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Yan X, Huang J, Chen X, Lin M. Association between increased systemic immune-inflammation index and postoperative delirium in older intertrochanteric fracture patients. J Orthop Surg Res 2024; 19:219. [PMID: 38566241 PMCID: PMC10988850 DOI: 10.1186/s13018-024-04699-8] [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] [Received: 11/21/2023] [Accepted: 03/25/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND AND PURPOSE The systemic immune-inflammation index (SII), a novel inflammation index derived from the counts of circulating platelets, neutrophils and lymphocytes, has been studied in the treatment of acute cancer and ischemic stroke (AIS). However, the clinical value of the SII in postoperative delirium patients has not been further investigated. The purpose of our research was to study the incidence and preoperative risk factors for postoperative delirium (POD) and verify whether the SII could serve as a potential marker for POD in older intertrochanteric fracture patients. Finally, we created a novel nomogram for predicting POD in older patients with intertrochanteric fractures. METHODS We enrolled elderly patients with intertrochanteric fractures who underwent proximal femoral nail antirotation (PFNA) between February 2021 and April 2023. Univariate and multivariate logistic analyses were subsequently performed to confirm the risk factors and construct a nomogram model.Calibration curve and clinical decision curve analysis (DCA) were used to assess the model's fitting performance. The performance of the nomogram was evaluated for discrimination, calibration, and clinical utility. RESULTS A total of 293 patients were eligible for inclusion in the study, 25.6% (75/293) of whom had POD. The POD patients had higher SII values than the non-POD patients. The SII was strongly correlated with POD in older intertrochanteric fracture patients, and the optimal cutoff value was 752.6 × 109. Multivariate analysis revealed that age, diabetes, total albumin, SII > 752.6 × 109 and a CRP > 20.25 mg/L were independent risk factors for POD patients. By incorporating these 5 factors, the model achieved a concordance index of 0.745 (95% CI, 0.683-0.808) and had a well-fitted calibration curve and good clinical application value. CONCLUSION The SII is a simple and valuable biomarker for POD, and the new nomogram model can be used to accurately predict the occurrence of POD. They can be utilized in clinical practice to identify those at high risk of POD in older intertrochanteric fracture patients.
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Affiliation(s)
- Xiaoxiao Yan
- Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Jin Huang
- Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Xiachan Chen
- Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Mian Lin
- Department of Orthopedics, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China.
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An X, Zhang Y, Li Z, Song Y, Chen J. Blood Pressure Fluctuation Pattern Associated with 90-Day Ischemic Stroke and Transient Ischemic Attack After Total Knee Arthroplasty-A Retrospective Study. Orthop Surg 2024; 16:383-390. [PMID: 38114302 PMCID: PMC10834200 DOI: 10.1111/os.13942] [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: 06/05/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVE Blood pressure (BP) fluctuation has been demonstrated to be closely associated with stroke. However, at present, no attention is paid to the BP fluctuation following total knee arthroplasty (TKA). The aim of this study is to investigate what is BP fluctuation patterns in stroke and transient ischemic attack (TIA) patients after primary TKA, compare clinical characteristics among different BP fluctuation patterns and determine whether it could predict the occurrence of a 90-day stroke. METHODS A retrospective study was conducted from February 1, 2011 to February 15, 2021. Stroke or TIA patients within 90 days after TKA were included. Data from a hospitalization management system were analyzed, including demographics, smoking status, comorbidities, medications, surgical variables, and 90-day stroke, mortality, and readmission rates. BP fluctuation patterns were defined based on the average BP in the first 3 days after TKA. A logistic regression analysis model was used to identify risk factors for 90-day stroke or TIA following TKA. RESULTS Of the 1687 patients who underwent primary TKA, 4.0% (68/1687) experienced a 90-day stroke or TIA. A total of 63 patients met the inclusion criteria, with an average age of 67.5 years and 55.6% (35/63) female. The number of stroke or TIA patients in each BP fluctuation pattern (T1-T5) was 6 (9.5%), 5 (7.9%), 4 (6.3%), 13 (20.6%), and 35 (55.6%) respectively. Patients with a T5 pattern tended to be older and had a greater reduction in average systolic blood pressure (SBP) 3 days after surgery compared to other patterns. The T5 pattern was associated with a higher occurrence of stroke and a lower occurrence of TIA. Patients with a T5 pattern also had a longer length of stay within 90 days following TKA. After adjusting for confounding factors, average SBP fluctuation ≥40 mmHg and the T5 pattern of BP fluctuation remained risk factors for 90-day stroke or TIA after TKA. CONCLUSION BP fluctuation patterns in the early postoperative period are associated with 90-day stroke and TIA following primary TKA.
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Affiliation(s)
- Xiao An
- PLA General Hospital, Medical College of Chinese PLABeijingChina
- Department of OrthopaedicsHainan Hospital of Chinese PLA General HospitalSanyaHainanChina
| | - Yan Zhang
- Quality Management DepartmentPLA Rocket Force Characteristic Medical CenterBeijingChina
| | - Zhirui Li
- Department of OrthopaedicsHainan Hospital of Chinese PLA General HospitalSanyaHainanChina
| | - Yuxiang Song
- Department of AnesthesiologyThe First Medical Center of Chinese People's Liberation Army (PLA) General HospitalBeijingChina
| | - Jiying Chen
- PLA General Hospital, Medical College of Chinese PLABeijingChina
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Zorko Garbajs N, Valencia Morales DJ, Singh TD, Herasevich V, Hanson AC, Schroeder DR, Weingarten TN, Gajic O, Sprung J, Rabinstein AA. Association of Blood Pressure Variability with Delirium in Patients with Critical Illness. Neurocrit Care 2023; 39:646-654. [PMID: 36526945 PMCID: PMC9757627 DOI: 10.1007/s12028-022-01661-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The objective was to examine the association of blood pressure variability (BPV) during the first 24 h after intensive care unit admission with the likelihood of delirium and depressed alertness without delirium ("depressed alertness"). METHODS This retrospective, observational, cohort study included all consecutive adult patients admitted to an intensive care unit at Mayo Clinic, Rochester, Minnesota, from July 1, 2004, through October 31, 2015. The primary outcomes were delirium and delirium-free days, and the secondary outcomes included depressed alertness and depressed alertness-free days. Logistic regression was performed to determine the association of BPV with delirium and depressed alertness. Proportional odds regression was used to assess the association of BPV with delirium-free days and depressed alertness-free days. RESULTS Among 66,549 intensive care unit admissions, delirium was documented in 20.2% and depressed alertness was documented in 24.4%. Preserved cognition was documented in 55.4% of intensive care unit admissions. Increased systolic and diastolic BPV was associated with an increased odds of delirium and depressed alertness. The magnitude of the association per 5-mm Hg increase in systolic average real variability (the average of absolute value of changes between consecutive systolic blood pressure readings) was greater for delirium (odds ratio 1.34; 95% confidence interval 1.29-1.40; P < 0.001) than for depressed alertness (odds ratio 1.06; 95% confidence interval 1.02-1.10; P = 0.004). Increased systolic and diastolic BPV was associated with fewer delirium-free days but not with depressed alertness-free days. CONCLUSIONS BPV in the first 24 h after intensive care unit admission is associated with an increased likelihood of delirium and fewer delirium-free days.
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Affiliation(s)
- Nika Zorko Garbajs
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
- Division of Neurology, Department of Vascular Neurology and Intensive Therapy, University Medical Centre, Ljubljana, Slovenia.
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.
| | | | - Tarun D Singh
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Neurology and Neurological Surgery, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Vitaly Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andrew C Hanson
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Darrell R Schroeder
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alejandro A Rabinstein
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Penfold RS, Hall AJ, Anand A, Clement ND, Duckworth AD, MacLullich AMJ. Delirium in hip fracture patients admitted from home during the COVID-19 pandemic is associated with higher mortality, longer total length of stay, need for post-acute inpatient rehabilitation, and readmission to acute services. Bone Jt Open 2023; 4:447-456. [PMID: 37326476 DOI: 10.1302/2633-1462.46.bjo-2023-0045.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
Aims Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days. Methods This observational study used routine clinical data in a consecutive sample of hip fracture patients aged ≥ 50 years admitted to a single large trauma centre during the COVID-19 pandemic between 1 March 2020 and 30 November 2021. Delirium was prospectively assessed as part of routine care by the 4 A's Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, Scottish Index of Multiple Deprivation quintile, COVID-19 infection within 30 days, and American Society of Anesthesiologists grade. Results A total of 1,821 patients were admitted, with 1,383 (mean age 79.5 years; 72.1% female) directly from home. Overall, 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1,734): 14.1% (189/1,340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20-day longer total length of stay (p < 0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (odds ratio (OR) 1.69 (95% confidence interval (CI) 1.13 to 2.54); p = 0.013), requirement for post-acute inpatient rehabilitation (OR 2.80 (95% CI 1.97 to 3.96); p < 0.001), and readmission to hospital within 180 days (OR 1.79 (95% CI 1.02 to 3.15); p = 0.041). Conclusion Delirium affects one in seven patients with a hip fracture admitted directly from home, and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care.
