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Othman SMA, Aziz MAA, Al-Mushiki GMA, Sriwayyapram C, Okubai T, Al-Muwaffaq G, Xu Q, Alqudaimi M. Association of postoperative delirium with hypotension in critically ill patients after cardiac surgery: a prospective observational study. J Cardiothorac Surg 2024; 19:476. [PMID: 39090732 PMCID: PMC11293154 DOI: 10.1186/s13019-024-02958-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 06/30/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD), an acute and variable disturbance in cognitive function, is an intricate and elusive phenomenon that occurs after cardiac surgery. Despite progress in surgical techniques and perioperative management, POD remains a formidable challenge, imposing a significant burden on patients, caregivers, and healthcare systems. METHODS This prospective observational study involved 307 patients who underwent cardiac surgery. Data on the occurrence of delirium, clinical parameters, and postoperative characteristics were collected. A multivariate analysis was performed to assess the relationship between POH and POD. RESULTS Sixty-one patients (21%) developed delirium, with an average onset of approximately 5 days postoperatively and a duration of approximately 6 days. On multivariate analysis, POH was significantly associated with POD, and the adjusted odds ratios indicated that patients with POH were more likely to develop delirium (OR, 5.61; p = 0.006). Advanced age (OR, 1.11; p = 0.002), emergency surgery (OR, 8.31; p = 0.001), and on-pump coronary artery bypass grafting were identified as risk factors of POD. Patients who developed delirium were typically older, more likely to be male, and had higher morbidity rates than those who did not. CONCLUSION POH is significantly associated with delirium in critically ill patients after cardiac surgery. Surgical complexity and advanced age contribute to the risk of developing POD and poor postoperative outcomes.
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Affiliation(s)
| | - Mohammed Ali Ali Aziz
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China
| | | | - Chanyanud Sriwayyapram
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China
| | - Tecleab Okubai
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China
| | - Gamil Al-Muwaffaq
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China
| | - Qin Xu
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China.
| | - Mohammed Alqudaimi
- Nanjing Medical University, Longmian Avenue No.101, Jiangning District, Nanjing, Jiangsu, China
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Sun Q, Wu W. Effect of near-infrared spectroscopy on postoperative delirium in cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis. Front Cardiovasc Med 2024; 11:1404210. [PMID: 38962088 PMCID: PMC11221214 DOI: 10.3389/fcvm.2024.1404210] [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: 03/20/2024] [Accepted: 06/07/2024] [Indexed: 07/05/2024] Open
Abstract
Background Postoperative delirium (POD) is a common anesthetic side effect in cardiac surgery. However, the role of oxygen saturation monitoring in reducing postoperative delirium has been controversial. Therefore, this meta-analysis aimed to analyze whether NIRS monitoring during cardiac surgery under cardiopulmonary bypass could reduce the incidence of postoperative delirium. Methods PubMed, Web of Science, Cochrane Library, Embase and China National Knowledge Infrastructure (CNKI) databases were systematically searched using the related keywords for randomized-controlled trials (RCTs) published from their inception to March 16, 2024. This review was conducted by the Preferred Reporting Project and Meta-Analysis Statement (PRISMA) guidelines for systematic review. The primary outcome was postoperative delirium, and the second outcomes included the length of ICU stay, the incidence of kidney-related adverse outcomes, and the incidence of cardiac-related adverse outcomes. Results The incidence of postoperative delirium could be reduced under the guidance of near-infrared spectroscopy monitoring (OR, 0.657; 95% CI, 0.447-0.965; P = 0.032; I2 = 0%). However, there were no significant differences in the length of ICU stay (SMD, 0.005 days; 95% CI, -0.135-0.146; P = 0.940; I2 = 39.3%), the incidence of kidney-related adverse outcomes (OR, 0.761; 95% CI, 0.386-1.500; P = 0.430; I2 = 0%), and the incidence of the cardiac-related adverse outcomes (OR, 1.165; 95% CI, 0.556-2.442; P = 0.686; I2 = 0%) between the two groups. Conclusion Near-infrared spectroscopy monitoring in cardiac surgery with cardiopulmonary bypass helps reduce postoperative delirium in patients. Systematic Review Registration PROSPERO, identifier, CRD42023482675.
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Affiliation(s)
| | - Weiguo Wu
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
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Xiao Y, Li PJ, Guo MY, Cao Y, Liang ZA. Effect of obstructive sleep apnea on postoperative delirium: a system review and meta-analysis. Sleep Breath 2024:10.1007/s11325-024-03073-6. [PMID: 38861133 DOI: 10.1007/s11325-024-03073-6] [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: 01/12/2024] [Revised: 05/24/2024] [Accepted: 06/03/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE To investigate the impact of obstructive sleep apnea (OSA) on postoperative delirium (PD), and evaluate the effectiveness of positive airway pressure (PAP) therapy on PD among OSA patients. METHODS We systematically searched Embase, Cochrane Library and PubMed databases from their establishment to November 27, 2022. A random-effects approach was employed to determine aggregated results. Subgroup and sensitivity analyses were carried out to investigate heterogeneity. RESULTS Sixteen eligible studies were included in the analysis. Thirteen studies revealed that OSA significantly elevated the likelihood of developing PD (OR = 1.71; 95%CI = 1.17 to 2.49; p = 0.005). Subgroup analysis according to delirium assessment scales showed that OSA did not exhibit an association with the incidence of PD assessed by the Confusion Assessment Method-Intensive Care Unit (OR = 1.14; 95%CI = 0.77 to 1.67; p = 0.51) but enhanced the likelihood of developing PD evaluated with other measurement scales (OR = 2.15; 95%CI = 1.44 to 3.19; p = 0.0002). Three additional studies explored the impact of PAP treatment on PD among OSA individuals, indicating no significant reduction in PD incidence with PAP use (OR = 0.58; 95%CI = 0.13 to 2.47; p = 0.46). CONCLUSIONS OSA may not be a risk factor for PD in critically ill patients in the intensive care unit, but may increase the likelihood of developing PD among individuals receiving regular care in the ward postoperatively. The efficacy of PAP therapy in decreasing PD incidence among OSA patients remains debatable.
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Affiliation(s)
- Yao Xiao
- West China School of Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, PR China
| | - Pei-Jun Li
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, PR China.
| | - Meng-Yao Guo
- West China School of Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, PR China
| | - Yuan Cao
- West China School of Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, PR China
| | - Zong-An Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, PR China
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Argalious MY. Melatonin as a component of bundled prevention strategies for postoperative delirium. Minerva Anestesiol 2024; 90:473-475. [PMID: 38869260 DOI: 10.23736/s0375-9393.24.18170-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Affiliation(s)
- Maged Y Argalious
- Department of Anesthesiology, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA -
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Geßele C, Saller T, Smolka V, Dimitriadis K, Amann U, Strobach D. Development and validation of a new drug-focused predictive risk score for postoperative delirium in orthopaedic and trauma surgery patients. BMC Geriatr 2024; 24:422. [PMID: 38741037 DOI: 10.1186/s12877-024-05005-1] [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: 02/23/2024] [Accepted: 04/24/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) is the most common complication following surgery in elderly patients. During pharmacist-led medication reconciliation (PhMR), a predictive risk score considering delirium risk-increasing drugs and other available risk factors could help to identify risk patients. METHODS Orthopaedic and trauma surgery patients aged ≥ 18 years with PhMR were included in a retrospective observational single-centre study 03/2022-10/2022. The study cohort was randomly split into a development and a validation cohort (6:4 ratio). POD was assessed through the 4 A's test (4AT), delirium diagnosis, and chart review. Potential risk factors available at PhMR were tested via univariable analysis. Significant variables were added to a multivariable logistic regression model. Based on the regression coefficients, a risk score for POD including delirium risk-increasing drugs (DRD score) was established. RESULTS POD occurred in 42/328 (12.8%) and 30/218 (13.8%) patients in the development and validation cohorts, respectively. Of the seven evaluated risk factors, four were ultimately tested in a multivariable logistic regression model. The final DRD score included age (66-75 years, 2 points; > 75 years, 3 points), renal impairment (eGFR < 60 ml/min/1.73m2, 1 point), anticholinergic burden (ACB-score ≥ 3, 1 point), and delirium risk-increasing drugs (n ≥ 2; 2 points). Patients with ≥ 4 points were classified as having a high risk for POD. The areas under the receiver operating characteristic curve of the risk score model were 0.89 and 0.81 for the development and the validation cohorts, respectively. CONCLUSION The DRD score is a predictive risk score assessable during PhMR and can identify patients at risk for POD. Specific preventive measures concerning drug therapy safety and non-pharmacological actions should be implemented for identified risk patients.
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Affiliation(s)
- Carolin Geßele
- Hospital Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany.
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Thomas Saller
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Vera Smolka
- Department of Orthopaedics and Trauma Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Ute Amann
- Faculty of Medicine, LMU Munich, Munich, Germany
| | - Dorothea Strobach
- Hospital Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany
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Igwe EO, Nealon J, O'Shaughnessy P, Ormonde C, Traynor V. Perioperative knowledge, self-efficacy and clinical practices related to postoperative delirium care in older people across geographical regions in Australia. Aust J Rural Health 2024; 32:354-364. [PMID: 38456229 DOI: 10.1111/ajr.13097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/13/2024] [Accepted: 02/19/2024] [Indexed: 03/09/2024] Open
Abstract
INTRODUCTION In older people undergoing surgery, there is a lower tolerance for complications. This highlights the need for documented clinical practices on proper prevention, pre-screening and management of complications such as postoperative delirium (POD). Evidence-based clinical practice guidelines exist for delirium management; however, the management of delirium in clinical settings differs widely. OBJECTIVE This study aims to develop an understanding of the knowledge, components of self-efficacy (confidence/competence), and clinical practice related to POD care among preoperative and recovery nurses across different types of geographical locations in Australia. DESIGN A 27-item online survey was sent out to professional associations focused on perioperative care across Australia. The participants included practicing registered nurses specialising in perioperative care. The main outcome measures were Knowledge, confidence/competence and clinical practice relating to POD care in older patients. FINDINGS Respondents were categorised into two groups-major cities and rural and remote. Mean age was 46.3 years for respondents in Australian major cities and 49.5 for the comparison group. There was a statistically significant difference between Australian major cities and 'rural and remote' in confidence in detecting hyperactive delirium, 25.2% versus 11.7% respectively as well as managing hyperactive delirium, 13.8% versus 1.7%, respectively. Similar results were also observed on hypoactive delirium. Respondents from both groups did not mirror the ideal situation in managing a hyperactive delirium. DISCUSSION Results from this study are inconclusive and there is no clear-cut observation in clinical practice or knowledge between the two geographical categories in this study. CONCLUSION The absence of a distinct strategy with POD prevention highlights the need for a uniform approach and consensus on POD prevention and management in older people. This can be achieved by creating more awareness and education through professional development related to POD.
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Affiliation(s)
- Ezinne O Igwe
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- School of Medical, Indigenous and Health Sciences, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Jessica Nealon
- School of Medical, Indigenous and Health Sciences, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Pauline O'Shaughnessy
- Faculty of Engineering and Information Sciences, School of Mathematics and Applied Statistics, Wollongong, New South Wales, Australia
| | - Callum Ormonde
- School of Medical, Indigenous and Health Sciences, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Victoria Traynor
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
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Oliveri S, Bocci T, Maiorana NV, Guidetti M, Cimino A, Rosci C, Ghilardi G, Priori A. Cognitive trajectories after surgery: Guideline hints for assessment and treatment. Brain Cogn 2024; 176:106141. [PMID: 38458027 DOI: 10.1016/j.bandc.2024.106141] [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: 11/29/2023] [Revised: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 03/10/2024]
Abstract
Elderly patients who undergo major surgery (not-neurosurgical) under general anaesthesia frequently complain about cognitive difficulties, especially during the first weeks after surgical "trauma". Although recovery usually occurs within a month, about one out of four patients develops full-blown postoperative Neurocognitive disorders (NCD) which compromise quality of life or daily autonomy. Mild/Major NCD affect approximately 10% of patients from three months to one year after major surgery. Neuroinflammation has emerged to have a critical role in the postoperative NCDs pathogenesis, through microglial activation and the release of pro-inflammatory cytokines which increase blood-brain-barrier permeability, enhance movement of leukocytes into the central nervous system (CNS) and favour the neuronal damage. Moreover, pre-existing Mild Cognitive Impairment, alcohol or drugs consumption, depression and other factors, together with several intraoperative and post-operative sequelae, can exacerbate the severity and duration of NCDs. In this context it is crucial rely on current progresses in serum and CSF biomarker analysis to frame neuroinflammation levels, along with establishing standard protocol for neuropsychological assessment (with specific set of tools) and to apply cognitive training or neuromodulation techniques to reduce the incidence of postoperative NCDs when required. It is recommended to identify those patients who would need such preventive intervention early, by including them in pre-operative and post-operative comprehensive evaluation and prevent the development of a full-blown dementia after surgery. This contribution reports all the recent progresses in the NCDs diagnostic classification, pathogenesis discoveries and possible treatments, with the aim to systematize current evidences and provide guidelines for multidisciplinary care.
