center, Nagaizumi-Cho, Shizuoka, Japan
| | - Louise B. D. Banning
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Barbara L. Van Leeuwen
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Bjørn E. Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Alwin Chuan
- South West Sydney Clinical School, University of New South Wales Australia, Sydney, New South Wales, Australia
- Department of Anaesthesia, Liverpool Hospital, Liverpool, New South Wales, Australia
| | | | - Jeroen L. A. Van Vugt
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Y. Raja Rampersaud
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Ontario, Canada
| | - Shingo Hatakeyama
- Department of Advanced Blood Purification Therapy, Hirosaki Graduate School of Medicine, Hirosaki, Japan
| | - Enrico Di Stasio
- Dipartimento di Scienze biotecnologiche di base, cliniche intensivologiche e perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di scienze laboratoristiche ed infettivologiche, UOC Chimica, Biochimica e Biologia Molecolare Clinica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Bastiaan Van Grootven
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
- Institute of Nursing Science, Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland
| | | | | | - Sarah J. Goodlin
- Geriatrics Section, Veterans Affairs Portland Health Services Center and Oregon Health & Science University, Portland, Oregon
| | - Diana Lungeanu
- Department of Functional Sciences, Centre for Modelling Biological Systems and Data Analysis, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Kris Denhaerynck
- Institute of Nursing Science, Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Vibhawari Dhakharia
- Department of Gynaecological Oncology, Health Care Global Enterprises Ltd, Bangalore, India
| | - Elizabeth L. Sampson
- Division of Psychiatry, University College London, London, UK
- Department of Psychological Medicine, East London NHS Foundation Trust, Royal London Hospital, London, UK
| | - Michael G. Zywiel
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Ontario, Canada
| | - Lisa Falco
- Zühlke Engineering AG, Schlieren, Switzerland
| | - Anna-Lisa V. Nguyen
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Stephana J. Moss
- Department of Critical Care, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Karla D. Krewulak
- Department of Critical Care, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Natalia Jaworska
- Department of Critical Care, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kara Plotnikoff
- Department of Critical Care, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Ryan Sandarage
- Department of Surgery, Division of Neurosurgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Jason W. Busse
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Canada
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Canada
- Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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8
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Ko CC, Hung KC, Chang YP, Liu CC, Cheng WJ, Wu JY, Li YY, Lin TC, Sun CK. Association of general anesthesia exposure with risk of postoperative delirium in patients receiving transcatheter aortic valve replacement: a meta-analysis and systematic review. Sci Rep 2023; 13:16241. [PMID: 37758810 PMCID: PMC10533830 DOI: 10.1038/s41598-023-43548-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 09/25/2023] [Indexed: 09/29/2023] Open
Abstract
The aim of this meta-analysis was to assess the association of general anesthesia (GA) exposure with the risk of POD in this patient population. Databases including Medline, EMBASE, Cochrane library, and Google Scholar were searched from inception to December 2022. Analysis of 17 studies published between 2015 and 2021 involving 10,678 individuals revealed an association of GA exposure with an elevated risk of POD [odd ratio (OR) = 1.846, 95% CI 1.329 to 2.563, p = 0.0003, I2 = 68.4%, 10,678 patients]. Subgroup analysis of the diagnostic methods also demonstrated a positive correlation between GA exposure and POD risk when validated methods were used for POD diagnosis (OR = 2.199, 95% CI 1.46 to 3.31, p = 0.0002). Meta-regression analyses showed no significant impact of age, male proportion, and sample size on the correlation between GA and the risk of POD. The reported overall incidence of POD from the included studies regardless of the type of anesthesia was between 0.8 and 27%. Our meta-analysis showed a pooled incidence of 10.3% (95% CI 7% to 15%). This meta-analysis suggested an association of general anesthesia with an elevated risk of postoperative delirium, implying the necessity of implementing appropriate prophylactic strategies against this complication when general anesthesia was used in this clinical setting.
