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Ghezzi ES, Greaves D, Boord MS, Davis D, Knayfati S, Astley JM, Sharman RLS, Goodwin SI, Keage HAD. How do predisposing factors differ between delirium motor subtypes? A systematic review and meta-analysis. Age Ageing 2022; 51:afac200. [PMID: 36153750 PMCID: PMC9509667 DOI: 10.1093/ageing/afac200] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/05/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Delirium is a common neurocognitive disorder in hospitalised older adults with vast negative consequences. The predominant method of subtyping delirium is by motor activity profile into hypoactive, hyperactive and mixed groups. OBJECTIVE This systematic review and meta-analysis investigated how predisposing factors differ between delirium motor subtypes. METHODS Databases (Medline, PsycINFO, Embase) were systematically searched for studies reporting predisposing factors (prior to delirium) for delirium motor subtypes. A total of 61 studies met inclusion criteria (N = 14,407, mean age 73.63 years). Random-effects meta-analyses synthesised differences between delirium motor subtypes relative to 22 factors. RESULTS Hypoactive cases were older, had poorer cognition and higher physical risk scores than hyperactive cases and were more likely to be women, living in care homes, taking more medications, with worse functional performance and history of cerebrovascular disease than all remaining subtypes. Hyperactive cases were younger than hypoactive and mixed subtypes and were more likely to be men, with better cognition and lower physical risk scores than all other subtypes. Those with no motor subtype (unable to be classified) were more likely to be women and have better functional performance. Effect sizes were small. CONCLUSIONS Important differences in those who develop motor subtypes of delirium were shown prior to delirium occurrence. We provide robust quantitative evidence for a common clinical assumption that indices of frailty (institutional living, cognitive and functional impairment) are seen more in hypoactive patients. Motor subtypes should be measured across delirium research. Motor subtyping has great potential to improve the clinical risk assessment and management of delirium.
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Affiliation(s)
- Erica S Ghezzi
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Danielle Greaves
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Monique S Boord
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing Unit at UCL, London, UK
| | - Sara Knayfati
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Jack M Astley
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Rhianna L S Sharman
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Stephanie I Goodwin
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory, Justice and Society, University of South Australia, Adelaide, Australia
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Ke Y, Chew S, Seet E, Wong WY, Lim V, Chua N, Zhang J, Lim B, Chua V, Loh NHW, Ti LK. Incidence and risk factors of delirium in post-anaesthesia care unit. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:87-95. [PMID: 35224604 DOI: 10.47102/annals-acadmedsg.2021297] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Post-anaesthesia care unit (PACU) delirium is a potentially preventable condition that results in a significant long-term effect. In a multicentre prospective cohort study, we investigate the incidence and risk factors of postoperative delirium in elderly patients undergoing major non-cardiac surgery. METHODS Patients were consented and recruited from 4 major hospitals in Singapore. Research ethics approval was obtained. Patients older than 65 years undergoing non-cardiac surgery >2 hours were recruited. Baseline perioperative data were collected. Preoperative baseline cognition was obtained. Patients were assessed in the post-anaesthesia care unit for delirium 30-60 minutes after arrival using the Nursing Delirium Screening Scale (Nu-DESC). RESULTS Ninety-eight patients completed the study. Eleven patients (11.2%) had postoperative delirium. Patients who had PACU delirium were older (74.6±3.2 versus 70.6±4.4 years, P=0.005). Univariate analysis showed those who had PACU delirium are more likely to be ASA 3 (63.6% vs 31.0%, P=0.019), had estimated glomerular filtration rate (eGFR) of >60mL/min/1.73m2 (36.4% vs 10.6%, P=0.013), higher HbA1C value (7.8±1.2 vs 6.6±0.9, P=0.011), raised random blood glucose (10.0±5.0mmol/L vs 6.5±2.4mmol/L, P=0.0066), and moderate-severe depression (18.2% vs 1.1%, P=0.033). They are more likely to stay longer in hospital (median 8 days [range 4-18] vs 4 days [range 2-8], P=0.049). Raised random blood glucose is independently associated with increased PACU delirium on multivariate analysis.
