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Hori Y, Mihashi M. Relationship Between Delirium Development and Its Causative Factors in the Intensive Care Unit After Cardiac Surgery. Yonago Acta Med 2023; 66:214-222. [PMID: 37229376 PMCID: PMC10203640 DOI: 10.33160/yam.2023.05.003] [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: 11/08/2022] [Accepted: 03/10/2023] [Indexed: 05/27/2023]
Abstract
Background Delirium is a clinical symptom that can have serious side effects in patients, and it develops acutely and shows reversibility. Postoperative delirium is an important neuropsychological complication after surgery that directly or indirectly affects patients. Cardiac surgery increases the risk of delirium due to the complexity of surgical procedures, use of intraoperative and postoperative anesthetics and other pharmacologic agents, and possible postoperative complications. This study aims to determine the relationship between the development of delirium and its causative factors after cardiac surgery and its associated postoperative complications, and identify the high-relevance risk factors of postoperative delirium. Methods The participants comprised 730 patients who were admitted to the intensive care unit and underwent cardiac surgery. The collected data included 19 risk factors based on the patients' medical information records. As a delirium diagnostic tool, we used the Intensive Care Delirium Screening Checklist, with four or more points indicating delirium. For statistical analysis, the dependent variables were determined based on the presence or absence of delirium, while the independent variables were determined based on the risk factors of delirium. A t-test, χ2 test, and logistic regression analysis were performed on risk factors between the two groups-the delirium group and no delirium group. Results Postoperative delirium was observed in 126 (17.3%) of 730 patients after cardiac surgery. Postoperative complications were more common in the delirium group. Independent risk factors associated with postoperative delirium were identified in 7 of the 12 factors. Conclusion As cardiac surgery is invasive and affects the development and severity of delirium, efforts and intervention methods are necessary to predict the risk factors for the development of delirium before surgery, and to prevent its occurrence after surgery. In the future, it is necessary to further investigate factors associated with delirium that can be directly intervened.
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Affiliation(s)
- Yukio Hori
- Kurume University Graduate School of Medicine, Kurume 830-0003, Japan and
| | - Mutsuko Mihashi
- Kurume University School of Medicine, Nursing, Kurume 830-0003, Japan
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Rivas E, Shehata P, Bravo M, Almonacid-Cardenas F, Shah K, Kopac O, Ruetzler K, Troianos CA, Turan A. Association between obstructive sleep apnea and atrial fibrillation and delirium after cardiac surgery. Sub-analysis of DECADE trial. J Clin Anesth 2023; 87:111109. [PMID: 36958074 DOI: 10.1016/j.jclinane.2023.111109] [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: 07/11/2022] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Atrial fibrillation and delirium are common complications after cardiac surgery. Both are associated with increased Intensive Care Unit (ICU) and hospital length of stay, functional decline, 30-day mortality and increase in health care costs. Obstructive Sleep Apnea (OSA) induces deleterious effects in the cardiovascular and nervous systems. We hypothesized that adult patients with preoperative OSA have a higher incidence of postoperative atrial fibrillation and delirium than patients without OSA, after cardiac surgery. METHODS Sub-analysis of the DECADE trial at Cleveland Clinic hospitals. Our exposure was OSA, defined by STOP-BANG questionnaire score higher than 5 and/or a preoperative diagnosis of OSA. The primary outcome was atrial fibrillation, defined by clinician diagnosis or documented arrhythmia. The secondary outcome was delirium assessed twice during the initial five postoperative days using the Confusion Assessment Method for ICU. We assessed the association between OSA, and atrial fibrillation and delirium using a logistic regression model adjusted for confounders using inverse probability of treatment weighting. RESULTS 590 patients were included in the final analysis. 133 were diagnosed with OSA and 457 had no OSA. Satisfactory balance between groups for most confounders (absolute standardized difference < 0.10) was achieved after weighting. The atrial fibrillation incidence was 37% (n = 49) in the patients with OSA and 33% (n = 150) in the non-OSA patients. OSA was not associated with atrial fibrillation with an estimated odds ratio of 1.22 (95% CI: 0.75,1.99;p = 0.416). The delirium incidence was 17% (n = 22) in patients with OSA and 15% (n = 67) in the non-OSA patients. OSA was not associated with delirium with an estimated odds ratio of 0.93 (95% CI: 0.51,1.69;p = 0.800). CONCLUSION In adult patients having cardiac surgery, OSA is not associated with a higher incidence of postoperative atrial fibrillation and delirium. These results suggest different prominent factors rather than OSA affect the incidence of these postoperative outcomes.
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Affiliation(s)
- Eva Rivas
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States; Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Peter Shehata
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Mauro Bravo
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | | | - Karan Shah
- Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Orkun Kopac
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | | | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States.
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Kim TW, Ko RE, Na SJ, Chung CR, Choi KH, Park CM, Yang JH. Associations of albumin and nutritional index factors with delirium in patients admitted to the cardiac intensive care unit. Front Cardiovasc Med 2023; 10:1100160. [PMID: 36937934 PMCID: PMC10020190 DOI: 10.3389/fcvm.2023.1100160] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/14/2023] [Indexed: 03/06/2023] Open
Abstract
Background Limited data are available on the association of malnutrition with the occurrence of delirium in the cardiac intensive care unit (CICU). Thus, we aimed to analyze whether nutritional indices and their components can predict the development of delirium in CICU. Methods We enrolled 2,783 patients admitted to the CICU of Samsung Medical Center for more than 24 h between September 2012 and December 2018. We assessed the nutritional status at admission using three indices, the Prognostic Nutrition Index (PNI), the Geriatric Nutritional Risk Index (GNRI), and the Controlling Nutritional Status (CONUT). Then, we compared predictive performances for the occurrence of delirium among nutritional indices using Delong's test. Results Delirium developed in 678 patients (24.3%) assessed three times daily for 7 days of CICU stay. Nutritional indices had fair predictive performance for development of delirium in critically ill cardiac patients using the area under the receiver-operating characteristic curve (AUROC: 0.729 for the GNRI, 0.728 for PNI, and 0.762 for CONUT). Furthermore, the AUROC of albumin alone (0.77, 95% CI, 0.75-0.79) was significantly greater than that of either GNRI (p < 0.001) or PNI (p < 0.001). In a multivariable analysis including each component of nutritional indices, albumin was a significant predictor for delirium but not absolute lymphocyte count, bodyweight/ideal bodyweight, or total cholesterol level as a component of nutritional indices. Conclusion Predictive performances of nutritional indices for the occurrence of delirium were acceptable in patients admitted to CICU. Albumin alone might be a helpful and straightforward indicator for the occurrence of delirium.
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Affiliation(s)
- Tae Wan Kim
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ryoung Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- *Correspondence: Jeong Hoon Yang,
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Chang YL, Hsieh MJ, Chang YC, Yeh SL, Chen SW, Tsai YF. Self-efficacy of caring for patients in the intensive care unit with delirium: Development and validation of a scale for intensive care unit nurses. Aust Crit Care 2022:S1036-7314(22)00117-5. [PMID: 36137875 DOI: 10.1016/j.aucc.2022.08.006] [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: 02/19/2022] [Revised: 07/13/2022] [Accepted: 08/06/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Improving the self-efficacy of intensive care unit nurses for delirium care could help them adapt to the changing situation of delirium patients. Validated measures of nurses' self-efficacy of delirium care are lacking OBJECTIVES: The objective of this study was to develop a Delirium Care Self-Efficacy Scale for assessing nurses' confidence about caring for patients in the intensive care unit and to examine the scale's psychometric properties. METHODS Draft scale items were generated from a review of relevant literature and face-to-face interviews with intensive care unit nurses; content validity was conducted with a panel of five experts in delirium. A group of nurses were recruited by convenience sampling from intensive care units (N = 299) for item analysis of the questionnaire, assessment of validity, and reliability of the scale. Nurse participants were recruited from nine adult critical care units affiliated with a hospital in Taiwan. Data were collected from August 2020 to July 2021. RESULTS Content validity index was 0.98 for the initial 26 items, indicating good validity. The critical ratio for item discrimination was 14.47-19.29, and item-to-total correlations ranged from 0.67 to 0.81. Principal component analysis reduced items to 13 and extracted two factors, confidence in delirium assessment and confidence in delirium management, which explained 66.82% of the total variance. Cronbach's alpha for internal consistency was 0.94 with good test-retest reliability (r = 0.92). High scale scores among participants were significantly associated with age (≥40 years), work experience in an intensive care unit (≥10 years), delirium education, and willingness to use delirium assessment tools. CONCLUSIONS The newly developed Delirium Care Self-Efficacy Scale demonstrated acceptable reliability and validity as a measure of confidence for intensive care nurses caring for and managing patients with delirium in the intensive care unit.