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Affiliation(s)
- Ching-Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, Tainan City, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung City, Taiwan
| | - Yang-Pei Chang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chien-Cheng Liu
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Wan-Jung Cheng
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Jheng-Yan Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan City, Taiwan
| | - Yu-Yu Li
- Department of Anesthesiology, Chi Mei Medical Center, Chiali, Tainan City, Taiwan
| | - Tso-Chou Lin
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Dachang Hospital, I-Shou University, No. 305, Dachang 1St Road, Sanmin District, Kaohsiung City, Taiwan.
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung City, Taiwan.
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9
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Yu M, Li Y, Li B, Ge Q. Inflammatory biomarkers and delirium: a Mendelian randomization study. Front Aging Neurosci 2023; 15:1221272. [PMID: 37649721 PMCID: PMC10464607 DOI: 10.3389/fnagi.2023.1221272] [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: 05/12/2023] [Accepted: 07/25/2023] [Indexed: 09/01/2023] Open
Abstract
Background The association between inflammatory biomarkers and individual delirium symptoms remains controversial in observational studies. We investigated the relationship between inflammatory biomarkers and the risk of developing delirium. Methods A bidirectional two-sample Mendelian randomization (MR) was performed. Genetic instruments associated with peripheral tumor necrosis factor-a (TNF-a) C-reactive protein (CRP), interleukin (IL)-1α, IL-1β, IL-2, IL-8, IL-6, soluble IL-6 receptor alpha (sIL-6Rα), and soluble gp130 were identified in three different large summary genome-wide association studies (GWAS) conducted in the European population. Summary-level statistics for delirium not induced by alcohol and other psychoactive substances were obtained from the FinnGen consortium (2,612 cases and 325,306 controls). The estimated causal effects were performed using instruments' variants at the genome-wide significant level (P < 5e-8 and P < 5e-6), applying a linkage disequilibrium clumping approach with a threshold of r2 < 0.001 for each of the exposures. Reverse causation was also performed. The inverse-variance weighted method (IVW), MR-Egger method, weighted median method, MR-Egger regression, and MR Pleiotropy RESidual Sum were used for MR analyses. Results At the genome-wide significant level (P < 5e-8, r2 < 0.001), genetically predicted sIL-6Rα was significantly associated with a decreased risk of delirium with less than three single-nucleotide polymorphisms (SNPs) in all three GWAS data sources (ORWaldratio = 0.89, 95% CI: 0.79-0.96, PWaldratio = 0.0016; ORIVW = 0.88, 95% CI: 0.79-0.97, PIVW = 0.008; ORIVW = 0.88, 95% CI: 0.80-0.96, PIVW = 0.004). The causal relationship between sIL-6Rα and delirium became non-significant when a more liberal threshold of P of < 5e-6 was applied (all PIVW > 0.05). At the two genome-wide significance levels (P < 5e-8 and P < 5e-6), we found no evidence for the causal effects of peripheral TNF-α, CRP, IL-1α, IL-1β, IL-2, IL-6, IL-8, and soluble gp130 on delirium (all P > 0.05). The MR-Egger intercept and MR-PRESSO results indicated that no SNP had possible pleiotropy (all P > 0.05). Regarding the reverse, no evidence for an effect of delirium on these inflammatory biomarkers could be found (all P > 0.05). Conclusion The results of this MR analysis did not support that peripheral TNF-α, CRP, IL-1α, IL-1β, IL-2, IL-6, sIL-6Rα, soluble gp130, and IL-8 were causally associated with delirium. More research is needed to explore the role of inflammatory factors in the pathogenesis of delirium.