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Affiliation(s)
- Yuhe Ke
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
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Liu S, Xv L, Wu X, Wang F, Wang J, Tang X, Dong R, Wang B, Lin X, Bi Y. 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. Front Psychiatry 2022; 13:941048. [PMID: 36311514 PMCID: PMC9606582 DOI: 10.3389/fpsyt.2022.941048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/20/2022] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Siyu Liu
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Lizhu Xv
- Medical Department, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Xiaoyue Wu
- Department of Anesthesiology, Dalian Medical University, Dalian, Liaoning, China
| | - Fei Wang
- Department of Anesthesiology, Nanjing Medical University, Nanjing, China
| | - Jiahan Wang
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Xinhui Tang
- Department of Anesthesiology, Dalian Medical University, Dalian, Liaoning, China
| | - Rui Dong
- Department of Anesthesiology, Gulou Hospital Affiliated to Medical College of Nanjing University, Nanjing, China
| | - Bin Wang
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Xu Lin
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Yanlin Bi
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
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Lin YJ, Lin LY, Peng YC, Zhang HR, Chen LW, Huang XZ, Chen Q. Association between glucose variability and postoperative delirium in acute aortic dissection patients: an observational study. J Cardiothorac Surg 2021; 16:82. [PMID: 33858463 PMCID: PMC8048274 DOI: 10.1186/s13019-021-01456-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 04/01/2021] [Indexed: 01/09/2023] Open
Abstract
Background Blood glucose variability is associated with poor prognosis after cardiac surgery, but the relationship between glucose variability and postoperative delirium in patients with acute aortic dissection is unclear. The study aims to investigate the association of blood glucose variability with postoperative delirium in acute aortic dissection patients. Methods We prospectively analyzed 257 patients including 103 patients with delirium. The patients were divided into two groups according to whether delirium was present. The outcome measures were postoperative delirium, the length of the Intensive Care Unit stay, and the duration of hospital stay. Multivariable Cox competing risk survival models was used to assess. Results A total of 257 subjects were enrolled, including 103 patients with delirium. There were statistically significant differences between the two groups in body mass index, history of cardiac surgery, first admission blood glucose, white blood cell counts, Acute Physiology and Chronic Health Evaluation II score, hypoxemia, mechanical ventilation duration, and the length of Intensive Care Unit stay(P < 0.05). The delirium group exhibited significantly higher values of the mean of blood glucose (MBG) and the standard deviation of blood glucose (SDBG) than in the non-delirium group(P < 0.05). In model 1, the adjusted hazard ratio (AHR) of the standard deviation of blood glucose was 1.436(P < 0.05). In Model 2, the standard deviation of blood glucose (AHR = 1.418, 95%CI = 1.195–1.681, P < 0.05) remained significant after adjusting for confounders. The area under the curve of the SDBG was 0.763(95%CI = 0.704–0.821, P < 0.01). The sensitivity was 81.6%, and the specificity was 57.8%. Conclusions Glucose variability is associated with the risk of delirium in patients after aortic dissection surgery, and high glycemic variability increases the risk of postoperative delirium.
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Affiliation(s)
- Yan-Juan Lin
- Department of Nursing, Union Hospital, Fujian Medical University, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
| | - Ling-Yu Lin
- Department of Nursing, Fujian Medical University, Fuzhou, China
| | - Yan-Chun Peng
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Hao-Ruo Zhang
- Department of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Liang-Wan Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China.
| | - Xi-Zhen Huang
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Qiong Chen
- Department of Nursing, Fujian Medical University, Fuzhou, China
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Zhang Z, Liu J, Xi J, Gong Y, Zeng L, Ma P. Derivation and Validation of an Ensemble Model for the Prediction of Agitation in Mechanically Ventilated Patients Maintained Under Light Sedation. Crit Care Med 2021; 49:e279-e290. [PMID: 33470778 DOI: 10.1097/ccm.0000000000004821] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Light sedation is recommended over deep sedation for invasive mechanical ventilation to improve clinical outcome but may increase the risk of agitation. This study aimed to develop and prospectively validate an ensemble machine learning model for the prediction of agitation on a daily basis. DESIGN Variables collected in the early morning were used to develop an ensemble model by aggregating four machine learning algorithms including support vector machines, C5.0, adaptive boosting with classification trees, and extreme gradient boosting with classification trees, to predict the occurrence of agitation in the subsequent 24 hours. SETTING The training dataset was prospectively collected in 95 ICUs from 80 Chinese hospitals on May 11, 2016, and the validation dataset was collected in 20 out of these 95 ICUs on December 16, 2019. PATIENTS Invasive mechanical ventilation patients who were maintained under light sedation for 24 hours prior to the study day and who were to be maintained at the same sedation level for the next 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 578 invasive mechanical