Postoperative delirium: the importance of pain and pain management

Postoperative delirium is common in geriatric patients. Few studies have examined events in the postoperative period that may contribute to the occurrence of postoperative delirium. We hypothesized that postoperative delirium is related to postoperative pain and/or pain management strategy. Patients aged > or =65 years who were scheduled for major noncardiac surgery were studied. A structured interview was conducted preoperatively and for the first 3 postoperative days to determine the presence of delirium using the Confusion Assessment Method. The method of postoperative pain management, as well as pre- and postoperative medications for the first 3 days, was collected. Pre- and postoperative pain at rest and with movement was recorded using the Visual Analog Scale. Three hundred thirty-three patients, with a mean age of 74 +/- 6 years, were studied. After surgery, 46% of patients developed postoperative delirium. By multivariate logistic regression, age (odds ratio [OR], 2.5; 95% confidence interval [CI] 1.5 to 4.2), moderate (OR, 2.2; 95% CI 1.2 to 4.0) and severe (OR, 3.7; 95% CI 1.5 to 9.0) preoperative resting pain, and increase in level of pain from baseline to postoperative day one (OR, 1.1; 95% CI 1.01 to 1.2) were independently associated with a greater risk for the development of postoperative delirium. In contrast, patients who used oral opioid analgesics as their sole means of postoperative pain control were at decreased risk of developing delirium in comparison with those who used opioid analgesics via IV patient-controlled analgesia technique (OR, 0.4; 95% CI 0.2 to 0.7). These results validate our hypothesis that pain and pain management strategies are important factors related to the development of postoperative delirium in elderly patients.     

Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery

This randomised, double-blinded, placebo-controlled study was primarily aimed to evaluate the potential of risperidone to prevent postoperative delirium following cardiac surgery with cardiopulmonary bypass and the secondary objective was to explore clinical factors associated with postoperative delirium. One-hundred-and-twenty-six adult patients undergoing elective cardiac surgery with cardiopulmonary bypass were randomly assigned to receive either 1 mg of risperidone or placebo sublingually when they regained consciousness. Delirium and other outcomes were assessed. The confusion assessment method for intensive care unit was used to assess postoperative delirium. The incidence of postoperative delirium in the risperidone group was lower than the placebo group (11.1% vs. 31.7% respectively, P=0.009, relative risk = 0.35, 95% confidence interval [CI] = 0.16-0.77). Other postoperative outcomes were not statistically different between the groups. In exploring the factors associated with delirium, univariate analysis showed many factors were associated with postoperative delirium. However multiple logistic regression analysis showed a lapse of 70 minutes from the time of opening eyes to following commands and postoperative respiratory failure were independent risk factors (P=0.003, odds ratio [OR] = 4.57, 95% CI = 1.66-12.59 and P=0.038, OR = 13.78, 95% CI = 1.15-165.18 respectively). A single dose of risperidone administered soon after cardiac surgery with cardiopulmonary bypass reduces the incidence of postoperative delirium. Multiple factors tended to be associated with postoperative delirium, but only the time from opening eyes to following commands and postoperative respiratory failure were independent risk factors in this study.     

Delirium following vascular surgery: increased incidence with preoperative β-blocker administration

Purpose

To determine if there is an association between perioperative administration of beta-blockers and postoperative delirium in patients undergoing vascular surgery.

Methods

After Institutional Review Board approval, data were retrospectively collected on patients who underwent vascular surgery in an academic hospital during the period January 2006 to January 2007. Patients with preoperative altered level of consciousness, carotid endarterectomy, or discharge within 24 h of surgery were excluded from the study. Identification of delirium was based on evaluation of the level of consciousness with the NEECHAM Confusion Scale and/or a chart-based instrument for delirium. Multivariable logistic regression analysis was used to identify independent perioperative predictors of postoperative delirium. Beta-blockers were tested for a potential effect.

Results

The incidence of postoperative delirium was 128/582 (22%). Independent predictors included age (OR 1.04, 95% CI [1.02–1.07]), history of cerebrovascular accident/transient ischemic attack (OR 2.64, 95% CI [1.57–4.55]), and depression (OR 3.56, 95% CI [1.53–8.28]). Open aortic reconstruction was associated with an OR of 5.34, 95% CI (2.54–11.2) and amputation with an OR of 4.66, 95% CI (1.96–11.09). Preoperative beta-blocker administration increased the odds of postoperative delirium 2.06 times (95% CI [1.18–3.6]). Statin administration reduced the odds of delirium by 44% (95% CI [0.37–0.88]). The model was reliable (Hosmer–Lemeshow test, P = 0.72) and discriminative (area under the receiver operating characteristic [ROC] curve = 0.729).