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Affiliation(s)
- Miao Yu
- Department of Nursing, Peking University Third Hospital, Beijing, China
| | - Yuxuan Li
- Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
| | - Baohua Li
- Department of Nursing, Peking University Third Hospital, Beijing, China
| | - Qinggang Ge
- Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
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10
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Vasunilashorn SM, Lunardi N, Newman JC, Crosby G, Acker L, Abel T, Bhatnagar S, Cunningham C, de Cabo R, Dugan L, Hippensteel JA, Ishizawa Y, Lahiri S, Marcantonio ER, Xie Z, Inouye SK, Terrando N, Eckenhoff RG. Preclinical and translational models for delirium: Recommendations for future research from the NIDUS delirium network. Alzheimers Dement 2023; 19:2150-2174. [PMID: 36799408 PMCID: PMC10576242 DOI: 10.1002/alz.12941] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 02/18/2023]
Abstract
Delirium is a common, morbid, and costly syndrome that is closely linked to Alzheimer's disease (AD) and AD-related dementias (ADRD) as a risk factor and outcome. Human studies of delirium have advanced our knowledge of delirium incidence and prevalence, risk factors, biomarkers, outcomes, prevention, and management. However, understanding of delirium neurobiology remains limited. Preclinical and translational models for delirium, while challenging to develop, could advance our knowledge of delirium neurobiology and inform the development of new prevention and treatment approaches. We discuss the use of preclinical and translational animal models in delirium, focusing on (1) a review of current animal models, (2) challenges and strategies for replicating elements of human delirium in animals, and (3) the utility of biofluid, neurophysiology, and neuroimaging translational markers in animals. We conclude with recommendations for the development and validation of preclinical and translational models for delirium, with the goal of advancing awareness in this important field.
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Affiliation(s)
- Sarinnapha M. Vasunilashorn
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nadia Lunardi
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - John C. Newman
- Department of Medicine, University of California, San Francisco, California, USA
- Buck Institute for Research on Aging, Novato, California, USA
| | - Gregory Crosby
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Leah Acker
- Department of Anesthesiology, Duke University, Durham, Massachusetts, USA
| | - Ted Abel
- Department of Neuroscience and Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Seema Bhatnagar
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Dublin, Ireland
- Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - Rafael de Cabo
- Translational Gerontology Branch, Intramural Research Program, National Institute on Aging, Baltimore, Maryland, USA
| | - Laura Dugan
- Vanderbilt Brain Institute, Vanderbilt University, Nashville, Tennessee, USA
- Division of Geriatric Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Joseph A. Hippensteel
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Yumiko Ishizawa
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shouri Lahiri
- Department of Neurology, Neurosurgery, and Biomedical Sciences, Cedar-Sinai Medical Center, Los Angeles, California, USA
| | - Edward R. Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Zhongcong Xie
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sharon K. Inouye
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Cell Biology, Duke University, Durham, North Carolina, USA
- Department of Immunology, Duke University, Durham, North Carolina, USA
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, USA
| | - Roderic G. Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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11
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Sun Y, Peng HP, Wu TT. Postoperative C-Reactive Protein Predicts Postoperative Delirium in Colorectal Cancer Following Surgery. Clin Interv Aging 2023; 18:559-570. [PMID: 37038607 PMCID: PMC10082577 DOI: 10.2147/cia.s387117] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
Background Postoperative delirium (POD) is a common complication in operative patients. Neuroinflammation has been reported to be a potential mechanism associated with the development of POD. Identifying available inflammatory markers such as C-reactive protein (CRP) would aid clinicians in early detection of POD. Previous studies have demonstrated that CRP may be a promising predictive marker for POD. Thus, this study aimed to explore the association between CRP and POD among those elderly colorectal cancer (CRC) patients. Methods 643 patients with CRC were included in this study. CRP levels were measured before operation and on postoperative day 1. The univariate and multivariate regression analyses were used to identify risk factors for POD. Results Of 643 patients with CRC, 112 cases (17.4%) had POD. CRC patients with POD showed older age, higher CRP level on postoperative day 1, and higher percentage of smoking, diabetes mellitus, and chronic obstructive pulmonary disease (COPD) than CRC patients without POD. Preoperative CRP level was not associated with the POD. Univariate and multivariate regression analyses showed that older age (> 70 years), diabetes mellitus, COPD, and higher CRP level on postoperative day 1 (> 48 mg/L) were risk factors for POD in CRC patients. Conclusion Postoperative CRP level is an independent indicator for POD among CRC patients, suggesting the predictive role of postoperative CRP levels for POD in elderly CRC patients undergoing surgery.