ventilation patients from 95 ICUs in 80 Chinese hospitals, including 459 in the training dataset and 119 in the validation dataset, were enrolled. Agitation was observed in 36% (270/578) of the invasive mechanical ventilation patients. The stepwise regression model showed that higher body temperature (odds ratio for 1°C increase: 5.29; 95% CI, 3.70-7.84; p < 0.001), greater minute ventilation (odds ratio for 1 L/min increase: 1.15; 95% CI, 1.02-1.30; p = 0.019), higher Richmond Agitation-Sedation Scale (odds ratio for 1-point increase: 2.43; 95% CI, 1.92-3.16; p < 0.001), and days on invasive mechanical ventilation (odds ratio for 1-d increase: 0.95; 95% CI, 0.93-0.98; p = 0.001) were independently associated with agitation in the subsequent 24 hours. In the validation dataset, the ensemble model showed good discrimination (area under the receiver operating characteristic curve, 0.918; 95% CI, 0.866-0.969) and calibration (Hosmer-Lemeshow test p = 0.459) in predicting the occurrence of agitation within 24 hours. CONCLUSIONS This study developed an ensemble model for the prediction of agitation in invasive mechanical ventilation patients under light sedation. The model showed good calibration and discrimination in an independent dataset.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingtao Liu
- SICU, The 8th Medical Center of General Hospital of Chinese People's Liberation Army, Beijing, People's Republic of China
| | - Jingjing Xi
- Department of Critical Care Medicine, Peking University Third Hospital, Beijing, People's Republic of China
| | - Yichun Gong
- SICU, The 8th Medical Center of General Hospital of Chinese People's Liberation Army, Beijing, People's Republic of China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, The Third Hospital of Peking University, Beijing, China
| | - Penglin Ma
- SICU, The 8th Medical Center of General Hospital of Chinese People's Liberation Army, Beijing, People's Republic of China
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Incidence and Risk Factors of Delirium in the Intensive Care Unit: A Prospective Cohort. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6219678. [PMID: 33506019 PMCID: PMC7810554 DOI: 10.1155/2021/6219678] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 12/01/2020] [Accepted: 12/28/2020] [Indexed: 12/03/2022]
Abstract
Purpose The purpose of this study was to determine the incidence, risk factors, and impact of delirium on outcomes in ICU patients. In addition, the scoring systems were measured consecutively to characterize how these scores changed with time in patients with and without delirium. Material and Methods. A prospective cohort study enrolling 400 consecutive patients admitted to the ICU between 2018 and 2019 due to trauma or surgery. Patients were followed up for the development of delirium over ICU days using the Confusion Assessment Method (CAM) for the ICU and Intensive Care Delirium Screening Checklist (ICDSC). Cox model logistic regression analysis was used to explore delirium risk factors. Results Delirium occurred in 108 (27%) patients during their ICU stay, and the median onset of delirium was 4 (IQR 3–4) days after admission. According to multivariate cox regression, the expected hazard for delirium was 1.523 times higher in patients who used mechanical ventilator as compared to those who did not (HR: 1.523, 95% CI: 1.197-2.388, P < 0.001). Conclusion Our findings suggest that an important opportunity for improving the care of critically ill patients may be the determination of modifiable risk factors for delirium in the ICU. In addition, the scoring systems (APACHE IV, SOFA, and RASS) are useful for the prediction of delirium in critically ill patients.
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Ishibashi-Kanno N, Takaoka S, Nagai H, Okubo-Sato M, Fukuzawa S, Uchida F, Yamagata K, Yanagawa T, Bukawa H. Postoperative delirium after reconstructive surgery for oral tumor: a retrospective clinical study. Int J Oral Maxillofac Surg 2020; 49:1143-1148. [DOI: 10.1016/j.ijom.2020.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 12/12/2019] [Accepted: 01/24/2020] [Indexed: 10/24/2022]
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Krewulak KD, Stelfox HT, Ely EW, Fiest KM. Risk factors and outcomes among delirium subtypes in adult ICUs: A systematic review. J Crit Care 2020; 56:257-264. [PMID: 31986369 DOI: 10.1016/j.jcrc.2020.01.017] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Use systematic review methodology to summarize risk factors and outcomes for each delirium subtype (hypoactive, hyperactive and mixed) in an adult ICU population. MATERIALS AND METHODS We searched the MEDLINE, Embase, CINAHL, SCOPUS, Web of Science and PsycINFO databases from database inception until August 13, 2018, with no restrictions. RESULTS Of 9635 abstracts, 20 studies were included. Older age was not associated with any delirium subtype in 4/7 (57%) studies. Sex was not associated with any delirium subtype in 4/4 (100%) studies. Mortality was consistently associated with hypoactive delirium in 4/7 (57%) studies. The evidence supporting the association of APACHE-II score, mechanical ventilation, length of stay, duration of delirium and removal of tubes were inconsistent across studies. CONCLUSIONS Although included studies reported on many subtype-specific risk factors and outcomes, heterogeneity in reporting and methodological quality limited the generalizability of the results and the evidence for many subtype-specific risk factors or outcomes is inconsistent across studies. Standardized methodology and the creation of a universal template for collecting data in ICU delirium studies are essential moving forward; helping to identify subtype-specific risk factors or outcomes and strengthen the association of potential risk factors or outcomes.
