The risk factors of postoperative delirium in general anesthesia patients with hip fracture: Attention needed

Projection of visual material on postoperative delirium in patients undergoing cardiac surgery: A double blind randomized clinical trial

BACKGROUND

Postoperative delirium is a neurobehavioral disorder that can appear after surgery. It is characterized by an altered level of consciousness and impaired cognitive function. The aim of this study was to evaluate the impact of visual projection of images of relatives or loved ones in patients undergoing cardiac surgery in the immediate postoperative period, and its influence on the incidence and development of postoperative delirium.

METHODS

A randomized, double-blind clinical trial was designed in the immediate postoperative period of adult patients undergoing cardiac surgery. Consolidated Statement of Reporting Trials guidelines were followed. A control group (CG) and an intervention group (IG) were established. In the IG, the patients underwent a visual projection, while the usual unit treatment was carried out with the CG. Sociodemographic, anthropometric, anesthetic, and surgical variables were also recorded. The postoperative delirium assessment scale used was the confusion assessment method for diagnosing delirium in intensive care unit patients.

RESULTS

Information was collected from 104 patients undergoing cardiac surgery. Most of the patients included in the study were men (66.35%) and the most performed surgical intervention was aortic valve replacement (34.62%). In the CG, positive patients in postoperative delirium increased from 19.23% to 25%, while in the IG they decreased from 5.77% to 1.92%. The logistic regression analysis presents a prediction model where the variables that influence the model are gender and group membership, meaning that being female and belonging to the IG significantly reduce the presence of delirium.

CONCLUSION

The projection of visual material reduced the incidence of postoperative delirium in patients undergoing cardiac surgery, although it cannot be established that it is effective as a treatment once the pathology is already established.

Risk factors and nomogram predictive model of severe postoperative complications in elderly patients with intertrochanteric fractures

Objective

To analyze risk factors of severe postoperative complications in elderly patients with intertrochanteric fractures (ITF), and to construct a predictive model.

Methods

The medical records of 316 elderly patients with ITF who underwent surgical treatment in Suzhou Hospital of Integrated Traditional Chinese and Western Medicine from January 2020 to December 2022 were retrospectively analyzed. Univariate and multivariate logistic regression analyses were performed to identify risk factors of severe postoperative complications. A nomogram prediction model was constructed using the RMS package of R4.1.2 software. Accuracy and stability of the model was assessed using the receiver operating characteristic (ROC) curve, Hosmer-Lemeshow goodness-of-fit test, and decision curve analysis.

Results

Age, American Society of Anesthesiologists (ASA) grading, combined medical diseases, preoperative bedridden condition, frailty, and preoperative albumin levels were all risk factors for severe postoperative complications in ITF patients were noted. These factors were then used to build a risk prediction model that had an area under the ROC curve (AUC) of 0.899 (95% confidence interval (CI): 0.846-0.951). The internal validation results of the Bootstrap method showed that the C-index value of the model was 0.899, and the calibration curve had a good fit with the ideal curve.

Conclusions

Age, ASA grading, combined medical diseases, preoperative bedridden condition, frailty, and preoperative albumin levels were independent risk factors for severe postoperative complications in elderly ITF patients. The constructed prediction model based on the above risk factors has a high predictive value.

Association between preoperative persistent hyperglycemia and postoperative delirium in geriatric hip fracture patients

BACKGROUND

The management of preoperative blood glucose levels in reducing the incidence of postoperative delirium (POD) remains controversial. This study aims to investigate the impact of preoperative persistent hyperglycemia on POD in geriatric patients with hip fractures.

METHODS

This retrospective cohort study analyzed medical records of patients who underwent hip fracture surgery at a tertiary medical institution between January 2013 and November 2023. Patients were categorized based on preoperative hyperglycemia (hyperglycemia defined as ≥ 6.1mmol/L), clinical classification of hyperglycemia, and percentile thresholds. Multivariate logistic regression and propensity score matching analysis (PSM) were employed to assess the association between different levels of preoperative glucose and POD. Subgroup analysis was conducted to explore potential interactions.

