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Ho AMH, Mizubuti GB. Co-induction with a vasopressor "chaser" to mitigate propofol-induced hypotension when intubating critically ill/frail patients-A questionable practice. J Crit Care 2019; 54:256-260. [PMID: 31630076 DOI: 10.1016/j.jcrc.2019.09.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 08/14/2019] [Accepted: 09/11/2019] [Indexed: 11/19/2022]
Abstract
Prophylactic administration of a vasopressor to mitigate the hypotensive effect of propofol (and/or other co-induction agents) during sedation/anesthesia immediately prior to tracheal intubation in frail patients in the intensive care unit and emergency and operating rooms appears to be not an uncommon practice. We submit that this practice is unnecessary and potentially harmful. Despite restoring the blood pressure, phenylephrine, for instance, may have an additive or synergistic effect with propofol in reducing the cardiac output and, ultimately, organ perfusion. Airway instrumentation often leads to sympathetic activation and hypertension (thereby increasing myocardial oxygen consumption) which may be exacerbated by an arbitrary prophylactic dose of phenylephrine. Finally, in spite of the well-recognized need to reduce dosages of propofol in frail patients, excessive doses are commonly given, leading to hypotension. We herein discuss each of these points and suggest alternative techniques to promote a stable induction in frail patients.
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Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
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2
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Ogawa M, Izawa KP, Satomi-Kobayashi S, Kitamura A, Tsuboi Y, Komaki K, Ono R, Sakai Y, Tanaka H, Okita Y. Preoperative exercise capacity is associated with the prevalence of postoperative delirium in elective cardiac surgery. Aging Clin Exp Res 2018; 30:27-34. [PMID: 28243862 DOI: 10.1007/s40520-017-0736-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 02/09/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is a critical complication that is closely associated with mortality and major morbidity in elective cardiac surgery. The identification of patients at risk for POD is crucial but has not been fully explored. AIMS The aim of this study was to determine the predictive value of the assessment of preoperative exercise capacity for POD. METHODS We enrolled 313 consecutive patients (mean age, 68.6 ± 14.8 years) undergoing elective cardiac surgery. We measured physical functions such as the 6-minute walking distance (6MWD) and Timed Up-and-Go test (TUG) before surgery. The assessment of delirium was conducted every 8 h from the day of surgery to 5 days after surgery using the Intensive Care Delirium Screening Checklist. RESULTS POD occurred in 46 patients (14.6%). Age, 6MWD, TUG, serum hemoglobin, estimated glomerular filtration rate, and length of intensive care unit stay were significantly different based on the presence or absence of POD (p < 0.05 for each). After multivariate analysis, 6MWD remained a statistically significant indicator for developing POD (OR 0.98; p = 0.02). The cut-off value of 6MWD for predicting POD was 345 m (AUC = 0.75; p = 0.001). CONCLUSIONS Poor exercise capacity was found to be an independent predictor of POD following elective cardiac surgery. This finding suggests the importance of preoperative functional evaluation in the prevention and management of POD in cardiac surgery patients.
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Affiliation(s)
- Masato Ogawa
- Division of Rehabilitation Medicine, Kobe University Hospital, Kobe, Hyogo, 654-0142, Japan
- Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma-ku, Kobe, Japan
| | - Kazuhiro P Izawa
- Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma-ku, Kobe, Japan.
| | - Seimi Satomi-Kobayashi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Aki Kitamura
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasunori Tsuboi
- Division of Rehabilitation Medicine, Kobe University Hospital, Kobe, Hyogo, 654-0142, Japan
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kodai Komaki
- Division of Rehabilitation Medicine, Kobe University Hospital, Kobe, Hyogo, 654-0142, Japan
| | - Rei Ono
- Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma-ku, Kobe, Japan
| | - Yoshitada Sakai
- Division of Rehabilitation Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Tanaka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Vahl CF. Postoperative Psychosyndrome. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-016-0078-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ogawa M, Izawa KP, Kitamura A, Ono R, Satomi-Kobayashi S, Sakai Y, Okita Y. Preoperative physical activity in relation to postoperative delirium in elective cardiac surgery patients. Int J Cardiol 2015; 201:154-6. [PMID: 26298363 DOI: 10.1016/j.ijcard.2015.06.154] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 06/27/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Masato Ogawa
- Division of Rehabilitation Medicine, Kobe University Hospital, Kobe, Japan; Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Kazuhiro P Izawa
- Kobe University Graduate School of Health Sciences, Kobe, Japan.