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Affiliation(s)
- Yu-Ling Chang
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Nursing, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Ju Hsieh
- School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Thoracic and Cardiovascular Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Che Chang
- School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shu-Ling Yeh
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan; Department of Nursing, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Shao-Wei Chen
- Department of Thoracic and Cardiovascular Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Thoracic and Cardiovascular Surgery, & Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yun-Fang Tsai
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan; Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan.
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He KQ, Wang S, Zhang W, Liu Q, Chai XQ. What is the impact of perioperative cerebral oxygen desaturation on postoperative delirium in old population: a systemic review and meta-analysis. Aging Clin Exp Res 2022; 34:1761-1770. [PMID: 35575947 DOI: 10.1007/s40520-022-02128-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 01/23/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Perioperative cerebral oxygen saturation (ScO2) has been reported to associate with postoperative delirium (POD) which is a common postoperative complication, however, the results were inconclusive. Therefore, we aimed to conduct an up-to-date review and meta-analyze the relationship between perioperative ScO2 and POD. METHODS We systematically searched PubMed, Embase and Web of science through January 13, 2022. The pooled results were estimated through a random-effects model meta-analysis and expressed as odds ratios (ORs) and standard mean differences (SMDs), accompanied with 95% confident intervals (CIs). RESULTS Finally, of 467 searched articles, ten articles were included. A total of six studies reported the baseline ScO2 value and the pooled result showed that preoperative baseline ScO2 was lower in POD groups (SMD = - 0.41, 95% CI - 0.64 to - 0.18). And beyond that, the pooled OR across four literatures about preoperative low ScO2 on POD was 3.44 (95% CI 1.69, 7.02). In contrast, insignificant differences were detected in baseline/lowest ScO2 value during intraoperative and postoperative period. Additionally, there were no statistically significant associations for intraoperative and postoperative low ScO2 effect on POD risk. Meta-regress analysis has found no significant impact factors. CONCLUSIONS Based on current evidence, POD patients have a lower ScO2, and ScO2 desaturation may increase POD incidence, indicating the role of ScO2 underlying pathological mechanisms. For generalizability of evidence, we should rely on high-quality, considering more comprehensively longitudinal, interdisciplinary studies.
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Affiliation(s)
- Ke-Qiang He
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, China.,Institute on Aging and Brain Disorders, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine , University of Science and Technology of China, Hefei, 230001, China
| | - Sheng Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, China
| | - Wei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, China
| | - Qiang Liu
- Institute on Aging and Brain Disorders, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine , University of Science and Technology of China, Hefei, 230001, China.
| | - Xiao-Qing Chai
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, China.
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6
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Fukunaga H, Sugawara H, Koyama A, Okamoto K, Fukui T, Ishikawa T, Takebayashi M, Sekiyama K, Hashimoto M. Relationship between preoperative anxiety and onset of delirium after cardiovascular surgery in elderly patients: focus on personality and coping process. Psychogeriatrics 2022; 22:453-459. [PMID: 35504791 DOI: 10.1111/psyg.12840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/05/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postoperative delirium is associated with increased mortality. Therefore, it is important to manage delirium during the entire perioperative period. Preoperative anxiety is associated with poor prognosis in postoperative patients who have undergone cardiovascular surgery. This study aims to investigate the relationship between preoperative anxiety and onset of delirium after cardiovascular surgery in elderly patients (aged 65 years or older), considering the individual psychological characteristics, such as personality and stress coping skills in response to anxiety, as confounding factors. METHODS This prospective study included patients aged >65 years in a preoperative state before undergoing cardiovascular surgery. Subjects were divided into two groups based on whether they experienced postoperative delirium, or not. We compared clinical and demographic factors, preoperative psychiatric and psychological factors, and intraoperative and perioperative physical factors between the control and delirium groups. Multiple imputations were used to account for missing data. RESULTS Out of 168 subjects enrolled in this study, 26 (15.5%) developed postoperative delirium. Univariate analysis showed significant differences in age (P = 0.027), cognitive function (P = 0.007), agreeableness (P = 0.029), and the Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score (P = 0.023) between the delirium and control groups. Multiple logistic regression analysis did not identify a significant association between preoperative anxiety and the onset of postoperative delirium. However, age (odds ratio (OR) = 1.114, P = 0.018), agreeableness (OR = 0.555, P = 0.008), and the APACHE-II score (OR = 1.227, P = 0.008) were identified as risk factors for postoperative delirium. CONCLUSION Agreeableness, one of the personality traits associated with preoperative anxiety, appears to be involved in the development of postoperative delirium as an independent psychological factor, regardless of age or physical factors.
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Affiliation(s)
- Hiroe Fukunaga
- Department of Nursing, Kumamoto School of Nursing, Kumamoto, Japan
| | - Hiroko Sugawara
- Department of Psychiatry, Kansai Rosai Hospital, Amagasaki, Japan.,Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Asuka Koyama
- Department of Neuropsychiatry, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Ken Okamoto
- Department of Cardiovascular Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Tomohisa Ishikawa
- Department of Neuropsychiatry, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Minoru Takebayashi
- Department of Neuropsychiatry, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kaoru Sekiyama
- Graduate School of Advanced Integrated Studies in Human Survivability, Kyoto University, Kyoto, Japan
| | - Mamoru Hashimoto
- Department of Neuropsychiatry, Kindai University Faculty of Medicine, Osaka, Japan
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Jiang L, Lei G. Albumin/fibrinogen ratio, an independent risk factor for postoperative delirium after total joint arthroplasty. Geriatr Gerontol Int 2022; 22:412-417. [PMID: 35365967 DOI: 10.1111/ggi.14381] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 02/09/2022] [Accepted: 03/08/2022] [Indexed: 12/16/2022]
Abstract
AIM Postoperative delirium (POD) is a very common and serious complication after total joint arthroplasty (TJA), which is closely associated with many adverse consequences and a poor prognosis. This study aimed to establish the potential risk factors for POD. METHODS In total, 336 patients who underwent elective TJA under general anesthesia between 2018 and 2021 were included and deemed eligible for inclusion. POD was diagnosed based on the criteria by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM V). The receiver operating characteristic curve was drawn to evaluate the predictive and cut-off values of continuous variables for POD. Potential risk factors for POD were evaluated by binary univariate and multivariate analysis with the "Enter" method. RESULTS According to the criteria by DSM V, 43 patients were categorized into the POD group, with an incidence of 12.8% (43 of 336). The receiver operating characteristic curve showed that albumin/fibrinogen ratio (AFR) was a good predictor for POD with an area under the curve of 0.754, cut-off value of 9.65, sensitivity of 57.00% and specificity of 83.72% (P <0.001). A low preoperative AFR level (<9.65) was determined as the only independent risk factor for POD by the univariate and multivariate logistic regression analyses (OR: 2.45, 95% CI: 2.01-2.94, P = 0.008). CONCLUSIONS Our results indicate that a low AFR is an independent risk factor for POD in elderly subjects after TJA. Geriatr Gerontol Int 2022; 22: 412-417.
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Affiliation(s)
- Liuying Jiang
- Department of Anesthesiology, Zhongshan Hospital Xiamen University, Xiamen City, China
| | - Gaofeng Lei
- Xiamen Medical Emergency Center, Xiamen City, China
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Abstract
This review provides an overview for health care teams involved in the perioperative care of cardiac surgery patients. The intention is to summarize key determinants of delirium, its impact on short- and long-term outcomes as well as to discuss effective management strategies. The first component of this review examines the prevalence and the factors associated with an increased risk of postoperative delirium. A multitude of predisposing (eg, baseline vulnerability and comorbidities) and precipitating (eg, type of cardiac surgery and postoperative care) factors that contribute to the occurrence of delirium are discussed.