RESULTS

A total of 1440 patients were included in this study, with an incidence rate of POD at 19.1% (275/1440). Utilizing multiple logistic analysis, we found that patients with hyperglycemia had a 1.65-fold increased risk of experiencing POD compared to those with normal preoperative glucose levels (95% CI: 1.17-2.32). Moreover, a significant upward trend was discerned in both the strength of association and the predicted probability of POD with higher preoperative glucose levels. PSM did not alter this trend, even after meticulous adjustments for potential confounding factors. Additionally, when treating preoperative glucose levels as a continuous variable, we observed a 6% increase in the risk of POD (95% CI: 1-12%) with each 1mmol/L elevation in preoperative glucose levels.

CONCLUSIONS

There exists a clear linear dose-response relationship between preoperative blood glucose levels and the risk of POD. Higher preoperative hyperglycemia was associated with a greater risk of POD.

CLINICAL TRIAL NUMBER

NCT06473324.

Predicting postoperative delirium after percutaneous transluminal angioplasty and stenting in patients with intracranial atherosclerotic stenosis

OBJECTIVE

Known as a major surgical complication, postoperative delirium (POD) has not been well studied in patients with intracranial atherosclerotic stenosis (ICAS). This study aimed to investigate the correlation between perioperative clinical characteristics and the occurrence of POD.

METHODS

Patients' demographic characteristics and perioperative testing data were collected. Binary logistic regression was conducted for assessing related risk factors. A nomogram was developed to predict the occurrence of POD after percutaneous transluminal angioplasty and stenting (PTAS) in patients with ICAS.

RESULTS

The occurrence of POD in this study was 30.67%. Among all the clinical and laboratory characteristics in patients, age (OR = 1.234, 95%CI = 1.004-1.517, p = 0.046), gender (OR = 5.676, 95%CI = 1.028-31.334, p = 0.046), preoperative MMSE scores (OR = 2.298, 95%CI = 1.005-5.259, p = 0.049), the degree of stenosis (OR = 6.294, 95%CI = 1.043-37.974, p = 0.045), operating time (OR = 1.088, 95%CI = 1.023-1.157, p = 0.006), and HbA1c levels (OR = 2.226, 95%CI = 1.199-4.130, p = 0.011) were the independent risk factors.

CONCLUSION

Male patients with advanced-age, lower preoperative MMSE scores, severe stenosis, longer operating time, and higher HbA1c levels are closely related to POD after PTAS. Fully perioperative assessments may play an important role in predicting the occurrence of POD.

Delirium management in perioperative geriatric services: a narrative review of non-pharmaceutical strategies

Delirium, a common complication in elderly surgical patients, poses significant challenges in perioperative care. Perioperative geriatric services (PGS) aim at managing comorbidities, postoperative complications, and initiating early recovery of mobility to enhance elderly patients' prognosis in the perioperative period. Studies have shown that patients with preoperative cognitive disorders are at a significantly increased risk of postoperative delirium. While postoperative delirium affects up to 70% of people over 60 and 90% of people with neurodegenerative diseases, it remains underdiagnosed in many cases. Postoperative delirium can lead to functional decline, prolonged hospitalization, increased healthcare costs, cognitive impairment, and psychological malaise. This article briefly summarizes the literature on delirium, its risk factors, and its non-pharmaceutical management strategies within the perioperative period. It highlights the importance of integrating cognitive and psychological assessments into perioperative care protocols to provide baseline data, improve patient outcomes, reduce hospital stays, and minimize complications associated with delirium. By embracing evidence-based delirium management protocols, healthcare professionals can better identify and manage delirium, ultimately improving the quality of care for elderly surgical patients, which would also benefit healthcare staff and healthcare institutions.