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Affiliation(s)
- Rose S Penfold
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- Scottish Hip Fracture Audit, Edinburgh, UK
| | - Andrew J Hall
- Scottish Hip Fracture Audit, Edinburgh, UK
- Department of Orthopaedics, Golden Jubilee University National Hospital, Clydebank, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Atul Anand
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- NHS Lothian, Edinburgh, UK
| | - Nick D Clement
- Scottish Hip Fracture Audit, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics & Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- Scottish Hip Fracture Audit, Edinburgh, UK
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Preoperative Risk Factors Associated with Increased Incidence of Postoperative Delirium: Systematic Review of Qualified Clinical Studies. Geriatrics (Basel) 2023; 8:geriatrics8010024. [PMID: 36826366 PMCID: PMC9956273 DOI: 10.3390/geriatrics8010024] [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: 09/30/2022] [Revised: 12/20/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Postoperative delirium (POD) is an acute alteration of mental state, characterized by reduced awareness and attention, occurring up to five postoperative days after recovery from anesthesia. Several original studies and reviews have identified possible perioperative POD risk factors; however, there is no comprehensive review of the preoperative risk factors in patients diagnosed with POD using only validated diagnostic scales. The aim of this systematic review was to report the preoperative risk factors associated with an increased incidence of POD in patients undergoing non-cardiac and non-brain surgery. The reviewed studies included original research papers that used at least one validated diagnostic scale to identify POD occurrence for more than 24 h. A total of 6475 references were retrieved from the database search, with only 260 of them being suitable for further review. Out of the 260 reviewed studies, only 165 that used a validated POD scale reported one or more preoperative risk factors. Forty-one risk factors were identified, with various levels of statistical significance. The extracted risk factors could serve as a preoperative POD risk assessment workup. Future studies dedicated to the further evaluation of the specific preoperative risk factors' contributions to POD could help with the development of a weighted screening tool.
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Zhang Y, Zhang Y, Zhou Z, Sang X, Qin M, Dai G, Zhao Z, Yan F, Zhang X. Higher intraoperative mean arterial blood pressure does not reduce postoperative delirium in elderly patients following gastrointestinal surgery: A prospective randomized controlled trial. PLoS One 2022; 17:e0278827. [PMID: 36548296 PMCID: PMC9778934 DOI: 10.1371/journal.pone.0278827] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study aimed to describe the relationship between the different levels of intraoperative mean arterial blood pressure (MAP) and postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery. MATERIALS AND METHODS This prospective controlled clinical trial enrolled 116 patients aged 65 to 85 years who underwent gastrointestinal laparoscopic surgery. These patients were randomized 1:1 to a MAP goal of 65 to 85 mmHg (L group) or an 86 to 100 mmHg (H group). The primary endpoint was the incidence of postoperative delirium, assessed twice daily with the Confusion Assessment Method (CAM) and Richmond Agitation-Sedation Scale (RASS) during the first five postoperative days. Delirium severity was evaluated with the Delirium-O-Meter (D-O-M). RESULTS 108 patients (L group n = 55, H group n = 53) were eventually included in intention-to-treat analyses. Postoperative delirium occurred in 18 (32.7%) of 55 cases of L group and in 15 (28.3%) of 53 cases of H group. The incidence of delirium subtypes between the two groups: hypoactive delirium 14.5% (8/55) vs 11.3% (6/53); hyperactive delirium 7.3% (4/55) vs 3.8% (2/53); mixed delirium 10.9% (6/55) vs 13.2% (7/53). However, the L group showed higher D-O-M scores of the first episode of delirium: 14.5 (Q1 = 12, Q3 = 18.5) vs 12 (Q1 = 10, Q3 = 14), which means the delirium is more severe. CONCLUSIONS Compared with 65 to 85 mmHg, maintaining intraoperative MAP at 86-100 mmHg did not reduce the incidence of postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery. However, the severity of delirium could be reduced and blood loss is a risk factor for postoperative delirium.
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Affiliation(s)
- Yanke Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Ying Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Zhou Zhou
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Xiaoqiao Sang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Miaomiao Qin
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Guangrong Dai
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Zhibin Zhao
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Fang Yan
- Department of Basic Medical Science, Kangda College of Nanjing Medical University, Lianyungang, China
| | - Xiaobao Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
- Department of Anesthesiology, Kangda College of Nanjing Medical University, Lianyungang, China
- * E-mail:
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Vacas S, Canales C, Deiner SG, Cole DJ. Perioperative Brain Health in the Older Adult: A Patient Safety Imperative. Anesth Analg 2022; 135:316-328. [PMID: 35584550 PMCID: PMC9288500 DOI: 10.1213/ane.0000000000006090] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
While people 65 years of age and older represent 16% of the population in the United States, they account for >40% of surgical procedures performed each year. Maintaining brain health after anesthesia and surgery is not only important to our patients, but it is also an increasingly important patient safety imperative for the specialty of anesthesiology. Aging is a complex process that diminishes the reserve of every organ system and often results in a patient who is vulnerable to the stress of surgery. The brain is no exception, and many older patients present with preoperative cognitive impairment that is undiagnosed. As we age, a number of changes occur in the human brain, resulting in a patient who is less resilient to perioperative stress, making older adults more susceptible to the phenotypic expression of perioperative neurocognitive disorders. This review summarizes the current scientific and clinical understanding of perioperative neurocognitive disorders and recommends patient-centered, age-focused interventions that can better mitigate risk, prevent harm, and improve outcomes for our patients. Finally, it discusses the emerging topic of sleep and cognitive health and other future frontiers of scientific inquiry that might inform clinical best practices.
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Affiliation(s)
- Susana Vacas
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Cecilia Canales
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Stacie G Deiner
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Daniel J Cole
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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9
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Albanese AM, Ramazani N, Greene N, Bruse L. Review of Postoperative Delirium in Geriatric Patients After Hip Fracture Treatment. Geriatr Orthop Surg Rehabil 2022; 13:21514593211058947. [PMID: 35282299 PMCID: PMC8915233 DOI: 10.1177/21514593211058947] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction Postoperative delirium (POD) is a serious complication occurring in 4–53.3%
of geriatric patients undergoing surgeries for hip fracture. Incidence of
hip fractures is projected to grow 11.9% from 258,000 in 2010 to 289,000 in
2030 based on 1990 to 2010 data. As prevalence of hip fractures is projected
to increase, POD is also anticipated to increase. Signficance Postoperative delirium remains the most common complication of emergency hip
fracture surgery leading to high morbidity and mortality rates despite
significant research conducted regarding this topic. This study reviews
literature from 1990 to 2021 regarding POD in geriatric hip fracture
management. Results Potentially modifiable and non-modifiable risk factors for developing POD
include, but are not limited to, male gender, older age, multiple
comorbidities, specific comorbidities (dementia, cognitive impairment,
diabetes, vision impairment, and abnormal blood pressure), low BMI,
preoperative malnutrition, low albumin, low hematocrit, blunted preoperative
cytokines, emergency surgery, time to admission and surgery, preoperative
medical treatment, polypharmacy, delirium-inducing medications, fever,
anesthesia time, and sedation depth and type. Although the pathophysiology
remains unclear, the leading theories suggest neurotransmitter imbalance,
inflammation, and electrolyte or metabolic derangements as the underlying
cause of POD. POD is associated with increased length of hospital stay,
cost, morbidity, and mortality. Prevention and early recognition are key
factors in managing POD. Methods to reduce POD include utilizing
interdisciplinary teams, educational programs for healthcare professionals,
reducing narcotic use, avoiding delirium-inducing medications, and
multimodal pain control. Conclusion While POD is a known complication after hip fracture surgery, further
exploration in prevention is needed. Early identification of risk factors is
imperative to prevent POD in geriatric patients. Early prevention will
enhance delivery of health care both pre- and post-operatively leading to
the best possible surgical outcome and better quality of life after hip
fracture treatment.
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Affiliation(s)
- Anita M Albanese
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Noyan Ramazani
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Natasha Greene
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Laura Bruse
- Adjunct Clinical Assistant Professor Community Faculty, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
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Aykanat VM, Myles PS, Weinberg L, Burrell A, Bellomo R. Low-Concentration Norepinephrine Infusion for Major Surgery: A Safety and Feasibility Pilot Randomized Controlled Trial. Anesth Analg 2021; 134:410-418. [PMID: 34872102 DOI: 10.1213/ane.0000000000005811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Prevention of hypotension during the intra- and postoperative period is an important goal. Peripheral administration of low-concentration norepinephrine may be a safe and effective strategy to reduce the risk of hypotension. METHODS We conducted a 2-center, randomized pilot feasibility trial, with a target of 60 adult patients undergoing major noncardiac surgery. We randomized patients to receive a peripheral low-concentration (10 µg/mL) norepinephrine or placebo (saline 0.9%) infusion. The study drug infusion was titrated to achieve a minimum systolic blood pressure target, preselected within 10% of baseline value and within the range limit 100 to 120 mm Hg during surgery and for up to 4 or 24 hours postoperatively. RESULTS We achieved a high consent rate (84%), successful study drug administration throughout surgery (98% of patients) and absence of unblinding. There were no important study drug-related adverse events. The average intraoperative systolic blood pressure was 120 ± 12.6 mm Hg in the norepinephrine group and 115 ± 14.9 mm Hg in the placebo group. The mean difference between the intraoperative systolic blood pressure achieved less the preselected minimum systolic blood pressure target was 10.0 ± 12.7 mm Hg in the norepinephrine group and 2.9 ± 14.7 mm Hg in the placebo group; difference in means, 7.1 (95% confidence interval, 0.2-14.0) mm Hg. CONCLUSIONS A future large trial evaluating the effectiveness and safety of peripheral administration of low-concentration norepinephrine during the perioperative period is feasible, and likely to achieve a minimum systolic blood pressure threshold.