Conclusions

Preoperative administration of beta-blockers is associated with an increased risk of postoperative delirium after vascular surgery. Conversely, preoperative statin administration is associated with a lower risk of postoperative delirium. A randomized prospective controlled trial is required to validate these findings.     

The association of preoperative delirium with postoperative outcomes following hip surgery in the elderly

Study objectiveTo determine the association of preoperative delirium with postoperative outcomes following hip surgery in the elderly.DesignRetrospective cohort study.SettingPostoperative recovery.Patients8466 patients all of whom were 65 years of age or older undergoing surgical repair of a femoral fracture. Of the total population studied, 1075 had preoperative delirium. Of those with preoperative delirium, 746 were ASA class 3 or below and 327 were ASA class 4 or above. Of the 7391 patients without preoperative delirium, 5773 were ASA class 3 or below and 1605 were ASA class 4 or above. The remainder in each group was of unknown ASA class.InterventionsWe used multivariable logistic regression to explore the association of preoperative delirium with 30-day postoperative outcomes. The odds ratio (OR) with associated 95% confidence interval (CI) was reported for each covariate.Measurements.Data was collected regarding the incidence of postoperative outcomes including: delirium, pulmonary complications, extended hospital stay, infection, renal complications, vascular complications, cardiac complications, transfusion necessity, readmission, and mortality.Main Results.After adjusting for potential confounders, the odds of postoperative delirium (OR 9.38, 95% CI 7.94–11.14), pulmonary complications (OR 1.83, 95% CI 1.4–2.36), extended hospital stay (OR 1.47, 95% CI 1.26–1.72), readmission (OR 1.27, 95% CI 1.01–1.59) and mortality (OR 1.92, 95% CI 1.54–2.39) were all significantly higher in patients with preoperative delirium compared to those without.ConclusionsAfter controlling for potential confounding variables, we showed that preoperative delirium was associated with postoperative delirium, pulmonary complications, extended hospital stay, hospital readmission, and mortality. Given the lack of studies on preoperative delirium and its postoperative outcomes, our data provides a strong starting point for further investigations as well as the development and implementation of targeted risk-reduction programs.     

Predictive nomogram for postoperative delirium in elderly patients with a hip fracture

To evaluate the risk factors for the development of postoperative delirium and design a predictive nomogram for the prevention of delirium in elderly patients with a hip fracture, we retrospectively studied 825 patients who sustained a femoral neck fracture from January 2005 to December 2015. Independent risk factors for developing delirium within 6 months of surgery were identified using multivariable logistic regression analyses. A predictive nomogram model was built based on the results, and the discrimination and calibration were determined by C-index and calibration plot. Of the 825 patients who met inclusion criteria, 118 (14.3%) developed postoperative delirium. According to the results, preoperative cognitive impairment (OR, 4.132, 95% CI, 1.831 to 9.324, P＜0.001), multiple medical comorbidities (OR, 1.452, 95% CI, 0.958–2.202, P?=?0.079), ASA classification (OR, 1.655, 95% CI, 1.073–2.553, P?=?0.023), transfusion exceeding 2 units of red blood cell (OR, 1.599, 95% CI, 1.043–2.451, P?=?0.035), and intensive care (OR, 1.817, 95% CI, 1.127–2.930, P?=?0.014) were identified to be the independent predictors of the development of postoperative delirium. The risk of postoperative delirium increased with the increasing risk score of predictive nomogram, and the C-index was 0.67 (0.62 - 0.72). The calibration showed that the predicted probabilities of delirium in the predictive nomogram were close to the observed frequency of delirium, and the decision curve analysis confirmed the clinical utility of the nomogram when the threshold probabilities were between 8% and 35% due to the net benefit.     

Risk factors for unfavourable postoperative outcome in patients with Crohn's disease undergoing right hemicolectomy or ileocaecal resection. An international audit by ESCP and S‐ECCO

Aim

Patient‐ and disease‐related factors, as well as operation technique, all have the potential to impact on postoperative outcome in Crohn's disease. The available evidence is based on small series and often displays conflicting results. The aim was to investigate the effect of preoperative and intra‐operative risk factors on 30‐day postoperative outcome in patients undergoing surgery for Crohn's disease.