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Affiliation(s)
- Karla D Krewulak
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Health Services, Calgary, AB, Canada; O'Brien Institute for Public Health, University of Calgary, Cumming School of Medicine, Calgary, AB, Canada
| | - E Wesley Ely
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (VA GRECC), Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Health Services, Calgary, AB, Canada; O'Brien Institute for Public Health, University of Calgary, Cumming School of Medicine, Calgary, AB, Canada; Department of Psychiatry, University of Calgary, Cumming School of Medicine, Calgary, AB, Canada; Hotchkiss Brain Institute, University of Calgary, Cumming School of Medicine, Calgary, AB, Canada.
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Windmann V, Spies C, Knaak C, Wollersheim T, Piper SK, Vorderwülbecke G, Kurpanik M, Kuenz S, Lachmann G. Intraoperative hyperglycemia increases the incidence of postoperative delirium. Minerva Anestesiol 2019; 85:1201-1210. [PMID: 31486622 DOI: 10.23736/s0375-9393.19.13748-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hyperglycemia frequently occurs during major surgery and is associated with adverse postoperative outcomes. This study aimed to investigate the influence of intraoperative hyperglycemia on incidences of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). METHODS Eighty-seven patients aged ≥65 years undergoing elective surgery were included in this prospective observational subproject of the BioCog study. Blood glucose (BG) levels were measured every 20 minutes intraoperatively. Hyperglycemia was defined as BG levels ≥150 mg·dL-1. Patients were assessed for POD twice daily until postoperative day 7. The occurrence of POCD was determined three months after surgery. Multivariable logistic regression was used to identify associations between hyperglycemia and POD as well as POCD. Secondary endpoints comprised duration of hyperglycemia, maximum glucose level (Glucosemax) and differences between diabetic and non-diabetic patients. RESULTS POD occurred in 41 (47.1%), POCD in five (15.2%) patients. In two separate multivariable logistic regression models, hyperglycemia was significantly associated with POD (OR 3.86 [CI 95% 1.13, 39.49], P=0.044) but not POCD (3.59 [NaN, NaN], P=0.157). Relative duration of hyperglycemia was higher in POD patients compared to patients without POD (20 [0; 71] % versus 0 [0; 55] %, P=0.075), whereas the maximum glucose levels during surgery were similar between the two groups. Considering only non-diabetic patients, relative duration of hyperglycemia (P=0.003) and Glucosemax (P=0.015) were significantly higher in patients with POD. CONCLUSIONS Intraoperative hyperglycemia was independently associated with POD but not POCD. Relative duration of hyperglycemia appeared thereby to also play a role. Especially hyperglycemic non-diabetic patients might be at high risk for POD.
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Affiliation(s)
- Victoria Windmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany -
| | - Cornelia Knaak
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Wollersheim
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sophie K Piper
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Gerald Vorderwülbecke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maryam Kurpanik
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sophia Kuenz
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gunnar Lachmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Xing J, Yuan Z, Jie Y, Liu Y, Wang M, Sun Y. Risk factors for delirium: are therapeutic interventions part of it? Neuropsychiatr Dis Treat 2019; 15:1321-1327. [PMID: 31190836 PMCID: PMC6529602 DOI: 10.2147/ndt.s192836] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 04/08/2019] [Indexed: 01/10/2023] Open
Abstract
Background: Delirium is associated with increased morbidity and mortality in critically ill patients. Research on risk factors for delirium allows clinicians to identify high-risk patients, which is the basis for early prevention and diagnosis. Besides the risk factors for delirium that are commonly studied, here we more focused on the less-studied therapeutic interventions for critically ill patients which are potentially modifiable. Materials and methods: A total of 320 non-comatose patients admitted to the ICU for more than 24 hrs during 9 months were eligible for the study. Delirium was screened once daily using the CAM-ICU. Demographics, admission clinical data, and daily interventions were collected. Results: Ninety-two patients (28.75%) experienced delirium at least once. Delirious patients were more likely to have longer duration of mechanical ventilation, ICU stay, and hospital stay. Most of the less-studied therapeutic interventions were linked to delirium in the univariate analysis, including gastric tube, artificial airway, deep intravenous catheter, arterial line, urinary catheter, use of vasoactive drugs, and sedative medication. After adjusting with age and ICU length of stay, mechanical ventilation (OR: 5.123; 95% CI: 2.501-10.494), Acute Physiology and Chronic Health Evaluation (APACHE) II score≥20 at admission (OR: 1.897; 95% CI: 1.045-3.441), and gastric tube (OR: 1.935, 95% CI: 1.012-3.698) were associated with increased risk of delirium in multivariate analysis. Conclusion: Delirium was associated with prolonged mechanical ventilation, ICU stay, and hospital stay. Multivariate risk factors were gastric tube, mechanical ventilation, and APACHE II score. Although being a preliminary study, this study suggests the necessity of earliest removal of tubes and catheters when no longer needed.