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Affiliation(s)
- Verna M Aykanat
- From the Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - Paul S Myles
- From the Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Aidan Burrell
- Department of Intensive Care, Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Intensive Care Austin Hospital, Melbourne, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Australia
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11
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Wang Y, Zhao L, Zhang C, An Q, Guo Q, Geng J, Guo Z, Guan Z. Identification of risk factors for postoperative delirium in elderly patients with hip fractures by a risk stratification index model: A retrospective study. Brain Behav 2021; 11:e32420. [PMID: 34806823 PMCID: PMC8671782 DOI: 10.1002/brb3.2420] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/29/2021] [Accepted: 10/05/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Postoperative delirium is one of the most common and dangerous psychiatric complications after hip surgery. The aim of this study was to investigate the incidence of postoperative delirium in elderly patients after hip fracture surgery and to identify risk factors for such, as part of developing a risk stratification index (RSI) system to predict a patient's risk of postoperative delirium. METHODS Elderly patients (aged 65 years or older) with hip fractures who had received surgical treatment in our hospital between March 2018 and December 2019 were retrospectively included. Clinical data were collected, and multivariate logistic regression analysis was performed to investigate the relevant risk factors of postoperative delirium. An RSI system was developed based on factors identified in the regression analysis. RESULTS Of 272 patients included, 52 (19.12%) experienced postoperative delirium. Drinking history (> 3/ week), the perioperative lactic acid level (Lac > 2 mmol/L), postoperative visual analog score (VAS) > 3, American Society of Anesthesiologists (ASA) physical status > II, application of the bispectral index, and preoperative diabetes were independent risk factors of postoperative delirium. When RSI ≥ 5, the rate of postoperative delirium significantly increased (p < .05). CONCLUSION The RSI system developed here can safely guide postoperative outcomes of elderly patients with hip fractures, and RSI ≥ 5 may be able to predict the onset of postoperative delirium.
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Affiliation(s)
- Ye Wang
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Lin Zhao
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Changsheng Zhang
- The Anesthesia and Operation Center, The First Medical Center, The Medical School of Chinese PLA, Beijing, China
| | - Qi An
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Qianqian Guo
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Jie Geng
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Zhenggang Guo
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Zhengpeng Guan
- The Department of Orthopedics, Peking University Shougang Hospital, Beijing, China
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Liu CY, Gong N, Liu W. The Association Between Preoperative Frailty and Postoperative Delirium: A Systematic Review and Meta-analysis. J Perianesth Nurs 2021; 37:53-62.e1. [PMID: 34756625 DOI: 10.1016/j.jopan.2020.12.006] [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] [Received: 10/11/2020] [Revised: 12/13/2020] [Accepted: 12/26/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE Identifying factors that place patients at high risk for developing postoperative delirium is an important first step to reduce incidence. Frailty is associated with poor postoperative outcomes. This meta-analysis aims to determine the association between preoperative frailty and postoperative delirium. DESIGN This is a systematic review and meta-analysis. METHODS We used PubMed, Scopus, Embase, CINAHL, Cochrane, and Web of Science as databases for the search up to April 23, 2020. We included cohort studies that assessed postoperative delirium as the outcome and described the prevalence of delirium among participants during the postoperative period. Odds ratio and 95% confidence interval were calculated to examine the association. FINDINGS Twenty cohort studies met our inclusion criteria, which included a total of 4,568 patients. We found that preoperative frailty was significantly associated with an increased risk of postoperative delirium (crude odds ratio: 3.28; 95% confidence interval: 2.51 to 4.28; I2 = 46.7%) (adjusted odds ratio: 2.45; 95% confidence interval: 1.58 to 3.81; I2 = 88.6%). CONCLUSIONS This meta-analysis showed that preoperative frailty is an independent risk factor for postoperative delirium. In patients undergoing cardiovascular surgery, there is a lower association between frailty and postoperative delirium. In patients with other types of surgery, preoperative frailty is closely related to postoperative delirium.
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Affiliation(s)
- Chang-Yuan Liu
- The Second Department of Anesthesiology, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - Ning Gong
- Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wei Liu
- School of Nursing, Liaoning University of Traditional Chinese Medicine, Shenyang, Liaoning, China.
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White LB, Coyne E, Grealish L. Management of delirium within intraoperative settings for older adults with hip fracture: a scoping review. J Clin Nurs 2021; 30:2169-2178. [PMID: 33616299 DOI: 10.1111/jocn.15720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/20/2021] [Accepted: 02/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Delirium is a common adverse event in older patients undergoing hip fracture repair surgery. The impact of hospital-acquired delirium during intraoperative phase of their treatment can have a significant impact on post-operative outcomes. While non-pharmacological, multicomponent delirium prevention interventions are considered standard practice in acute medical units, delirium management in the intraoperative setting is less clear. OBJECTIVES The aim was to identify evidence-based delirium management interventions which are, and could be, undertaken within the intraoperative setting for older patients undergoing hip fracture repair surgery. DESIGN A scoping review following the principles developed by Arksey and O'Malley (2005). DATA SOURCES Seven databases including Cochrane, CINAHL, Embase, MEDLINE, PsychINFO, PubMed and SCOPUS were systematically searched. The search was limited to the last 11 years (2009-2020). Research studies included both primary and secondary sources of evidence. RESULTS A total of 2464 articles were initially identified. These articles were further refined using keyword searches and exclusion criteria, with a final set of 16 articles meeting the inclusion criteria. Three main themes were as follows: anaesthetic-related interventions used to prevent delirium; recognising non-modifiable and potentially modifiable risk factors; and screening and diagnosis of delirium. CONCLUSIONS While there is a strong focus on anaesthetist-led interventions in the intraoperative setting, there are opportunities for more nurse-led interventions through adequate pain management and haemodynamic monitoring that require further research. Identifying the best test for screening and diagnosing delirium in the intraoperative setting requires further research.
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Affiliation(s)
- Laura Beth White
- School of Nursing & Midwifery & Menzies Health Institute, Griffith University
| | - Elisabeth Coyne
- School of Nursing & Midwifery & Menzies Health Institute, Griffith University
| | - Laurie Grealish
- School of Nursing & Midwifery & Menzies Health Institute, Griffith University.,Gold Coast Health
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Wu J, Gao S, Zhang S, Yu Y, Liu S, Zhang Z, Mei W. Perioperative risk factors for recovery room delirium after elective non-cardiovascular surgery under general anaesthesia. Perioper Med (Lond) 2021; 10:3. [PMID: 33531068 PMCID: PMC7856719 DOI: 10.1186/s13741-020-00174-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/28/2020] [Indexed: 12/31/2022] Open
Abstract
Background Although postoperative delirium is a frequent complication of surgery, little is known about risk factors for delirium occurring in the post-anaesthesia care unit (PACU). The aim of this study was to determine pre- and intraoperative risk factors for the development of recovery room delirium (RRD) in patients undergoing elective non-cardiovascular surgery. Methods RRD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We collected perioperative data in 228 patients undergoing elective non-cardiovascular surgery under general anaesthesia and performed univariate and multivariate logistic regression to identify risk factors related to RRD. PACU and postoperative events were recorded to assess the outcome of RRD. Results Fifty-seven patients (25%) developed RRD. On multivariate analysis, maintenance of anaesthesia with inhalation anaesthetic agents (OR = 6.294, 95% CI 1.4–28.8, corrected p = 0.03), malignant primary disease (OR = 3.464, 95% CI = 1.396–8.592, corrected p = 0.018), American Society of Anaesthesiologists Physical Status (ASA-PS) III–V (OR = 3.389, 95% CI = 1.401–8.201, corrected p = 0.018), elevated serum total or direct bilirubin (OR = 2.535, 95% CI = 1.006–6.388, corrected p = 0.049), and invasive surgery (OR = 2.431, 95% CI = 1.103–5.357, corrected p = 0.035) were identified as independent risk factors for RRD. RRD was associated with higher healthcare costs (31,428 yuan [17,872–43,674] versus 16,555 yuan [12,618–27,788], corrected p = 0.002), a longer median hospital stay (17 days [12–23.5] versus 11 days [9–17], corrected p = 0.002), and a longer postoperative stay (11 days [7–15] versus 7 days [5–10], corrected p = 0.002]). Conclusions Identifying patients at high odds for RRD preoperatively would enable the formation of more timely postoperative delirium management programmes.
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Affiliation(s)
- Jiayi Wu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shaojie Gao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shuang Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yao Yu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shangkun Liu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Zhiguo Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, China
| | - Wei Mei
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China.
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Wang L, Zou W. Research progress in influence of perioperative hypotension on postoperative outcome of patients. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2021; 46:84-90. [PMID: 33678641 PMCID: PMC10878287 DOI: 10.11817/j.issn.1672-7347.2021.200448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Indexed: 11/03/2022]
Abstract
With the advancement of disease treatments, the number of patients undergoing surgery worldwide is increasing. However, many patients still experience severe perioperative complications. Perioperative hypotension is one of the common side effects during surgery. Physiologically, perioperative hypotension can lead to insufficient perfusion of important organs and result in acute and chronic irreversible organ injury, which cause serious consequences for the patient's postoperative hospitalization and even the long-term outcome. Therefore, in order to optimize perioperative circulation management and improve the quality of life for patients after surgery, it is of great importance to investigate the relationship between perioperative hypotension and postoperative myocardial injury, ischemic stroke, postoperative delirium, acute kidney injury, and postoperative mortality. Individualized circulation management and reasonable application of vasoactive drugs may be the key point to early prevention and correct treatment of perioperative hypotension, which is of great significance for reducing perioperative related morbidity and mortality and improving the prognosis for the surgical patients.
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Affiliation(s)
- Lei Wang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha 410008, China.
| | - Wangyuan Zou
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha 410008, China.