Association between preoperative albumin levels and postoperative delirium in geriatric hip fracture patients

Objective

This study aims to examine the association between preoperative serum albumin levels and postoperative delirium (POD) in geriatric patients who have undergone hip fracture surgery, with the goal of offering novel insights for clinical interventions targeting POD.

Methods

A retrospective analysis was conducted on the medical records of patients who underwent hip fracture surgery in a tertiary medical institution from January 2013 to November 2023. The patients were classified based on hypoalbuminemia (defined as a serum albumin level < 35 g/L) and clinical threshold. Multivariable logistic regression and propensity score matching analysis (PSM) were employed to calculate the adjusted odds ratios (OR) and 95% confidence intervals (95% CI) for POD to eliminate potential confounding factors. Additionally, subgroup analysis was performed to explore the interaction effect.

Results

The retrospective cohort study included 1,440 patients, with an incidence of POD found to be 19.1%. In a multivariable logistic regression analysis, patients with hypoalbuminemia had an adjusted OR of 2.99 (95%CI: 2.14-4.18) compared to those with normal albumin levels (≥ 35 g/L). Furthermore, a significant trend was observed across different severity categories, including mild hypoalbuminemia (34.9-30.0 g/L; adjusted OR = 2.71, 95%CI: 1.84-3.99), moderate hypoalbuminemia (29.9-25.0 g/L, adjusted OR = 3.44, 95%CI: 1.88-6.28), and severe hypoalbuminemia (<25.0 g/L; adjusted OR = 3.97, 95%CI: 1.78-8.86), with a trend value of p <0.001. Similar results were observed in the PSM analysis. Additionally, treating preoperative serum albumin level as a continuous variable, the risk of POD increased by 11% (95% CI, 1.08-1.15) with each 1 g/L decrease in preoperative serum albumin level.

Conclusion

Low preoperative levels of albumin are strongly associated with POD in geriatric patients with hip fractures, and a significant dose-response relationship exists between them.

Risk prediction models for postoperative delirium in elderly patients with fragility hip fracture: A systematic review and critical appraisal

BACKGROUND

Elderly patients with fragility hip fracture continue to experience a high rate of postoperative delirium (POD), which has a significant negative impact on prognosis and imposes a huge economic burden. A number of risk prediction models have been developed to detect POD early. However, the risk of bias and clinical applicability of the models remain unclear. The aim of this study was to systematically evaluate risk prediction models for POD.

METHODS

CNKI, WanFang DATA, Vip Database, SinoMed, PubMed, Web of Science, Embase, and the Cochrane Library were searched for studies published by July 2023. The literature was screened independently by two investigators. The Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies (CHARMS) and the Prediction Model Risk of Bias Assessment Tool (PROBAST) were respectively used for data extraction, risk of bias, and applicability assessment.

RESULTS

A total of 16 studies on the construction of POD risk prediction models were included. The area under the ROC curve of the models ranges from 0.670 to 0.957. The most common predictors of POD included age, history of dementia, history of delirium, ASA classification, preoperative waiting time, and preoperative albumin level. All models had a high risk of bias, mainly due to inadequate sample size, inappropriate handling of missing data, a lack of model performance evaluation, and overfitting of the models.

CONCLUSIONS

Overall, risk prediction models for POD in fragility hip fracture patients are still in the development stage. The majority of POD prediction models have substantial bias risks, attributable primarily to poor reporting of analysis and evaluation of model performance. In future research, it is recommended to conduct validation of the models or develop localized prediction models with demonstrated high performance, with the aim of benefiting POD screening.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023449153.