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Affiliation(s)
- Jinyan Xing
- Department of Critical Care Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Zhiyong Yuan
- Department of Critical Care Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Yaqi Jie
- School of Life Sciences, Qingdao University, Qingdao, 266071, People's Republic of China
| | - Ying Liu
- Department of Critical Care Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Mingxue Wang
- Department of Critical Care Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Yunbo Sun
- Department of Critical Care Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
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Kotfis K, Szylińska A, Listewnik M, Brykczyński M, Ely EW, Rotter I. Diabetes and elevated preoperative HbA1c level as risk factors for postoperative delirium after cardiac surgery: an observational cohort study. Neuropsychiatr Dis Treat 2019; 15:511-521. [PMID: 30863073 PMCID: PMC6388975 DOI: 10.2147/ndt.s196973] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common complication of cardiac surgery associated with increased mortality, morbidity, and long-term cognitive dysfunction. Diabetic patients, especially those with poor diabetes control and long-standing hyperglycemia, may be at risk of developing delirium. The aim of this study was to analyze whether the occurrence of POD in cardiac surgery is associated with diabetes or elevated preoperative glycated hemoglobin (HbA1c) level. MATERIALS AND METHODS We performed a cohort analysis of prospectively collected data from a register of cardiac surgery department of a university hospital. Delirium assessment was performed twice a day during the first 5 days after the operation based on Diagnostic Statistical Manual of Mental Disorders, fifth edition criteria. RESULTS We analyzed a cohort of 3,178 consecutive patients, out of which 1,010 (31.8%) were diabetic and 502 (15.8%) were diagnosed with POD. Patients with delirium were more often diabetic (42.03% vs 29.86%, P<0.001) and on oral diabetic medications (34.66% vs 24.07%, P<0.001), no difference was found in patients with insulin treatment. Preoperative HbA1c was elevated above normal (≥6%) in more delirious than nondelirious patients (44.54% vs 33.04%, P<0.001), but significance was reached only in nondiabetic patients (20.44% vs 14.86%, P=0.018). In univariate analysis, the diagnosis of diabetes was associated with an increased risk of developing POD (OR: 1.703, 95% CI: 1.401-2.071, P<0.001), but only for patients on oral diabetic medications (OR: 1.617, 95% CI: 1.319-1.983, P<0.001) and an association was noted between HbA1c and POD (OR: 1.269, 95% CI: 1.161-1.387, P<0.001). Multivariate analysis controlled for diabetes showed that POD was associated with age, heart failure, preoperative creatinine, extracardiac arteriopathy, and preoperative HbA1c level. CONCLUSION More diabetic patients develop POD after cardiac surgery than nondiabetic patients. Elevated preoperative HbA1c level is a risk factor for postcardiac surgery delirium regardless of the diagnosis of diabetes.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Aleksandra Szylińska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin, Poland,
| | - Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland
| | | | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Iwona Rotter
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin, Poland,
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Glucose variability during delirium in diabetic and non-diabetic intensive care unit patients: A prospective cohort study. PLoS One 2018; 13:e0205637. [PMID: 30439957 PMCID: PMC6237332 DOI: 10.1371/journal.pone.0205637] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/30/2018] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To determine whether glucose variability is altered during delirium days compared to non-delirious days in critically ill patients with and without diabetes in the intensive care unit (ICU). MATERIALS AND METHODS Critically ill patients with delirious and non-delirious days during ICU stay were included from a prospective cohort study which was conducted from January 2011- June 2013. Glucose variability was measured each observation day using various definitions (change in mean glucose, standard deviation, mean absolute glucose, daily delta and occurrence of hypo- and hyperglycemia). Mixed-effects models and generalized mixed-effects models with logit link function were performed to study the association between delirium and glucose variability, adjusting for potential confounders. RESULTS With the exception of the risk of hypoglycemia, delirium was not linked to higher glucose variability using the various definitions of this estimate. For hypoglycemia, we did find an association with delirium in diabetic patients (OR adj.: 2.78; 95% CI: 1.71-6.32, p = 0.005), but not in non-diabetic patients (OR adj.: 1.16; 95% CI: 0.58-2.28, p = 0.689). CONCLUSIONS Despite the positive association between delirium and hypoglycemia in critically ill patients with diabetes, delirium was not associated with more pronounced glucose variability. Our findings suggest that glucose levels should be monitored more closely in diabetic patients during delirium at the ICU to prevent hypoglycemia.