Method

This was an international prospective snapshot audit including consecutive patients undergoing right hemicolectomy or ileocaecal resection. The study analysed a subset of patients who underwent surgery for Crohn's disease. The primary outcome measure was the overall Clavien–Dindo postoperative complication rate. The key secondary outcomes were anastomotic leak, reoperation, surgical site infection and length of stay in hospital. Multivariable binary logistic regression analyses were used to produce odds ratios and 95% confidence intervals.

Results

In all, 375 resections in 375 patients were included. The median age was 37 and 57.1% were women. In multivariate analyses, postoperative complications were associated with preoperative parenteral nutrition (OR 2.36, 95% CI 1.10–4.97), urgent/expedited surgical intervention (OR 2.00, 95% CI 1.13–3.55) and unplanned intra‐operative adverse events (OR 2.30, 95% CI 1.20–4.45). The postoperative length of stay in hospital was prolonged in patients who received preoperative parenteral nutrition (OR 31, 95% CI 1.08–1.61) and those who had urgent/expedited operations (OR 1.21, 95% CI 1.07–1.37).

Conclusion

Preoperative parenteral nutritional support, urgent/expedited operation and unplanned intra‐operative adverse events were associated with unfavourable postoperative outcome. Enhanced preoperative optimization and improved planning of operation pathways and timings may improve outcomes for patients.     

骨科常见手术术后谵妄的危险因素分析

 目的 分析骨科常见手术术后发生谵妄的相关危险因素。方法 回顾性分析2011年1月至2013年12月行股骨转子间骨折内固定术（155例）、人工股骨头置换术（64例）、全髋关节置换术（169例）、膝关节置换术（65例）和肩关节周围手术（72例）患者525例,根据是否发生术后谵妄分为谵妄组（56例）和非谵妄组（469例）。记录谵妄组和非谵妄组患者年龄、性别、血型以及住院天数、手术方式、麻醉方式、术前准备时间、术前基础疾病状况、术前及术后白蛋白、术前及术后血红蛋白水平、术后电解质是否紊乱、术中出血量、手术持续时间、术后是否ICU监护和输血量等围手术期因素共17项。采用单因素和多因素Logistic回归分析术后发生谵妄的相关危险因素。结果 单因素Logistic回归分析结果显示,可能与术后谵妄相关的因素有年龄、手术方式、术前准备时间、术前白蛋白水平、术前血红蛋白水平、术后电解质是否紊乱、手术持续时间、是否术后ICU监护和输血量等9项。多因素Logistic回归分析显示：年龄70~80岁和>80岁组术后谵妄发生率高于年龄<70岁组,OR值分别为12.998（95%CI：2.829,59.713）和36.210（95%CI：8.222,159.476）;术前准备时间4~6 d组术后谵妄发生率高于术前准备时间≥7 d组,OR值为3.903（95%CI：1.658,9.188）;术后电解质紊乱组术后谵妄的发生率高于电解质正常组,OR值为2.160（95%CI：1.065,4.382）。结论 高龄、术前准备时间不充分和术后电解质紊乱是骨科术后发生谵妄的高危因素。     

Medical optimisation can reduce morbidity and mortality associated with elective aortic aneurysm repair.

OBJECTIVES: Patients with aortic aneurysms have significant comorbidities which influence outcome. Our practice includes comprehensive assessment to identify comorbidities, allowing subsequent medical optimisation prior to aneurysm repair. The aim of this study was to assess this process and to identify any factors predictive of outcome. DESIGN: Prospective observational study. MATERIALS: Medical case notes of 200 patients referred with aortic pathology. METHODS: Data analysed included preoperative, perioperative and postoperative factors. Multiple logistic regression analysis was performed to identify predictors of outcome. RESULTS: Following assessment 17 patients (8.5%) were found to be unfit for intervention and 165 patients (82.5%) proceeded to aneurysm repair. In this group assessment uncovered previously undiagnosed cardiac, respiratory and renal comorbidity in 19%, 57% and 29% of patients respectively. Multiple logistic regression analysis indicated that optimisation by a renal physician reduced post-operative renal impairment (OR 0.12, 95% CI 0.03-0.45, P=0.002) while optimisation by a cardiologist reduced respiratory complications (OR 0.7, 95% CI 0.05-0.99, P=0.049). An abnormal echocardiogram was associated with pneumonia (OR 6.9, 95% CI 1.6-29, P=0.01) and death (OR 7.9, 95% CI 1.15-54, P=0.036). CONCLUSION: Pre-operative assessment identifies previously undiagnosed comorbidity in a significant proportion of patients. Subsequent medical optimisation may reduce post-operative morbidity and mortality.     