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Affiliation(s)
- Serena Oliveri
- "Aldo Ravelli" Center for Neurotechnology and Brain Therapeutics Department of Health Sciences, University of Milan, Italy; Neurological Clinic, Azienda Socio Sanitaria Territoriale - Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy.
| | - Tommaso Bocci
- "Aldo Ravelli" Center for Neurotechnology and Brain Therapeutics Department of Health Sciences, University of Milan, Italy; Neurological Clinic, Azienda Socio Sanitaria Territoriale - Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| | - Natale Vincenzo Maiorana
- "Aldo Ravelli" Center for Neurotechnology and Brain Therapeutics Department of Health Sciences, University of Milan, Italy
| | - Matteo Guidetti
- "Aldo Ravelli" Center for Neurotechnology and Brain Therapeutics Department of Health Sciences, University of Milan, Italy
| | - Andrea Cimino
- Department of Health Science, School of Medicine and Surgery, University of Milano-Bicocca, Italy; Neurosurgery Unit, Neuroscience Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Chiara Rosci
- Neurological Clinic, Azienda Socio Sanitaria Territoriale - Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| | - Giorgio Ghilardi
- Department of Health Science, School of Medicine and Surgery, University of Milano-Bicocca, Italy; General Surgery Unit, Azienda Socio Sanitaria Territoriale - Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| | - Alberto Priori
- "Aldo Ravelli" Center for Neurotechnology and Brain Therapeutics Department of Health Sciences, University of Milan, Italy; Neurological Clinic, Azienda Socio Sanitaria Territoriale - Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
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Cordoza ML, Anderson BJ, Cevasco M, Diamond JM, Younes M, Gerardy B, Iroegbu C, Riegel B. Feasibility and Acceptability of Using Wireless Limited Polysomnography to Capture Sleep Before, During, and After Hospitalization for Patients With Planned Cardiothoracic Surgery. J Cardiovasc Nurs 2024:00005082-990000000-00180. [PMID: 38509035 DOI: 10.1097/jcn.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
BACKGROUND Sleep disruption, a common symptom among patients requiring cardiovascular surgery, is a potential risk factor for the development of postoperative delirium. Postoperative delirium is a disorder of acute disturbances in cognition associated with prolonged hospitalization, cognitive decline, and mortality. OBJECTIVE The aim of this study was to evaluate the feasibility and acceptability of using polysomnography (PSG) to capture sleep in patients with scheduled cardiothoracic surgery. METHODS Wireless limited PSG assessed sleep at baseline (presurgery at home), postoperatively in the intensive care unit, and at home post hospital discharge. Primary outcomes were quality and completeness of PSG signals, and acceptability by participants and nursing staff. RESULTS Among 15 patients, PSG data were of high quality, and mean percentage of unscorable data was 5.5% ± 11.1%, 3.7% ± 5.4%, and 3.7% ± 8.4% for baseline, intensive care unit, and posthospitalization measurements, respectively. Nurses and patients found the PSG monitor acceptable. CONCLUSIONS Wireless, limited PSG to capture sleep across the surgical continuum was feasible, and data were of high quality. Authors of future studies will evaluate associations of sleep indices and development of postoperative delirium in this high-risk population.
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Cylinder DM, van Zundert AA, Solt K, van Swinderen B. Time to Wake Up! The Ongoing Search for General Anesthetic Reversal Agents. Anesthesiology 2024; 140:610-627. [PMID: 38349760 PMCID: PMC10868874 DOI: 10.1097/aln.0000000000004846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
How general anesthetics work remains a topic of ongoing study. A parallel field of research has sought to identify methods to reverse general anesthesia. Reversal agents could shorten patients' recovery time and potentially reduce the risk of postoperative complications. An incomplete understanding of the mechanisms of general anesthesia has hampered the pursuit for reversal agents. Nevertheless, the search for reversal agents has furthered understanding of the mechanisms underlying general anesthesia. The study of potential reversal agents has highlighted the importance of rigorous criteria to assess recovery from general anesthesia in animal models, and has helped identify key arousal systems (e.g., cholinergic, dopaminergic, and orexinergic systems) relevant to emergence from general anesthesia. Furthermore, the effects of reversal agents have been found to be inconsistent across different general anesthetics, revealing differences in mechanisms among these drugs. The presynapse and glia probably also contribute to general anesthesia recovery alongside postsynaptic receptors. The next stage in the search for reversal agents will have to consider alternate mechanisms encompassing the tripartite synapse.
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Affiliation(s)
- Drew M. Cylinder
- Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
| | - André A.J. van Zundert
- Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, The University of Queensland, Brisbane, QLD, Australia
| | - Ken Solt
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, U.S.A
- Department of Anaesthesia, Harvard Medical School, Boston, MA, U.S.A
| | - Bruno van Swinderen
- Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
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Stanley ME, Ehsan A, Sodha NR, Sellke FW. History of Psychoactive Medication a Risk Factor for Neurocognitive Decline After Cardiac Surgery. J Surg Res 2024; 295:414-422. [PMID: 38070255 PMCID: PMC10922466 DOI: 10.1016/j.jss.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 09/24/2023] [Accepted: 11/08/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Neurocognitive decline (NCD) is a common complication after cardiac surgery with implications for outcomes and quality of life. Identifying risk factors can help surgeons implement preventative measures, optimize modifiable risk factors, and counsel patients about risk and prognosis. METHODS Prospective cohort study at a single academic center. 104 patients planned to undergo cardiac surgery were enrolled. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was used to measure neurocognitive function preoperatively, on postoperative day four, and postoperative day 30. NCD is defined as a change in RBANS scaled score of < -8 from baseline to postoperative day 4. Patient charts were reviewed for medication history: beta-blockers, angiotensin-converting enzyme and angiotensin receptor blockers, calcium channel blockers, statins, oral hypoglycemic agents, and psychoactive medications. Charts were also reviewed to calculate postoperative opioid usage. RESULTS NCD was detected in 42.9% of patients. Incidence of NCD was significantly higher in patients taking a psychoactive medication (56.8%) than patients not (31.9%), P < 0.03. There was no relationship between historical use of beta-blocker, calcium-channel blocker, statin, or oral hypoglycemic medications and incidence of NCD. Simple linear regression showed no relationship between change in RBANS total scaled score and opioid usage. There was no difference in incidence of NCD at 1 mo. CONCLUSIONS Patients with a history of taking psychoactive medications prior to cardiac surgery have an increased risk of acute postoperative NCD.
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Affiliation(s)
- Madigan E Stanley
- Divison of Cardiothoracic Surgery, Warren Alpert Medical School at Brown University and Rhode Island Hospital, Providence, Rhode Island.
| | - Afshin Ehsan
- Divison of Cardiothoracic Surgery, Warren Alpert Medical School at Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Neel R Sodha
- Divison of Cardiothoracic Surgery, Warren Alpert Medical School at Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Frank W Sellke
- Divison of Cardiothoracic Surgery, Warren Alpert Medical School at Brown University and Rhode Island Hospital, Providence, Rhode Island
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Liu Z, Jin Y, Wang L, Huang Z. The Effect of Ciprofol on Postoperative Delirium in Elderly Patients Undergoing Thoracoscopic Surgery for Lung Cancer: A Prospective, Randomized, Controlled Trial. Drug Des Devel Ther 2024; 18:325-339. [PMID: 38344256 PMCID: PMC10857903 DOI: 10.2147/dddt.s441950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/18/2024] [Indexed: 02/15/2024] Open
Abstract
Purpose This study was conducted to assess whether ciprofol vs propofol could affect the incidence of postoperative delirium (POD) in elderly patients with lung cancer after thoracoscopic surgery. Patients and Methods In this study, a total of 84 elderly patients undergoing thoracoscopic surgery for lung cancer were recruited and randomized into two groups to receive anesthesia with either ciprofol or propofol. The primary outcome was the incidence of POD within three days after surgery. Secondary outcomes included the Confusion Assessment Method (CAM) score, intraoperative indicators related to mean arterial pressure (MAP), and cerebral tissue oxygen saturation (SctO2). Moreover, MAP- and SctO2-related indicators associated with POD were analyzed. Results The incidence of POD was 7.1% and 16.7%, respectively, in the ciprofol group and the propofol group (risk ratio [RR], 0.37; 95% confidence interval [CI], 0.07 to 2.03; risk difference [RD], -9.6%; 95% CI, -23.3% to 4.1%; p = 0.178). Compared with those in the propofol group, patients in the ciprofol group had lower CAM scores three days after surgery (13 (12, 15) vs 15 (14, 17); 12 (11, 13) vs 14 (13, 16); 12 (11, 12) vs 13 (12, 14), p<0.05). Besides, patients in the ciprofol group exhibited higher mean and minimum MAP (88.63 ± 6.7 vs 85 ± 8.3; 69.81 ± 9.59 vs 64.9 ± 9.43, p<0.05) and SctO2 (77.26 ± 3.96 vs 75.3 ± 4.49, 71.69 ± 4.51 vs 68.77 ± 6.46, p<0.05) and percentage of time for blood pressure stabilization (0.6 ± 0.14 vs 0.45 ± 0.14, p<0.05) than those in the propofol group. Furthermore, MAP and SctO2-related indicators were validated to correlate with POD. Conclusion Anesthesia with ciprofol did not increase the incidence of POD compared with propofol. The results demonstrated that ciprofol could improve intraoperative MAP and SctO2 levels and diminish postoperative CAM scores.
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Affiliation(s)
- Zhaohui Liu
- Department of Anesthesiology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning, People’s Republic of China
| | - Yi Jin
- Department of Anesthesiology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning, People’s Republic of China
| | - Lingfei Wang
- Department of Anesthesiology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning, People’s Republic of China
| | - Zeqing Huang
- Department of Anesthesiology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning, People’s Republic of China
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Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Aceto P, Audisio R, Cherubini A, Cunningham C, Dabrowski W, Forookhi A, Gitti N, Immonen K, Kehlet H, Koch S, Kotfis K, Latronico N, MacLullich AMJ, Mevorach L, Mueller A, Neuner B, Piva S, Radtke F, Blaser AR, Renzi S, Romagnoli S, Schubert M, Slooter AJC, Tommasino C, Vasiljewa L, Weiss B, Yuerek F, Spies CD. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol 2024; 41:81-108. [PMID: 37599617 PMCID: PMC10763721 DOI: 10.1097/eja.0000000000001876] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.