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Abstract
PURPOSE OF REVIEW Monitoring of mental status and peripheral circulatory changes can be accomplished noninvasively in patients in the ICU. Emphasis on physical examination in conditions such as sepsis have gained increased attention as these evaluations can often serve as a surrogate marker for short-term treatment efficacy of therapeutic interventions. Sepsis associated encephalopathy and mental status changes correlate with worse prognosis in patients. Evaluation of peripheral circulation has been shown to be a convenient, easily accessible, and accurate marker for prognosis in patients with septic shock. The purpose of this article is to emphasize the main findings according to recent literature into the monitoring of physical examination changes in patients with sepsis. RECENT FINDINGS Several recent studies have expanded our knowledge about the pathophysiology of mental status changes and the clinical assessment of peripheral circulation in patients with sepsis. Sepsis-associated encephalopathy is associated with an increased rate of morbidity and mortality in an intensive care setting. Increased capillary refill time (CRT) and persistent skin mottling are strongly predictive of mortality, whereas temperature gradients can reveal vasoconstriction and more severe organ dysfunction. SUMMARY Monitoring of physical examination changes is a significant and critical intervention in patients with sepsis. Utilizing repeated neurologic evaluations, and assessing CRT, mottling score, and skin temperature gradients should be emphasized as important noninvasive diagnostic tools. The significance of these methods can be incorporated during the utilization of therapeutic strategies in resuscitation protocols in patients with sepsis.
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Abstract
Glucose toxicity may play a crucial role in evoking neurologic complications of critical illness. We studied whether the neuropathological alterations in fatal human critical illness observed under hyperglycemia are present and can be attenuated by maintaining normoglycemia in a mouse model of prolonged sepsis induced by cecal ligation and puncture. Mice were randomized to moderate hyperglycemia (>8.3 mmol/L, n = 8) or normoglycemia (4.4-6.7 mmol/L, n = 8). After 5 days, hippocampus and frontal cortex from septic mice were compared with those from healthy controls (n = 8). Blood glucose was 7.8 ± 1.3 mmol/L in hyperglycemic and 6.1 ± 0.7 mmol/L in normoglycemic critically ill mice (P = 0.007). The percentage of damaged neurons was twofold higher in frontal cortex (P = 0.01) and hippocampus (P = 0.06) of hyperglycemic ill mice than that of healthy mice. In frontal cortex, neuronal damage was attenuated under normoglycemia (P = 0.04). Critical illness reduced astrocyte density and activation status fourfold in hippocampus (P ≤ 0.02), but not in frontal cortex, irrespective of glycemic control. Microglia were twofold to fourfold more abundant in both brain areas of hyperglycemic critically ill mice (P ≤ 0.002), but only in frontal cortex were they reduced in number with normoglycemia (P = 0.0008). The density of apoptotic cells and abundance of carbonylated proteins were significantly higher than normal in frontal cortex of hyperglycemic ill mice only (P = 0.05). In a mouse model of prolonged polymicrobial sepsis, remarkable neuropathological changes develop with neuronal damage, impaired astrocyte activation, increased microglia, apoptosis, and accumulation of carbonylated proteins. These changes were partially prevented or attenuated when hyperglycemia was prevented with insulin. Frontal cortex appeared more vulnerable to hyperglycemic insults than hippocampus.