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Wu J, Yin Y, Jin M, Li B. The risk factors for postoperative delirium in adult patients after hip fracture surgery: a systematic review and meta-analysis. Int J Geriatr Psychiatry 2021; 36:3-14. [PMID: 32833302 DOI: 10.1002/gps.5408] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/30/2020] [Accepted: 08/08/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Postoperative delirium (POD) is the most common complication in patients after hip fracture surgery, and the incidence of POD is associated with mortality and disability in patients following hip fracture surgery. Therefore, this study aimed to identify the individual as well as anesthetic and operative risk factors associated with the POD in adult patients after hip fracture surgery. METHODS We searched relevant articles published to February 2020 in Cochrane Library, PubMed, and Embase. Studies involving adult patients who underwent hip fracture surgery were regarded as relevant if the studies contained the individual or anesthetic and surgical characteristics of participants. The pooled relative risk ratios (RRs) or weight mean difference of the variables were estimated by the Mantel-Haenszel or Inverse-Variance methods. RESULTS A total of 44 studies were included, which altogether included 104572 participants with hip fracture surgery (17703 patients with POD and 86869 patients without POD) and the incidence of POD was 16.93%. A total of 14 risk factors, classified into two categories which were individual as well as anesthetic and operative factors, were identified originally, which included age (weight mean difference [WMD]:2.33;95% confidential interval [CI]: 1.64-3.03), sex (RR: 0.89; 95% CI:0.85-0.93), American society of Anesthesiologists classification(RR:0.56; 95%CI:0.51-0.59), body mass index (WMD:-0.62; 95%CI:-0.81 to -0.44), function dependency(RR:1.52; 95% CI:1.24-1.87), visual impairment (RR:1.62; 95% CI: 1.16-2.27), smoking (RR:0.86; 95% CI:0.79-0.94), preoperative delirium (RR: 2.71; 95% CI: 2.50-2.72), dementia (RR:2.60; 95% CI:2.50-2.72), hypertension (RR: 1.10; 95% CI:1.04-1.15), chronic obstructive pulmonary disease (RR:1.08; 95% CI: 1.01-1.16), regional anesthesia (RR:1.20; 95% CI: 1.01-1.43), transfusion (RR: 1.41; 95% CI: 1.22-1.63), and elective surgery (RR: 0.91; 95% CI: 0.84-0.99). CONCLUSIONS Patients possessed above risk factors might be high-risk patients. Clinician should maintain keen vigilance at those patients.
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Affiliation(s)
- Juan Wu
- Department of Anesthesiology, Central Theater Command General Hospital of the Chinese People's Liberation Army, Wuhan, China
| | - Yushuang Yin
- Department of Anesthesiology, Central Theater Command General Hospital of the Chinese People's Liberation Army, Wuhan, China
| | - Man Jin
- Department of Anesthesiology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Bixi Li
- Department of Anesthesiology, Central Theater Command General Hospital of the Chinese People's Liberation Army, Wuhan, China
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Lunardelli ML, Crupi R, Siracusa R, Cocuzza G, Cordaro M, Martini E, Impellizzeri D, Di Paola R, Cuzzocrea S. Co-ultraPEALut: Role in Preclinical and Clinical Delirium Manifestations. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2020; 18:530-554. [PMID: 31244434 DOI: 10.2174/1871527318666190617162041] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/08/2019] [Accepted: 05/15/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Delirium is a disorder in awareness, attention and cognition. Pathophysiologically it is a response to stress. Postoperative delirium (POD) is a usual complication in aged patients following hip fracture surgery. Neuroinflammation is an important factor linked with the progress of POD. Though there are no efficient cures for delirium the endocannabinoid system may have a role in neuropsychiatric disorders. OBJECTIVE Therefore, we examined the effects of co-ultramicronized PEALut (co-ultraPEALut) in the LPS murine model of delirium and in elderly hip fractured patients. METHODS In the preclinical study, mice were injected intraperitoneally (i.p.) with Escherichia coli LPS (10 mg/kg). Co-ultraPEALut (1 mg/kg o.s.) was administered 1h before LPS injection or 1h and 6h after LPS injection or 1h before LPS injection and 1h and 6h after LPS. In the clinical study, the effects of Glialia® (co-ultramicronized 700 mg PEA + 70 mg luteolin) administration was evaluated in elderly hip fractured patients with an interventional, randomized, single-blind, monocentric study. RESULTS Administration of co-ultraPEALut to LPS-challenged mice ameliorated cognitive dysfunctions and locomotor activity; moreover, it reduced inflammation and apoptosis, while stimulating antioxidant response and limiting the loss of neurotrophins. In the clinical study, the results obtained demonstrated that administration of Glialia® to these surgical patients prevented the onset of POD and attenuated symptom intensity and their duration. CONCLUSION Therefore, the results obtained enhanced the idea that co-ultraPEALut may be a potential treatment to control cognitive impairment and the inflammatory and oxidative processes associated with delirium.
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Affiliation(s)
- Maria Lia Lunardelli
- Geriatric Unit - Orthogeriatric Ward, Universitary Sant'Orsola Policlinic Bologna, Bologna, Italy
| | - Rosalia Crupi
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy
| | - Rosalba Siracusa
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy
| | - Giorgio Cocuzza
- Geriatric Unit - Orthogeriatric Ward, Universitary Sant'Orsola Policlinic Bologna, Bologna, Italy
| | - Marika Cordaro
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy
| | - Emilio Martini
- Geriatric Unit - Orthogeriatric Ward, Universitary Sant'Orsola Policlinic Bologna, Bologna, Italy
| | - Daniela Impellizzeri
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy
| | - Rosanna Di Paola
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy
| | - Salvatore Cuzzocrea
- Department of Chemical, Biological, Pharmaceutical and Environmental Science, University of Messina, Messina, Italy.,Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, Saint Louis, MO, United States
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He R, Wang F, Shen H, Zeng Y, LijuanZhang. Association between increased neutrophil-to-lymphocyte ratio and postoperative delirium in elderly patients with total hip arthroplasty for hip fracture. BMC Psychiatry 2020; 20:496. [PMID: 33028273 PMCID: PMC7539448 DOI: 10.1186/s12888-020-02908-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/30/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Delirium is a common complication in elderly patients with total hip arthroplasty (THA) for hip fracture. The mechanism of postoperative delirium (POD) is associated with the neuroinflammatory process. The aim of this study was to the incidence and perioperative risk factors of POD and investigate whether NLR could serve as a potential marker for POD in elderly patients with THA for hip fracture. METHODS This was a multicenter prospective study, we included elderly patients with THA for hip fracture under general anesthesia. Receiver operating characteristic (ROC) curve was performed to identify the optimal cut point of NLR for POD. The relationship between NLR and POD was analyzed by multivariable analysis. RESULTS Seven hundred eighty patients (mean age 73.33 ± 7.66) were eligible for inclusion in the study. 23.33% (182/780) of patients had POD. ROC curve analysis showed that the optimal cut point of NLR for POD was NLR ≥ 3.5. Compared with no POD, higher NLR, older age, diabetes, and higher neutrophil count were more likely in patients with POD(P < 0.05). Multivariate logistic regression analysis showed that NLR ≥ 3.50 [adjusted odds ratio(aOR), 3.93; confidence interval (CI), 2.47-6.25; P < 0.001)], older age (aOR, 1.04; 95%CI, 1.02-1.07; P = 0.001), diabetes (aOR, 1.58; 95% CI, 1.06-2.36; P = 0.025),higher neutrophil count (aOR, 1.25; 95%CI, 1.15-1.35; P < 0.001) were associated with increased risk of POD. CONCLUSIONS Older age, diabetes, higher neutrophil count, and NLR ≥ 3.5 were independent risk factors for POD, and NLR can be used as a potential marker for prediction of delirium in elderly patients with THA for hip fracture.
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Affiliation(s)
- Rui He
- Department of Joint Surgery, The Second People’s Hospital of Chengdu, Chengdu, 610021 People’s Republic of China
| | - Fei Wang
- Department of Joint Surgery, The Third People’s Hospital of Chengdu, Chengdu, 610000 People’s Republic of China
| | - Huarui Shen
- Department of Joint Surgery, Affiliated Traditional Chinese Medical Hospital of Southwest Medical University of Sichuan Province, Luzhou, 646000 People’s Republic of China
| | - Yong Zeng
- Department of Joint Surgery, The Second People’s Hospital of Chengdu, Chengdu, 610021 People’s Republic of China
| | - LijuanZhang
- Department of Neurology, The Second Affiliated Hospital of Chengdu College, Nuclear Industry 416 Hospital, Chengdu, 610051 People’s Republic of China
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Investigating Association between Intraoperative Hypotension and Postoperative Neurocognitive Disorders in Non-Cardiac Surgery: A Comprehensive Review. J Clin Med 2020; 9:jcm9103183. [PMID: 33008109 PMCID: PMC7601108 DOI: 10.3390/jcm9103183] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/29/2020] [Accepted: 09/29/2020] [Indexed: 12/19/2022] Open
Abstract
Postoperative delirium (POD) and postoperative cognitive decline (deficit) (POCD) are related to a higher risk of postoperative complications and long-term disability. Pathophysiology of POD and POCD is complex, elusive and multifactorial. Intraoperative hypotension (IOH) constitutes a frequent and vital health hazard in the perioperative period. Unfortunately, there are no international recommendations in terms of diagnostics and treatment of neurocognitive complications which may arise from hypotension-related hypoperfusion. Therefore, we performed a comprehensive review of the literature evaluating the association between IOH and POD/POCD in the non-cardiac setting. We have concluded that available data are quite inconsistent and there is a paucity of high-quality evidence convincing that IOH is a risk factor for POD/POCD development. Considerable heterogeneity between studies is the major limitation to set up reliable recommendations regarding intraoperative blood pressure management to protect the brain against hypotension-related hypoperfusion. Further well-designed and effectively-performed research is needed to elucidate true impact of intraoperative blood pressure variations on postoperative cognitive functioning.
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Hughes CG, Boncyk CS, Culley DJ, Fleisher LA, Leung JM, McDonagh DL, Gan TJ, McEvoy MD, Miller TE. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention. Anesth Analg 2020; 130:1572-1590. [PMID: 32022748 DOI: 10.1213/ane.0000000000004641] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.