Decoding the Neurological Sequelae of General Anesthesia: A Review

General anesthesia is an integral part of modern surgical practice, but it is associated with a number of complications, including neurological ones. This article provides a thorough analysis of these complications, taking into account the most common ones like drug complications, through delirium, postoperative cognitive impairment (POCD), to the rarest ones like perioperative stroke (POS), spinal cord ischemia (SCI), and postoperative visual loss (POVL). Its main goal is to familiarize healthcare professionals, especially those involved in anesthesiology, with the intricacies of neurological complications. Given their specificity and frequency of occurrence, it is well known that the diagnosis and management of these complications can sometimes cause problems for physicians without advanced neurological knowledge. Also, in addition to complex diagnostics, the pathomechanism of non-pharmacological complications is often not fully understood due to their multifactoriality and sometimes paucity of research. For this reason, an increasing amount of work is being done in the medical community to better understand this group of conditions, enabling faster diagnosis and more effective treatment, as well as perioperative prevention. This paper aims to increase awareness and vigilance among physicians across the spectrum of surgical patient care, from premedication to postoperative follow-up. Drawing on the authors' experience and the extensive medical literature, this paper includes 39 selected articles from 1994 to 2023, seeking the latest insights in the constantly evolving field of neurology and anesthesiology. This article aims to review the neurological complications of general anesthesia.

Risk factors for postoperative delirium in orthopaedic hip surgery patients: a database review

BACKGROUND

Postoperative delirium is a common problem affecting admitted patients that decreases patient satisfaction and increases the cost and complexity of care. The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to compare rates and risk factors of postoperative delirium for total hip arthroplasty (THA) and hemiarthroplasty patients indicated for osteoarthritis or proximal femur fracture.

METHODS

The 2021 NSQIP database was queried for patients using Current Procedural Terminology (CPT) codes for THA and hemiarthroplasty and ICD-10 codes for osteoarthritis or proximal femur fracture. Demographic, past medical history, preoperative labs, and functional status data were recorded. Procedural data were also collected. Finally, postoperative outcomes and complications were reviewed.

RESULTS

Overall, 16% of patients had postoperative delirium. Delirium patients were older on average (82.4 years vs. 80.7 years, p < 0.001), had a lower BMI (19.5 vs. 24.8, p < 0.001), were more likely to have a history of dementia (54.6% vs. 13.6%, p < 0.001), were less likely to have an independent functional status (p < 0.001) or live alone (p < 0.001), and were more likely to have sustained a recent fall (p < 0.001). Delirium patients were more likely to be hyponatremic or hypernatremic (p = 0.002), anemic (p < 0.001), and severely dehydrated (p < 0.001), among other lab abnormalities. Delirium patients were also more likely to experience additional postoperative complications, including pneumonia, pulmonary embolism, urinary tract infection, stroke, cardiac arrest, sepsis, and unplanned reoperation and readmission after discharge (all p < 0.05).

CONCLUSIONS

In this study, factors associated with postoperative delirium in patients undergoing hemiarthroplasty and THA were identified, including older age, lower BMI, certain medical conditions, decreased functional status, certain lab abnormalities, and postoperative complications. These findings can be used by clinicians to better inform care and to determine when orthopaedic joint replacement patients may be at an increased risk for postoperative delirium.

Inflammatory and nutritional markers predict the risk of post-operative delirium in elderly patients following total hip arthroplasty

Objectives

This study intended to explore whether albumin-associated inflammatory and nutritional markers could predict post-operative delirium (POD) in older patients after total hip arthroplasty (THA). In addition, we established a nomogram model for POD prediction.

Methods

Totally, 254 elderly cases who received THA were included. Clinical and laboratory data of these patients were retrospectively collected. Albumin-associated inflammatory and nutritional markers included neutrophil-to-albumin ratio (NAR), CRP-to-albumin ratio (CAR), prognostic nutritional index (PNI), and systemic inflammation score (SIS). The LASSO, univariate and multivariate logistic regression analyses were utilized to screen risk factors. A nomogram model was developed according to the results of multivariate regression analyses.

Results

Among 254 patients, 49 cases had POD with an incidence of 19.3%. LASSO regression and multivariate logistic analyses suggested that preoperative NAR, preoperative PNI, preoperative SIS, and age >75 years were risk factors for POD. A nomogram model was developed according to the results of multivariate logistic analyses. The calibration curve suggested that the predicted probability of this nomogram model was in good line with the actual probability. The DCA showed that this nomogram model had net benefits for the prediction of POD for elderly patients following THA.