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Fatehi Hassanabad A, Bahrami N, Novick RJ, Ali IS. Delirium and depression in cardiac surgery: A comprehensive review of risk factors, pathophysiology, and management. J Card Surg 2021; 36:2876-2889. [PMID: 34120376 DOI: 10.1111/jocs.15610] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Mental health and wellbeing continue to gain more attention as they are inextricably associated with clinical outcomes, particularly quality of life. Many medical ailments and major surgeries affect patients' mental health, including depression and delirium. AIMS The objective of this manuscript was to comprehensively review and critically examine the literature pertaining to cardiac surgery, depression, and delirium. METHODS This is a narrative review article. We performed our search analysis by using the following key words: "Cardiac Surgery", "Depression", "Delirium", "Clinical outcomes", and "Mental Health". Search analysis was done on MedLine PubMed, accessing indexed peer-reviewed publications. RESULTS Cardiac Surgery is a life-altering intervention indicated to improve morbidity and mortality in patients with cardiovascular diseases. Psychiatric conditions before and after cardiac surgery worsen patient prognosis and increase mortality rate. Specifically, preoperative depression increases postoperative depression and is associated with impaired functional status, slow physical recovery, and an increased readmission rate. DISCUSSION Although the exact pathophysiology between depression and cardiovascular disease (CVD) is unknown, several pathways have been implicated. Unmanaged depression can also lead to other psychological conditions such as delirium. Like depression, the exact association between delirium and CVD is not well understood, but believed to be multifactorial. CONCLUSION Herein, we provide a comprehensive review of the links between depression, delirium, and cardiovascular surgery. We critically examine the current data that pertains to the pathophysiology of these debilitating mental health issues in the context of cardiac surgery. Finally, we summarize the various treatment options available for managing depression and delirium in the cardiac surgery patient population.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Nabila Bahrami
- Department of Medicine, Department of Medicine, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Richard J Novick
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Imtiaz S Ali
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, Alberta, Canada
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Igwe EO. A survey about postoperative delirium in older patients among nurses and anaesthetists: implications for future practice and policy. J Res Nurs 2021; 26:341-351. [PMID: 35251260 PMCID: PMC8894989 DOI: 10.1177/1744987120949893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Postoperative delirium is a major complication associated with anaesthesia and surgery, more commonly seen in older people. AIMS The aims of this study were to explore the knowledge and understanding of anaesthetists and nurses involved in anaesthesia through their responses to two case scenarios of postoperative delirium experienced by older people. METHODS A 30-item online survey was sent to 500 potential respondents. RESULTS Two hundred and twenty-six practitioners from Australia, New Zealand and Scotland responded. Most had no workplace protocols for anaesthesia planning in older people. There was substantial variability in practice in relation to postoperative delirium screening, detection, prevention and management. CONCLUSIONS Improvements in education and awareness, together with a more coherent approach, for example, as recommended in the European Society of Anaesthesiology Guidelines, could help to reduce the impact of postoperative delirium in older people. This should be combined with ongoing research into perioperative optimisation of detection, prevention and management of postoperative delirium.
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Affiliation(s)
- Ezinne O Igwe
- Ezinne O Igwe, School of Medicine, Faculty of Science Medicine and Health, University of Wollongong, NSW 2522, Australia.
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Cortés-Beringola A, Vicent L, Martín-Asenjo R, Puerto E, Domínguez-Pérez L, Maruri R, Moreno G, Vidán MT, Bueno H. Diagnosis, prevention, and management of delirium in the intensive cardiac care unit. Am Heart J 2021; 232:164-176. [PMID: 33253676 DOI: 10.1016/j.ahj.2020.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 11/16/2020] [Indexed: 12/01/2022]
Abstract
Delirium is a frequent complication in patients admitted to intensive cardiac care units (ICCU) with potentially severe consequences including increased risks of mortality, cognitive impairment and dependence at discharge, and longer times on mechanical ventilation and hospital stay. Delirium has been widely documented and studied in general intensive care units and in patients after cardiac surgery, but it has barely been studied in acute nonsurgical cardiac patients. Moreover, delirium (especially in its hypoactive form) is commonly misdiagnosed. We propose a protocol for delirium prevention and management in ICCUs. A daily comprehensive assessment to improve detection should be done using validated scales (ie, confusion assessment method). Preventive measures are particularly relevance and constitute the basis of treatment as well, acting on reversible risk factors, including environmental interventions, such as quiet time, sleep promotion, family support, communication, and adequate treatment of pain and dyspnea. Pharmacological prophylaxis is not indicated with the exception of patients at risk of withdrawal syndrome but should only be used in patients with confirmed delirium. Dexmedetomidine is the drug of choice in patients with severe agitation, and those weaning from invasive mechanical ventilation. As the complexity of ICCUs increases, clinical scenarios posing challenges for the management of delirium become more frequent. Efforts should be done to improve the identification of patients at risk during admission in order to establish preventive interventions to avoid this complication. Patient-centered protocols will increase the awareness of the healthcare professionals for better prevention and earlier diagnosis and will positively impact on prognosis.
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Affiliation(s)
- Alejandro Cortés-Beringola
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Cardiology Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Lourdes Vicent
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Roberto Martín-Asenjo
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Elena Puerto
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Laura Domínguez-Pérez
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Ramón Maruri
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Guillermo Moreno
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - María T Vidán
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Department of Geriatric Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain
| | - Héctor Bueno
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
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12
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Itagaki A, Sakurada K, Matsuhama M, Yajima J, Yamashita T, Kohzuki M. Impact of frailty and mild cognitive impairment on delirium after cardiac surgery in older patients. J Cardiol 2020; 76:147-153. [DOI: 10.1016/j.jjcc.2020.02.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 12/06/2019] [Accepted: 02/08/2020] [Indexed: 02/03/2023]
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13
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Brock L. Dexmedetomidine in Adult Patients in Cardiac Surgery Critical Care: An Evidence-Based Review. AACN Adv Crit Care 2020; 30:259-268. [PMID: 31462522 DOI: 10.4037/aacnacc2019888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Although several options are available for postoperative sedation in the intensive care unit, the selective α2-adrenoceptor agonist dexmedetomidine may offer advantages for patients after cardiac surgery. The author conducted a review of the literature on the use of dexmedetomidine in the cardiac surgery population to determine possible advantages and disadvantages in this patient population. Although the use of dexmedetomidine has not been conclusively shown to change overall morbidity and mortality and may be associated with higher drug cost, its other demonstrated effects offer advantages for postoperative cardiac surgery patients that other forms of sedation cannot match.
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Affiliation(s)
- Lyndsay Brock
- Lyndsay Brock is Acute Care Nurse Practitioner, Surgical Intensive Care Unit, University Hospitals of Cleveland Ahuja Medical Center, 3999 Richmond Rd, Beachwood, OH 44122
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14
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Preoperative C-Reactive Protein/Albumin Ratio, a Risk Factor for Postoperative Delirium in Elderly Patients After Total Joint Arthroplasty. J Arthroplasty 2019; 34:2601-2605. [PMID: 31326244 DOI: 10.1016/j.arth.2019.06.042] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/18/2019] [Accepted: 06/18/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD), as an acute brain failure, is widely reported as a very common postoperative complication, and it is closely associated with increased morbidity and mortality. This study aimed to investigate potential risk factors including C-reactive protein/albumin ratio (CAR) for POD in elderly subjects after total joint arthroplasty (TJA). METHODS A total of 272 elderly patients (aged 65∼85 years) who were scheduled to undergo elective TJA with epidural anesthesia were consecutively recruited. The data of baseline characteristics, operation-associated indexes, and preoperative laboratory tests were collected. POD assessment was performed daily within postoperative 7 days. Receiver operating characteristic curve analysis was utilized for evaluating the predictive and cut-off value of CAR for POD. Risk factors for POD were evaluated by the binary univariate and multivariate logistic regression analyses. RESULTS Within postoperative 7 days, there were 55 patients who had suffered POD with an incidence of 20.2% (55/272). The area under the curve of CAR for POD was 0.804, with the cut-off value of 2.35, a sensitivity of 66.82%, and a specificity of 80.00%, respectively (95% confidence interval [CI]: 0.737-0.872, P < .001). Age (odds ratio: 2.02, 95% CI: 1.03-3.96, P = .038) and preoperative CAR level (odds ratio: 3.04, 95% CI: 1.23-7.23, P = .016) were 2 independent risk factors for POD in elderly subjects undergoing TJA. CONCLUSIONS Preoperative CAR level may be a promising predictor for POD in elderly subjects following TJA.