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Affiliation(s)
- Yan Sun
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Hui-Ping Peng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Ting-Ting Wu
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People’s Republic of China
- Correspondence: Ting-Ting Wu; Hui-Ping Peng, Email ;
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12
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Xiao MZ, Liu CX, Zhou LG, Yang Y, Wang Y. Postoperative delirium, neuroinflammation, and influencing factors of postoperative delirium: A review. Medicine (Baltimore) 2023; 102:e32991. [PMID: 36827061 PMCID: PMC11309669 DOI: 10.1097/md.0000000000032991] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 02/25/2023] Open
Abstract
Postoperative delirium (POD) is an acute cognitive dysfunction that is mainly characterized by memory impairment and disturbances in consciousness. POD can prolong the hospital stay and increase the 1-month mortality rate of patients. The overall incidence of POD is approximately 23%, and its prevalence can go up to 50% in high-risk surgeries. Neuroinflammation is an important pathogenic mechanism of POD that mediates microglial activation and leads to synaptic remodeling. Neuroinflammation, as an indispensable pathogenesis of POD, can occur due to a variety of factors, including aseptic inflammation caused by surgery, effects of anesthetic drugs, disruption of the blood-brain barrier, and epigenetics. Understanding these factors and avoiding the occurrence of risk factors may help prevent POD in time. This review provides a brief overview of POD and neuroinflammation and summarizes various factors affecting POD development mediated by neuroinflammation, which may serve as future targets for the prevention and treatment of POD.
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Affiliation(s)
- M. Z. Xiao
- Department of Anesthesiology, The Second Affiliated Hospital of University of South China, Hengyang, China
| | - C. X. Liu
- Department of Anesthesiology, The Second Affiliated Hospital of University of South China, Hengyang, China
| | - L. G. Zhou
- Department of Anatomy, Hengyang Medical College of University of South China, Hengyang, China
| | - Y. Yang
- Department of Anesthesiology, The Second Affiliated Hospital of University of South China, Hengyang, China
| | - Y. Wang
- Department of Anesthesiology, The Second Affiliated Hospital of University of South China, Hengyang, China
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13
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Hung KC, Chiu CC, Hsu CW, Ho CN, Ko CC, Chen IW, Sun CK. Association of preoperative prognostic nutritional index with risk of postoperative delirium: A systematic review and meta-analysis. Front Med (Lausanne) 2023; 9:1017000. [PMID: 36698831 PMCID: PMC9868631 DOI: 10.3389/fmed.2022.1017000] [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: 08/11/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Study objective To assess the association between prognostic nutritional index (PNI) and risk of postoperative delirium (POD) in adult patients. Methods MEDLINE, Google scholar, EMBASE, and Cochrane library databases were searched from inception till April 2022. The primary outcome was the association between PNI and the risk of POD, while the secondary outcomes were correlations of other prognostic factors with POD risk. The correlation between PNI and the incidence of POD was assessed with three approaches: Difference in preoperative PNI between POD and non-POD groups (Model 1) as well as the association of PNI as a continuous parameter (Model 2) or as a binary variable (i.e., low vs. high using a PNI cut-off value of 50) (Model 3) with POD risk. Results Analysis of nine observational studies published from 2010 to 2021 recruiting 3,743 patients showed a POD incidence of 6.4-35%. Our meta-analysis demonstrated a lower PNI among patients in the POD group (MD: -3.78, 95% CI: -4.85 to -2.71, p < 0.0001, I 2 = 54.2%) compared to the non-POD group (Model 1). Pooled results revealed a negative association between PNI and POD risk for both Model 2 (OR: 0.91, 95% CI: 0.86-0.97, p = 0.002, I 2 = 71%) and Model 3 (OR: 1.68, 95% CI: 1.26-2.23, p < 0.0001, I 2 = 0%). Besides, while our results supported an age-dependent increase in POD risk, other factors including body-mass index, surgical time, health status, hypertension, diabetes mellitus, and male gender were non-significant predictors of POD. Conclusion Our results demonstrated a negative association between PNI and POD, which warrant further large-scale studies for validation. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022323809.