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Affiliation(s)
- Christopher G Hughes
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S Boncyk
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Deborah J Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacqueline M Leung
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - David L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, and Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Zhang W, Wang T, Wang G, Yang M, Zhou Y, Yuan Y. Effects of Dexmedetomidine on Postoperative Delirium and Expression of IL-1β, IL-6, and TNF-α in Elderly Patients After Hip Fracture Operation. Front Pharmacol 2020; 11:678. [PMID: 32477139 PMCID: PMC7235357 DOI: 10.3389/fphar.2020.00678] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/24/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Postoperative delirium (POD) is a common surgical complication in elderly patients. This study investigated the effects of dexmedetomidine on POD and pro-inflammatory markers in elderly patients with hip fracture. METHODS This randomized, double-blind, controlled trial enrolled patients ≥65 years of age who underwent an operation for hip fracture at Beijing JiShuiTan Hospital from October 2016 to January 2017. The patients were divided into the DEX group (injected with dexmedetomidine 0.5 µg/kg/h) and the NS group (injected with normal saline). After surgery, the incidence of delirium at postoperative day 1 (T1), 2 (T2), and 3 (T3) was assessed using the Confusion Assessment Method delirium scale. Interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α blood levels were detected at T0 (before surgery), T1, and T3. RESULTS Data from 240 patients were analyzed, with 120/group (intent-to-treat analysis). Dexmedetomidine decreased POD incidence (18.2 vs. 30.6%, P = 0.033). Compared to T0, all three pro-inflammatory markers were higher at T1 and then decreased at T3 (time interaction, all P < 0.001). IL-6 (P < 0.001) levels were lower in the DEX group at T1, and TNF-α (P = 0.003) levels were lower in the DEX group at T1 and T3, but IL-1β levels were similar between the two groups. The rate of adverse events was similar in the two groups. CONCLUSION Dexmedetomidine reduced the incidence of POD in elderly patients on the first day after hip fracture surgery, and reduced IL-6 and TNF-α levels over the first 3 days after surgery.
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Affiliation(s)
- Wenchao Zhang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Geng Wang
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Minghui Yang
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Yan Zhou
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Yi Yuan
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
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Emergency Surgery and Male Gender Are Risk Factors of Postoperative Delirium After General or Gastrointestinal Surgery in Elderly Patients: A Multicenter Cohort Study. Int Surg 2020. [DOI: 10.9738/intsurg-d-16-00112.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
The aim of this study was to investigate the incidence and risk factors of postoperative delirium (PD) in elderly patients after general or gastrointestinal surgery.
Summary of background data
Societies worldwide are rapidly aging, and the number of surgeries in elderly patients has been increasing. PD, which adversely influences postoperative course, has thus become more common.
Methods
The Surgery and Anesthesia Network Group of the National Hospital Organization in Japan conducted this retrospective cohort study of patients older than 70 years of age who underwent general or gastrointestinal surgery.
Results
A total of 219 patients from 9 participating institutes underwent surgery between July 2013 and August 2014. We excluded 2 patients who died within 2 weeks after surgery. Of the remaining 217 cases, 31 (14.3%) developed PD. These patients were older (80 versus 76 years, P = 0.013), more likely to be male (74.2 versus 54.8%, P = 0.039), and had higher American Society of Anesthesia Physical Status scores than those without PD. Emergency surgery was more common than elective surgery in the PD group (41.9 versus 10.2%, P < 0.0001). Multivariate analysis showed that male gender (odds ratio, 3.31; 95% confidence interval, 1.32 to 9.39; P = 0.0098) and emergency surgery (odds ratio, 7.47; 95% confidence interval, 2.79 to 20.83; P < 0.0001) were independent risk factors of PD.
Conclusions
The incidence of PD was high in male patients and those undergoing emergency surgery. Effective interventions in these groups will be necessary to improve treatment outcomes in elderly patients.
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Internal carotid artery blood flow is enhanced by elevating blood pressure during combined propofol-remifentanil and thoracic epidural anaesthesia. Eur J Anaesthesiol 2020; 37:482-490. [DOI: 10.1097/eja.0000000000001189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Maheshwari K, Ahuja S, Khanna AK, Mao G, Perez-Protto S, Farag E, Turan A, Kurz A, Sessler DI. Association Between Perioperative Hypotension and Delirium in Postoperative Critically Ill Patients. Anesth Analg 2020; 130:636-643. [DOI: 10.1213/ane.0000000000004517] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Romagnoli S, Franchi F, Ricci Z. Processed EEG monitoring for anesthesia and intensive care practice. Minerva Anestesiol 2019; 85:1219-1230. [PMID: 31630505 DOI: 10.23736/s0375-9393.19.13478-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Individual response to sedatives and hypnotics is characterized by high variability and the identification of a personalized dose during anesthesia in the operating room and during sedation in the intensive care unit may have beneficial effects. Although the brain is the main target of general intravenous and inhaled anesthetic agents, electroencephalography (EEG) is not routinely utilized to explore cerebral response to sedation and anesthesia probably because EEG trace reading is complex and requires encephalographers' skills. Automated processing algorithms (processed EEG, pEEG) of raw EEG traces provide easy-to-use indices that can be utilized to optimize anesthetic management. A large number of high-quality studies and the recommendations of international scientific societies have confirmed the deleterious consequences of inadequate or excessively deep anesthesia (and sedation) level. In this context, anesthesia in the operating rooms and moderate/deep sedation in intensive care units driven by pEEG monitors could become a standard practice in the near future. The aim of the present review was to provide an overview of current knowledge and debate on available technologies for pEEG monitoring and their role in clinical practice for anesthesia and sedation.
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Affiliation(s)
- Stefano Romagnoli
- Section of Anesthesiology and Intensive Care, Department of Health Science, University of Florence, Florence, Italy - .,Department of Anesthesiology and Intensive Care, Careggi University Hospital, Florence, Italy -
| | - Federico Franchi
- Department of Medicine, Surgery and Neuroscience, Anesthesiology and Intensive Care, University Hospital of Siena, Siena, Italy
| | - Zaccaria Ricci
- Unit of Pediatric Cardiac Intensive Care, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Wang Y, Yu H, Qiao H, Li C, Chen K, Shen X. Risk Factors and Incidence of Postoperative Delirium in Patients Undergoing Laryngectomy. Otolaryngol Head Neck Surg 2019; 161:807-813. [PMID: 31331229 DOI: 10.1177/0194599819864304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To explore the risk factors and incidence of postoperative delirium (POD) in patients undergoing laryngectomy for laryngeal cancer. STUDY DESIGN Prospective cohort study. SETTING Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University. SUBJECTS AND METHODS A total of 323 patients underwent laryngectomy from April 4, 2018, to December 28, 2018. Perioperative data were collected. The primary outcome was the presence of POD as defined by the Confusion Assessment Method diagnostic algorithm. Univariate and multivariable logistic regression analyses were used to identify risk factors associated with POD. RESULTS Of the patients who underwent laryngectomy during the study period, 99.1% were male, with a mean age of 60.0 years. Of these patients, 28 developed POD, with most episodes (88.1%) occurring during the first 3 postoperative days. The type of POD was hyperactive in 7 cases and hypoactive in 21 cases. The mean duration of POD was 1 day. The mean Delirium Rating Scale-Revised-98 score (a measure of POD severity) was 11.5. For the multivariable analysis, risk factors associated with POD included advanced cancer stage, lower educational level, higher American Society of Anesthesiologists classification, and intraoperative hypotension lasting at least 30 minutes. Intraoperative dexmedetomidine use was protective against POD. CONCLUSION This study identified risk factors associated with POD, providing a target population for quality improvement initiatives. Furthermore, intraoperative dexmedetomidine use can reduce POD.
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Affiliation(s)
- Yiru Wang
- Department of Anesthesiology, Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Huiqian Yu
- Department of Otorhinolaryngology, Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Hui Qiao
- Department of Anesthesiology, Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Chan Li
- Department of Anesthesiology, Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Kaizheng Chen
- Department of Anesthesiology, Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Xia Shen
- Department of Anesthesiology, Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
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Marcantonio AJ, Pace M, Brabeck D, Nault KM, Trzaskos A, Anderson R. Team Approach: Management of Postoperative Delirium in the Elderly Patient with Femoral-Neck Fracture. JBJS Rev 2019; 5:e8. [PMID: 29064845 DOI: 10.2106/jbjs.rvw.17.00026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Andrew J Marcantonio
- Departments of Orthopaedics (A.J.M.), Anesthesiology (M.P.), Hospital Medicine (D.B.), and Rehabilitation Services (A.T.), and Surgical Critical Care Clinical Pharmacy (K.M.N. and R.A.), Lahey Hospital and Medical Center, Burlington, Massachusetts
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Kassie GM, Kalisch Ellett LM, Nguyen TA, Roughead EE. Use of medicines that may precipitate delirium prior to hospitalisation in older Australians with delirium: An observational study. Australas J Ageing 2019; 38:124-131. [DOI: 10.1111/ajag.12608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 11/26/2018] [Accepted: 12/05/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Gizat M. Kassie
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
| | - Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
| | - Tuan A. Nguyen
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
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Meng L, Yu W, Wang T, Zhang L, Heerdt PM, Gelb AW. Blood Pressure Targets in Perioperative Care. Hypertension 2018; 72:806-817. [DOI: 10.1161/hypertensionaha.118.11688] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Lingzhong Meng
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, CT (L.M., P.M.H.)
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, China (W.Y.)
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (T.W.)
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan Province, China (L.Z.)
| | - Paul M. Heerdt
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, CT (L.M., P.M.H.)
| | - Adrian W. Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (A.W.G.)