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15
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Tseng PT, Su KP. Pharmacological Management of Delirium-Reply. JAMA Psychiatry 2019; 76:983-984. [PMID: 31268510 DOI: 10.1001/jamapsychiatry.2019.1522] [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: 11/14/2022]
Affiliation(s)
- Ping-Tao Tseng
- WinShine Clinics in Specialty of Psychiatry, Kaohsiung City, Taiwan
| | - Kuan-Pin Su
- Department of Psychiatry & Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
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16
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Knowledge, opinions and clinical practice regarding postoperative delirium in older patients: A survey of nurses and anaesthetists. J Clin Anesth 2019; 57:108-109. [PMID: 30965270 DOI: 10.1016/j.jclinane.2019.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/14/2019] [Accepted: 04/02/2019] [Indexed: 11/24/2022]
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17
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Fleischmann R, Tränkner S, Bathe-Peters R, Rönnefarth M, Schmidt S, Schreiber SJ, Brandt SA. Diagnostic Performance and Utility of Quantitative EEG Analyses in Delirium: Confirmatory Results From a Large Retrospective Case-Control Study. Clin EEG Neurosci 2019; 50:111-120. [PMID: 29631447 DOI: 10.1177/1550059418767584] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. The lack of objective disease markers is a major cause of misdiagnosis and nonstandardized approaches in delirium. Recent studies conducted in well-selected patients and confined study environments suggest that quantitative electroencephalography (qEEG) can provide such markers. We hypothesize that qEEG helps remedy diagnostic uncertainty not only in well-defined study cohorts but also in a heterogeneous hospital population. Methods. In this retrospective case-control study, EEG power spectra of delirious patients and age-/gender-matched controls (n = 31 and n = 345, respectively) were fitted in a linear model to test their performance as binary classifiers. We subsequently evaluated the diagnostic performance of the best classifiers in control samples with normal EEGs (n = 534) and real-world samples including pathologic findings (n = 4294). Test reliability was estimated through split-half analyses. Results. We found that the combination of spectral power at F3-P4 at 2 Hz (area under the curve [AUC] = .994) and C3-O1 at 19 Hz (AUC = .993) provided a sensitivity of 100% and a specificity of 99% to identify delirious patients among normal controls. These classifiers also yielded a false positive rate as low as 5% and increased the pretest probability of being delirious by 57% in an unselected real-world sample. Split-half reliabilities were .98 and .99, respectively. Conclusion. This retrospective study yielded preliminary evidence that qEEG provides excellent diagnostic performance to identify delirious patients even outside confined study environments. It furthermore revealed reduced beta power as a novel specific finding in delirium and that a normal EEG excludes delirium. Prospective studies including parameters of pretest probability and delirium severity are required to elaborate on these promising findings.
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Affiliation(s)
- Robert Fleischmann
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Neurointensive Care Unit, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Steffi Tränkner
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Rouven Bathe-Peters
- St. Hedwig Hospital, Department of Psychiatry, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maria Rönnefarth
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sein Schmidt
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan J Schreiber
- Department of Neurology, Asklepios Fachklinikum Brandenburg, Brandenburg, Germany
| | - Stephan A Brandt
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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18
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Wang XT, Lyu L, Tang B, Wang C, Liu DW. Delirium in Intensive Care Unit Patients: Ten Important Points of Understanding. Chin Med J (Engl) 2018; 130:2498-2502. [PMID: 29052572 PMCID: PMC5684621 DOI: 10.4103/0366-6999.216405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Xiao-Ting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Lin Lyu
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia 014040, China
| | - Bo Tang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Cui Wang
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550001, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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19
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IVKIN АА, GRIGORIEV EV, SHUKEVICH DL. DIAGNOSTICS OF COGNITIVE DYSFUNCTION IN PATIENTS IN THE INTENSIVE CARE WARDS. MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2018. [DOI: 10.21292/2078-5658-2018-15-3-47-55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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20
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Current status of perioperative management for elderly patients. Nihon Ronen Igakkai Zasshi 2017; 54:299-313. [PMID: 28855453 DOI: 10.3143/geriatrics.54.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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21
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Kamali A, Sanatkar A, Sharifi M, Moshir E. Evaluation of amiodarone versus metoprolol in treating atrial fibrillation after coronary artery bypass grafting. Interv Med Appl Sci 2017. [DOI: 10.1556/1646.9.2017.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Alireza Kamali
- Department of Anesthesiology, Arak University of Medical Sciences, Arak, Iran
| | - Amir Sanatkar
- Department of Surgery, Arak University of Medical Sciences, Arak, Iran
| | - Mehrzad Sharifi
- Department of Surgery, Arak University of Medical Sciences, Arak, Iran
| | - Esmaeil Moshir
- Department of Anesthesiology, Arak University of Medical Sciences, Arak, Iran
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22
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Sonoda A, Kondo Y, Tsuneyoshi Y, Iwashita Y, Nakao S, Ishida K, Oniki K, Saruwatari J, Irie T, Ishitsuka Y. Predictive factors for effectiveness and safety of enoxaparin for total knee arthroplasty in aged Japanese patients: a retrospective review. J Pharm Health Care Sci 2017; 3:6. [PMID: 28116117 PMCID: PMC5241995 DOI: 10.1186/s40780-017-0075-x] [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: 09/28/2016] [Accepted: 01/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aims of this study were to investigate predictive factors involved in effectiveness and safety of enoxaparin for prevention of postoperative venous thromboembolism in aged Japanese total knee arthroplasty (TKA) patients. METHODS Japanese patients over 65 years old who were administered enoxaparin for TKA were enrolled in this study. Their medical records were retrospectively reviewed. Data were corrected at the Izumi Regional Medical Center, from September 2009 to March 2014. Patients were stratified into groups according to whether enoxaparin was effective (no deep vein thrombosis event up to postoperative day 7) or not, and whether they had an adverse drug event (ADE) or not. RESULTS A total of 128 patients were included in this study. One hundred five (82.0%) patients were in the effective group and 20 (15.6%) in the adverse drug event (ADE) group. Anemia (13 patients), abnormalities in liver function tests (4 patients), clinically relevant non-major bleeding (4 patients) and urticaria (1 patient) were observed as ADEs. Multivariate logistic regression analysis showed that the serum total protein level at postoperative day 1 (POD1, before enoxaparin administration), was associated with effectiveness of enoxaparin, while the serum total protein and hemoglobin level at POD1 were involved in ADE caused by enoxaparin. CONCLUSIONS Although further large scale studies will be warranted, our results suggest that serum total protein level just before enoxaparin treatment for TKA relates to the effectiveness and safety of enoxaparin in a Japanese aged population. In addition, the results indicate that the development of anemia should be carefully monitored during enoxaparin treatment for TKA, particularly in patients with lower levels of serum hemoglobin before treatment.
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Affiliation(s)
- Akihiro Sonoda
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Kumamoto, Chuo-ku 862-0973 Japan.,Department of Pharmacy, Izumi Regional Medical Center, 4513 Akasegawa, Akune, Kagoshima 899-1611 Japan
| | - Yuki Kondo
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Kumamoto, Chuo-ku 862-0973 Japan
| | - Yasuhiro Tsuneyoshi
- Department of Orthopedic Surgery, Izumi Regional Medical Center, 4513 Akasegawa, Akune, Kagoshima 899-1611 Japan
| | - Yoshitaka Iwashita
- Department of Pharmacy, Izumi Regional Medical Center, 4513 Akasegawa, Akune, Kagoshima 899-1611 Japan
| | - Shoji Nakao
- Department of Pharmacy, Izumi Regional Medical Center, 4513 Akasegawa, Akune, Kagoshima 899-1611 Japan
| | - Kazuhisa Ishida
- Department of Pharmacy, Izumi Regional Medical Center, 4513 Akasegawa, Akune, Kagoshima 899-1611 Japan
| | - Kentaro Oniki
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Kumamoto, Chuo-ku 862-0973 Japan
| | - Junji Saruwatari
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Kumamoto, Chuo-ku 862-0973 Japan
| | - Tetsumi Irie
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Kumamoto, Chuo-ku 862-0973 Japan.,Center for Clinical Pharmaceutical Sciences, Faculty of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Kumamoto, Chuo-ku 862-0973 Japan
| | - Yoichi Ishitsuka
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Kumamoto, Chuo-ku 862-0973 Japan
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23
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Chang YL, Tsai YF. Early illness experiences related to unexpected heart surgery: A qualitative descriptive study. Aust Crit Care 2017; 30:279-285. [PMID: 28063723 DOI: 10.1016/j.aucc.2016.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/15/2016] [Accepted: 11/16/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Most studies on patients' experiences following emergency cardiac surgery focus on evaluation of patients after their discharge. Few studies have evaluated patients' experiences after being transferred from intensive care and before being discharged. OBJECTIVE This study aimed to describe patients' experiences in the early stages of recovery following emergency heart surgery. METHODS For this exploratory qualitative descriptive study, 13 patients were recruited from a medical centre in northern Taiwan. Participants had undergone emergency heart surgery and had resided in the cardiothoracic surgical ward for ≥6 days following transfer from the ICU; all expected to be discharged from the hospital within 3 days. Semi-structured, face-to-face interviews were conducted in private after the patients had been transferred to the cardiothoracic surgical wards. Audiotaped interviews were transcribed and analysed using content analysis. FINDINGS Data analysis identified four themes, which represented different recovery stages: sudden and serious symptoms, nightmares and vivid dreams, physical and emotional disturbances, and establishing a new life after emergency surgery. A fifth theme, support for a new lifestyle, occurred between the four stages. CONCLUSION Participants experienced symptoms of physical and psychological stress during the early recovery stages following emergency heart surgery. A lack of understanding of the process of recovery increased these difficulties; participants wanted and needed multidisciplinary care and education. Emergency heart surgery does not allow healthcare professionals to inform patients of what to expect post-surgery. Our findings suggest that rather than waiting until discharge to offer disease information and treatment plans, multidisciplinary care should be initiated as soon as possible to facilitate recovery.