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Affiliation(s)
- César Aldecoa
- From the Department of Anaesthesia and Postoperative Critical Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Biomedical Studies, University of the Republic of San Marino, San Marino (GB), Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy (FB, AF, LM), Specialty of Anaesthetics & NHMRC Clinical Trials Centre, University of Sydney & Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital (RDS), Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt Universität zu Berlin, Campus Charité Mitte, and Campus Virchow Klinikum (CDS, SK, AM, BN, LV, BW, FY), Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (PA), Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy (PA), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden (RA), Geriatria, Accettazione Geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy (AC), School of Biochemistry and Immunology and Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland (CC), First Department of Anaesthesiology and Intensive Care Medical University of Lublin, Poland (WD), Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland (KI), Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland (KK), Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia (NG, NL, SP, SR), Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy (NL, SP), Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom (AMJM), Department of Anaesthesia and Intensive Care, Nykoebing Hospital; University of Southern Denmark, SDU (SK, FR), Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia (ARB), Center for Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland (ARB), Department of Health Science, Section of Anesthesiology, University of Florence (SR), Department of Anaesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy (SR), School of Health Sciences, Institute of Nursing, ZHAW Zurich University of Applied Science, Winterthur, Switzerland (MS), Departments of Psychiatry and Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (AJCS), Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium (AJCS) and Dental Anesthesia and Intensive Care Unit, Polo Universitario Ospedale San Paolo, Department of Biomedical, Surgical and Odontoiatric Sciences, University of Milano, Milan, Italy (CT)
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Shorofi SA, Dadashian P, Arbon P, Moosazadeh M. The efficacy of earplugs and eye masks for delirium severity and sleep quality in patients undergoing coronary artery bypass grafting in cardiac intensive care units: A single-blind, randomised controlled trial. Aust Crit Care 2024; 37:74-83. [PMID: 37802695 DOI: 10.1016/j.aucc.2023.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/31/2023] [Accepted: 08/26/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Delirium is a neuropsychiatric syndrome with a wide range of possible causes and multiple complications in patients admitted to intensive care units. It is, therefore, necessary to seek appropriate and safe strategies to prevent and manage delirium. This study is intended to examine the efficacy of eye masks and earplugs for delirium severity and sleep quality in patients with coronary artery bypass grafting in a cardiac intensive care unit. MATERIALS AND METHODS This single-blind, randomised controlled trial was conducted on 114 patients who were consecutively enrolled and randomly assigned to either the experimental group or the control group. The experimental group received routine care plus eye masks and earplugs, and the control group received only routine care. The delirium severity and sleep quality were measured with the Neelon and Champagne confusion scale and the Verran and Snyder-Halpern sleep scale. RESULTS The mean delirium severity score differed significantly between the two groups on the second, third, and fourth postoperative days (p < 0.001). Although the trend of changes in the mean delirium severity score from the first postoperative day (before the intervention) to the second, third, and fourth postoperative days was downward in the two groups (trending towards higher delirium severity), the control group experienced greater changes than the experimental group. An intragroup analysis of delirium severity detected a statistically significant difference in both the experimental and control groups (p < 0.001). The sleep quality domains (sleep disturbance, sleep effectiveness, sleep supplementation) showed a statistically significant difference between the two groups across the three intervention days (p < 0.001). CONCLUSION The overnight use of eye masks and earplugs were found to have positive effects on sleep quality domains (sleep disturbance, sleep effectiveness, sleep supplementation) and delirium severity in coronary artery bypass grafting patients admitted to the cardiac intensive care unit for several days. It was also found that a significant interaction effect between the sleep disturbance subscale and delirium severity exists. CLINICAL TRIAL REGISTRATION NUMBER (https://en.irct.ir): IRCT20210523051370N2.
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Affiliation(s)
- Seyed Afshin Shorofi
- Traditional and Complementary Medicine Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran; Adjunct Research Fellow, Flinders University, Adelaide, Australia.
| | - Pooneh Dadashian
- Student Research Committee, School of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran
| | - Paul Arbon
- Torrens Resilience Institute, Flinders University, Adelaide, Australia
| | - Mahmood Moosazadeh
- Health Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
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Yan E, Veitch M, Saripella A, Alhamdah Y, Butris N, Tang-Wai DF, Tartaglia MC, Nagappa M, Englesakis M, He D, Chung F. Association between postoperative delirium and adverse outcomes in older surgical patients: A systematic review and meta-analysis. J Clin Anesth 2023; 90:111221. [PMID: 37515876 DOI: 10.1016/j.jclinane.2023.111221] [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: 01/27/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
STUDY OBJECTIVE To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients. DESIGN A systematic review and meta-analysis with multiple databases searched from inception to February 22, 2022. SETTING Postoperative assessments. PATIENTS Non-cardiac and non-neurological surgical patients aged ≥60 years with and without postoperative delirium. Included studies must report ≥1 postoperative outcome. Studies with a small sample size (N < 100 subjects) were excluded. MEASUREMENTS Outcomes comprised the pooled incidence of postoperative delirium and its postoperative outcomes, including mortality, complications, unplanned intensive care unit admissions, length of stay, and non-home discharge. For dichotomous and continuous outcomes, OR and difference in means were computed, respectively, with a 95% CI. MAIN RESULTS Fifty-four studies (20,988 patients, 31 elective studies, 23 emergency studies) were included. The pooled incidence of postoperative delirium was 19% (95% CI: 16%, 23%) after elective surgery and 32% (95% CI: 25%, 39%) after emergency surgery. In elective surgery, postoperative delirium was associated with increased mortality at 1-month (OR: 6.60; 95% CI: 1.58, 27.66), 6-month (OR: 5.69; 95% CI: 2.33, 13.88), and 1-year (OR: 2.87; 95% CI: 1.63, 5.06). The odds of postoperative complications, unplanned intensive care unit admissions, prolonged length of hospital stay, and non-home discharge were also higher in delirium cases. In emergency surgery, patients with postoperative delirium had greater odds of mortality at 1-month (OR: 3.56; 95% CI: 1.77, 7.15), 6-month (OR: 2.60; 95% CI: 1.88, 3.61), and 1-year (OR: 2.30; 95% CI: 1.77, 3.00). CONCLUSIONS Postoperative delirium was associated with higher odds of mortality, postoperative complications, unplanned intensive care unit admissions, length of hospital stay, and non-home discharge. Prevention and perioperative management of delirium may optimize surgical outcomes.
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Affiliation(s)
- Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Matthew Veitch
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Yasmin Alhamdah
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Nina Butris
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - David F Tang-Wai
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Maria Carmela Tartaglia
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mahesh Nagappa
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada.
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15
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Jiang LS, Lai L, Chen YJ, Liu K, Shen QH. Prophylactic effect of exogenous melatonin and melatonin receptor agonists on postoperative delirium in elderly patients: a systemic review and meta-analysis of randomized controlled trials. Aging Clin Exp Res 2023; 35:2323-2331. [PMID: 37776484 DOI: 10.1007/s40520-023-02564-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 09/13/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND The prophylactic effect of exogenous melatonin and melatonin receptor agonists (MMRAs) on postoperative delirium (POD) in elderly patients remains controversial. OBJECTIVE This study aimed to assess the prophylactic effect of MMRAs on POD by conducting a systemic review and meta-analysis of randomized controlled trials (RCTs). METHODS We systematically searched four electronic databases including PubMed, Web of Science, Cochrane Library, and Embase for the eligible studies up to February 28, 2023. The Cochrane risk of bias tool was used for assessing the risk of bias in the included RCTs. The occurrence of POD was the primary outcome. The quality of evidence was evaluated by Grading of Recommendations Assessment, Development, and Evaluation. RESULTS A total of 11 RCTs comprising patients (MMRA group: 777 patients and placebo group: 781 patients) were included. The results of the meta-analysis showed that the MMRA group had a lower occurrence of POD than the placebo group (risk ratio = 0.70, 95% confidence interval: 0.51-0.97, P < 0.05, I2 = 59%). The subgroup analysis showed that melatonin significantly reduced the occurrence of POD (moderate-quality evidence), whereas ramelteon and tryptophan had no significant impact (moderate-quality evidence). CONCLUSION Existing evidence suggested that perioperative use of melatonin can prevent POD in elderly patients.
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Affiliation(s)
- Li-Shan Jiang
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, No.1882, Zhonghuan SouthRoad, Jiaxing, 315800, Zhejiang, China
| | - Lan Lai
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, No.1882, Zhonghuan SouthRoad, Jiaxing, 315800, Zhejiang, China
| | - Yan-Jun Chen
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, No.1882, Zhonghuan SouthRoad, Jiaxing, 315800, Zhejiang, China
| | - Ke Liu
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, No.1882, Zhonghuan SouthRoad, Jiaxing, 315800, Zhejiang, China
| | - Qi-Hong Shen
- Department of Anesthesiology, Affiliated Hospital of Jiaxing University, No.1882, Zhonghuan SouthRoad, Jiaxing, 315800, Zhejiang, China.
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Bargnes V, Oliver B, Wang E, Greenspan S, Jin Z, Yeung I, Bergese S. Taming Postoperative Delirium with Dexmedetomidine: A Review of the Therapeutic Agent's Neuroprotective Effects following Surgery. Pharmaceuticals (Basel) 2023; 16:1453. [PMID: 37895924 PMCID: PMC10610260 DOI: 10.3390/ph16101453] [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: 09/01/2023] [Revised: 10/11/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
Postoperative delirium (POD) represents a perioperative neurocognitive disorder that has dreaded ramifications on a patient's recovery from surgery. Dexmedetomidine displays multiple mechanisms of neuroprotection to assist in preventing POD as a part of a comprehensive anesthetic care plan. This review will cover dexmedetomidine's pharmacological overlap with the current etiological theories behind POD along with pre-clinical and clinical studies on POD prevention with dexmedetomidine. While the body of evidence surrounding the use of dexmedetomidine for POD prevention still requires further development, promising evidence exists for the use of dexmedetomidine in select dosing and circumstances to enhance recovery from surgery.
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Affiliation(s)
- Vincent Bargnes
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA
| | - Brian Oliver
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA
| | - Emily Wang
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Seth Greenspan
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA
| | - Isaac Yeung
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA
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Chen YC, Hung IY, Hung KC, Chang YJ, Chu CC, Chen JY, Ho CH, Yu CH. Incidence change of postoperative delirium after implementation of processed electroencephalography monitoring during surgery: a retrospective evaluation study. BMC Anesthesiol 2023; 23:330. [PMID: 37794315 PMCID: PMC10548752 DOI: 10.1186/s12871-023-02293-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common complication in the elderly, which is associated with poor outcomes after surgery. Recognized as predisposing factors for POD, anesthetic exposure and burst suppression during general anesthesia can be minimized with intraoperative processed electroencephalography (pEEG) monitoring. In this study, we aimed to evaluate whether implementation of intraoperative pEEG-guided anesthesia is associated with incidence change of POD. METHODS In this retrospective evaluation study, we analyzed intravenous patient-controlled analgesia (IVPCA) dataset from 2013 to 2017. There were 7425 patients using IVPCA after a noncardiac procedure under general anesthesia. Patients incapable of operating the device independently, such as cognitive dysfunction or prolonged sedation, were declined and not involved in the dataset. After excluding patients who opted out within three days (N = 110) and those with missing data (N = 24), 7318 eligible participants were enrolled. Intraoperative pEEG has been implemented since July 2015. Participants having surgery after this time point had intraoperative pEEG applied before induction until full recovery. All related staff had been trained in the application of pEEG-guided anesthesia and the assessment of POD. Patients were screened twice daily for POD within 3 days after surgery by staff in the pain management team. In the first part of this study, we compared the incidence of POD and its trend from 2013 January-2015 July with 2015 July-2017 December. In the second part, we estimated odds ratios of risk factors for POD using multivariable logistic regression in case-control setting. RESULTS The incidence of POD decreased from 1.18 to 0.41% after the administration of intraoperative pEEG. For the age group ≧ 75 years, POD incidence decreased from 5.1 to 1.56%. Further analysis showed that patients with pEEG-guided anesthesia were associated with a lower odd of POD (aOR 0.33; 95% CI 0.18-0.60) than those without after adjusting for other covariates. CONCLUSIONS Implementation of intraoperative pEEG was associated with a lower incidence of POD within 3 days after surgery, particularly in the elderly. Intraoperative pEEG might be reasonably considered as part of the strategy to prevent POD in the elder population. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Yi-Chen Chen
- Department of Medical Research, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - I-Yin Hung
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
- Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, 60 Erren Road, Rende District, Tainan, Taiwan
| | - Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
- Department of Recreation and Health Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, 60 Erren Road, Rende District, Tainan, Taiwan
| | - Chin-Chen Chu
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan
- Department of Information Management, Southern Taiwan University of Science and Technology, 1 Nantai St, Yongkang District, Tainan, Taiwan
| | - Chia-Hung Yu
- Department of Anesthesiology, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan, Taiwan.
- Department of Computer Science and Information Engineering, Southern Taiwan University of Science and Technology, 1 Nantai St, Yongkang District, Tainan, Taiwan.