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Intraoperative tight glucose control using hyperinsulinemic normoglycemia increases delirium after cardiac surgery. Anesthesiology 2015; 122:1214-23. [PMID: 25992877 DOI: 10.1097/aln.0000000000000669] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Postoperative delirium is common in patients recovering from cardiac surgery. Tight glucose control has been shown to reduce mortality and morbidity. Therefore, the authors sought to determine the effect of tight intraoperative glucose control using a hyperinsulinemic-normoglycemic clamp approach on postoperative delirium in patients undergoing cardiac surgery. METHODS The authors enrolled 198 adult patients having cardiac surgery in this randomized, double-blind, single-center trial. Patients were randomly assigned to either tight intraoperative glucose control with a hyperinsulinemic-normoglycemic clamp (target blood glucose, 80 to 110 mg/dl) or standard therapy (conventional insulin administration with blood glucose target, <150 mg/dl). Delirium was assessed using a comprehensive delirium battery. The authors considered patients to have experienced postoperative delirium when Confusion Assessment Method testing was positive at any assessment. A positive Confusion Assessment Method was defined by the presence of features 1 (acute onset and fluctuating course) and 2 (inattention) and either 3 (disorganized thinking) or 4 (altered consciousness). RESULTS Patients randomized to tight glucose control were more likely to be diagnosed as being delirious than those assigned to routine glucose control (26 of 93 vs. 15 of 105; relative risk, 1.89; 95% CI, 1.06 to 3.37; P = 0.03), after adjusting for preoperative usage of calcium channel blocker and American Society of Anesthesiologist physical status. Delirium severity, among patients with delirium, was comparable with each glucose management strategy. CONCLUSION Intraoperative hyperinsulinemic-normoglycemia augments the risk of delirium after cardiac surgery, but not its severity.
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Bilotta F, Lauretta MP, Tewari A, Haque M, Hara N, Uchino H, Rosa G. Insulin and the Brain: A Sweet Relationship With Intensive Care. J Intensive Care Med 2015; 32:48-58. [PMID: 26168800 DOI: 10.1177/0885066615594341] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/28/2015] [Accepted: 05/15/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Insulin receptors (IRs) in the brain have unique molecular features and a characteristic pattern of distribution. Their possible functions extend beyond glucose utilization. In this systematic review, we explore the interactions between insulin and the brain and its implications for anesthesiologists, critical care physicians, and other medical disciplines. METHODS A literature search of published preclinical and clinical studies between 1978 and 2014 was conducted, yielding 5996 articles. After applying inclusion and exclusion criteria, 92 studies were selected for this systematic review. RESULTS The IRs have unique molecular features, pattern of distribution, and mechanism of action. It has effects on neuronal function, metabolism, and neurotransmission. The IRs are involved in neuronal apoptosis and neurodegenerative processes. CONCLUSION In this systematic review, we present a close relationship between insulin and the brain, with discernible effects on memory, learning abilities, and motor functions. The potential therapeutic effects extend from acute brain insults such as traumatic brain injury, brain ischemia, and hemorrhage, to chronic neurodegenerative diseases such as Alzheimer and Parkinson disease. An understanding of the wider effects of insulin conveyed in this review will prompt anaesthesiologists and critical care physicians to consider its therapeutic potential and guide future studies.
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Affiliation(s)
- F Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Rome, Rome, Italy
| | - M P Lauretta
- Anesthesia and Intensive Care Department, "La Sapienza" University of Rome, Rome, Italy .,Critical Care Department, University College London Hospital, London, United Kingdom
| | - A Tewari
- Department of Pediatric Neuroanesthesia and IONM, Cincinnati Children Hospital & Medical Center, Cincinnati, OH, USA
| | - M Haque
- Anesthesia and Critical Care Department, University College London Hospital, London, United Kingdom
| | - N Hara
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - H Uchino
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - G Rosa
- Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Rome, Rome, Italy
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Abstract
Sepsis often is characterized by an acute brain dysfunction, which is associated with increased morbidity and mortality. Its pathophysiology is highly complex, resulting from both inflammatory and noninflammatory processes, which may induce significant alterations in vulnerable areas of the brain. Important mechanisms include excessive microglial activation, impaired cerebral perfusion, blood-brain-barrier dysfunction, and altered neurotransmission. Systemic insults, such as prolonged inflammation, severe hypoxemia, and persistent hyperglycemia also may contribute to aggravate sepsis-induced brain dysfunction or injury. The diagnosis of brain dysfunction in sepsis relies essentially on neurological examination and neurological tests, such as EEG and neuroimaging. A brain MRI should be considered in case of persistent brain dysfunction after control of sepsis and exclusion of major confounding factors. Recent MRI studies suggest that septic shock can be associated with acute cerebrovascular lesions and white matter abnormalities. Currently, the management of brain dysfunction mainly consists of control of sepsis and prevention of all aggravating factors, including metabolic disturbances, drug overdoses, anticholinergic medications, withdrawal syndromes, and Wernicke's encephalopathy. Modulation of microglial activation, prevention of blood-brain-barrier alterations, and use of antioxidants represent relevant therapeutic targets that may impact significantly on neurologic outcomes. In the future, investigations in patients with sepsis should be undertaken to reduce the duration of brain dysfunction and to study the impact of this reduction on important health outcomes, including functional and cognitive status in survivors.