Uncomplicated carotid endarterectomy: factors contributing to blood pressure instability precluding safe early discharge

This study was undertaken to identify preoperative and intraoperative factors that correlate with the need for postoperative vasoactive medication (VM) use. Clinical data from 100 carotid endarterectomies (CEAs) performed in 93 patients were reviewed. Baseline comorbidities, medications, perioperative physiologic data, and operative technique were evaluated for their association with the need for postoperative VM use. Statistical analysis included univariate and multivariate logistic regression with odds ratios (ORs) and 95% confidence intervals (CIs) reported. Hemodynamic instability affected 43 patients, of whom 32 had VM started in the postanesthesia care unit (PACU). No patient who was hemodynamically stable in the PACU later required VM. The only preoperative factor associated with a need for postoperative VM was a prior stroke (OR 4.5; 95% CI 1.2-16.2; p = .02). Intraoperative factors associated with the need for postoperative VM included use of a shunt (OR 5.1; 95% CI 1.2-22.2; p = .03) and a peak intraoperative systolic blood pressure greater than 200 mm Hg (OR 5.1; 95% CI 1.2-22.2; p = .03). The number and type of preoperative blood pressure medications, preoperative hypertension, comorbidities, symptomatic presentation, and intraoperative use of VM did not correlate with postoperative VM use. There were two strokes and no deaths. Patients undergoing CEA who are hemodynamically stable in the PACU appear to be reasonable candidates for same-day discharge and warrant further prospective study.     

The efficacy of peri‐operative interventions to decrease postoperative delirium in non‐cardiac surgery: a systematic review and meta‐analysis.

The purpose of this meta‐analysis was to determine the efficacy of peri‐operative interventions in decreasing the incidence of postoperative delirium. An electronic search of four databases was conducted. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were adhered to. We included randomised controlled trials of non‐cardiac surgery with a peri‐operative intervention and that reported postoperative delirium, and identified 29 trials. Meta‐analysis revealed that peri‐operative geriatric consultation (OR 0.46, 95% CI 0.32–0.67) and lighter anaesthesia (OR 2.66, 95% CI 1.27–5.56) were associated with a decreased incidence of postoperative delirium. For the other interventions, the point estimate suggested possible protection with prophylactic haloperidol (OR 0.62, 95% CI 0.36–1.05), bright light therapy (OR 0.20, 95% CI 0.03–1.19) and general as opposed to regional anaesthesia (OR 0.76, 95% CI 0.47–1.23). This meta‐analysis has shown that peri‐operative geriatric consultations with multicomponent interventions and lighter anaesthesia are potentially effective in decreasing the incidence of postoperative delirium.     

ICU髋部骨折患者术后谵妄的回顾性分析

目的：研究重症监护病房（ICU）髋部骨折患者术詹谵妄的发生率、临床特点及相关危险因素。方法：279例髋部骨折手术患者,67例术后转入ICU。用ICU意识紊乱评估方法（CAM-ICU）进行监测,有7项因素被选作谵妄的危险因素予以分析：骨折前痴呆史．合并血管危险因素．贫血．低蛋白血症、脱水、电解质紊乱、低氧血症。结果：19例（28．4％）患者在手术后7d内发生谵妻。单因素分析具有统计学意义的变量有既往痴呆史（OR=3．16,95％Cl 1.24～8,15）、术后脱水（OR=3．64,95％cl 1．02～7．44）．合并三个及以上的血管危险因素（OR=3．76,95％cl 1．38～10;53）;多因素回归分析显示具有统计学意义的相关因素有既往痴呆病史（RR=3．06。P=0．014）,合并三个及以上的血管危险因素（RR=3．74,P=O．021）。结论：ICU髓部骨折患者手术后谵妄发生率较高,采用CAM-ICU牟亩助诊断和观察．能提高诊断率．骨折前痴呆史、合并三个及以上的血管危险因素是发生手术后谵妄的危险因素。     