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Versloot J, Minotti SC, Amer S, Ali A, Ma J, Peters ML, Saab H, Tang T, Kerr J, Reid R. Effectiveness of a Multi-component Delirium Prevention Program Implemented on General Medicine Hospital Units: an Interrupted Time Series Analysis. J Gen Intern Med 2023; 38:2936-2944. [PMID: 37429974 PMCID: PMC10593633 DOI: 10.1007/s11606-023-08238-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/09/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Delirium is among the most prevalent harmful events in hospitals that is associated with an elevated risk for severe outcomes such as functional decline, falls, longer length of stay, and increased mortality. OBJECTIVE To evaluate the impact of the implementation of a multi-component delirium program on the prevalence of delirium and the incidence of falls among patients staying on general medicine inpatient hospital units. DESIGN A pre-post intervention study using retrospective chart abstraction and interrupted time series analysis. COHORT Patients were selected from adult patients that stayed at least 1 day on one of the five general medicine units in a large community hospital in Ontario, Canada. A total of 16 random samples of 50 patients per month for 8 consecutive months pre-intervention (October 2017 to May 2018) and 8 months post intervention (January 2019 to August 2019) were selected for a total of 800 patients. There were no exclusion criteria. INTERVENTION The delirium program included multiple components: education of staff and hospital leadership, twice per day bed-side screen for delirium, non-pharmacological and pharmacological prevention, and intervention strategies and a delirium consultation team. MEASUREMENT Delirium prevalence was assessed using the evidence-based delirium chart abstraction method, CHART-del. Demographic data as well as fall incidence were also collected. RESULT Our evaluation showed that the implementation of a multicomponent delirium program led to a reduction in delirium prevalence and fall incidences. The reduction in both delirium and falls was the largest for patients in the ages between 72 and 83 years old and varied across inpatient units. CONCLUSION A multi-component delirium program to improve the prevention, recognition, and management of delirium reduces the prevalence of delirium and fall incidence among patients in general medicine units.
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Affiliation(s)
- Judith Versloot
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON Canada
| | - Simona C. Minotti
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Samia Amer
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
| | - Amna Ali
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
| | - Julia Ma
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
| | | | - Hana Saab
- Trillium Health Partners, Mississauga, ON Canada
| | - Terence Tang
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
- Department of Medicine, University of Toronto, Toronto, ON Canada
| | - Jason Kerr
- Trillium Health Partners, Mississauga, ON Canada
- Department of Medicine, University of Toronto, Toronto, ON Canada
| | - Robert Reid
- Institute for Better Health, Trillium Health Partners, Mississauga, ON Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON Canada
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Tsai CY, Liu KH, Lai CC, Hsu JT, Hsueh SW, Hung CY, Yeh KY, Hung YS, Lin YC, Chou WC. Association of preoperative frailty and postoperative delirium in older cancer patients undergoing elective abdominal surgery: A prospective observational study in Taiwan. Biomed J 2023; 46:100557. [PMID: 35985478 PMCID: PMC10345226 DOI: 10.1016/j.bj.2022.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/09/2022] [Accepted: 08/09/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common surgical complication in elderly patients. As frailty is a relatively novel concept, its clinical significance for POD has seldom been examined. This study aimed to investigate the association between frailty and POD in aged cancer patients undergoing elective abdominal surgery in Taiwan. METHODS We prospectively enrolled 345 consecutive patients aged ≥65 years with newly diagnosed cancer who underwent elective abdominal surgery between 2016 and 2018. Frailty assessment was performed using the Comprehensive Geriatric Assessment (CGA). POD was assessed daily using the Confusion Assessment Method from postoperative day 1 until discharge. Patients were allocated into fit and frail groups. RESULTS POD occurred in 19 (5.5%) of 345 patients. POD incidence was 1.6%, 3.1%, 4.8%, 11.5%, and 10.0% in patients with 0, 1, 2, 3, and 4+ frail conditions, respectively, which presented a positive linear correlation among patients with an increased number of frail conditions and POD incidence. Based on CGA, 159 (46.1%) and 186 (53.9%) patients were allocated to fit and frail groups, respectively. POD incidence was 2.5% and 8.1% for the fit and frail groups, respectively. Frailty status was an independent risk factor for POD occurrence in multivariate analysis. CONCLUSION Our study identified frailty as an independent risk factor for POD in aged Taiwanese cancer patients undergoing elective abdominal surgery. Given the high prevalence of frailty among older cancer patients, preoperative assessment is important to identify high risk of POD and to improve the quality of postoperative care.
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Affiliation(s)
- Chun-Yi Tsai
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Keng-Hao Liu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chou Lai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Colon and Rectal Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jun-Te Hsu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shun-Wen Hsueh
- Department of Oncology, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Chia-Yen Hung
- Division of Hematology and Oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Kun-Yun Yeh
- Department of Oncology, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Yu-Shin Hung
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Yung-Chang Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Wen-Chi Chou
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
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Wilczyński B, Śnieżyński J, Nowakowska M, Wallner G. Neurological complications in patients undergoing general surgery: A literature review. POLISH JOURNAL OF SURGERY 2023; 96:71-77. [PMID: 38348989 DOI: 10.5604/01.3001.0053.6869] [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] [Indexed: 02/15/2024]
Abstract
Surgical procedures are extremely burdensome for patients, as in addition to complications directly related to the intervention, they expose the patient to further complications resulting from the disturbance of key functions of homeostasis in the body's systems, particularly the circulatory, respiratory, and nervous systems. Furthermore, they may contribute to the exacerbation of symptoms of underlying chronic diseases. This paper focuses on the most common possible neurological complications that may occur after surgical procedures and includes topics such as stroke, chronic pain, neuropathy, and delirium. The risk factors for neurological deficits, their known or possible etiology, the most characteristic symptoms, and potential preventive actions are discussed. The paper analyzes articles from the PubMed, ResearchGate, and Scopus databases. A surge0on's knowledge of possible complications that may occur in the perioperative period enables early recognition and effective reduction of their negative impact on the patient's functioning and quality of life after surgery, contributing to better overall treatment outcomes.
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Affiliation(s)
- Bartosz Wilczyński
- Second Department of General & Gastrointestinal Surgery & Surgical Oncology of the Alimentary Tract, Medical University of Lublin, Poland
| | - Jan Śnieżyński
- Second Department of General & Gastrointestinal Surgery & Surgical Oncology of the Alimentary Tract, Medical University of Lublin, Poland
| | | | - Grzegorz Wallner
- Second Department of General & Gastrointestinal Surgery & Surgical Oncology of the Alimentary Tract, Medical University of Lublin, Poland
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21
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Gong XY, Hou DJ, Yang J, He JL, Cai MJ, Wang W, Lu XY, Gao J. Incidence of delirium after non-cardiac surgery in the Chinese elderly population: a systematic review and meta-analysis. Front Aging Neurosci 2023; 15:1188967. [PMID: 37455941 PMCID: PMC10346854 DOI: 10.3389/fnagi.2023.1188967] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background POD places a heavy burden on the healthcare system as the number of elderly people undergoing surgery is increasing annually because of the aging population. As a large country with a severely aging population, China's elderly population has reached 267 million. There has been no summary analysis of the pooled incidence of POD in the elderly Chinese population. Methods Systematic search databases included PubMed, Web of Science, EMBASE, Cochrane Library Databases, China Knowledge Resource Integrated Database (CNKI), Chinese Biomedical Database (CBM), WanFang Database, and Chinese Science and Technology Periodicals (VIP). The retrieval time ranged from the database's establishment to February 8, 2023. The pooled incidence of delirium after non-cardiac surgery was calculated using a random effects model. Meta-regression, subgroup, and sensitivity analyses were used to explore the source of heterogeneity. Results A total of 52 studies met the inclusion criteria, involving 18,410 participants. The pooled incidence of delirium after non-cardiac surgery in the elderly Chinese population was 18.6% (95% CI: 16.4-20.8%). The meta-regression results revealed anesthesia method and year of publication as a source of heterogeneity. In the subgroup analysis, the gender subgroup revealed a POD incidence of 19.6% (95% CI: 16.9-22.3%) in males and 18.3% (95% CI: 15.7-20.9%) in females. The year of publication subgroup analysis revealed a POD incidence of 20.3% (95% CI: 17.4-23.3%) after 2018 and 14.6 (95% CI: 11.6-17.6%) in 2018 and before. In the subgroup of surgical types, the incidence of hip fracture surgery POD was 20.7% (95% CI: 17.6-24.3%), the incidence of non-cardiac surgery POD was 18.4% (95% CI: 11.8-25.1%), the incidence of orthopedic surgery POD was 16.6% (95% CI: 11.8-21.5%), the incidence of abdominal neoplasms surgery POD was 14.3% (95% CI: 7.6-21.1%); the incidence of abdominal surgery POD was 13.9% (95% CI: 6.4-21.4%). The anesthesia methods subgroup revealed a POD incidence of 21.5% (95% CI: 17.9-25.1%) for general anesthesia, 15.0% (95% CI: 10.6-19.3%) for intraspinal anesthesia, and 8.3% (95% CI: 10.6-19.3%) for regional anesthesia. The measurement tool subgroup revealed a POD incidence of 19.3% (95% CI: 16.7-21.9%) with CAM and 16.8% (95% CI: 12.6-21.0%) with DSM. The sample size subgroup revealed a POD incidence of 19.4% (95% CI: 16.8-22.1%) for patients ≤ 500 and 15.3% (95% CI: 11.0-19.7%) for patients > 500. The sensitivity analysis suggested that the pooled incidence of postoperative delirium in this study was stable. Conclusion Our systematic review of the incidence of delirium after non-cardiac surgery in elderly Chinese patients revealed a high incidence of postoperative delirium. Except for cardiac surgery, the incidence of postoperative delirium was higher for hip fracture surgery than for other types of surgery. However, this finding must be further explored in future large-sample studies. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: PROSPERO CRD42023397883.
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Affiliation(s)
- Xiao-Yan Gong
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Dong-Jiang Hou
- School of Medicine and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jing Yang
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jia-li He
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Ming-Jin Cai
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Wei Wang
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Xian-Ying Lu
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jing Gao
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
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22
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Vlisides PE, Ragheb J, McKinney A, Mentz G, Runstadler N, Martinez S, Jewell E, Lee U, Vanini G, Schmitt EM, Inouye SK, Mashour GA. Caffeine, Postoperative Delirium And Change In Outcomes after Surgery (CAPACHINOS)-2: protocol for a randomised controlled trial. BMJ Open 2023; 13:e073945. [PMID: 37188468 PMCID: PMC10186430 DOI: 10.1136/bmjopen-2023-073945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/27/2023] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Delirium is a major public health issue for surgical patients and their families because it is associated with increased mortality, cognitive and functional decline, prolonged hospital admission and increased healthcare expenditures. Based on preliminary data, this trial tests the hypothesis that intravenous caffeine, given postoperatively, will reduce the incidence of delirium in older adults after major non-cardiac surgery. METHODS AND ANALYSIS The CAffeine, Postoperative Delirium And CHange In Outcomes after Surgery-2 (CAPACHINOS-2) Trial is a single-centre, placebo-controlled, randomised clinical trial that will be conducted at Michigan Medicine. The trial will be quadruple-blinded, with clinicians, researchers, participants and analysts all masked to the intervention. The goal is to enrol 250 patients with a 1:1:1: allocation ratio: dextrose 5% in water placebo, caffeine 1.5 mg/kg and caffeine 3 mg/kg as a caffeine citrate infusion. The study drug will be administered intravenously during surgical closure and on the first two postoperative mornings. The primary outcome will be delirium, assessed via long-form Confusion Assessment Method. Secondary outcomes will include delirium severity, delirium duration, patient-reported outcomes and opioid consumption patterns. A substudy analysis will also be conducted with high-density electroencephalography (72-channel system) to identify neural abnormalities associated with delirium and Mild Cognitive Impairment at preoperative baseline. ETHICS AND DISSEMINATION This study was approved by the University of Michigan Medical School Institutional Review Board (HUM00218290). An independent data and safety monitoring board has also been empanelled and has approved the clinical trial protocol and related documents. Trial methodology and results will be disseminated via clinical and scientific journals along with social and news media. TRIAL REGISTRATION NUMBER NCT05574400.