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Affiliation(s)
- Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan,Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, E-Da Cancer Hospital, Kaohsiung City, Taiwan,School of Medicine, College of Medicine, I-Shou University, Kaohsiung City, Taiwan,Department of Medical Education and Research, E-Da Cancer Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Chun-Ning Ho
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Ching-Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, Tainan City, Taiwan,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan,Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung City, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan,*Correspondence: I-Wen Chen,
| | - Cheuk-Kwan Sun
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung City, Taiwan,Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan,Cheuk-Kwan Sun,
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14
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Zhang Y, Hu J, Zuo W, He P, Xue Q, Feng X, Zhang Y, Maze M. Longitudinal Profiling of Plasma Cytokines and Its Association With Postoperative Delirium in Elderly Patients Undergoing Major Lower Limb Surgery: A Prospective Observational Study. Anesth Analg 2023; 136:34-42. [PMID: 36534715 DOI: 10.1213/ane.0000000000006250] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgery is accompanied by a systemic inflammatory response that may presage delirium in susceptible individuals. Little is known about the trajectory of plasma proinflammatory cytokines and their potential associations with postoperative delirium (POD). The current study longitudinally assessed both pro and anti-inflammatory plasma cytokine response and development of POD in older surgical patients to investigate associations with individual and/or clusters of cytokines that may indicate pathogenic mechanisms. METHODS A prospective longitudinal study sought to enroll patients >60 years old who were scheduled for major lower limb surgery under general anesthesia. Blood was obtained preoperatively and postoperatively from day 1 through postoperative day 4 for measurement of plasma interleukin-1β (IL-1β), IL-2, IL-4, IL-6, soluble IL-6 receptor (sIL-6R), IL-10, and tumor necrosis factor-α (TNF-α). Participants were assessed for POD twice daily for 4 days using the confusion assessment method. Trajectory of postoperative changes in plasma cytokines was determined by a group-based trajectory modeling analysis that was informed by distinct cytokines identified by time-dependent Cox regression model. RESULTS One hundred eighty-eight patients were assessed for eligibility of whom 129 underwent major surgery and 126 had complete datasets for final analysis. POD was diagnosed in 31 of 126 patients (24.6%). Time-dependent Cox regression model identified that higher IL-6 and sIL-6R levels were associated with higher risk of developing POD. A two-cluster model (stable lower and fluctuating higher levels) was considered to be the most statistically appropriate model for IL-6 and sIL-6R trajectory. More participants with fluctuating higher IL-6 were delirious (73.3% vs 18.0%, P = .001) as were those with fluctuating higher sIL-6R (81.3% vs 16.4%, P = .001). CONCLUSIONS As higher IL-6 and sIL-6R levels were significantly associated with higher risk of POD and the combination is required for IL-6 trans-signaling, it is possible that activation of this pathway may be associated with POD. Furthermore, it will be important to determine whether high levels of the combination of IL-6 and sIL-6R can be an early biomarker for the subsequent development of POD.