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Affiliation(s)
- Yu-Ling Chang
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan; School of Nursing, College of Medicine, Chang Gung University, Taiwan.
| | - Yun-Fang Tsai
- School of Nursing, College of Medicine, Chang Gung University, Taiwan; Department of Nursing, Chang Gung University of Science and Technology, Taiwan; Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Taiwan.
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24
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Rudiger A, Begdeda H, Babic D, Krüger B, Seifert B, Schubert M, Spahn DR, Bettex D. Intra-operative events during cardiac surgery are risk factors for the development of delirium in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:264. [PMID: 27544077 PMCID: PMC4992555 DOI: 10.1186/s13054-016-1445-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/29/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Risk factors for delirium following cardiac surgery are incompletely understood. The aim of this study was to investigate whether intra-operative pathophysiological alterations and therapeutic interventions influence the risk of post-operative delirium. METHODS This retrospective cohort study was performed in a 12-bed cardiosurgical intensive care unit (ICU) of a university hospital and included patients consecutively admitted after cardiac surgery during a 2-month period. The diagnosis of delirium was made clinically using validated scores. Comparisons between patients with and without delirium were performed with non-parametric tests. Logistic regression was applied to identify independent risk factors. Results are given as number (percent) or median (range). RESULTS Of the 194 consecutive post-cardiac surgery patients, 50 (26 %) developed delirium during their ICU stay. Univariate analysis revealed that significant differences between patients with and without delirium occurred in the following intra-operative variables: duration of cardiopulmonary bypass (184 [72-299] vs 113 (37-717) minutes, p < 0.001), lowest mean arterial pressure (50 [30-70] vs 55 [30-75] mmHg, p = 0.004), lowest haemoglobin level (85 [56-133] vs 98 [53-150] g/L, p = 0.005), lowest body temperature (34.5 [24.4-37.2] vs 35.1 [23.9-37.2] °C, p = 0.035), highest noradrenaline support (0.11 [0.00-0.69] vs 0.07 [0.00-0.42] μg/kg/minute, p = 0.001), and frequency of red blood cell transfusions (18 [36 %] vs 26 [18 %], p = 0.018) and platelet transfusions (23 [46 %] vs 24 [17 %], p < 0.001). Only platelet transfusions remained an independent risk factor in the multivariate analysis (p < 0.001). CONCLUSIONS In patients undergoing cardiac surgery, various intra-operative events, such as transfusion of platelets, were risk factors for the development of a post-operative delirium in the ICU. Further research is needed to unravel the underlying mechanisms.
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Affiliation(s)
- Alain Rudiger
- Cardio-Surgical Intensive Care Unit, Institute of Anesthesiology, University Hospital Zurich and University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.
| | - Hülya Begdeda
- Cardio-Surgical Intensive Care Unit, Institute of Anesthesiology, University Hospital Zurich and University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Daniela Babic
- Cardio-Surgical Intensive Care Unit, Institute of Anesthesiology, University Hospital Zurich and University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Bernard Krüger
- Cardio-Surgical Intensive Care Unit, Institute of Anesthesiology, University Hospital Zurich and University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Burkhardt Seifert
- Epidemiology, Biostatistics and Prevention Institute (EBPI), Department of Biostatistics, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland
| | - Maria Schubert
- Centre of Clinical Nursing Science, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.,Directorate of Nursing/MTT, Inselspital, University Hospital, Freiburgstrasse, 3010, Bern, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University Hospital Zurich and University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Dominique Bettex
- Cardio-Surgical Intensive Care Unit, Institute of Anesthesiology, University Hospital Zurich and University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
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25
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Booka E, Kamijo T, Matsumoto T, Takeuchi M, Kitani T, Nagaoka M, Imai A, Iida Y, Shimada A, Takebayashi K, Niihara M, Mori K, Onitsuka T, Tsubosa Y, Takeuchi H, Kitagawa Y. Incidence and risk factors for postoperative delirium after major head and neck cancer surgery. J Craniomaxillofac Surg 2016; 44:890-4. [PMID: 27235151 DOI: 10.1016/j.jcms.2016.04.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 03/31/2016] [Accepted: 04/19/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Postoperative delirium is a common and serious complication after extensive surgery. This study aimed to investigate the incidence and risk factors for postoperative delirium after major head and neck cancer surgery. METHODS A retrospective analysis was performed for 293 patients who underwent major head and neck cancer surgery lasting >6 h at our institution between January 2012 and November 2015. All data were assessed by two psychiatrists. Univariate and multivariate analyses were performed. RESULTS Postoperative delirium developed in 50 (17.1%) patients; most cases (84.0%) of postoperative delirium were observed between postoperative day (POD) 1 and POD 3. Multivariate analysis revealed that an age >70 years was the significant risk factor for postoperative delirium incidence after major head and neck cancer surgery; the multivariate hazard ratio was 3.935 (95% confidence interval 1.873-8.265, p < 0.001). CONCLUSIONS Most cases of postoperative delirium after major head and neck cancer surgery were observed between POD 1 and POD 3, and a multivariate analysis revealed that an age >70 years was a significant risk factor for postoperative delirium incidence. Clinicians should pay particular attention to the possibility of delirium incidence during the first 3 days after surgery for patients aged >70 years.
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Affiliation(s)
- Eisuke Booka
- Division of Head and Neck Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan; Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan; Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Tomoyuki Kamijo
- Division of Head and Neck Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan.