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Miller D, Lewis SR, Pritchard MW, Schofield‐Robinson OJ, Shelton CL, Alderson P, Smith AF. Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery. Cochrane Database Syst Rev 2018; 8:CD012317. [PMID: 30129968 PMCID: PMC6513211 DOI: 10.1002/14651858.cd012317.pub2] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of anaesthetics in the elderly surgical population (more than 60 years of age) is increasing. Postoperative delirium, an acute condition characterized by reduced awareness of the environment and a disturbance in attention, typically occurs between 24 and 72 hours after surgery and can affect up to 60% of elderly surgical patients. Postoperative cognitive dysfunction (POCD) is a new-onset of cognitive impairment which may persist for weeks or months after surgery.Traditionally, surgical anaesthesia has been maintained with inhalational agents. End-tidal concentrations require adjustment to balance the risks of accidental awareness and excessive dosing in elderly people. As an alternative, propofol-based total intravenous anaesthesia (TIVA) offers a more rapid recovery and reduces postoperative nausea and vomiting. Using TIVA with a target controlled infusion (TCI) allows plasma and effect-site concentrations to be calculated using an algorithm based on age, gender, weight and height of the patient.TIVA is a viable alternative to inhalational maintenance agents for surgical anaesthesia in elderly people. However, in terms of postoperative cognitive outcomes, the optimal technique is unknown. OBJECTIVES To compare maintenance of general anaesthesia for elderly people undergoing non-cardiac surgery using propofol-based TIVA or inhalational anaesthesia on postoperative cognitive function, mortality, risk of hypotension, length of stay in the postanaesthesia care unit (PACU), and hospital stay. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 11), MEDLINE (1946 to November 2017), Embase (1974 to November 2017), PsycINFO (1887 to November 2017). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA We included randomized controlled trials (RCTs) with participants over 60 years of age scheduled for non-cardiac surgery under general anaesthesia. We planned to also include quasi-randomized trials. We compared maintenance of anaesthesia with propofol-based TIVA versus inhalational maintenance of anaesthesia. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, and synthesized findings. MAIN RESULTS We included 28 RCTs with 4507 randomized participants undergoing different types of surgery (predominantly cardiovascular, laparoscopic, abdominal, orthopaedic and ophthalmic procedures). We found no quasi-randomized trials. Four studies are awaiting classification because we had insufficient information to assess eligibility.All studies compared maintenance with propofol-based TIVA versus inhalational maintenance of anaesthesia. Six studies were multi-arm and included additional TIVA groups, additional inhalational maintenance or both. Inhalational maintenance agents included sevoflurane (19 studies), isoflurane (eight studies), and desflurane (three studies), and was not specified in one study (reported as an abstract). Some studies also reported use of epidural analgesia/anaesthesia, fentanyl and remifentanil.We found insufficient reporting of randomization methods in many studies and all studies were at high risk of performance bias because it was not feasible to blind anaesthetists to study groups. Thirteen studies described blinding of outcome assessors. Three studies had a high of risk of attrition bias, and we noted differences in the use of analgesics between groups in six studies, and differences in baseline characteristics in five studies. Few studies reported clinical trials registration, which prevented assessment of risk of selective reporting bias.We found no evidence of a difference in incidences of postoperative delirium according to type of anaesthetic maintenance agents (odds ratio (OR) 0.59, 95% confidence interval (CI) 0.15 to 2.26; 321 participants; five studies; very low-certainty evidence); we noted during sensitivity analysis that using different time points in one study may influence direction of this result. Thirteen studies (3215 participants) reported POCD, and of these, six studies reported data that could not be pooled; we noted no difference in scores of POCD in four of these and in one study, data were at a time point incomparable to other studies. We excluded one large study from meta-analysis because study investigators had used non-standard anaesthetic management and this study was not methodologically comparable to other studies. We combined data for seven studies and found low-certainty evidence that TIVA may reduce POCD (OR 0.52, 95% CI 0.31 to 0.87; 869 participants).We found no evidence of a difference in mortality at 30 days (OR 1.21, 95% CI 0.33 to 4.45; 271 participants; three studies; very low-certainty evidence). Twelve studies reported intraoperative hypotension. We did not perform meta-analysis for 11 studies for this outcome. We noted visual inconsistencies in these data, which may be explained by possible variation in clinical management and medication used to manage hypotension in each study (downgraded to low-certainty evidence); one study reported data in a format that could not be combined and we noted little or no difference between groups in intraoperative hypotension for this study. Eight studies reported length of stay in the PACU, and we did not perform meta-analysis for seven studies. We noted visual inconsistencies in these data, which may be explained by possible differences in definition of time points for this outcome (downgraded to very low-certainty evidence); data were unclearly reported in one study. We found no evidence of a difference in length of hospital stay according to type of anaesthetic maintenance agent (mean difference (MD) 0 days, 95% CI -1.32 to 1.32; 175 participants; four studies; very low-certainty evidence).We used the GRADE approach to downgrade the certainty of the evidence for each outcome. Reasons for downgrading included: study limitations, because some included studies insufficiently reported randomization methods, had high attrition bias, or high risk of selective reporting bias; imprecision, because we found few studies; inconsistency, because we noted heterogeneity across studies. AUTHORS' CONCLUSIONS We are uncertain whether maintenance with propofol-based TIVA or with inhalational agents affect incidences of postoperative delirium, mortality, or length of hospital stay because certainty of the evidence was very low. We found low-certainty evidence that maintenance with propofol-based TIVA may reduce POCD. We were unable to perform meta-analysis for intraoperative hypotension or length of stay in the PACU because of heterogeneity between studies. We identified 11 ongoing studies from clinical trials register searches; inclusion of these studies in future review updates may provide more certainty for the review outcomes.
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Affiliation(s)
- David Miller
- North Cumbria University HospitalsAcademic UnitCumberland InfirmaryNewtown RoadCarlisleUKCA2 7HY
| | - Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Oliver J Schofield‐Robinson
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | | | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
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Abstract
PURPOSE OF REVIEW The extrinsic risk factors for postoperative cognitive disturbance have been a source of concern during the perioperative period, and these risk factors remain the subject of controversy. This review of recent studies focuses on the effect of these factors on postoperative cognitive disturbance during the perioperative period. RECENT FINDINGS Impairment of cerebral autoregulation may predispose patients to intraoperative cerebral malperfusion, which may subsequently induce postoperative cognitive disturbance. The neurotoxicity of several volatile anesthetics may contribute to cognitive functional decline, and the impact of intravenous anesthesia on cognitive function requires further exploration. Multimodal analgesia may not outperform traditional postoperative analgesia in preventing postoperative delirium. Furthermore, acute pain and chronic pain may exacerbate the cognitive functional decline of patients with preexisting cognitive impairment. The nuclear factor-kappa beta pathway is an important node in the neuroinflammatory network. SUMMARY Several intraoperative factors are associated with postoperative cognitive disturbance. However, if these factors are optimized in perioperative management, postoperative cognitive disturbance will improve.
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Affiliation(s)
- Huiqun Fu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Du CH, Glick D, Tung A. Error-checking intraoperative arterial line blood pressures. J Clin Monit Comput 2018; 33:407-412. [PMID: 29869762 DOI: 10.1007/s10877-018-0167-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 05/31/2018] [Indexed: 01/24/2023]
Abstract
Electronic medical records now store a wealth of intraoperative hemodynamic data. However, analysis of such data is plagued by artifacts related to the monitoring environment. Here, we present an algorithm for automated identification of artifacts and replacement using interpolation of arterial line blood pressures. After IRB approval, minute-by-minute digital recordings of systolic, diastolic, and mean arterial pressures (MAP) obtained during anesthesia care were analyzed using predetermined metrics to identify values anomalous from adjacent neighbors. Anomalous data points were then replaced with linear interpolation of neighbors. The algorithm was then validated against manual artifact identification in 54 anesthesia records and 41,384 arterial line measurements. To assess the algorithm's effect on data analysis, we calculated the percent of time spent with MAP below 55 mmHg and above 100 mmHg for both raw and conditioned datasets. Manual review of the dataset identified 1.23% of all pressure readings as artifactual. When compared to manual review, the algorithm identified artifacts with 87.0% sensitivity and 99.4% specificity. The average difference between manual review and algorithm in identifying the start of arterial line monitoring was 0.17, and 2.1 min for the end of monitoring. Application of the algorithm decreased the percent of time below 55 mmHg from 4.3 to 2.0% (2.1% with manual review) and time above 100 mmHg from 8.8 to 7.3% (7.3% manual). This algorithm's performance was comparable to manual review by a human anesthesiologist and reduced the incidence of abnormal MAP values identified using a sample analysis tool.
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Affiliation(s)
| | - David Glick
- Department of Anesthesia and Critical Care, University of Chicago, 5841 S. Maryland Ave MC4028, Chicago, IL, 60637, USA
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, 5841 S. Maryland Ave MC4028, Chicago, IL, 60637, USA.
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Yamada T, Vacas S, Gricourt Y, Cannesson M. Improving Perioperative Outcomes Through Minimally Invasive and Non-invasive Hemodynamic Monitoring Techniques. Front Med (Lausanne) 2018; 5:144. [PMID: 29868596 PMCID: PMC5966660 DOI: 10.3389/fmed.2018.00144] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/25/2018] [Indexed: 01/10/2023] Open
Abstract
An increasing number of patients require precise intraoperative hemodynamic monitoring due to aging and comorbidities. To prevent undesirable outcomes from intraoperative hypotension or hypoperfusion, appropriate threshold settings are required. These setting can vary widely from patient to patient. Goal-directed therapy techniques allow for flow monitoring as the standard for perioperative fluid management. Based on the concept of personalized medicine, individual assessment and treatment are more advantageous than conventional or uniform interventions. The recent development of minimally and noninvasive monitoring devices make it possible to apply detailed control, tracking, and observation of broad patient populations, all while reducing adverse complications. In this manuscript, we review the monitoring features of each device, together with possible advantages and disadvantages of their use in optimizing patient hemodynamic management.