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Affiliation(s)
- Phillip E Vlisides
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Consciousness Science, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Amy McKinney
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Graciela Mentz
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | | | | | | | - UnCheol Lee
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Consciousness Science, University of Michigan, Ann Arbor, Michigan, USA
| | - Giancarlo Vanini
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Consciousness Science, University of Michigan, Ann Arbor, Michigan, USA
| | - Eva M Schmitt
- Hebrew SeniorLife Institute for Aging Research, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Hebrew SeniorLife Institute for Aging Research, Harvard Medical School, Boston, Massachusetts, USA
| | - George A Mashour
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Consciousness Science, University of Michigan, Ann Arbor, Michigan, USA
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Zhang Y, Baldyga K, Dong Y, Song W, Villanueva M, Deng H, Mueller A, Houle TT, Marcantonio ER, Xie Z. The association between gut microbiota and postoperative delirium in patients. Transl Psychiatry 2023; 13:156. [PMID: 37160886 PMCID: PMC10170091 DOI: 10.1038/s41398-023-02450-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/11/2023] Open
Abstract
Postoperative delirium is a common postoperative complication in older patients, and its pathogenesis and biomarkers remain largely undetermined. The gut microbiota has been shown to regulate brain function, and therefore, it is vital to explore the association between gut microbiota and postoperative delirium. Of 220 patients (65 years old or older) who had a knee replacement, hip replacement, or laminectomy under general or spinal anesthesia, 86 participants were included in the data analysis. The incidence (primary outcome) and severity of postoperative delirium were assessed for two days. Fecal swabs were collected from participants immediately after surgery. The 16S rRNA gene sequencing was used to assess gut microbiota. Principal component analyses along with a literature review were used to identify plausible gut microbiota, and three gut bacteria were further studied for their associations with postoperative delirium. Of the 86 participants [age 71.0 (69.0-76.0, 25-75% percentile of quartile), 53% female], 10 (12%) developed postoperative delirium. Postoperative gut bacteria Parabacteroides distasonis was associated with postoperative delirium after adjusting for age and sex (Odds Ratio [OR] 2.13, 95% Confidence Interval (CI): 1.09-4.17, P = 0.026). The association between delirium and both Prevotella (OR: 0.59, 95% CI: 0.33-1.04, P = 0.067) and Collinsella (OR: 0.57, 95% CI: 0.27-1.24, P = 0.158) did not meet statistical significance. These findings suggest that there may be an association between postoperative gut microbiota, specifically Parabacteroides distasonis, and postoperative delirium. However, further research is needed to confirm these findings and better understand the gut-brain axis's role in postoperative outcomes.
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Affiliation(s)
- Yiying Zhang
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA.
| | - Kathryn Baldyga
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Yuanlin Dong
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Wenyu Song
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Mirella Villanueva
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
| | - Hao Deng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Edward R Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Zhongcong Xie
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA.
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24
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Xu X, Wang J, Shen J, Chen R. Association of preexisting obstructive sleep apnea with postoperative delirium in patients undergoing major surgeries: A systematic review and meta-analysis. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023. [DOI: 10.1016/j.tacc.2023.101239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
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25
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Kim SY, Jo HY, Na HS, Han SH, Do SH, Shin HJ. The Effect of Peripheral Nerve Block on Postoperative Delirium in Older Adults Undergoing Hip Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2023; 12:jcm12072459. [PMID: 37048543 PMCID: PMC10095174 DOI: 10.3390/jcm12072459] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
This meta-analysis aimed to determine whether peripheral nerve blocks (PNB) reduce postoperative delirium (POD) in elderly patients undergoing hip surgery. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022328320). The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for randomized controlled trials (RCTs) on 26 April 2022. A total of 19 RCTs with 1977 participants were included. Perioperative PNB lowered the POD incidence on the third postoperative day (OR: 0.59, 95% CI [0.40 to 0.87], p = 0.007, I2 = 35%), in patients without underlying cognitive impairment (OR: 0.47, 95% CI [0.30 to 0.74], p = 0.001, I2 = 30%), and when a fascia iliaca compartment block (OR: 0.58, 95% CI [0.37 to 0.91], p = 0.02, I2 = 0%) or a femoral nerve block (OR: 0.33, 95% CI [0.11 to 0.99], p = 0.05, I2 = 66%) were performed. The pain score was also reduced (SMD: -0.83, 95% CI [-1.36 to -0.30], p = 0.002, I2 = 95%) after PNB. Perioperative PNB can lower the POD incidence and pain scores up to the third postoperative day. However, considering the wide variety of PNBs performed, more trials are needed to identify the effects of each PNB on POD.
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Affiliation(s)
- Su Yeon Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Ha Young Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Sung-Hee Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Sang-Hwan Do
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Hyun-Jung Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
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26
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Ju JW, Nam K, Sohn JY, Joo S, Lee J, Lee S, Cho YJ, Jeon Y. Association between intraoperative body temperature and postoperative delirium: A retrospective observational study. J Clin Anesth 2023; 87:111107. [PMID: 36924749 DOI: 10.1016/j.jclinane.2023.111107] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/20/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023]
Abstract
STUDY OBJECTIVE The effect of perioperative body temperature derangement on postoperative delirium remains unclear. This study aimed to evaluate the association between intraoperative body temperature and postoperative delirium in patients having noncardiac surgery. DESIGN Single-center retrospective observational study. SETTING Tertiary university hospital. PATIENT Adult patients who had major noncardiac surgery under general anesthesia for at least two hours between 2019 and 2021. INTERVENTIONS Patients were classified into three groups according to their intraoperative time-weighted average body temperature: severe hypothermia (<35.0 °C), mild hypothermia (35.0 °C-36.0 °C), and normothermia (≥36.0 °C) groups. MEASUREMENTS The primary outcome was the risk of delirium occurring within seven days after surgery, which was compared using logistic regression analysis. A multivariable procedure was performed adjusting for potential confounders including demographics, history of hypertension, diabetes, atrial fibrillation or flutter, myocardial infarction, congestive heart failure, and stroke or transient ischemic attack, preoperative use of antidepressants and statins, preoperative sodium imbalance, high-risk surgery, emergency surgery, duration of surgery, and red blood cell transfusion. Cox regression analysis was also performed using the same covariates. MAIN RESULTS Among 27,674 patients analyzed, 5.5% experienced postoperative delirium. The incidence rates of delirium were 6.2% (63/388) in the severe hypothermia group, 6.4% (756/11779) in the mild hypothermia group, and 4.6% (712/15507) in the normothermia group. Compared with the normothermia group, the risk of delirium was significantly higher in the severe hypothermia (adjusted odds ratio, 1.43; 95% confidence interval, 1.04-1.97) and mild hypothermia (1.15; 1.02-1.28) groups. The mild hypothermia group also had a significantly increased risk of cumulative development of delirium than the normothermia group (adjusted hazard ratio 1.14; 95% confidence interval, 1.03-1.26). CONCLUSIONS Intraoperative hypothermia (even mild hypothermia) was significantly associated with an increased risk of postoperative delirium.
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Affiliation(s)
- Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Jin Young Sohn
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Somin Joo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jaemoon Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Lai CC, Liu KH, Tsai CY, Hsu JT, Hsueh SW, Hung CY, Chou WC. Risk factors and effect of postoperative delirium on adverse surgical outcomes in older adults after elective abdominal cancer surgery in Taiwan. Asian J Surg 2023; 46:1199-1206. [PMID: 36041906 DOI: 10.1016/j.asjsur.2022.08.079] [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: 06/29/2022] [Revised: 07/27/2022] [Accepted: 08/18/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common complication in older adults, with unknown epidemiology and effects on surgical outcomes in Asian geriatric cancer patients. This study evaluated incidence, risk factors, and association between adverse surgical outcomes and POD after intra-abdominal cancer surgery in Taiwan. METHODS Overall, 345 patients aged ≥65 years who underwent elective abdominal cancer surgery at a medical center in Taiwan were prospectively enrolled. Delirium was assessed daily using the Confusion Assessment Method. Univariate and multivariate logistic regression analyses investigated risk factors for POD occurrence and estimated the association with adverse surgical outcomes. RESULTS POD occurred in 19 (5.5%) of the 345 patients. Age ≥73 years, Charlson comorbidity index ≥3, and operative time >428 min were independent predictors for POD occurrence. Patients presenting with one, two, and three risk factors had 4.1-fold (95% confidence interval [CI], 0.4-35.8, p = 0.20), 17.4-fold (95% CI, 2.2-138, p = 0.007), and 30.8-fold likelihood (95% CI, 2.9-321, p = 0.004) for POD occurrence, respectively. Patients with POD had a higher probability of prolonged hospital stay (adjusted odds ratio [OR] 2.8; 95% CI, 1.0-8.1; p = 0.037), intensive care stay (adjusted OR: 3.9; 95% CI, 1.5-10.5; p = 0.008), 30-day readmission (adjusted OR 3.1; 95% CI, 1.1-9.7; p = 0.039), and 90-day postoperative death (adjusted OR: 4.2; 95% CI, 1.0-17.7; p = 0.041). CONCLUSION POD occurrence was significantly associated with adverse surgical outcomes in geriatric patients undergoing elective abdominal cancer surgery, highlighting the importance of early POD identification in geriatric patients to improve postoperative care quality.
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Affiliation(s)
- Cheng-Chou Lai
- Department of Colon and Rectal Surgery, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, 333, Taoyuan, Taiwan
| | - Keng-Hao Liu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, 333, Taoyuan, Taiwan
| | - Chun-Yi Tsai
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, 333, Taoyuan, Taiwan
| | - Jun-Te Hsu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, 333, Taoyuan, Taiwan
| | - Shun-Wen Hsueh
- Department of Oncology, Chang Gung Memorial Hospital at Keelung, 204, Keelung, Taiwan
| | - Chia-Yen Hung
- Division of Hematology and Oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, 104, Taiwan; Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Wen-Chi Chou
- Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan.
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28
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Alvarez EA, Rojas VA, Caipo LI, Galaz MM, Ponce DP, Gutierrez RG, Salech F, Tobar E, Reyes FI, Vergara RC, Egaña JI, Briceño CA, Penna A. Non-pharmacological prevention of postoperative delirium by occupational therapy teams: A randomized clinical trial. Front Med (Lausanne) 2023; 10:1099594. [PMID: 36817762 PMCID: PMC9931896 DOI: 10.3389/fmed.2023.1099594] [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: 11/16/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
Background Patients who develop postoperative delirium (POD) have several clinical complications, such as increased morbidity, increased hospital stays, higher hospital costs, cognitive and functional impairment, and higher mortality. POD is a clinical condition preventable by standard non-pharmacological measures An intensive Occupational Therapy (OT) intervention has been shown to be highly effective in preventing delirium in critically ill medical patients, but it is unknown the effect in surgical patients. Thus, we designed a prospective clinical study with the aim to determine whether patients undergoing intervention by the OT team have a lower incidence of POD compared to the group treated only with standard measures. Methods A multicenter, single-blind, randomized clinical trial was conducted between October 2018 and April 2021, in Santiago of Chile, at a university hospital and at a public hospital. Patients older than 75 years undergoing elective major surgery were eligible for the trial inclusion. Patients with cognitive impairment, severe communication disorder and cultural language limitation, delirium at admission or before surgery, and enrolled in another study were excluded. The intervention consisted of OT therapy twice a day plus standard internationally recommended non-pharmacological prevention intervention during 5 days after surgery. Our primary outcome was development of delirium and postoperative subsyndromal delirium. Results In total 160 patients were studied. In the interventional group, treated with an intensive prevention by OT, nine patients (12.9%) developed delirium after surgery and in the control group four patients (5.5%) [p = 0.125, RR 2.34 CI 95 (0.75-7.27)]. Whereas subsyndromal POD was present in 38 patients in the control group (52.1%) and in 34 (48.6%) in the intervention group [p = 0.4, RR 0.93 CI95 (0.67-1.29)]. A post hoc analysis determined that the patient's comorbidity and cognitive status prior to hospitalization were the main risk factors to develop delirium after surgery. Discussion Patients undergoing intervention by the OT team did not have a lower incidence of POD compared to the group treated only with standard non-pharmacological measures in adults older than 75 years who went for major surgery. Clinical trial registration www.ClinicalTrials.gov, identifier NCT03704090.