Conclusion

Albumin-associated inflammatory and nutritional markers including NAR, PNI, and SIS could predict POD in elderly patients following THA.

[Non-pharmacological Management of Postoperative Delirium]

Postoperative delirium is common especially in the elderly and is associated with high rates of morbidity and mortality. Non-pharmacological multicomponent interventions are effective in reducing the incidence and to a degree the duration of postoperative delirium and are recommended in international guidelines on postoperative delirium as first line intervention for management of delirium. Non-pharmacological management of postoperative delirium consists of strategies for risk stratification, risk reduction by non-pharmacological bundle interventions, early recognition of delirium by screening protocols and immediate therapy of underlying causes of delirium and continuation of non-pharmacological bundles. Non-pharmacological bundle interventions address common perioperative risk factors. Bundles comprise strategies for oxygenation, mobilization, hydration and nutrition, sensory and cognitive stimulation, reorientation, modifications of environmental factors such as design aspects and noise reduction, adequate analgesia, management of agitation and anxiety, protecting circadian rhythms for example by adequate light exposure during daytime, family involvement and timely reduction of unnecessary catheters and anticholinergic drugs. The article aims at providing an overview of non-pharmacological management of postoperative delirium in the hospital.

Metabolic syndrome and the risk of postoperative delirium and postoperative cognitive dysfunction: a multi-centre cohort study

BACKGROUND

Metabolic syndrome and its components are risk factors for cognitive impairment, but their contribution to perioperative neurocognitive disorders is unknown. We examined their associations with the risk of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) in older patients.

METHODS

In 765 male and female participants aged ≥65 years, we measured preoperative metabolic parameters and screened for POD for 7 days or until discharge. POCD was defined through comparison of cognitive change on six neuropsychological tests with non-surgical controls. Multiple logistic regression analyses examined the association of metabolic parameters with risk of POD and POCD with adjustment for age, sex, and surgery type.

RESULTS

A total of 149 patients (19.5% of 765) developed POD and 53 (10.1% of 520 attendees) had POCD at 3 months. Patients with metabolic syndrome were at 1.85-fold higher risk of POD (95% confidence interval [CI] 1.26-2.70). Each 1 mmol L^-1 higher high-density lipoprotein cholesterol (HDL-C) was associated with a 0.47-fold lower POD risk (95% CI 0.30-0.74). Each 1 kg m^-2 higher body mass index (BMI) was associated with a 1.09-fold higher POCD risk (95% CI 1.02- 1.16).

CONCLUSIONS

Older surgical patients with metabolic syndrome were at increased risk of POD. Only reduced HDL-C was significantly associated with POD. For POCD, a higher preoperative BMI was identified as a risk factor. These findings add to mounting evidence of a distinct epidemiology of POD and POCD. Screening programmes taking advantage of HDL-C and BMI measurements and of metabolic interventions in reducing perioperative neurocognitive disorders should be evaluated.

CLINICAL TRIAL REGISTRATION

NCT02265263.

A predictive scoring system for postoperative delirium in the elderly patients with intertrochanteric fracture

OBJECTIVE

To establish a scoring system to predict the postoperative delirium in elderly patients with intertrochanteric fracture.

MATERIALS AND METHODS

We retrospectively reviewed 159 elderly patients with a diagnosis of intertrochanteric fracture and underwent closed reduction and intramedullary nail fixation, and then divided them into two groups including the delirium group (23 cases) or non-delirium group (136 cases) in our hospital from January 2017 to December 2019. The following clinical characteristics were recorded and analyzed: age, gender, fracture classification, body mass index (BMI), history of diabetes mellitus, history of stroke, preoperative albumin, preoperative hemoglobin (Hb), preoperative arterial partial pressure of oxygen (PaO₂), time between admission and surgery, lower limb thrombosis, American Society of Anesthesiologists (ASA) grade, operative time, operative blood loss, and intraoperative blood transfusion. The prevalence of these clinical characteristics in delirium group was evaluated, and the scoring system was established using logistic regression analysis. The performance of the scoring system was also prospectively validated.