| | - Teruaki Matsumoto
- Division of Psycho-Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan
| | - Mari Takeuchi
- Division of Psycho-Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan; Palliative Care Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Takashi Kitani
- Division of Head and Neck Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan
| | - Masato Nagaoka
- Division of Head and Neck Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan
| | - Atsushi Imai
- Division of Head and Neck Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan
| | - Yoshiyuki Iida
- Division of Head and Neck Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan
| | - Ayako Shimada
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan; Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Katsushi Takebayashi
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan
| | - Masahiro Niihara
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan
| | - Keita Mori
- Clinical Trial Coordination Office, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan
| | - Tetsuro Onitsuka
- Division of Head and Neck Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan
| | - Yasuhiro Tsubosa
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
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Hollinger A, Siegemund M, Goettel N, Steiner LA. Postoperative Delirium in Cardiac Surgery: An Unavoidable Menace? J Cardiothorac Vasc Anesth 2015; 29:1677-87. [DOI: 10.1053/j.jvca.2014.08.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Indexed: 01/20/2023]
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Gosselt AN, Slooter AJ, Boere PR, Zaal IJ. Risk factors for delirium after on-pump cardiac surgery: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:346. [PMID: 26395253 PMCID: PMC4579578 DOI: 10.1186/s13054-015-1060-0] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 09/04/2015] [Indexed: 12/13/2022]
Abstract
Introduction As evidence-based effective treatment protocols for delirium after cardiac surgery are lacking, efforts should be made to identify risk factors for preventive interventions. Moreover, knowledge of these risk factors could increase validity of etiological studies in which adjustments need to be made for confounding variables. This review aims to systematically identify risk factors for delirium after cardiac surgery and to grade the evidence supporting these associations. Method A prior registered systematic review was performed using EMBASE, CINAHL, MEDLINE and Cochrane from 1990 till January 2015 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007371). All studies evaluating patients for delirium after cardiac surgery with cardiopulmonary bypass (CPB) using either randomization or multivariable data analyses were included. Data was extracted and quality was scored in duplicate. Heterogeneity impaired pooling of the data; instead a semi-quantitative approach was used in which the strength of the evidence was graded based on the number of investigations, the quality of studies, and the consistency of the association reported across studies. Results In total 1462 unique references were screened and 34 were included in this review, of which 16 (47 %) were graded as high quality. A strong level of evidence for an association with the occurrence of postoperative delirium was found for age, previous psychiatric conditions, cerebrovascular disease, pre-existent cognitive impairment, type of surgery, peri-operative blood product transfusion, administration of risperidone, postoperative atrial fibrillation and mechanical ventilation time. Postoperative oxygen saturation and renal insufficiency were supported by a moderate level of evidence, and there is no evidence that gender, education, CPB duration, pre-existent cardiac disease or heart failure are risk factors. Conclusion Of many potential risk factors for delirium after cardiac surgery, for only 11 there is a strong or moderate level of evidence. These risk factors should be taken in consideration when designing future delirium prevention strategies trials or when controlling for confounding in future etiological studies. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1060-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alex Nc Gosselt
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Arjen Jc Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Pascal Rq Boere
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Irene J Zaal
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Higashi H, Inaba S, Saito M, Yamaoka M, Yanagimoto R, Okiura N, Gen Y, Kojima Y, Sumimoto T. Heart failure as a strong independent predictor of delirium after pacemaker operations. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.ijcme.2015.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Current Concepts in the Diagnosis, Pathophysiology, and Treatment of Delirium: A European Perspective. CURRENT GERIATRICS REPORTS 2015. [DOI: 10.1007/s13670-015-0142-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Delirium, Subsyndromal Delirium, and Cognitive Changes in Individuals Undergoing Elective Coronary Artery Bypass Graft Surgery. J Cardiovasc Nurs 2015; 30:340-5. [DOI: 10.1097/jcn.0000000000000170] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Androsova G, Krause R, Winterer G, Schneider R. Biomarkers of postoperative delirium and cognitive dysfunction. Front Aging Neurosci 2015; 7:112. [PMID: 26106326 PMCID: PMC4460425 DOI: 10.3389/fnagi.2015.00112] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/28/2015] [Indexed: 01/19/2023] Open
Abstract
Elderly surgical patients frequently experience postoperative delirium (POD) and the subsequent development of postoperative cognitive dysfunction (POCD). Clinical features include deterioration in cognition, disturbance in attention and reduced awareness of the environment and result in higher morbidity, mortality and greater utilization of social financial assistance. The aging Western societies can expect an increase in the incidence of POD and POCD. The underlying pathophysiological mechanisms have been studied on the molecular level albeit with unsatisfying small research efforts given their societal burden. Here, we review the known physiological and immunological changes and genetic risk factors, identify candidates for further studies and integrate the information into a draft network for exploration on a systems level. The pathogenesis of these postoperative cognitive impairments is multifactorial; application of integrated systems biology has the potential to reconstruct the underlying network of molecular mechanisms and help in the identification of prognostic and diagnostic biomarkers.
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Affiliation(s)
- Ganna Androsova
- Bioinformatics core, Luxembourg Centre for Systems Biomedicine (LCSB), University of LuxembourgBelvaux, Luxembourg
| | - Roland Krause
- Bioinformatics core, Luxembourg Centre for Systems Biomedicine (LCSB), University of LuxembourgBelvaux, Luxembourg
| | - Georg Winterer
- Experimental and Clinical Research Center (ECRC), Department of Anesthesiology and Operative Intensive Care Medicine, Charité University Medicine BerlinBerlin, Germany
| | - Reinhard Schneider
- Bioinformatics core, Luxembourg Centre for Systems Biomedicine (LCSB), University of LuxembourgBelvaux, Luxembourg
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van Meenen LCC, van Meenen DMP, de Rooij SE, ter Riet G. Risk Prediction Models for Postoperative Delirium: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2014; 62:2383-90. [DOI: 10.1111/jgs.13138] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Sophia E. de Rooij
- Geriatrics Section; Department of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Gerben ter Riet
- Department of General Practice; Academic Medical Center; University of Amsterdam; Amsterdam the Netherlands
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Trabold B, Metterlein T. Postoperative Delirium: Risk Factors, Prevention, and Treatment. J Cardiothorac Vasc Anesth 2014; 28:1352-60. [DOI: 10.1053/j.jvca.2014.03.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Indexed: 01/07/2023]
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Roggenbach J, Klamann M, von Haken R, Bruckner T, Karck M, Hofer S. Sleep-disordered breathing is a risk factor for delirium after cardiac surgery: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:477. [PMID: 25189637 PMCID: PMC4175616 DOI: 10.1186/s13054-014-0477-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 07/23/2014] [Indexed: 01/26/2023]
Abstract
Introduction Delirium is a frequent complication after cardiac surgery. Although various risk factors for postoperative delirium have been identified, the relationship between nocturnal breathing disorders and delirium has not yet been elucidated. This study evaluated the relationship between sleep-disordered breathing (SDB) and postoperative delirium in cardiac surgery patients without a previous diagnosis of obstructive sleep apnea. Methods In this prospective cohort study, 92 patients undergoing elective cardiac surgery with extracorporeal circulation were evaluated for both SDB and postoperative delirium. Polygraphic recordings were used to calculate the apnea-hypopnea index (AHI; mean number of apneas and hypopneas per hour recorded) of all patients preoperatively. Delirium was assessed during the first four postoperative days using the Confusion Assessment Method. Clinical differences between individuals with and without postoperative delirium were determined with univariate analysis. The relationship between postoperative delirium and those covariates that were associated with delirium in univariate analysis was determined by a multivariate logistic regression model. Results The median overall preoperative AHI was 18.3 (interquartile range, 8.7 to 32.8). Delirium was diagnosed in 44 patients. The median AHI differed significantly between patients with and without postoperative delirium (28 versus 13; P = 0.001). A preoperative AHI of 19 or higher was associated with an almost sixfold increased risk of postoperative delirium (odds ratio, 6.4; 95% confidence interval, 2.6 to 15.4; P <0.001). Multivariate logistic regression analysis showed that preoperative AHI, age, smoking, and blood transfusion were independently associated with postoperative delirium. Conclusions Preoperative SDB (for example, undiagnosed obstructive sleep apnea) were strongly associated with postoperative delirium, and may be a risk factor for postoperative delirium. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0477-1) contains supplementary material, which is available to authorized users.
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Krzych ŁJ, Wybraniec MT, Krupka-Matuszczyk I, Skrzypek M, Bochenek AA. Delirium Screening in Cardiac Surgery (DESCARD): A Useful Tool for Nonpsychiatrists. Can J Cardiol 2014; 30:932-9. [DOI: 10.1016/j.cjca.2014.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/18/2014] [Accepted: 04/18/2014] [Indexed: 11/27/2022] Open
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Bathula M, Gonzales JP. The pharmacologic treatment of intensive care unit delirium: a systematic review. Ann Pharmacother 2014; 47:1168-74. [PMID: 24259732 DOI: 10.1177/1060028013500466] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To systematically evaluate the treatment of ICU delirium. DATA SOURCES Literature searches were conducted using PubMed and Ovid MEDLINE (January 1980 to March 2013). Clinical trials/reports evaluating the use of pharmacologic treatment for ICU delirium were selected. References from major guidelines and publications were reviewed. STUDY SELECTION AND DATA EXTRACTION English-language articles related to the treatment of ICU delirium were included. The following were excluded: (1) used pharmacologic treatment for the prevention of delirium; (2) inclusion of non-critically ill, palliative care, or hospice care patients; (3) letters to the editor; (4) case studies; (5) case series; (6) studies without delirium-related end points; and (7) studies with a predominantly postoperative population. Data extracted included: study design, population, treatment, number of participants, end points, outcomes/authors' conclusions, and adverse effects. DATA SYNTHESIS Four studies were included in this review. The US Preventative Services Task Force classification scheme was used to assess the quality of evidence. All 4 studies reviewed were level I evidence studies. There are few well-designed, randomized studies that evaluate ICU delirium treatment. The 2 main randomized studies have small sample sizes and methodological concerns. Antipsychotic therapy may reduce the duration of ICU delirium. However, more robust studies are needed to demonstrate benefit. CONCLUSIONS There is a lack of evidence supporting pharmacologic treatment for ICU delirium. Prospective, well-designed studies using proper delirium identification tools and severity are necessary to confirm the overall impact of pharmacologic therapy on the duration of delirium and associated complications.