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Affiliation(s)
- Evelyn A. Alvarez
- Terapia Ocupacional, Universidad Central de Chile, Santiago, Chile,Departamento de Terapia Ocupacional y Ciencia de la Ocupación, Universidad de Chile, Santiago, Chile
| | - Veronica A. Rojas
- Critical Care Unit, Department of Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile,Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile
| | - Lorena I. Caipo
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile
| | - Melany M. Galaz
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile
| | - Daniela P. Ponce
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile
| | - Rodrigo G. Gutierrez
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile,Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Felipe Salech
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile,Sección de Geriatría, Departamento de Medicina, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Eduardo Tobar
- Critical Care Unit, Department of Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Fernando I. Reyes
- Servicio de Anestesiología, Hospital Santiago Oriente Doctor Luis Tisné Brousse, Santiago, Chile
| | - Rodrigo C. Vergara
- Núcleo de Bienestar y Desarrollo Humano (NUBIDEH), Centro de Investigación en Educación (CIE-UMCE), Universidad Metropolitana de Ciencias de la Educación, Santiago, Chile,Facultad de Artes y Educación Física, Departamento de Kinesiología, Universidad Metropolitana de Ciencias de la Educación, Santiago, Chile,Centro Nacional de Inteligencia Artificial (CENIA), Santiago, Chile
| | - Jose I. Egaña
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile,Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Constanza A. Briceño
- Departamento de Terapia Ocupacional y Ciencia de la Ocupación, Universidad de Chile, Santiago, Chile
| | - Antonello Penna
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile,Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico de la Universidad de Chile, Santiago, Chile,*Correspondence: Antonello Penna,
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Li R, Zhang Y, Zhu Q, Wu Y, Song W. The role of anesthesia in peri‑operative neurocognitive disorders: Molecular mechanisms and preventive strategies. FUNDAMENTAL RESEARCH 2023. [DOI: 10.1016/j.fmre.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Xie Z, Zhang Y, Baldyga K, Dong Y, Song W, Villanueva M, Deng H, Mueller A, Houle T, Marcantonio E. The association between gut microbiota and postoperative delirium in patients. RESEARCH SQUARE 2023:rs.3.rs-2456664. [PMID: 36747650 PMCID: PMC9900981 DOI: 10.21203/rs.3.rs-2456664/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Postoperative delirium is one of the most common postoperative complications in older patients. Its pathogenesis and biomarkers, however, remain largely undetermined. Majority of human microbiota is gut microbiota and gut microbiota has been shown to regulate brain function. Therefore, this study aimed to determine the association between gut microbiota and postoperative delirium in patients. Of 220 patients (65 years old or older) who had a knee replacement, hip replacement, or laminectomy under general or spinal anesthesia, 86 participants were included in the data analysis. The incidence (primary outcome) and severity of postoperative delirium was assessed for two days. Fecal swabs were collected from participants immediately after surgery. The 16S rRNA gene sequencing was used to assess gut microbiota. Using principal component analyses along with a literature review to identify biologically plausible mechanisms, and three bacterials were studied for their associations with postoperative delirium. Of the 86 participants [age 71.0 (69.0-76.0, 25%-75% percentile of quartile), 53% female], ten (12%) developed postoperative delirium. Postoperative gut bacteria Parabacteroides distasonis (Odds Ratio [OR] 2.13, 95% Confidence Interval (CI): 1.09-4.17, P = 0.026) was associated with postoperative delirium after adjusting for age and sex. The association between delirium and both Prevotella (OR: 0.59, 95% CI: 0.33-1.04, P = 0.067) and Collinsella (OR: 0.57, 95% CI: 0.27-1.24, P = 0.158) did not meet statistical significance. These findings suggest that postoperative gut microbiota (e.g., Parabacteroides distasonis ) may serve as biomarkers in the pathogenesis of postoperative delirium, pending confirmative studies.
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Affiliation(s)
| | | | | | - Yuanlin Dong
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School
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Ormseth CH, LaHue SC, Oldham MA, Josephson SA, Whitaker E, Douglas VC. Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review. JAMA Netw Open 2023; 6:e2249950. [PMID: 36607634 PMCID: PMC9856673 DOI: 10.1001/jamanetworkopen.2022.49950] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups. OBJECTIVE To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting. EVIDENCE REVIEW A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium. FINDINGS A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity. CONCLUSIONS AND RELEVANCE In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.
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Affiliation(s)
- Cora H. Ormseth
- Department of Emergency Medicine, University of California, San Francisco
| | - Sara C. LaHue
- Department of Neurology, University of California, San Francisco
| | - Mark A. Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | | | - Evans Whitaker
- University of California, San Francisco, School of Medicine
| | - Vanja C. Douglas
- Department of Neurology, University of California, San Francisco
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Chew WZ, Teoh WY, Sivanesan N, Loh PS, Shariffuddin II, Ti LK, Ng KT. Bispectral Index (BIS) Monitoring and Postoperative Delirium in Elderly Patients Undergoing Surgery: A Systematic Review and Meta-Analysis With Trial Sequential Analysis. J Cardiothorac Vasc Anesth 2022; 36:4449-4459. [PMID: 36038444 DOI: 10.1053/j.jvca.2022.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/20/2022] [Accepted: 07/04/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine the effect of bispectral index (BIS)-guided anesthesia on the incidence of postoperative delirium (POD) in elderly patients undergoing surgery. DESIGN A systematic review, meta-analysis, and trial sequential analysis (TSA). SETTING In the operating room, postoperative anesthesia care units (PACU), and ward. PARTICIPANTS Elderly patients (>60 years old) undergoing surgery. INTERVENTIONS The EMBASE, MEDLINE, and CENTRAL databases were searched systematically from their inception until December 2020 for randomized controlled trials comparing BIS and usual care or blinded BIS. MEASUREMENTS AND MAIN RESULTS Ten trials (N = 3,891) were included for quantitative meta-analysis. In comparison to the control group, there was no significant difference in the incidence of POD in elderly patients randomized to BIS-guided anesthesia (odds ratio [OR] 0.71, 95% CI 0.47-1.08, I2 = 76%, p = 0.11, level of evidence = very low, TSA = inconclusive). The authors' review demonstrated that elderly patients with BIS-guided anesthesia were significantly associated with a lower incidence of postoperative cognitive dysfunction (POCD) (OR 0.64, 95% CI 0.46-0.88, p = 0.006), extubation time (mean difference [MD] -3.38 minutes, 95% CI -4.38 to -2.39, p < 0.00001), time to eye opening (MD -2.17 minutes, 95% CI -4.21 to -0.14, p = 0.04), and time to discharge from the PACU (MD -10.77 minutes, 95% CI -11.31 to - 10.23, p < 0.00001). CONCLUSION The authors' meta-analysis demonstrated that BIS-guided anesthesia was not associated with a reduced incidence of POD, but it was associated with a reduced incidence of POCD and improved recovery parameters.
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Affiliation(s)
- Wei Zhuen Chew
- Faculty of Medicine, University of Glasgow, Glasgow, Scotland
| | - Wan Yi Teoh
- Faculty of Medicine, University of Liverpool, Liverpool, United Kingdom
| | | | - Pui San Loh
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
| | - Ina Ismiarti Shariffuddin
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Jalan Universiti, Kuala Lumpur, Malaysia
| | - Lian Kah Ti
- Department of Anaesthesia, National University Hospital, Singapore
| | - Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Jalan Universiti, Kuala Lumpur, Malaysia.
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Anada S, Iigaya M, Takahashi M, Soda K, Wada N. Impact of early mobilization on the duration of delirium in elderly hospitalized patients: A retrospective cohort pilot study. Medicine (Baltimore) 2022; 101:e31641. [PMID: 36343083 PMCID: PMC9646638 DOI: 10.1097/md.0000000000031641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Development of delirium during hospitalization impairs the activities of daily living in elderly hospitalized patients. In clinical practice, early mobilization from bed is recommended to reduce delirium incidence and hospitalization stay. However, the effects of early mobilization on elderly inpatients with delirium have not been established yet. The aim of this study was to investigate the association between early mobilization and the duration of delirium in elderly inpatients with delirium. This retrospective cohort pilot study examined 45 participants (23 males, 22 females; mean age: 84.5 ± 6.6 years), who developed delirium during hospitalization. Of the participants, 28 were surgically treated and 17 were non-surgically treated. We classified early or delayed mobilization based on the median number of days until the start of mobilization and compared after propensity score matching to adjust for baseline characteristics. Additionally, we examined the correlation between the number of days until the start of mobilization and the duration of delirium. The duration of delirium was significantly shorter in the early mobilization group, particularly in terms of sitting on the bed and wheelchair use than that in the delayed mobilization group {median: 4.0 [interquartile range (IQR): 2.0-6.0] vs 8.0 [IQR: 7.0-14.5] days, P = .013; median: 3.0 [IQR: 2.0-5.5] vs 11.0 [IQR: 7.5-14.5] days, P = .004, respectively}. Moreover, the duration of delirium significantly positively moderate correlated with the time until the start of sitting on the bed and wheelchair use (Spearman r = 0.527; P = .012, Spearman r = 0.630; P = .002, respectively). The results of this study suggest that early mobilization from sitting on the bed or wheelchair use after hospitalization or surgery may shorten the duration of delirium. Because the sample size of this pilot study is small, careful interpretation is needed, and further research is warranted.
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Affiliation(s)
- Satoshi Anada
- Department of Rehabilitation, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
- *Correspondence: Satoshi Anada, Department of Rehabilitation, Kitasato University Kitasato Institute Hospital, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8642, Japan (e-mail: )
| | - Miho Iigaya
- Department of Neurology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Megumi Takahashi
- Department of Psychiatry, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Kazue Soda
- Department of Pharmacy, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Namiko Wada
- Department of Nursing, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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Prevalence of Emergence Delirium and Associated Factors among Older Patients Who Underwent Elective Surgery: A Multicenter Observational Study. Anesthesiol Res Pract 2022; 2022:2711310. [PMID: 36119120 PMCID: PMC9481404 DOI: 10.1155/2022/2711310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/27/2022] [Indexed: 11/30/2022] Open
Abstract
Background Emergence delirium is a common and serious postoperative complication in older surgical patients. It occurs at any time in the perioperative period, during or immediately following emergence from general anesthesia. Unfortunately, it is highly associated with postoperative complications such as a decrease in functional capacity, prolonged hospital stay, an increase in health care costs, and morbidity and mortality. The goal of this study was to determine the prevalence of emergence delirium and associated factors among older patients who underwent elective surgery in the teaching hospitals of Ethiopia at the postanesthesia care unit in 2021. Methods A multicenter prospective observational study was conducted at the postanesthetic care unit in the four teaching hospitals of Ethiopia. Older surgical patients admitted to the postanesthesia care unit who underwent elective surgery in the four teaching hospitals of Ethiopia were selected by using simple random sampling. Pretested structured questionnaire was used to collect data. Data were entered into EpiData (version 4.6) and exported to the SPSS (version 25.0). Binary logistic regression was used to identify factors independently associated with the emergence delirium. Results Out of 384 older patients included in the study, the prevalence of emergence delirium was 27.6%. Preoperative low hemoglobin levels (AOR: 2.0, 95% CI; 1.77–3.46), opioid (AOR: 8.0, 95% CI; 3.22–27.8), anticholinergic premedications (AOR: 8.5, 95% CI; 6.85–17.35), and postoperative pain (AOR: 3.10, 95 CI; 2.07–9.84) at PACU were independently associated with emergence delirium. Conclusion The prevalence of emergence delirium was high among older patients who underwent elective surgery. Opioid and anticholinergic premedication, low preoperative hemoglobin, and the presence of postoperative pain were independently associated with the emergence delirium. Adequate preoperative optimization and postoperative analgesia may reduce the prevalence of emergence delirium.