RESULTS

The predictive scoring system was based on five clinical characteristics confirmed as significant predictors of postoperative delirium, namely, age > 75 years, history of stroke, preoperative Hb ≤ 100 g/L, preoperative PaO₂ ≤ 60 mmHg, and time between admission to surgery > 3 days. Delirium group showed a significant higher score than non-delirium (6.26 vs. 2.29, P < 0.001), and the optimal cut-off value for the scoring system was 4 points. The sensitivity and specificity of the scoring system for predicting postoperative delirium were 82.61% and 81.62% in derivation set, respectively, and 72.71% and 75.00% in validation set.

CONCLUSION

The predictive scoring system confirmed with achieve satisfactory sensitivity and specificity in predicting postoperative delirium in the elderly with intertrochanteric fracture. The risk of postoperative delirium in patients with the score of 5 to 11 is high, while the score of 0 to 4 is low.

Unwanted spontaneous responsiveness and burst suppression in patients undergoing entropy-guided total intravenous anesthesia with target-controlled infusion: An observational prospective trial

STUDY OBJECTIVE

To estimate the incidence of unwanted spontaneous responsiveness and burst suppression (BSupp) in patients undergoing state entropy (SE) and surgical pleth index (SPI)-guided total intravenous anesthesia (TIVA) with target-controlled infusion (TCI).

DESIGN

Observational, prospective, single-center study.

SETTINGS

Operating room.

PATIENTS

107 adult (<65 years) and elderly (≥65 years) women undergoing breast surgery.

INTERVENTIONS

Propofol-remifentanil TIVA-TCI-guided by SE for depth of anesthesia monitoring (target value 40-60) and SPI for antinociception monitoring (target value 20-50) without neuromuscular blockade.

MEASUREMENTS

Age; body mass index; American Society of Anesthesiologists physical status classification; concentration at the effect site of propofol (CeP) and remifentanil (CeR) at loss of responsiveness (LoR), median during anesthesia maintenance (MdM), and at return of responsiveness (RoR); propofol infusion duration; incidence of postoperative delirium (POD) with Confusing Assessment Method for the Intensive Care Unit.

MAIN RESULTS

During SE-SPI-guided TIVA-TCI, 13.1% of patients showed unwanted spontaneous responsiveness, whereas 45.8% showed BSupp. Unwanted spontaneous responsiveness was observed mainly in adults (p < 0.05), and higher CeP RoR (p < 0.05) was registered. BSupp was observed mainly in patients showing a lower CeP MdM (p < 0.01) and CeP RoR (p < 0.05). Unwanted spontaneous responsiveness and BSupp were not associated with significant differences in CeRs. An age-related hysteresis effect was observed, resulting in higher CeP LoR than CeP RoR (p < 0.001). 12.2% of patients showed POD. Only preoperative serum albumin was associated with increased likelihood of POD (p = 0.046).

CONCLUSIONS

The SE-SPI-guided TIVA-TCI did not prevent unwanted spontaneous responsiveness and BSupp. CeP RoR may be used as a proxy for anesthetic sensitivity.

Type 2 Diabetes Mellitus with Tight Glucose Control and Poor Pre-Injury Stair Climbing Capacity May Predict Postoperative Delirium: A Secondary Analysis