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Affiliation(s)
- Matt Bathula
- University of Maryland School of Pharmacy, Baltimore, MD, USA
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Cigarette smoking as a risk factor for delirium in hospitalized and intensive care unit patients. A systematic review. Ann Am Thorac Soc 2014; 10:496-503. [PMID: 24161052 DOI: 10.1513/annalsats.201301-001oc] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Active smokers are prevalent in hospitalized and critically ill patients. Cigarette smoking and nicotine withdrawal may increase delirium in these populations. This systematic review aims to determine whether active cigarette smoking increases the risk for delirium in hospitalized and intensive care unit (ICU) patients. METHODS A systematic search of English-, Spanish-, and French-language articles published from 1966 to April 2013 was performed. Studies were included if they measured cigarette smoking as a risk factor and delirium as an outcome in adult hospitalized or ICU patients. Methodologic quality of studies was assessed using both the validated Newcastle Ottawa Scale and an additional evidence-based quality rating scale. RESULTS A total of 14 cohort studies of surgical and ICU populations were included in the review. No studies in non-ICU inpatients were identified. The incidence of delirium ranged from 9 to 52%, and the prevalence of active smokers ranged from 9 to 44%. The quality of assessment for active smoking varied widely. None of the studies used biochemical measures to determine cigarette smoke exposure. Of the six studies restricting the smoking group to active smokers only, active smoking was independently associated with delirium in one study, trended toward an association in one study, and showed a dose response in one study. Quantitative summary measures were not calculated due to study heterogeneity and missing data. CONCLUSIONS There is currently insufficient evidence to determine if cigarette smoking is a risk factor for delirium. Future studies should consider using biochemical measures of cigarette smoke exposure to objectively quantify smoking behavior.
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Zhang X, Zhao X, Wang Y. Dexmedetomidine: a review of applications for cardiac surgery during perioperative period. J Anesth 2014; 29:102-11. [PMID: 24913070 DOI: 10.1007/s00540-014-1857-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 05/19/2014] [Indexed: 12/12/2022]
Abstract
Cardiac surgery is associated with a high incidence of cardiovascular and other complications during the perioperative period that translate into increased mortality and prolonged hospital stays. Safe comprehensive perioperative management is required to eliminate these adverse events. Dexmedetomidine is a selective α2-adrenoreceptor agonist that has been described as an ideal medication in the perioperative period of cardiac surgery. The major clinical effects of dexmedetomidine in this perioperative period can be summarized as attenuating the hemodynamic response, cardioprotective effects, antiarrhythmic effects, sedation in the ICU setting, treatment of delirium, and procedural sedation. Although there are some side effects of dexmedetomidine, it is emerging as an effective therapeutic agent in the management of a wide range of clinical conditions with an efficacious, safe profile. The present review serves as an overview update in the diverse applications of dexmedetomidine for cardiac surgery during the perioperative period.
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Affiliation(s)
- Xiaoyu Zhang
- Department of Anesthesiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China
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Lahariya S, Grover S, Bagga S, Sharma A. Delirium in patients admitted to a cardiac intensive care unit with cardiac emergencies in a developing country: incidence, prevalence, risk factor and outcome. Gen Hosp Psychiatry 2014; 36:156-64. [PMID: 24295565 DOI: 10.1016/j.genhosppsych.2013.10.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/04/2013] [Accepted: 10/07/2013] [Indexed: 12/14/2022]
Abstract
AIM To assess the incidence, prevalence, risk factors and outcome of delirium in patients admitted to a cardiac intensive care unit (ICU) of a tertiary care hospital. METHODS Three hundred nine consecutive patients admitted to a 22-bed coronary care unit were screened for presence of delirium by using Confusion Assessment Method for Intensive Care Unit (CAM-ICU), and those found positive on CAM-ICU were further evaluated by a psychiatrist to confirm the diagnosis of delirium as per DSM-IV-TR criteria. Patients were also evaluated for the risk factors for delirium and outcome of delirium. RESULTS Incidence rate of delirium was 9.27%, and prevalence rate was 18.77%. The risk factors identified for delirium in binary logistic regression analysis were hypokalemia, Sequential Organ Failure Assessment score, presence of cognitive deficits, receiving more than three medications, sepsis, hyponatremia, presence of cardiogenic shock, having undergone coronary artery bypass grafting, left ventricular ejection fraction <30, currently receiving opioids, age more than 65 years, presence of diabetes mellitus, presence of uncontrolled diabetes mellitus, history of seizures, presence of congestive cardiac failure, having undergone angioplasty, presence of atrial fibrillation, ongoing depression, currently receiving/taking benzodiazepines, warfarin, ranitidine, steroids, non-steroidal anti-inflammatory drugs, higher total number of medications, presence of raised creatinine, anaemia, hypoglycemia, Acute Physiology and Chronic Health Evaluation II score and Charlson Comorbidity Index score. About one fourth (n=22; 27%) of the patients who developed delirium died during the hospital stay in contrast to 1% mortality in the non-delirious group. Those with delirium also had longer stay in the ICU. CONCLUSIONS Delirium is highly prevalent in the cardiac ICU setting and is associated with presence of many modifiable risk factors. Development of delirium increases the mortality risk and is associated with longer cardiac ICU stay.
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Affiliation(s)
- Sanjay Lahariya
- Department of Psychiatry Postgraduate Institute of Medical Education & Research, Chandigarh160012, India
| | - Sandeep Grover
- Department of Psychiatry Postgraduate Institute of Medical Education & Research, Chandigarh160012, India.
| | - Shiv Bagga
- Department of Psychiatry Postgraduate Institute of Medical Education & Research, Chandigarh160012, India
| | - Akhilesh Sharma
- Department of Psychiatry Postgraduate Institute of Medical Education & Research, Chandigarh160012, India
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Kennedy M, Enander RA, Tadiri SP, Wolfe RE, Shapiro NI, Marcantonio ER. Delirium risk prediction, healthcare use and mortality of elderly adults in the emergency department. J Am Geriatr Soc 2014; 62:462-9. [PMID: 24512171 DOI: 10.1111/jgs.12692] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To create a risk prediction rule for delirium in elderly adults in the emergency department (ED) and to compare mortality and resource use of elderly adults in the ED with and without delirium. DESIGN Prospective observational study. SETTING Urban tertiary care ED. PARTICIPANTS Individuals aged 65 and older presenting for ED care (N = 700). MEASUREMENTS A trained research assistant performed a structured mental status assessment and attention tests, after which delirium was determined using the Confusion Assessment Method. Data were collected on participant demographics, comorbidities, medications, ED course, hospital and intensive care unit (ICU) admission, length of stay, hospital charges, 30-day rehospitalization, and mortality. RESULTS Nine percent of elderly study participants had delirium. Using logistic regression, a delirium prediction rule consisting of older age, prior stroke or transient ischemic attack, dementia, suspected infection, and acute intracranial hemorrhage was created had good predictive accuracy (area under the receiver operating characteristic curve = 0.77). Admitted participants with ED delirium had longer median lengths of stay (4 vs 2 days) and were more likely to require ICU admission (13% vs 6%) and to be discharged to a new long-term care facility (37% vs 9%) than those without. In all participants, ED delirium was associated with higher 30-day mortality (6% vs 1%) and 30-day readmission (27% vs 13%). CONCLUSION This risk prediction rule may help identify a group of individuals in the ED at high risk of developing delirium who should undergo screening, but it requires external validation. Identification of delirium in the ED may enable physicians to implement strategies to decrease delirium duration and avoid inappropriate discharge of individuals with acute delirium, improving outcomes.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Hatano Y, Narumoto J, Shibata K, Matsuoka T, Taniguchi S, Hata Y, Yamada K, Yaku H, Fukui K. White-matter hyperintensities predict delirium after cardiac surgery. Am J Geriatr Psychiatry 2013; 21:938-45. [PMID: 24029014 DOI: 10.1016/j.jagp.2013.01.061] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 05/31/2012] [Accepted: 06/27/2012] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Postoperative delirium is a common psychiatric disorder among patients who undergo cardiac surgery. Although several studies have investigated risk factors for delirium after cardiac surgery, the association between delirium and cerebral white-matter hyperintensities (WMH) on magnetic resonance (MR) imaging has not been previously studied. The aim of this study was to identify general risk factors for delirium, as well as to examine the specific relationship between WMH and delirium. DESIGN Retrospective chart review. SETTING University hospital. PARTICIPANTS A total of 130 patients who underwent cardiac surgery. MEASUREMENTS Variables recorded included patient demographics, comorbidities, mental health, laboratory data, surgical information, and cerebrovascular disease. The presence of WMH was assessed using MR images. Two groups of patients were compared (patients with and without delirium) using both univariate and multiple logistic analyses. RESULTS Delirium occurred in 18 patients (13.8%) and patients with delirium were significantly older than patients who did not develop delirium. The prevalence of severe WMH (Fazekas score = 3) was significantly higher in patients with delirium. Three independent predictors of delirium were identified: abnormal creatinine (odds ratio [OR]: 4.5; 95% confidence interval [CI]: 1.4-13.9), severe WMH (OR: 3.9; 95% CI: 1.2-12.5), and duration of surgery (OR: 1.4; 95% CI: 1.0-1.8). CONCLUSIONS The results of this study suggest that white-matter abnormality is one of the most important risk factors for development of delirium after cardiac surgery. These factors can be used for prediction and prevention of delirium following cardiac surgery.