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Bisschop PH, de Rooij SE, Zwinderman AH, van Oosten HE, van Munster BC. Cortisol, insulin, and glucose and the risk of delirium in older adults with hip fracture. J Am Geriatr Soc 2011; 59:1692-6. [PMID: 21883119 DOI: 10.1111/j.1532-5415.2011.03575.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To determine the relationship between perioperative delirium and cortisol, glucose, and insulin in older adults acutely admitted for hip fracture. DESIGN Prospective cohort study. SETTING Tertiary university center. PARTICIPANTS Consecutive individuals aged 65 and older acutely admitted for hip fracture were invited to participate. MEASUREMENTS All participants were repeatedly examined to determine presence and severity of delirium. Blood samples for cortisol, glucose, and insulin were drawn at 11:00 a.m. Differences in characteristics of participants with and without delirium were evaluated using t-tests and Mann-Whitney tests. A logistic regression analysis was performed to correct for other important risk factors for delirium. RESULTS One hundred forty-three participants, 70 (49%) with delirium and 73 (51%) without, were included. In univariate analyses, there was a trend toward higher cortisol levels (odds ratio = 1.003 (95% confidence interval = 1.001-1.004, P = .004), but this association was not statistically significant after multivariable analysis and may reflect an association between high cortisol and preexisting cognitive and functional impairment, and there was no association with insulin or glucose levels. Adjusting for sex and prefracture cognitive and functional impairment made the trend with cortisol and delirium statistically nonsignificant. CONCLUSION Delirium in older adults acutely admitted for hip fracture may be linked with higher cortisol concentrations, but it may be that this association reflects an association between higher cortisol and preexisting cognitive and functional impairment.
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Affiliation(s)
- Peter H Bisschop
- Department of Endocrinology and Metabolism, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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Polito A, Brouland JP, Porcher R, Sonneville R, Siami S, Stevens RD, Guidoux C, Maxime V, de la Grandmaison GL, Chrétien FC, Gray F, Annane D, Sharshar T. Hyperglycaemia and apoptosis of microglial cells in human septic shock. Crit Care 2011; 15:R131. [PMID: 21612615 PMCID: PMC3218997 DOI: 10.1186/cc10244] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 04/03/2011] [Accepted: 05/25/2011] [Indexed: 02/22/2023] Open
Abstract
Introduction The effect of hyperglycaemia on the brain cells of septic shock patients is unknown. The objective of this study was to evaluate the relationship between hyperglycaemia and apoptosis in the brains of septic shock patients. Methods In a prospective study of 17 patients who died from septic shock, hippocampal tissue was assessed for neuronal ischaemia, neuronal and microglial apoptosis, neuronal Glucose Transporter (GLUT) 4, endothelial inducible Nitric Oxide Synthase (iNOS), microglial GLUT5 expression, microglial and astrocyte activation. Blood glucose (BG) was recorded five times a day from ICU admission to death. Hyperglycaemia was defined as a BG 200 mg/dL g/l and the area under the BG curve (AUBGC) > 2 g/l was assessed. Results Median BG over ICU stay was 2.2 g/l. Neuronal apoptosis was correlated with endothelial iNOS expression (rho = 0.68, P = 0.04), while microglial apoptosis was associated with AUBGC > 2 g/l (rho = 0.70; P = 0.002). Neuronal and microglial apoptosis correlated with each other (rho = 0.69, P = 0.006), but neither correlated with the duration of septic shock, nor with GLUT4 and 5 expression. Neuronal apoptosis and ischaemia tended to correlate with duration of hypotension. Conclusions In patients with septic shock, neuronal apoptosis is rather associated with iNOS expression and microglial apoptosis with hyperglycaemia, possibly because GLUT5 is not downregulated. These data provide a mechanistic basis for understanding the neuroprotective effects of glycemic control.
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Affiliation(s)
- Andrea Polito
- General Intensive Care Medicine, Raymond Poincaré Hospital, University of Versailles Saint Quentin en Yvelines, 104 boulevard R. Poincaré, Garches, France
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