(1) Background: Previous evidence demonstrates that tight glycemic control and good physical function could reduce the risk of delirium. This study aimed to investigate whether the occurrence of postoperative delirium (POD) in older hip fracture surgery patients is associated with preoperative glycemic control factors or pre-injury physical performance. (2) Methods: Three-hundred and nine individuals aged over 65 years and scheduled for hip fracture surgery were included at a single center. Glycemic control factors and pre-injury physical performance were assessed preoperatively. The presence of delirium was assessed using the Confusion Assessment Method on postoperative hospitalization days. Univariate and multivariable logistic regression models and a risk prediction model of POD were established. (3) Results: Among the 309 patients, 52 (16.83%) experienced POD during the hospital stay. The numbers of pre-injury physical performance and type 2 diabetes mellitus (T2DM) patients were significantly different in the POD and non-POD groups. The multivariable model showed that development of delirium was significantly explained by preoperative fasting blood glucose (FBG) (OR 0.804, p = 0.004), stair climbing (OR 0.709, p = 0.003), T2DM (odds ratio (OR) 3.654, p = 0.001), and age-adjusted Charlson comorbidity index (ACCI) (OR 1.270, p = 0.038). The area under the receiver operating characteristic curve (AUROC) of the risk prediction model including those covariates was 0.770. (4) Conclusions: More older T2DM patients develop POD after hip fracture surgery than patients without T2DM. A simple assessment of preoperative FBG and pre-injury stair climbing capacity may identify those at high risk for the development of POD. Higher preoperative FBG and good pre-injury stair climbing capacity are protective factors for POD.

Development and Validation of a Nomogram for Predicting Postoperative Delirium in Patients With Elderly Hip Fracture Based on Data Collected on Admission

Delirium is a common postoperative complication in elderly hip fracture patients that seriously affects patients’ lives and health, and early delirium risk prediction, and targeted measures can significantly reduce the incidence of delirium. The purpose of this study was to develop and validate a nomogram for the prediction of postoperative delirium (POD) in elderly hip fracture patients. A total of 328 elderly patients with hip fractures enrolled retrospectively in department 1 of our hospital were randomly divided into the training set (n = 230) and the internal validation set (n = 98). The least absolute shrinkage and selection operator (LASSO) regression analysis was used for feature variable selection, and multivariate logistic regression with a backward stepwise method was used to construct a nomogram in the training set. The discrimination efficacy and calibration efficacy of the nomogram were evaluated through the receiver operating characteristic (ROC) curve and calibration curve, respectively. The clinical usefulness was estimated through decision curve analysis (DCA) and clinical impact curve (CIC) analysis. Another validation set from department 2 of our hospital, containing 76 elderly patients with hip fractures, was used for external validation of the nomogram. A total of 43 (13.1%) and 12 (15.8%) patients had POD in department 1 and department 2, respectively. The nomogram was constructed by three predictors, including dementia, chronic obstructive pulmonary disease (COPD), and albumin level. The nomogram showed good discrimination efficacy and calibration efficacy, with the AUC of 0.791 (95% CI, 0.708–0.873), 0.820 (95% CI, 0.676–0.964), and 0.841 (95% CI, 0.717–0.966) in the training set, the internal validation set, and the external validation set, respectively. Both DCA and CIC demonstrated that this nomogram has good clinical usefulness. The nomogram constructed by dementia, COPD, and albumin level can be conveniently used to predict POD in patients with elderly hip fractures.

Potential value of preoperative fasting blood glucose levels in the identification of postoperative delirium in non-diabetic older patients undergoing total hip replacement: The perioperative neurocognitive disorder and biomarker lifestyle study

BACKGROUND

Postoperative delirium (POD) is a common complication after total hip replacement. This study aims to explore the relationship between preoperative fasting blood glucose (FBG) levels and POD in non-diabetic older patients undergoing total hip replacement.

MATERIALS AND METHODS

This study included a total of 625 patients undergoing elective total hip replacement under combined spinal and epidural anesthesia from the PNDABLE study. The relationship between POD and preoperative FBG was analyzed by using the logistic regression model. The associations of FBG with individual cerebrospinal fluid (CSF) biomarkers were detected by using the multivariable linear regression model controlling for age, gender, and education level. The mediation effects were explored by mediation analyses with 5,000 bootstrap iterations, while sensitivity analysis was used to test the reliability and stability of the results. The receiver operating characteristic (ROC) curve and the nomogram model were applied to evaluate the efficacy of FBG and POD-related CSF biomarkers in predicting POD. POD assessment was performed two times daily by a trained anesthesiologist at 9:00-10:00 am and 2:00-3:00 pm on postoperative days 1-7 or before the patients were discharged from the hospital. POD was defined by the Confusion Assessment Method (CAM), and POD severity was measured using the Memorial Delirium Assessment Scale (MDAS). Enzyme-linked immunosorbent assay (ELISA) was used to measure CSF Aβ₄₀, Aβ₄₂, T-tau, and P-tau levels.