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Affiliation(s)
- Yu Zhang
- From the Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Jun Hu
- From the Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Weiguang Zuo
- Department of Clinical Laboratory, The Second Hospital of Anhui Medical University, Hefei, China
| | - Pei He
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Qi Xue
- From the Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Xiaomei Feng
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Ye Zhang
- From the Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, China
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care and Centre for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
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15
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Correlation Analysis of Inflammatory Markers CRP and IL-6 and Postoperative Delirium (POD) in Elderly Patients: A Meta-Analysis of Observational Studies. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2022; 2022:1136386. [PMID: 36444287 PMCID: PMC9701131 DOI: 10.1155/2022/1136386] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/23/2022] [Indexed: 11/21/2022]
Abstract
Background Postoperative delirium (POD) is very common in the elderly surgical population, and its occurrence is associated with multiple factors such as preoperative, intraoperative, and postoperative factors, and the increase of serum inflammatory markers such as C-reactive protein (CRP) and interleukin-6 (IL-6) is considered to be associated with the occurrence of POD, but the results of multiple studies are inconsistent. In this study, we investigated the correlation between inflammatory markers CRP and IL-6 and POD in elderly patients by literature search and meta-analysis. Methods We searched PubMed, Web of Science, the Cochrane library, Embase, Ovid, and Springer Link for cohort studies or case-control studies that investigated the factors involved in the occurrence of POD, used the Newcastle-Ottawa Scale (NOS) to assess the quality of the selected literature, and combined the differences in serum CRP and IL-6 levels between POD and non-POD patients after surgery to evaluate the predictive value of CRP and IL-6 for the occurrence of POD. Results This research comprised 16 papers for quantitative analysis, with a total of 2967 patients, 758 with POD and 2209 with non-POD. There were 16 cohort studies (100%) and 0 case-control studies (0%) across all the collected literatures; there were 15 prospective cohort studies and 1 retrospective cohort research. A meta-analysis revealed a statistically significant difference in serum IL-6 levels between POD patients after surgery and non-POD patients [MD = 115.68, 95% CI (25.70, 206.66), Z = 2.52, P = 0.012], as well as a statistically significant difference in serum CRP levels [MD = 27.67, 95% CI (12.77, 42.58), Z = 3.64, P = 0.0003]. Discussion. Early after surgery, serum IL-6 and CRP levels were considerably higher in POD patients than in non-POD patients, indicating that early serum inflammatory variables are likely to be predictors of POD. After surgery, the levels of the aforementioned inflammatory factors should be actively monitored to forecast the emergence of delirium, and active treatment should be used to limit the creation and release of the aforementioned inflammatory factors.
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16
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Pasqui E, de Donato G, Brancaccio B, Casilli G, Ferrante G, Cappelli A, Palasciano G. The Predictive Role of Inflammatory Biochemical Markers in Post-Operative Delirium After Vascular Surgery Procedures. Vasc Health Risk Manag 2022; 18:747-756. [PMID: 36128257 PMCID: PMC9482775 DOI: 10.2147/vhrm.s368194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background Post-operative delirium (POD) is a common complication, especially in elderly patients who underwent vascular surgery procedures. The aim of this study was to evaluate the relation of inflammatory biochemical markers as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and systemic inflammation index (SII) with POD occurrence. Methods This was a single-center, retrospective, observational study. We analyzed the perioperative data of patients who had undergone elective vascular surgery procedures. The occurrence of delirium after procedure was used to divide the population in two groups: POD-pos and POD-neg group. ROC curves were performed to find the appropriate cut-off values of NLR, PLR and SII. Multivariate analysis was used to identify the independent predictors for POD. Results A total of 646 patients were enrolled. Mean age was 76.2±9.8 years, 68.4% were male. Seventy-three patients (11.3%) developed POD. Mean hospital stay was significantly increased in the POD-pos group (6.1±5.4 vs 3.2±2.8 days, p=0.0001). In-hospital reinterventions were more frequent in the POD-pos group (8.2% vs 3.8%). Blood values analysis reported significant differences: Hb, NLR, PLR, SII, creatinine and RCP were strongly increased (p<0.05) in the POD-pos group. ROC curves identified cut-off values for NLR>3.57, PLR>139.2 and SII>676.4. Multivariate analysis revealed that age, Renal Failure, peripheral revascularization procedures, major amputation, general anesthesia, hospitalization in the previous month, NLR>3.57 and SII>676.4 were independent risk factors for POD. Conclusion POD represents a common complication of vascular surgery patients. Our study demonstrated that NLR, PLR and SII are reliable and readily available laboratory predictors of POD in vascular surgery that could help in POD risk-stratification.