老年股骨转子间骨折患者内固定术后发生谵妄的危险因素分析

目的探讨老年股骨转子间骨折患者内固定术后发生谵妄的相关危险因素。方法回顾性分析2010年12月至2018年4月期间保定市第二中心医院骨科接受闭合复位股骨近端防旋髓内钉固定治疗的423例股骨转子间骨折患者资料。男205例,女218例;年龄为70~98岁,平均78.6岁;骨折AO分型:31-A1型239例,31-A2型141例,31-A3型43例;362例患者合并内科疾病。受伤至手术时间为4~72 h,平均46.6 h。统计患者术后发生谵妄的情况。对患者的隐性失血量、性别、年龄、体重指数、并发症情况、麻醉方式、术前准备时间及电解质紊乱情况等进行单因素分析筛选危险因素,对于P<0.05的因素再采用多因素logistic回归分析确定主要的独立危险因素。结果423例患者中49例(11.58%)术后发生谵妄,其中29例发生于术后第1天,20例发生于术后第2天;374例(88.42%)患者未发生谵妄。单因素分析结果显示:发生谵妄患者与未发生谵妄患者在受伤至手术时间、隐性失血量及电解质紊乱方面比较差异均有统计学意义(P<0.05)。多因素logistic回归分析显示:受伤至手术时间>48 h(OR=3.386,95%CI:1.362~6.638)、隐性失血量>600 mL(OR=10.292,95%CI:1.244~35.091)、术后电解质紊乱(OR=4.157,95%CI:1.595~7.626)是老年股骨转子间骨折患者内固定术后发生谵妄的独立危险因素。结论受伤至手术时间长、隐性失血量多与术后发生电解质紊乱是老年股骨转子间骨折患者内固定术后发生谵妄的独立危险因素。     

Validity of the Hardman index to predict outcome in ruptured abdominal aortic aneurysm

This study assessed the validity of the Hardman index in predicting outcome following open repair of ruptured abdominal aortic aneurysm and whether this scoring system can be used reliably to select patients for surgical repair. Patients undergoing open repair of ruptured abdominal aortic aneurysm in two university teaching hospitals over a 5-year period were identified from a computerized hospital database. Thirty-day mortality was the main outcome measure. Five Hardman index factors were calculated and related to outcome retrospectively. There were 178 patients with a mean age of 73.9 years (range 51-94) and a male to female ratio of 5.4:1. The overall in-hospital mortality was 57.3% (102/178). Univariate analysis of risk factors showed that age >76 years (P = 0.007, odds ratio [OR] 2.34, 95% confidence interval [CI] 1.26-4.37) and electrocardiograghic evidence of ischemia on admission (P = 0.002, OR 3.75, 95% CI 1.57-8.93) were associated with high mortality. However, loss of consciousness (P = 0.155, OR 1.56, 95% CI 0.85-2.86), hemoglobin <9 g/dL (P = 0.118, OR 1.89, 95% CI 0.85-4.22), and serum creatinine >0.19 mmol/L (P = 0.691, OR 1.25, 95% CI 0.42-3.70) were not significant predictors of mortality. Using a multivariate analysis, age >76 years (P = 0.043, OR 2.29, 95% CI 1.03-5.11) and myocardial ischemia (P = 0.029, OR 2.93, 95% CI 1.12-7.67) were again found to be the significant predictors of mortality. The operative mortality was 44%, 46%, 68%, 79%, and 100% for Hardman scores of 0, 1, 2, 3, and 4, respectively. No patient had a score of 5. The Hardman index is not a reliable predictor of outcome following repair of ruptured abdominal aortic aneurysm. High-risk patients may still survive and should not be denied surgical repair based on the scoring system alone. Further evaluation of the risk factors is required to reliably and justifiably exclude those patients in whom the intervention is inappropriate.     