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Affiliation(s)
- Takashige Yamada
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA, United States.,Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Susana Vacas
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Yann Gricourt
- Departement Anesthesie Réanimation Douleur Urgence, Centre Hospitalaire Universitaire Caremeau, Nimes, France
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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Postoperative Delirium in Severely Burned Patients Undergoing Early Escharotomy: Incidence, Risk Factors, and Outcomes. J Burn Care Res 2018; 38:e370-e376. [PMID: 27388882 DOI: 10.1097/bcr.0000000000000397] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The aim of this study is to investigate the incidence, related risk factors, and outcomes of postoperative delirium (POD) in severely burned patients undergoing early escharotomy. This study included 385 severely burned patients (injured <1 week; TBSA, 31-50% or 11-20%; American Society of Anesthesiologists physical status, II-IV) aged 18 to 65 years, who underwent early escharotomy between October 2014 and December 2015, and were selected by cluster sampling. The authors excluded patients with preoperative delirium or diagnosed dementia, depression, or cognitive dysfunction. Preoperative, perioperative, intraoperative, and postoperative information, such as demographic characteristics, vital signs, and health history were collected. The Confusion Assessment Method was used once daily for 5 days after surgery to identify POD. Stepwise binary logistic regression analysis was used to identify the risk factors for POD, t-tests, and χ tests were performed to compare the outcomes of patients with and without the condition. Fifty-six (14.55%) of the patients in the sample were diagnosed with POD. Stepwise binary logistic regression showed that the significant risk factors for POD in severely burned patients undergoing early escharotomy were advanced age (>50 years old), a history of alcohol consumption (>3/week), high American Society of Anesthesiologists classification (III or IV), time between injury and surgery (>2 days), number of previous escharotomies (>2), combined intravenous and inhalation anesthesia, no bispectral index applied, long duration surgery (>180 min), and intraoperative hypotension (mean arterial pressure < 55 mm Hg). On the basis of the different odds ratios, the authors established a weighted model. When the score of a patient's weighted odds ratios is more than 6, the incidence of POD increased significantly (P < .05). When the score of a patient's weighted odds ratios is more than 6, the incidence of POD increased significantly (P < .05). Further, POD was associated with more postoperative complications, including hepatic and renal function impairment and hypernatremia, as well as prolonged hospitalization, increased medical costs, and higher mortality.
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Guo Y, Zhang Y, Jia P, Wang W, Zhou Q, Sun L, Zhao A, Zhang X, Wang X, Li Y, Zhang J, Jiang W. Preoperative Serum Metabolites Are Associated With Postoperative Delirium in Elderly Hip-Fracture Patients. J Gerontol A Biol Sci Med Sci 2017; 72:1689-1696. [PMID: 28180239 DOI: 10.1093/gerona/glx001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/25/2017] [Indexed: 12/18/2022] Open
Abstract
Background Hypotheses on the development of postoperative delirium (PD) include "neuroinflammatory," "neuronal aging," "oxidative stress," "neurotransmitter deficiency," and "neuroendocrine." Here, we employed metabolomics to determine the serum metabolites in the baseline associated with an increased risk of PD. Methods Two hundred and nine elderly hip-fracture patients who had undergone hemiarthroplasty and had completed our assessments were selected. Fasting venous blood was collected at 7:00 on the morning of surgery and a serum sample bank was created for analysis. On the first 3 postoperative days, the patients were assessed twice daily using the Confusion Assessment Method - Chinese Revision. Ultimately, 43 patients were diagnosed with PD, who comprised the PD group. Meanwhile, 43 matched non-PD patients were selected based on age, sex, and body mass index. Serum samples from the two groups were analyzed by gas chromatography-time-of-flight mass spectrometry and Acquity ultra-performance liquid chromatography-quadrupole time-of-flight mass spectrometry. Results The demographic characteristics of the groups were matched. Four metabolites associated with an increased risk of PD were identified, including S-methylcysteine, linolenic acid, eicosapentaenoic acid, and linoleic acid. Conclusions Multiple metabolic pathways in the PD group altered before surgery, including deficiency of ω3 and ω6 fatty acids, energy metabolism and oxidative stress with interactions between hypoxia and mitochondrial dysfunction, in addition to glutamate-glutamine cycle dysfunction. These metabolic abnormalities could possibly increase the fragility of the brain and then contribute to PD.
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Affiliation(s)
- Yong Guo
- Department of Anesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China.,Department of Anesthesiology and Critical Care Medicine, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, China
| | - Yinan Zhang
- Center for Translational Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China
| | - Peiyu Jia
- Department of Anesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China
| | - Wenying Wang
- Department of Anesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China
| | - Quanhong Zhou
- Department of Anesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China
| | - Lulu Sun
- Department of Anesthesiology and Critical Care Medicine, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, China
| | - Aihua Zhao
- Center for Translational Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China
| | - Xin Zhang
- Department of Anesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China
| | - Xuemin Wang
- Department of Anesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China
| | - Yingchuan Li
- Department of Anesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China
| | - Junfeng Zhang
- Department of Anesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China
| | - Wei Jiang
- Department of Anesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China
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Hu A, Qiu Y, Zhang P, Hu B, Yang Y, Li S, Zhao R, Zhang Z, Zhang Y, Zheng Z, Qiu C, Li F, Gong X. Comparison of the effect of high versus low mean arterial pressure levels on clinical outcomes and complications in elderly patients during non-cardiothoracic surgery under general anesthesia: study protocol for a randomized controlled trial. Trials 2017; 18:554. [PMID: 29162132 PMCID: PMC5698923 DOI: 10.1186/s13063-017-2233-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 10/04/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Intraoperative blood pressure (BP) is a concern in daily clinic anesthesia and contributes to the differences in clinical outcome. We conducted a randomized controlled trial (RCT) to compare the effect of high vs. low mean arterial pressure (MAP) levels on clinical outcomes and complications in elderly patients under general anesthesia (GA). METHODS In this multicenter, randomized, parallel-controlled, open-label, assessor-blinded clinical trial, 322 patients aged more than 65 years will be randomized for a low-level MAP (60-70 mmHg) or high-level MAP (90-100 mmHg) during non-cardiothoracic surgery under GA. The primary outcome will be the incidence of postoperative delirium. The secondary outcomes will include the delirium duration days, intraoperative urine volume, intraoperative blood loss, specific postoperative complications, and all-cause 28-day mortality. DISCUSSION Results of this trial will help clarify whether BP management is beneficial for elderly patients under GA and will make clear whether the effect of high-level MAP can reduce the postoperative complication compared to low-level MAP. TRIAL REGISTRATION ClinicalTrials.gov, NCT02857153 . Registered on 15 July 2016.
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Affiliation(s)
- Anmin Hu
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, 518001, China.,Shenzhen Anesthesiology Engineering Center, Shenzhen, 518001, China.,The Second Clinical Medical College, Jinan University, Shenzhen, 518001, China
| | - Yan Qiu
- Department of Anesthesiology and Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, 610000, China
| | - Peng Zhang
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, 610072, China
| | - Bailong Hu
- Department of Anesthesiology, Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Yali Yang
- Department of Anesthesiology, Henan Provincial People's Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Shutao Li
- Department of Anesthesiology, Taihe Hospital of Hubei University of Medicine, Shiyan, Hubei, 442000, People's Republic of China
| | - Rui Zhao
- Department of Anesthesiology, The Third Affiliated Hospital of Kunming Medical University, Kunming, 650106, China
| | - Zhongjun Zhang
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, 518001, China. .,Shenzhen Anesthesiology Engineering Center, Shenzhen, 518001, China. .,The Second Clinical Medical College, Jinan University, Shenzhen, 518001, China.
| | - Yaoxian Zhang
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, 518001, China.,Shenzhen Anesthesiology Engineering Center, Shenzhen, 518001, China.,The Second Clinical Medical College, Jinan University, Shenzhen, 518001, China
| | - Zihao Zheng
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, 518001, China.,Shenzhen Anesthesiology Engineering Center, Shenzhen, 518001, China.,The Second Clinical Medical College, Jinan University, Shenzhen, 518001, China
| | - Chen Qiu
- Clinical Medical Research Center, The Second Clinical Medicine College, Jinan University, Shenzhen, 518001, China
| | - Furong Li
- Clinical Medical Research Center, The Second Clinical Medicine College, Jinan University, Shenzhen, 518001, China
| | - Xiaolei Gong
- Clinical Medical Research Center, The Second Clinical Medicine College, Jinan University, Shenzhen, 518001, China
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Risk factors for postoperative delirium after spine surgery in middle- and old-aged patients. Aging Clin Exp Res 2017; 29:1039-1044. [PMID: 27766513 DOI: 10.1007/s40520-016-0640-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Postoperative delirium is a common complication following various operative procedures with an incidence rate of 10-77 %. AIM To analyze various risk factors for postoperative delirium after spine surgery in the middle- and old-aged patients. METHODS This study retrospectively reviewed 451 patients (226 males and 225 females, an average age of 65.1 ± 18.3 years) who underwent spinal surgery in our hospital between January 2010 and August 2015. Patients who had features of acute onset and fluctuating course and any two of the other features were diagnosed with delirium. Cognitive tests consisting of Clinical Dementia Rating and Global Deterioration Scale were performed to evaluate delirium. T tests were used for statistical analysis of the difference between the two groups, and logistic regression analyses were used for determining the risk factors. RESULTS A total of 42 (9.3 %) patients were diagnosed with delirium. Delirious and non-delirious patients had no difference in age, gender, BMI, education level, drug treatment, comorbid disease history, surgical history, preoperative blood pressure, intraoperative blood loss, blood transfusion, use of surgical implants, surgical site, use of fentanyl and propofol, and preoperative VAS score. Intraoperative hypotension and use of dezocine were related to postoperative delirium (P = 0.03 and P = 0.07). The multiple regression equation was Y = -0.11 + 0.52 × X 0 + 0.21 × X 1, where X 0 = amount of dezocine, X 1 = instances of intraoperative hypotension. CONCLUSION Postoperative delirium commonly occurs after spine surgery. Intraoperative hypotension <80 mmHg and intraoperative use of dezocine represent valuable new predictors of the risk of delirium.