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Affiliation(s)
- Edoardo Pasqui
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Gianmarco de Donato
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Brenda Brancaccio
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Giulia Casilli
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Giulia Ferrante
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Alessandro Cappelli
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Giancarlo Palasciano
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
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Song Y, Luo Y, Zhang F, Ma Y, Lou J, Li H, Liu Y, Mi W, Cao J. Systemic immune-inflammation index predicts postoperative delirium in elderly patients after surgery: a retrospective cohort study. BMC Geriatr 2022; 22:730. [PMID: 36064357 PMCID: PMC9446812 DOI: 10.1186/s12877-022-03418-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative delirium (POD) is a common complication among elderly patients after surgery. It is unclear whether the systemic immune-inflammation index (SII) can be a predictor of POD. We explored the prognostic value of the SII in predicting POD in elderly patients undergoing non-neurosurgery and non-cardiac surgery in a large retrospective cohort. Methods We enrolled elderly patients undergoing non-neurosurgery and non-cardiac surgery between January 2014 and August 2019. Univariate and multivariate logistic regression analyses were performed to explore the correlation between POD and the SII value as both a continuous and categorical variable. Then, propensity score matching (PSM) analysis was applied to eliminate the confounding effect of covariates and prove our results. Subgroup analyses were then performed to discover the association between the SII and POD in different subgroups. Results A total of 29,608 patients with a median age of 70 years (IQR: 67–74) were enrolled in the retrospective cohort. The cut-off value of the SII was 650, which was determined by the receiver operating characteristic (ROC) curve. The ORs of an SII value > 650 was 2.709 (95% CI:2.373–3.092, P < 0.001), 1.615 (95% CI:1.384–1.882, P < 0.001), 1.855 (95% CI:1.602–2.146, P < 0.001), and 1.302 (95% CI:1.106–1.531, P = 0.001) for prediction of POD in univariate model and three multivariate regression models. After PSM, the OR of an SII value > 650 was 1.301 (95% CI: 1.062–1.598, P = 0.011). The subgroup analysis indicated that the SII indicates a significantly increased risk of POD in patients with Hb < 130 g/L, 4*109/L < WBC ≤ 10*109/L, albumin < 39 g/L, or duration of MAP < 60 mmHg ≥ 5 min. The SII was found to be a useful prognostic predictor of POD for patients of different ages, sexes, and ASA classifications. Conclusions The SII had a predictive value for POD in patients undergoing non-neurosurgery and non-cardiac surgery. As an index generated from routine blood tests, the SII has advantages regarding cost and time. After further validation, the SII may provide a new option for POD prediction. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03418-4.
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Affiliation(s)
- Yuxiang Song
- Department of Anesthesiology, The First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Yungen Luo
- Department of Anesthesiology, The First Medical Center of Chinese, PLA General Hospital, Beijing, China.,Medical School of Chinese People's Liberation Army, Beijing, China
| | - Faqiang Zhang
- Department of Anesthesiology, The First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Yulong Ma
- Department of Anesthesiology, The First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Jingsheng Lou
- Department of Anesthesiology, The First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Hao Li
- Department of Anesthesiology, The First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Yanhong Liu
- Department of Anesthesiology, The First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Weidong Mi
- Department of Anesthesiology, The First Medical Center of Chinese, PLA General Hospital, Beijing, China.
| | - Jiangbei Cao
- Department of Anesthesiology, The First Medical Center of Chinese, PLA General Hospital, Beijing, China.
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