食管癌患者术前睡眠障碍与术后谵妄的相关性

目的探讨食管癌根治术患者术前睡眠障碍与术后谵妄(POD)的相关性,以及睡眠参数与POD的关系。方法选择2019年9—12月择期行食管癌根治术患者97例,男71例,女26例,年龄60～75岁,ASAⅠ或Ⅱ级。根据是否发生POD将患者分为两组:未发生POD组(nPOD组)和发生POD组(POD组)。采用双腔支气管插管全身麻醉,术中维持血流动力学平稳、采用小潮气量肺保护性通气策略,术后采用患者自控静脉镇痛(PCIA)。术前1 d采用匹兹堡睡眠质量指数(PSQI)量表评价睡眠质量,并记录入睡时间、觉醒次数、觉醒时间、睡眠时间等睡眠参数。术后1～7 d采用意识评估(CAM)量表进行认知功能评估。结果术后7 d内共有24例(25%)患者发生POD。与nPOD组比较,POD组术前合并睡眠障碍发生率明显升高,觉醒次数明显增多,觉醒时间明显延长,有效睡眠时间明显缩短,觉醒占总睡眠比例(WASO)明显升高(P0.05)。多因素Logistic回归分析结果显示,觉醒次数增加(OR=3.868,95%CI 1.645～9.006,P=0.002)和有效睡眠时间缩短(OR=3.802,95%CI 1.577～9.174,P=0.003)是POD的独立危险因素。结论术前合并睡眠障碍的食管癌根治术患者发生POD风险增加,睡眠中断以及有效睡眠时间缩短进一步增加POD发生风险。     

Does angiographic severity of coronary artery disease predict postoperative outcome after coronary artery bypass surgery?

OBJECTIVE: It is not clear whether the severity of coronary artery disease as assessed on angiography has an impact on the postoperative outcome after coronary artery bypass surgery (CABG). DESIGN: The angiographic status of 15 coronary arteries/segments of 2,233 patients who underwent isolated on-pump CABG was graded according to the following criteria: 1 = no stenosis; 2 = stenosis <50%; 3 = stenosis of 50-69%; 4 = stenosis of 70-89%; 5 = stenosis of 90-99%; 6 = vessel occlusion; and 7 = vessel is not visualized. RESULTS: Thirty-seven patients (1.7%) died during the in-hospital stay and 108 (4.8%) developed postoperatively low cardiac output syndrome. Multivariate analysis showed that along with other risk factors the overall coronary angiographic score was predictive of postoperative death (p = 0.03; OR: 1.027, 95% CI: 1.003-1.052) and of low cardiac output syndrome (p = 0.04; OR: 1.172, 95% CI: 1.010-1.218). The status of the proximal segment of the left circumflex coronary artery, the diagonal arteries and the left obtuse marginal arteries was most closely associated with adverse postoperative outcome. CONCLUSION: The angiographic status of coronary arteries has an impact on the immediate outcome after CABG.     

Introduction of adjuncts and their influence on changing results in 402 consecutive thoracoabdominal aortic aneurysm repairs.

OBJECTIVE: To assess the influence of adjuncts, cerebrospinal fluid drainage (CSFD) and evoked potentials, on morbidity and mortality after thoracoabdominal aortic aneurysm (TAAA) repair and to update our experience. METHODS: Between February 1981 and February 2003, 402 consecutive patients underwent repair of their TAAA using simple cross-clamping between 1981 and 1994 (n = 123; CC), left heart bypass (from 1987; n = 254) or extracorporeal circulation (n = 25; ADJ). Somatosensory evoked potentials were used in 264 patients and motor evoked potentials in 176 patients. CSFD was used in 202 patients (50.2%). RESULTS: Overall hospital mortality was 10.9:14.1% in the CC-group versus 9.1% in the ADJ-group (P = 0.07). The incidence of postoperative dialysis was 6.1%. Paraplegia and paraparesis together was found in 11.3%. Independent risk factors for hospital mortality were age (OR 1.1 per year, 95% CI 1.04-1.16), rupture (OR 3.8, 95% CI 1.7-8.8) and postoperative hemodialysis (OR 8.1, 95% CI 3.2-20.3). For postoperative hemodialysis the risk factors were age >/=75 years (OR 3.2, 95% CI 1.1-9.7), a preoperative creatinine level higher than 150 microM/l (OR 6.5, 95% CI 2.6-16.2), and as a protective factor operation performed after 1995 (OR 0.2, 95% CI 0.06-0.6). For spinal cord dysfunction (paraplegia and paraparesis together) the protective factors were age >/=75 years (OR 0.16, 95% CI 0.02-1.2), operation performed after 1995 (OR 0.31, 95% CI 0.15-0.65) and a previous aortic dissection (OR 0.38, 95% CI 0.15-0.9). CONCLUSIONS: The use of different adjuncts introduced over the years clearly influenced our results in a positive way.     