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Affiliation(s)
- Yutaka Hatano
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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Lingehall HC, Smulter N, Engström KG, Gustafson Y, Olofsson B. Validation of the Swedish version of the Nursing Delirium Screening Scale used in patients 70 years and older undergoing cardiac surgery. J Clin Nurs 2013; 22:2858-66. [DOI: 10.1111/j.1365-2702.2012.04102.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVE Delirium, an acute organ dysfunction, is common among critically ill patients leading to significant morbidity and mortality; its epidemiology in a mixed cardiology and cardiac surgery ICU is not well established. We sought to determine the prevalence and risk factors for delirium among cardiac surgery ICU patients. DESIGN Prospective observational study. SETTING Twenty-seven-bed medical-surgical cardiac surgery ICU. PATIENTS Two hundred consecutive patients with an expected cardiac surgery ICU length of stay >24 hrs. INTERVENTIONS None. MEASUREMENTS Baseline demographic data and daily assessments for delirium using the validated and reliable Confusion Assessment Method for the ICU were recorded, and quantitative tracking of delirium risk factors were conducted. Separate analyses studied the role of admission risk factors for occurrence of delirium during the cardiac surgery ICU stay and identified daily occurring risk factors for the development of delirium on a subsequent cardiac surgery ICU day. MAIN RESULTS Prevalence of delirium was 26%, similar among cardiology and cardiac surgical patients. Nearly all (92%) exhibited the hypoactive subtype of delirium. Benzodiazepine use at admission was independently predictive of a three-fold increased risk of delirium (odds ratio 3.1 [1, 9.4], p = 0.04) during the cardiac surgery ICU stay. Of the daily occurring risk factors, patients who received benzodiazepines (2.6 [1.2, 5.7], p = 0.02) or had restraints or devices that precluded mobilization (2.9 [1.3, 6.5], p < 0.01) were more likely to have delirium the following day. Hemodynamic status was not associated with delirium. CONCLUSIONS Delirium occurred in one in four patients in the cardiac surgery ICU and was predominately hypoactive in subtype. Chemical restraints via use of benzodiazepines or the use of physical restraints/restraining devices predisposed patients to a greater risk of delirium, pointing to areas of quality improvement that would be new to the vast majority of cardiac surgery ICUs.
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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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Incidence, prevalence, risk factor and outcome of delirium in intensive care unit: a study from India. Gen Hosp Psychiatry 2012; 34:639-46. [PMID: 22819154 DOI: 10.1016/j.genhosppsych.2012.06.009] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 06/13/2012] [Accepted: 06/14/2012] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To evaluate the incidence, prevalence, risk factors and outcome of delirium in the respiratory intensive care unit of a tertiary care hospital. METHODS Consecutive patients admitted to an eight-bed respiratory intensive care unit were screened for presence of delirium by a psychiatrist. Patients found to have delirium were evaluated using univariate techniques for their clinical profiles, risk factors for delirium, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, duration of stay (in days) and outcome at discharge from intensive care unit besides evaluation on Delirium Rating Scale-Revised 98 version (DRS-R-98). RESULTS Incidence and prevalence rate of delirium were 24.4% and 53.6% respectively. Univariate analyses revealed that the prevalence of delirium was higher (64%) in mechanically ventilated patients. The predisposing risk factors identified for delirium in univariate analysis were higher age; higher Glasgow Coma Scale score; increased APACHE II score; hyperuricemia; hypoalbuminemia; presence of acidosis; abnormal alkaline transferase levels; use of mechanical ventilation; higher number of total medication received and use of sedative, steroids and insulin. Univariate analysis showed that patients who were diagnosed with delirium had significantly longer duration of intensive care unit (ICU) stay and higher mortality rates. Age, multiple organ failure, hypoactive delirium and higher DRS-R-98 scores were significant risk factors for mortality in patients with delirium. CONCLUSIONS Delirium is highly prevalent in the ICU setting and delirium is associated with longer ICU stay and higher mortality.
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Taipale PG, Ratner PA, Galdas PM, Jillings C, Manning D, Fernandes C, Gallaher J. The association between nurse-administered midazolam following cardiac surgery and incident delirium: An observational study. Int J Nurs Stud 2012; 49:1064-73. [DOI: 10.1016/j.ijnurstu.2012.03.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 03/27/2012] [Accepted: 03/28/2012] [Indexed: 10/28/2022]
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Takeuchi M, Takeuchi H, Fujisawa D, Miyajima K, Yoshimura K, Hashiguchi S, Ozawa S, Ando N, Shirahase J, Kitagawa Y, Mimura M. Incidence and risk factors of postoperative delirium in patients with esophageal cancer. Ann Surg Oncol 2012; 19:3963-70. [PMID: 22699802 DOI: 10.1245/s10434-012-2432-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative delirium is a common complication after major surgery and is characterized by acute confusion with fluctuating consciousness. The aim of this study was to investigate the incidence and risk factors of postoperative delirium in patients with esophageal cancer. METHODS We conducted a retrospective cohort analysis of 306 consecutive patients who had undergone an esophagectomy at Keio University Hospital from January 1998 to December 2009. All data were assessed by psychiatrists, and delirium was diagnosed according to criteria of the Diagnostic and Statistical Manual Disorder, fourth edition. Univariate and multivariate analyses were performed. RESULTS Postoperative delirium developed in 153 (50.0 %) of 306 patients. One hundred fourteen (37.3 %) of the 306 patients required psychoactive medication for symptoms associated with delirium. Univariate analyses showed that older age, male gender, additional flunitrazepam for sedation in intensive care unit (ICU) after surgery, longer periods of time under mechanical ventilation after surgery, longer ICU stays, occurrence of postoperative complications, and longer hospital stays were significantly associated with postoperative delirium. Multivariate analysis revealed that development of delirium was linked to older age, additional flunitrazepam in ICU, and occurrence of postoperative complication. CONCLUSIONS The development of postoperative delirium in patients with esophageal cancer is a problem that cannot be ignored. Our results suggest that the risk of developing delirium is associated with older age, use of flunitrazepam in ICU, and postoperative complications.
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Affiliation(s)
- Mari Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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Abstract
Delirium is a common neuropsychiatric syndrome in the elderly that can occur in several different settings caused by several different processes. It is common and causes increased morbidity and mortality to those affected. This clinical review discusses the prediction, prevention, diagnosis, and treatment of delirium in the elderly population. Several strategies to predict delirium are noted with the discussion of pharmacological and nonpharmacological trials of prevention and treatment. Diagnosis of delirium, specifically with the use of objective instruments, is discussed, as is the evidence for pharmacological and nonpharmacological treatment strategies. Discussion of the neurobiology and genetic markers for delirium may elucidate further areas for future research.
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Slor CJ, de Jonghe JF, Vreeswijk R, Groot E, Ploeg TV, van Gool WA, Eikelenboom P, Snoeck M, Schmand B, Kalisvaart KJ. Anesthesia and Postoperative Delirium in Older Adults Undergoing Hip Surgery. J Am Geriatr Soc 2011; 59:1313-9. [DOI: 10.1111/j.1532-5415.2011.03452.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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