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Kimura A, Shiraishi Y, Sawamura H, Sugawara R, Inoue H, Takeshita K. Predictors of Postoperative Delirium in Older Patients Undergoing Elective Spine Surgery. Spine Surg Relat Res 2022; 7:13-18. [PMID: 36819629 PMCID: PMC9931407 DOI: 10.22603/ssrr.2022-0118] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/24/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction This prospective study was conducted to investigate the prevalence and predictors of postoperative delirium (POD) in a cohort of patients aged ≥65 years who were scheduled to undergo elective spine surgery. Methods Patients aged ≥65 years who were scheduled to undergo elective spine surgery from February 2018 to May 2019 were prospectively recruited for this study. Delirium was diagnosed according to the Confusion Assessment Method algorithm. Candidate predictors included patient characteristics, comorbidities, surgical time, blood loss, preoperative laboratory parameters, and preoperative cognitive function, as assessed by the Mini-Cog test. These variables were compared between patients with and without POD. Multivariate logistic regression was performed to identify the independent predictors of POD. For the continuous variables, a receiver operating characteristic curve was used to determine the optimal cutoff value for predicting POD. Results Of the 106 patients included in the study, 12 (11.3%) patients developed POD, with a median time to onset of 3 d and median duration of 2 d. After adjusting for confounders, the occurrence of POD was independently associated with older age, a higher blood urea nitrogen (BUN) concentration, and a lower Mini-Cog score. The optimal cutoff point of the Mini-Cog score for predicting the occurrence of POD was ≤3. Conclusions POD was a common complication after spine surgery, showing an incidence of 11.3% in this study. Older age, a higher BUN concentration, and impaired cognition, as defined by the Mini-Cog, were independent predictors of POD. The current results may be useful for early identification of patients at risk of POD and facilitation of targeted interventions for preventing POD or mitigating its severity.
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Affiliation(s)
- Atsushi Kimura
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Yasuyuki Shiraishi
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Hideaki Sawamura
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Ryo Sugawara
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Hirokazu Inoue
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Mao M, Wang LY, Zhu LY, Wang F, Ding Y, Tong JH, Sun J, Sun Q, Ji MH. Higher serum PGE2 is a predicative biomarker for postoperative delirium following elective orthopedic surgery in elderly patients. BMC Geriatr 2022; 22:685. [PMID: 35982410 PMCID: PMC9389800 DOI: 10.1186/s12877-022-03367-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Postoperative delirium (POD), one of the most common complications following major surgery, imposes a heavy burden on patients and society. The objective of this exploratory study was to conduct a secondary analysis to identify whether there exist novel and reliable serum biomarkers for the prediction of POD. Methods A total of 131 adult patients (≥ 65 years) undergoing lower extremity orthopedic surgery with were enrolled in this study. Cognitive function was assessed preoperatively with Mini-Mental State Examination (MMSE). Delirium was diagnosed according to the Confusion Assessment Method (CAM) criteria on preoperative day and postoperative days 1–3. The preoperative serum levels of a panel of 16 biochemical parameters were measured by ELISA. Results Thirty-five patients developed POD, with an incidence of 26.7%. Patients in POD group were older (P = 0.001) and had lower preoperative MMSE scores (P = 0.001). Preoperative serum levels of prostaglandin E2 (PGE2, P < 0.001), S100β (P < 0.001), glial fibrillary acidic protein (P < 0.001) and neurofilament light (P = 0.002) in POD group were significantly increased. Logistic regression analysis showed that advanced age (OR = 1.144, 95%CI: 1.008 ~ 1.298, P = 0.037), higher serum neurofilament light (OR = 1.003, 95%CI: 1.000 ~ 1.005, P = 0.036) and PGE2 (OR = 1.031, 95%CI: 1.018 ~ 1.044, P < 0.001) levels were associated with the development of POD. In addition, serum level of PGE2 yielded an area under the ROC curve (AUC) of 0.897 to predict POD (P < 0.001), with a sensitivity of 80% and a specificity of 83.3%. Conclusions Our study showed that higher preoperative serum PGE2 level might be a biomarker to predict the occurrence of POD in elderly patients undergoing elective orthopedic surgery. Trial registration NCT03792373 www.clinicaltrials.gov.
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Affiliation(s)
- Meng Mao
- Department of Anesthesiology, the Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of Anesthesiology, the Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lei-Yuan Wang
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China
| | - Lan-Yue Zhu
- Department of Anesthesiology, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Fei Wang
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China
| | - Ying Ding
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China
| | - Jian-Hua Tong
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China
| | - Jie Sun
- Department of Anesthesiology, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Qiang Sun
- Department of Anesthesiology, the Second Affiliated Hospital of Nanjing Medical University, Nanjing, China. .,Department of Anesthesiology, the Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China.
| | - Mu-Huo Ji
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China.
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Karalapillai D, Weinberg L, Neto AS, Peyton PJ, Ellard L, Hu R, Pearce B, Tan C, Story D, O'Donnell M, Hamilton P, Oughton C, Galtieri J, Appu S, Wilson A, Eastwood G, Bellomo R, Jones DA. Intraoperative low tidal volume ventilation and the risk of ICD-10 coded delirium and the use for antipsychotic medications. BMC Anesthesiol 2022; 22:149. [PMID: 35578170 PMCID: PMC9109306 DOI: 10.1186/s12871-022-01689-3] [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: 10/20/2021] [Accepted: 05/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low tidal volume (VT) ventilation and its associated increase in arterial carbon dioxide (PaCO2) may affect postoperative neurologic function. We aimed to test the hypothesis that intraoperative low VT ventilation affect the incidence of postoperative ICD-10 coded delirium and/or the need for antipsychotic medications. METHODS This is a post-hoc analysis of a large randomized controlled trial evaluating low vs. conventional VT ventilation during major non-cardiothoracic, non-intracranial surgery. The primary outcome was the incidence of ICD-10 delirium and/or the use of antipsychotic medications during hospital stay, and the absolute difference with its 95% confidence interval (CI) was calculated. RESULTS We studied 1206 patients (median age of 64 [55-72] years, 59.0% males, median ARISCAT of 26 [19-37], and 47.6% of ASA 3). ICD-10 coded delirium and /or antipsychotic medication use was diagnosed in 11.2% with similar incidence between low and conventional VT ventilation (11.1% vs. 11.3%; absolute difference, -0.24 [95%CI, -3.82 to 3.32]; p = 0.894). There was no interaction between allocation group and type of surgery. CONCLUSION In adult patients undergoing major surgery, low VT ventilation was not associated with increased risk of ICD-10 delirium and/or the use of antipsychotic medications during hospital stay. TRIAL REGISTRATION ANZCTR Identifier: ACTRN12614000790640 .
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Affiliation(s)
- Dharshi Karalapillai
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia. .,Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia. .,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Data Analytics Research and Evaluation (DARE) Centre, University of Melbourne, Melbourne, VIC, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Philip J Peyton
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Louise Ellard
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Raymond Hu
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Brett Pearce
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Chong Tan
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - David Story
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Mark O'Donnell
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
| | - Patrick Hamilton
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
| | - Chad Oughton
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
| | - Jonathan Galtieri
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
| | - Sree Appu
- Department of Surgery, Austin Hospital, Melbourne, VIC, Australia
| | - Anthony Wilson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Data Analytics Research and Evaluation (DARE) Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Daryl A Jones
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Abstract
PURPOSE OF REVIEW Postoperative neurocognitive disorders (NCD) are significant causes of morbidity and mortality. In this paper, we will review our understanding and potential management of postoperative NCD. RECENT FINDINGS Postoperative delirium, delayed neurocognitive recovery and postoperative cognitive dysfunction (POCD) are recognized as a part of the continuous spectrum of postoperative NCD. Although the pathophysiology is still poorly understood, there is renewed focus on improving neurocognitive outcomes of aging surgical population. Novel methods of neurocognitive screening are developed and research in the prevention and management of NCD has gained traction. SUMMARY A spectrum of NCD exists in surgical patients ranging from postoperative delirium, delayed neurocognitive recovery, and POCD. Identification of patients at-risk for developing NCD can help target appropriate perioperative intervention. Also, specialized care teams and the implementation of standardized protocols are crucial for the successful management perioperative NCD. Finally, large, randomized, multicenter studies are needed to confirm benefits of preventive and treatment strategies.
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Tran NN, Hoang TPN, Ho TKT. Diagnosis and Risk Factors for Delirium in Elderly Patients in the Emergency Rooms and Intensive Care Unit of the National Geriatric Hospital Emergency Department: A Cross-Sectional Observational Study. Int J Gen Med 2021; 14:6505-6515. [PMID: 34675618 PMCID: PMC8518479 DOI: 10.2147/ijgm.s325365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/20/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To diagnose delirium and identify risk factors for its development in elderly patients in the emergency department (ED) and intensive care units (ICU) at the National Geriatric Hospital (Vietnam). Patients and Methods A cross-sectional observational study was conducted with a convenience sample of non-surgical patients admitted to ED and ICU at Hanoi National Geriatric Hospital in Vietnam. In total, 163 patients met the selection criteria and were included in the study. Screening involved using the Confusion Assessment Method (CAM) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). The diagnosis was established according to the DSM-5 and ICD-10 codes. Results Delirium was found in a total of 106 (63.1%) patients. The factors significantly affecting its development were vision impairment (OR, 3.3; 95% CI, 1.5 to 7.4, P=0.003), hearing impairment (OR, 3.6; 95% CI, 1.77 to 7.36, P=0.0001), acute or chronic kidney failure (OR, 7.1; 95% CI, 2.05 to 6.39, P<0.001), respiratory disorders (OR, 2.7; 95% CI, 1.4 to 5.2, P=0.004), and malnutrition (OR, 9.17; 95% CI, 3.43–24.5, P=0.0001). The list also include the fall risk factors (OR, 12.2; 95% CI, 4.1–36.3, P=0.0001), frailty (OR, 8.35; 95% CI, 3.4–20.6, P=0.0001), activities of daily living (OR, 8.35; 95% CI, 3.4–20.6, P=0.0001), hyponatremia (OR, 2.48; 95% CI, 1.07 to 5.75, P=0.001), hypernatremia (OR, 13.1; 95% CI, 1.67 to 2.5, P=0.001), and treatment interventions. In addition, delirium was linked to the duration of ICU admission (OR, 6.53; 95% CI, 4.5–25.5, P < 0.0001). Conclusion The CAM/CAM-ICU diagnostic algorithm makes it possible to diagnose delirium successfully. The present study confirmed the role of several premorbid and triggering factors in the occurrence of delirium in elderly patients in ED and ICU. There is a need for further research into risk factors for delirium in elderly patients.
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Affiliation(s)
- Nguyen Ngoc Tran
- Department of Psychiatry, Ha Noi Medical University, Ha Noi, VietNam
| | - Thi Phuong Nam Hoang
- Department Geriatrics, Hanoi Medical University, Ha Noi, VietNam.,National Geriatric Hospital, Ha Noi, VietNam
| | - Thi Kim Thanh Ho
- Department of Family Medicine, Ha Noi Medical University, Ha Noi, VietNam
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Han QYC, Rodrigues NG, Klainin-Yobas P, Haugan G, Wu X. Prevalence, Risk Factors, and Impact of Delirium on Hospitalized Older Adults With Dementia: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2021; 23:23-32.e27. [PMID: 34648761 DOI: 10.1016/j.jamda.2021.09.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/03/2021] [Accepted: 09/04/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES High prevalence of delirium superimposed on dementia (DSD) was previously reported, with associated negative impact on hospitalized older adults. However, data were conflicting, and no meta-analysis has been conducted. Although dementia is the leading risk factor for delirium, risk factors for DSD have not been adequately studied. This systematic review and meta-analysis aims to elucidate the prevalence, risk factors, and impact of DSD in hospitalized older adults. Comparisons were made between older adults with DSD and persons with dementia alone (PWDs). DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS Observational studies reporting prevalence, risk factors, or impact of DSD in hospitalized older adults. METHODS Database search was conducted till December 2020 in PubMed, Embase, CENTRAL, PsycINFO, CINAHL, Scopus, Web of Science, ProQuest, and OpenGrey for relevant primary and secondary studies. A piloted data collection form was used for data extraction, and methodological quality was assessed using Joanna Briggs Institute critical appraisal checklists. Meta-analyses, with risk ratio and mean differences as effect measures, were performed using random effects model with Review Manager software. Cochran's Q and I2 statistics were used to assess heterogeneity, which was investigated using subgroup analyses. RESULTS A total of 81 studies were eligible. The pooled prevalence of DSD was 48.9%, with the highest prevalence found in the Americas and orthopedic wards. Risk factors, including nonmodifiable hospital-, illness-, and medication-related factors, were found to precipitate DSD. Patients with DSD had longer length of hospitalization, disclosed worse cognitive and functional outcomes, and a higher risk of institutionalization and mortality than patients with dementia. CONCLUSIONS AND IMPLICATIONS These findings suggested high prevalence and detrimental impact of DSD in hospitalized older adults, highlighting a need for early identification, prevention, and treatments. Further research on risk factors of DSD should be conducted as data were sparse and conflicting. Future high-quality studies regarding DSD are warranted to improve knowledge of this common but under-recognized phenomenon.