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Perioperative hemodynamics and risk for delirium and new onset dementia in hip fracture patients; A prospective follow-up study. PLoS One 2017; 12:e0180641. [PMID: 28700610 PMCID: PMC5503267 DOI: 10.1371/journal.pone.0180641] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 06/19/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Delirium is common in hip fracture patients and many risk factors have been identified. Controversy exists regarding the possible impact of intraoperative control of blood pressure upon acute (delirium) and long term (dementia) cognitive decline. We explored possible associations between perioperative hemodynamic changes, use of vasopressor drugs, risk of delirium and risk of new-onset dementia. METHODS Prospective follow-up study of 696 hip fracture patients, assessed for delirium pre- and postoperatively, using the Confusion Assessment Method. Pre-fracture cognitive function was assessed using the Informant Questionnaire of Cognitive Decline in the Elderly and by consensus diagnosis. The presence of new-onset dementia was determined at follow-up evaluation at six or twelve months after surgery. Blood pressure was recorded at admission, perioperatively and postoperatively. RESULTS Preoperative delirium was present in 149 of 536 (28%) assessable patients, and 124 of 387 (32%) developed delirium postoperatively (incident delirium). The following risk factors for incident delirium in patients without pre-fracture cognitive impairment were identified: low body mass index, low level of functioning, severity of physical illness, and receipt of ≥ 2 blood transfusions. New-onset dementia was diagnosed at follow-up in 26 of 213 (12%) patients, associated with severity of physical illness, delirium, receipt of vasopressor drugs perioperatively and high mean arterial pressure postoperatively. CONCLUSION Risk factors for incident delirium seem to differ according to pre-fracture cognitive status. The use of vasopressors during surgery and/or postoperative hypertension is associated with new-onset dementia after hip fracture.
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Yang Y, Zhao X, Dong T, Yang Z, Zhang Q, Zhang Y. Risk factors for postoperative delirium following hip fracture repair in elderly patients: a systematic review and meta-analysis. Aging Clin Exp Res 2017; 29:115-126. [PMID: 26873816 DOI: 10.1007/s40520-016-0541-6] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/20/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND No formal systematic review or meta-analysis was performed up to now to summarize the risk factors of delirium after hip surgery. AIMS The present study aimed to quantitatively and comprehensively conclude the risk factors of delirium after hip surgery in elderly patients. METHODS A search was applied to CNKI, Embase, Medline, and Cochrane central database (all up to August 2015). All studies assessing the risk factors of delirium after hip surgery in elderly patients without language restriction were reviewed, and qualities of included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled and a meta-analysis was completed. RESULTS A total of 24 studies were selected, which altogether included 5364 patients with hip fracture. One thousand and ninety of them were cases of delirium occurred after surgery, suggesting the accumulated incidence of 24.0 %. Results of meta-analyses showed that elderly patients with preoperative cognitive impairment [odds ratio (OR) 3.21, 95 % confidence interval (CI) 2.26-4.56), advanced age (standardized mean difference 0.50, 95 % CI 0.33-0.67), living in an institution (OR 2.94; 95 % CI 1.65-5.23), heart failure (OR 2.46; 95 % CI 1.72-3.53), total hip arthroplasty (OR 2.21; 95 % CI 1.16-4.22), multiple comorbidities (OR 1.37; 95 % CI 1.12-1.68) and morphine usage (OR 3.01; 95 % CI 1.30-6.94) were more likely to sustain delirium after hip surgery. Females were less likely to develop delirium after hip surgery (OR 0.83; 95 % CI 0.70-0.98). CONCLUSIONS Related prophylaxis strategies should be implemented in elderly patients involved with above-mentioned risk factors to prevent delirium after hip surgery.
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Affiliation(s)
- Yanjiang Yang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Xin Zhao
- Department of Functional and Physical Examination, Hebei General Hospital, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Tianhua Dong
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Zongyou Yang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Qi Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.
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Smith TO, Cooper A, Peryer G, Griffiths R, Fox C, Cross J. Factors predicting incidence of post-operative delirium in older people following hip fracture surgery: a systematic review and meta-analysis. Int J Geriatr Psychiatry 2017; 32:386-396. [PMID: 28093812 DOI: 10.1002/gps.4655] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/01/2016] [Accepted: 12/06/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Delirium is one of the most common complications following hip fracture surgery in older people. This study identified pre- and peri-operative factors associated with the development of post-operative delirium following hip fracture surgery. METHODS Published and unpublished literature were searched to identify all evidence reporting variables on patient characteristics, on-admission, intra-operative and post-operative management assessing incident delirium in older people following hip fracture surgery. Pooled odds ratio (OR) and mean difference of those who experienced delirium compared to those who did not were calculated for each variable. Evidence was assessed using the Downs and Black appraisal tool and interpreted using the GRADE approach. RESULTS A total of 6704 people (2090 people with post-operative delirium) from 32 studies were analysed. There was moderate evidence of nearly a two-times greater probability of post-operative delirium for those aged 80 years and over (OR: 1.77; 95% CI: 1.09, 2.87), whether patients lived in a care institution pre-admission (OR: 2.65; 95% CI: 1.79, 3.92), and a six-times greater probability of developing post-operative delirium with a pre-admission diagnosis of dementia (OR: 6.07, 95% CI: 4.84, 7.62). There was no association with intra-operative variables and probability of delirium. CONCLUSION Clinicians treating people with a hip fracture should be vigilant towards post-operative delirium if their patients are older, have pre-existing cognitive impairment and poorer overall general health. This is also the case for those who experience post-operative complications such as pneumonia or a urinary tract infection. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- T O Smith
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - A Cooper
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - G Peryer
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - R Griffiths
- Department of Anaesthesia, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK
| | - C Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - J Cross
- School of Health Sciences, University of East Anglia, Norwich, UK
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Development of a nomogram for predicting the probability of postoperative delirium in patients undergoing free flap reconstruction for head and neck cancer. Eur J Surg Oncol 2017; 43:683-688. [DOI: 10.1016/j.ejso.2016.09.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 09/29/2016] [Indexed: 11/21/2022] Open
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Miller ID, Shelton CL, Lewis SR, Alderson P, Smith AF. Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly surgical patients. Cochrane Database Syst Rev 2016. [DOI: 10.1002/14651858.cd012317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- I. David Miller
- North Cumbria University Hospitals; Academic Unit; Cumberland Infirmary Newtown Road Carlisle UK CA2 7HY
| | - Cliff L Shelton
- Lancaster University; Lancaster Medical School; Lancaster UK
| | - Sharon R Lewis
- Royal Lancaster Infirmary; Patient Safety Research Department; Pointer Court 1, Ashton Road Lancaster UK LA1 1RP
| | - Phil Alderson
- National Institute for Health and Care Excellence; Level 1A, City Tower, Piccadilly Plaza Manchester UK M1 4BD
| | - Andrew F Smith
- Royal Lancaster Infirmary; Department of Anaesthesia; Ashton Road Lancaster Lancashire UK LA1 4RP
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Xue FS, Liu GP, Yang GZ, Sun C. Is longer storage time of red blood cells really not associated with risks of delirium and complications after hip fracture surgery? Injury 2016; 47:1359-60. [PMID: 27084111 DOI: 10.1016/j.injury.2016.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 03/29/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Fu-Shan Xue
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Gao-Pu Liu
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gui-Zhen Yang
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao Sun
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Guo Y, Jia P, Zhang J, Wang X, Jiang H, Jiang W. Prevalence and risk factors of postoperative delirium in elderly hip fracture patients. J Int Med Res 2016; 44:317-27. [PMID: 26920926 PMCID: PMC5580064 DOI: 10.1177/0300060515624936] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 12/07/2015] [Indexed: 12/15/2022] Open
Abstract
Objective To explore the risk factors associated with postoperative delirium (PD) in elderly patients following total hip arthroplasty (THA) for hip fracture. Methods This prospective study enrolled elderly patients (≥ 65 years) with hip fractures who underwent THA under general anaesthesia, and who had a complete set of postoperative observations. Detailed medical history and perioperative characteristics were recorded. During the postoperative period, patients were assessed twice daily for PD using the Confusion Assessment Method. Results A total of 572 patients were eligible for inclusion in the study. Of these, 120 patients (21.0%) were diagnosed with PD and 452 patients (79.0%) did not experience PD. Multivariate stepwise logistic regression analyses showed that older age, a history of stroke, lower albumin, higher blood glucose, higher total bilirubin, higher C-reactive protein, longer surgery duration and higher volume of red blood cell transfusions were independent risk factors for PD. Conclusions Correcting the modifiable risk factors might help prevent PD. Strategies might include nutritional support, tight blood glucose control, improvement of liver function, preoperative infection control and minimizing surgical injury or blood loss.
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Affiliation(s)
- Yong Guo
- Department of Anaesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China Department of Anaesthesiology and Critical Care Medicine, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Peiyu Jia
- Department of Anaesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Junfeng Zhang
- Department of Anaesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xuemin Wang
- Department of Anaesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hong Jiang
- Department of Anaesthesiology and Critical Care Medicine, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Jiang
- Department of Anaesthesiology and Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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