| | - Aki Kitamura
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Rei Ono
- Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Seimi Satomi-Kobayashi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yoshitada Sakai
- Division of Rehabilitation Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Mangusan RF, Hooper V, Denslow SA, Travis L. Outcomes associated with postoperative delirium after cardiac surgery. Am J Crit Care 2015; 24:156-63. [PMID: 25727276 DOI: 10.4037/ajcc2015137] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium after surgery is a common condition that leads to poor outcomes. Few studies have examined the effect of postoperative delirium on outcomes after cardiac surgery. OBJECTIVES To assess the relationship between delirium after cardiac surgery and the following outcomes: length of stay after surgery, prevalence of falls, discharge to a nursing facility, discharge to home with home health services, and use of inpatient physical therapy. METHODS Electronic medical records of 656 cardiac surgery patients were reviewed retrospectively. RESULTS Postoperative delirium occurred in 161 patients (24.5%). Patients with postoperative delirium had significantly longer stays (P < .001) and greater prevalence of falls (P < .001) than did patients without delirium. Patients with delirium also had a significantly greater likelihood for discharge to a nursing facility (P < .001) and need for home health services if discharged to home (P < .001) and a significantly higher need for inpatient physical therapy (P < .001). Compared with patients without postoperative delirium, patients who had this complication were more likely to have received zolpidem and benzodiazepines postoperatively and to have a history of arrhythmias, renal disease, and congestive heart failure. CONCLUSIONS Patients who have delirium after cardiac surgery have poorer outcomes than do similar patients without this complication. Development and implementation of an extensive care plan to address postoperative delirium is necessary for cardiac surgery patients who are at risk for or have delirium after the surgery.
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Affiliation(s)
- Ralph Francis Mangusan
- Ralph F. Mangusan is a clinical research nurse and Sheri A. Denslow is a biostatistician, Research Institute, Mission Hospital, Asheville, North Carolina. Vallire Hooper is a manager, Nursing Research, Mission Health System, Asheville, North Carolina. Lucille Travis is a professor, School of Nursing, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Vallire Hooper
- Ralph F. Mangusan is a clinical research nurse and Sheri A. Denslow is a biostatistician, Research Institute, Mission Hospital, Asheville, North Carolina. Vallire Hooper is a manager, Nursing Research, Mission Health System, Asheville, North Carolina. Lucille Travis is a professor, School of Nursing, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Sheri A. Denslow
- Ralph F. Mangusan is a clinical research nurse and Sheri A. Denslow is a biostatistician, Research Institute, Mission Hospital, Asheville, North Carolina. Vallire Hooper is a manager, Nursing Research, Mission Health System, Asheville, North Carolina. Lucille Travis is a professor, School of Nursing, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Lucille Travis
- Ralph F. Mangusan is a clinical research nurse and Sheri A. Denslow is a biostatistician, Research Institute, Mission Hospital, Asheville, North Carolina. Vallire Hooper is a manager, Nursing Research, Mission Health System, Asheville, North Carolina. Lucille Travis is a professor, School of Nursing, University of North Carolina at Charlotte, Charlotte, North Carolina
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Lin Y, Chen J, Wang Z. Meta-analysis of factors which influence delirium following cardiac surgery. J Card Surg 2012; 27:481-92. [PMID: 22784203 DOI: 10.1111/j.1540-8191.2012.01472.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The aim of this study is to determine the risk factors of delirium after cardiac surgery. METHODS A systematic literature search of MEDLINE, EMBASE, the Cochrane Library, and Science Citation Index limited to 2008 to 2011 and review of studies was conducted. Eligible studies were of randomized controlled trials or cohort studies, using delirium assessment tool, reporting at least one risk factor associated with delirium, and available to full text. RESULTS The search identified 106 potentially relevant publications; only 25 met selection criteria. Our systematic review revealed 33 risk factors: 17 predisposing and 16 precipitating factors for delirium after elective cardiac surgery. The most established predisposing risk factors were age, depression, and history of stroke, cognitive impairment, diabetes mellitus, and atrial fibrillation. The most established precipitating risk factors were duration of surgery, prolonged intubation, surgery type, red blood cell transfusion, elevation of inflammatory markers and plasma cortisol level, and postoperative complications. Moreover, sedation with dexmedetomidine may significantly predict the absence of postoperative delirium. CONCLUSIONS Postoperative delirium is related to several risk factors following cardiac surgery. Sedation with dexmedetomidine and fast-track weaning protocols may decrease the incidence of delirium in cardiac surgical patients.
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Affiliation(s)
- Yiyun Lin
- Department of Cardiothoracic Surgery, Changzheng Hospital, The Second Military Medical University, Shanghai, China
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Current world literature. Curr Opin Psychiatry 2012; 25:251-9. [PMID: 22456191 DOI: 10.1097/yco.0b013e328352dd8d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Current World Literature. Curr Opin Anaesthesiol 2012; 25:111-20. [DOI: 10.1097/aco.0b013e32834fd93c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Current World Literature. Curr Opin Anaesthesiol 2011; 24:705-12. [DOI: 10.1097/aco.0b013e32834e25f9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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