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Affiliation(s)
- Qin Yun Claudia Han
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Natalie Grace Rodrigues
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Piyanee Klainin-Yobas
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gørill Haugan
- Department of Public Health and Nursing, Centre for Health Promoting Research, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
| | - XiVivien Wu
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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The assessment of risk factors for postoperative delirium using cubic spline curves in gastroenterological surgery. Surg Today 2021; 51:1969-1977. [PMID: 34562176 DOI: 10.1007/s00595-021-02379-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/25/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Delirium is associated with longer hospital stays and increased medical costs and mortality. This study explored the risk factors for postoperative delirium in gastroenterological surgery and investigated the association between qualitative changes in risk factors and the incidence of postoperative delirium. METHODS A total of 418 patients > 18 years old who underwent gastroenterological surgery at our department between April 2018 and September 2019 were included. Risk factors were identified by comparing patients with and without postoperative delirium. Continuous variables were evaluated graphically using cubic spline curves. A logistic regression analysis was performed to assess independent risk factors. RESULTS The incidence of postoperative delirium was 6.9%. The cubic spline curve showed that the incidence of postoperative delirium began to increase at 50 years old and increased sharply at 70 years old. A multiple logistic regression analysis of patients > 50 years old identified 5 risk factors: age ≥ 70 years, preoperative serum albumin ≤ 3.8 g/dL, psychosis, sedative-hypnotics, and intensive-care unit admission. CONCLUSION The risk of postoperative delirium increases progressively at 50 years old and sharply at 70 years old. Advanced age, preoperative hypoalbuminemia, psychosis, sedative-hypnotics, and intensive-care unit admission are risk factors for postoperative delirium in patients > 50 years old undergoing gastroenterological surgery.
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Postoperative Delirium. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00445-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Pipanmekaporn T, Punjasawadwong Y, Wongpakaran N, Wongpakaran T, Suwannachai K, Chittawatanarat K, Mueankwan S. Risk factors and adverse clinical outcomes of postoperative delirium in Thai elderly patients: A prospective cohort study. Perspect Psychiatr Care 2021; 57:1073-1082. [PMID: 33111390 DOI: 10.1111/ppc.12658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/05/2020] [Accepted: 10/11/2020] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To determine the incidence, risk factors, and adverse clinical outcomes of postoperative delirium (POD) in elderly patients. DESIGN AND METHODS A total of 429 patients scheduled to undergo noncardiac surgery were recruited. Delirium was assessed using the confusion assessment method. FINDINGS The incidence of POD was 5.4%. Risk factors of POD were age over 70 years, an American Society of Anesthesiologist physical status 2 and 3, cognitive impairment, history of psychiatric illness, and preoperative hemoglobin ≤ 10 g/dl. PRACTICE IMPLICATIONS The correction of modifiable risk factors, the use of preventive strategies, and the monitoring of POD are advisable to improve the quality of perioperative care.
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Affiliation(s)
- Tanyong Pipanmekaporn
- Department of Anesthesiology, Chiang Mai University, Chiang Mai, Thailand.,Clinical Epidemiology and Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | | | | | | | | | - Sirirat Mueankwan
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Burfeind KG, Tirado Navales AA, Togioka BM, Schenning K. Prevention of postoperative delirium through the avoidance of potentially inappropriate medications in a geriatric surgical patient. BMJ Case Rep 2021; 14:14/4/e240403. [PMID: 33875501 PMCID: PMC8057549 DOI: 10.1136/bcr-2020-240403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We demonstrate the utility of risk stratification for postoperative delirium in geriatric patients and show that postoperative delirium can be prevented in high-risk patients when potentially inappropriate medications (PIMs) (medications that are best avoided in older adults) are avoided. In this case, a 65-year-old woman underwent two debridement procedures with similar presurgical risk for postoperative delirium. There was no risk stratification or preoperative cognitive assessment in the first procedure, she received PIMs and developed postoperative delirium. In the second procedure, PIMs were intentionally avoided and postoperative delirium did not occur. This case supports recent recommendations from the European Society of Anaesthesiology, the American Society of Anesthesiologists and the American Geriatrics Society that providers assess a patient's cognitive function and delirium risk profile preoperatively to appropriately guide perioperative management.
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Affiliation(s)
- Kevin G Burfeind
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Medical Scientist Training Program, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrés A Tirado Navales
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Brandon Michael Togioka
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Katie Schenning
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Dexmedetomidine reduces postoperative cognitive and behavioral dysfunction in adults submitted to general anesthesia for non-cardiac surgery: meta-analysis of randomized clinical trials. Braz J Anesthesiol 2021; 71:413-420. [PMID: 33685760 PMCID: PMC9373211 DOI: 10.1016/j.bjane.2021.02.020] [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: 04/11/2020] [Accepted: 08/26/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction and objectives Dexmedetomidine (DEX) has been associated with a decrease in postoperative cognitive and behavioral dysfunction in patients submitted to general anesthesia, whether inhalation or total intravenous anesthesia. Consequently, the DEX effects on postoperative agitation and delirium in patients submitted to general anesthesia for non-cardiac surgery have been investigated. Method A systematic review and meta-analysis of randomized and double-blind clinical trials (RCTs) was undertaken assessing adults submitted to elective procedures under general anesthesia receiving DEX or placebo. The search included articles published in English in the Pubmed and Web of Science databases using keywords such as dexmedetomidine, delirium, and agitation. Duplicate publications, studies involving cardiac surgery or using active control (other than saline solution) were included. A random effects model was adopted using the DerSimonian-Laird method and estimate of Odds Ratio (OR) for dichotomous variables, and weighted mean difference for continuous variables, with their respective 95% Confidence Intervals (95% CI). Results Of the 484 articles identified, 15 were selected comprising 2,183 patients (1,079 and 1,104 patients in the DEX and control group, respectively). The administration of DEX was considered a protective factor for postoperative cognitive and behavioral dysfunction (OR = 0.36; 95% CI 0.23–0.57 and p < 0.001), regardless of the anesthesia technique used. Conclusion Dexmedetomidine administration reduced by at least 43% the likelihood of postoperative cognitive and behavioral dysfunction in adult patients submitted to general anesthesia for non-cardiac surgery.
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Improving quality in colon and rectal surgery through palliative care. SEMINARS IN COLON AND RECTAL SURGERY 2020; 31:100783. [PMID: 33041605 PMCID: PMC7531922 DOI: 10.1016/j.scrs.2020.100783] [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] [Indexed: 11/25/2022]
Abstract
Palliative care is a medical discipline that emphasizes quality of life and can be provided in parallel with recovery-directed treatments in colon and rectal surgery. Palliative care is receiving increasing attention and investigation for its potential to improve quality and outcomes for a wide spectrum of patients by benefiting symptom management, supporting complex health care decision making and facilitating care transitions. Primary palliative care refers to the application of palliative care principles by clinicians of all disciplines whereas specialty palliative care is a multidisciplinary approach and includes a clinician with advanced training and experience.
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Ding L, Chen DX, Li Q. Effects of electroencephalography and regional cerebral oxygen saturation monitoring on perioperative neurocognitive disorders: a systematic review and meta-analysis. BMC Anesthesiol 2020; 20:254. [PMID: 32998697 PMCID: PMC7526409 DOI: 10.1186/s12871-020-01163-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Perioperative neurocognitive disorders (PND) is a common postoperative complication including postoperative delirium (POD), postoperative cognitive decline (POCD) or delayed neurocognitive recovery. It is still controversial whether the use of intraoperative cerebral function monitoring can decrease the incidence of PND. The purpose of this study was to evaluate the effects of different cerebral function monitoring (electroencephalography (EEG) and regional cerebral oxygen saturation (rSO2) monitoring) on PND based on the data from randomized controlled trials (RCTs). METHODS The electronic databases of Ovid MEDLINE, PubMed, EMBASE, Cochrane Library database were systematically searched using the indicated keywords from their inception to April 2020. The odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) were employed to analyze the data. Heterogeneity across analyzed studies was assessed with chi-square test and I2 test. RESULTS Twenty two RCTs with 6356 patients were included in the final analysis. Data from 12 studies including 4976 patients were analyzed to assess the association between the EEG-guided anesthesia and PND. The results showed that EEG-guided anesthesia could reduce the incidence of POD in patients undergoing non-cardiac surgery (OR: 0.73; 95% CI: 0.57-0.95; P = 0.02), but had no effect on patients undergoing cardiac surgery (OR: 0.44; 95% CI: 0.05-3.54; P = 0.44). The use of intraoperative EEG monitoring reduced the incidence of POCD up to 3 months after the surgery (OR: 0.69; 95% CI: 0.49-0.96; P = 0.03), but the incidence of early POCD remained unaffected (OR: 0.61; 95% CI: 0.35-1.07; P = 0.09). The remaining 10 studies compared the effect of rSO2 monitoring to routine care in a total of 1380 participants on the incidence of PND. The results indicated that intraoperative monitoring of rSO2 could reduce the incidence of POCD (OR 0.53, 95% CI 0.39-0.73; P < 0.0001), whereas no significant difference was found regarding the incidence of POD (OR: 0.74; 95% CI: 0.48-1.14; P = 0.17). CONCLUSIONS The findings in the present study indicated that intraoperative use of EEG or/and rSO2 monitor could decrease the risk of PND. TRIAL REGISTRATION PROSPREO registration number: CRD42019130512 .
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Affiliation(s)
- Lin Ding
- National Clinical Research Center for Geriatrics and department of Anesthesiology, West China Hospital of Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, 610041, China
| | - Dong Xu Chen
- National Clinical Research Center for Geriatrics and department of Anesthesiology, West China Hospital of Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, 610041, China
| | - Qian Li
- National Clinical Research Center for Geriatrics and department of Anesthesiology, West China Hospital of Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, 610041, China.
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Stepien KM, Gevorkyan AK, Hendriksz CJ, Lobzhanidze TV, Pérez-López J, Tol G, Del Toro Riera M, Vashakmadze ND, Lampe C. Critical clinical situations in adult patients with Mucopolysaccharidoses (MPS). Orphanet J Rare Dis 2020; 15:114. [PMID: 32410642 PMCID: PMC7227065 DOI: 10.1186/s13023-020-01382-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/13/2020] [Indexed: 01/16/2023] Open
Abstract
Background Mucopolysaccharidoses (MPS) are rare, inherited disorders associated with enzyme deficiencies that result in glycosaminoglycan (GAG) accumulation in multiple organ systems. Management of MPS is evolving as patients increasingly survive to adulthood and undergo multiple surgeries throughout their lives. As surgeries in these patients are considered to be high risk, this can result in a range of critical clinical situations in adult patients. Results We discuss strategies to prepare for and manage critical clinical situations in adult patients with MPS, including supporting the multidisciplinary team, preoperative and airway assessments, surgical preparations, and postoperative care. We also present eight critical clinical cases (age range: 21–38 years) from four leading inherited metabolic disease centres in Europe to highlight challenges and practical solutions to optimise the care of adult patients with MPS. Critical clinical situations included surgical procedures, pregnancy and a thrombus in a port-a-cath. Conclusions Individualised strategies to manage critical clinical situations need to be developed for each patient to compensate for the heterogeneous symptoms that may be present and the potential complications that may occur. These strategies should include input from the wider MDT, and be coordinated by metabolic specialists with expertise in the management of MPS disorders and surgery in adult patients with MPS.
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Affiliation(s)
- Karolina M Stepien
- The Mark Holland Metabolic Unit, Adult Inherited Metabolic Diseases, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.
| | | | | | | | | | - Govind Tol
- Anaesthetics Department, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | | | | | - Christina Lampe
- HELIOS Dr. Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
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