RESULTS

POD was detected in 10.2% (60/588) of the patients. Logistic regression analysis showed that after adjusting for age and education level, the increased levels of FBG (OR 1.427, 95% CI 1.117-1.824, P = 0.004), CSF P-tau (OR 1.039, 95% CI 1.019-1.060, P < 0.001), and CSF T-tau (OR 1.013, 95% CI 1.009-1.018, P < 0.001) were risk factors for POD, and the increased level of CSF Aβ₄₂ (OR 0.996, 95% CI 0.994-0.998, P = 0.001) was a protective factor for POD. Multivariable linear regression models showed that when adjusting for age, gender, and education level, in the POD group, higher preoperative FBG levels were negatively correlated with the CSF Aβ42 level (β = -0.290, P = 0.028) and positively correlated with CSF P-tau (β = 0.384, P = 0.004) and T-tau (β = 0.447, P < 0.001). In the non-POD group, a higher preoperative FBG was not related to CSF biomarkers. Mediated effect analysis showed that CSF T-tau (proportion = 17.1%) had an apparent mediation effect on the relationship between FBG and POD. Sensitivity analysis revealed that the results from the logistic regression and multivariable linear regression models were consistent with previous results.

CONCLUSION

Increased preoperative FBG was a risk factor for POD in older patients without T₂DM, and T-tau might mediate the relationship between FBG and POD.

Association between General Anesthesia and the Occurrence of Cerebrovascular Accidents in Hip Fracture Patients

Background

General anesthesia is an important factor leading to postoperative complications, and cerebrovascular accidents take the first place in the causes of postoperative death. Therefore, it is extremely important to explore the correlation between general anesthesia and the occurrence of cerebrovascular accidents in hip fracture patients.

Objective

To explore the association between general anesthesia and the occurrence of cerebrovascular accidents in hip fracture patients.

Methods

The data of 240 hip fracture patients treated in our hospital from February 2017 to February 2021 were retrospectively analyzed, and the patients were divided into the general anesthesia group (n = 120) and nongeneral anesthesia group (n = 120) according to whether or not they received general anesthesia, so as to compare their incidence rate of cerebrovascular accidents between the two groups, record their hemodynamic changes, and analyze the association between various risk factors under general anesthesia and the occurrence of cerebrovascular accidents.

Results

No statistical differences in patients' general information such as age and gender between the two groups were observed (P > 0.05); compared with the nongeneral anesthesia group, the incidence rate of cerebrovascular accidents was significantly higher in the general anesthesia group (P < 0.001); between the two groups, the heart rates and mean arterial pressure (MAP) at 15 min after anesthesia, at the time of skin incision, and 15 min before the end of surgery were significantly different (P < 0.05); according to the multiple logistic regression analysis, general anesthesia was a risk factor affecting the occurrence of cerebrovascular accidents in hip fracture patients, and under general anesthesia, age ≥80 years, BMI ≥23 kg/m², types of anesthetic drugs ≥4, intraoperative blood pressure ≥140 mmHg, and intraoperative heart rate ≥80 bpm were also regarded as the risk factors.

Conclusion

General anesthesia is a risk factor affecting the occurrence of cerebrovascular accidents in hip fracture patients, and under general anesthesia, age ≥80 years, BMI ≥23 kg/m², types of anesthetic drugs ≥4, intraoperative blood pressure ≥140 mmHg, and intraoperative heart rate ≥80 bpm will further increase the possibility of cerebrovascular accidents.