In-hospital outcomes after carotid endarterectomy for stroke stratified by modified Rankin scale score and time of intervention

ObjectiveAlthough the benefits of carotid endarterectomy (CEA) for treating symptomatic carotid stenosis are well known, the optimal timing of intervention after acute stroke and whether the optimal timing will vary with preoperative stroke severity has remained unclear. Therefore, we assessed the effect of stroke severity and timing of the intervention on the postoperative outcomes for patients who had undergone CEA for stroke.MethodsWe identified all patients in the Vascular Quality Initiative who had undergone CEA from 2012 to 2020 for prior stroke. The patients were stratified using the preoperative modified Rankin scale score (mRS score, 0-5) and time to CEA after stroke onset (≤2 days, 3-14 days, 15-90 days, 91-180 days). After univariate comparisons, the patients were stratified into the following mRS cohorts for further analysis: 0 to 1, 2, 3 to 4, and 5. The primary outcome was in-hospital stroke/death.ResultsWe identified 15,601 patients, of whom 30% had had an mRS score of 0, 34% an mRS score of 1, 17% an mRS score of 2, 11% an mRS score of 3, 8% an mRS score of 4, and 1% an mRS score of 5. Overall, 9.3% of the patients had undergone CEA within ≤2 days, 46% within 3 to 14 days, 36% in 15 to 90 days, and 8.4% within 90 to 180 days. A decreasing mRS score and an increasing time to CEA were associated with lower rates of perioperative stroke/death (P_trend < .01). After risk adjustment, with CEA at 3 to 14 days as the comparator group, the mRS score 0 to 1 group had had a higher incidence of stroke/death after CEA within ≤2 days (3.6% vs 2.0%; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2-2.7). The mRS score 2 group had had a similar incidence of stroke/death after CEA within ≤2 days (4.4% vs 3.9%; OR, 1.2; 95% CI, 0.6-2.3) but a lower incidence after CEA at 15 to 90 days (2.1% vs 3.9%; OR 0.5; 95% CI, 0.3-0.96). The mRS score 3 to 4 group had had a higher incidence of stroke/death after CEA within ≤2 days (8.0% vs 3.8%; OR, 2.4; 95% CI, 1.5-3.9) but a similar incidence of stroke/death after CEA at 15 to 90 days (3.0% vs 3.8%; OR, 0.8; 95% CI, 0.5-1.3). For the mRS score 5 group, the stroke/death rates were ≥6.5% across all the time to CEA groups. However, the low sample size limited meaningful comparisons.ConclusionsPatients with minimal disability after stroke (mRS score, 0-1) seemed to benefit from CEA within 3 to 14 days. However, those with severe disability (mRS score 5) have a very high risk from CEA at any time point given the poor outcomes. In contrast to the current guidelines, patients with mild disability (mRS score 2) could benefit from delaying CEA to 15 to 90 days, and those with moderate disability (mRS score 3-4) might benefit from CEA within 3 to 90 days given the acceptable in-hospital outcomes. These data should be considered within the context of the clinical situation in the weeks after index event to determine the net benefit of delayed CEA.     

Preoperative factors associated with postoperative change in confusion assessment method score in hip fracture patients

Postoperative delirium is a major problem in elderly patients undergoing surgical repair of hip fracture. It is imperative to identify potentially treatable preoperative factors associated with the onset of postoperative delirium to optimize outcome. We sought to determine what preoperative variables are associated with postoperative delirium in geriatric patients undergoing surgical repair of hip fracture. In a prospective, IRB-approved study, patients admitted to the geriatric hip fracture service were examined daily in the hospital for the occurrence of postoperative delirium. All patients with a preoperative diagnosis of dementia or delirium were eliminated. A positive confusion assessment method score ([+]CAM) was used to determine the presence of postoperative delirium during the acute hospital stay. To determine the association between preoperative variables (demographics, laboratory values, and comorbidities) and postoperative (+)CAM scores, chi(2) and logistic regression analysis were performed with calculation for the odds ratios (OR). One-hundred-sixty-eight patients (72% women) were included in the analysis. Twenty-eight percent (n = 47) of patients had a (+)CAM score. Three variables were significant predictors of a (+)CAM score: (a) normal white blood cell count (OR, 2.2), (b) abnormal serum sodium (OR, 2.4); and (c) ASA physical status >II (OR, 11.3). The results suggest that preoperative medical conditions (abnormal serum sodium and ASA physical status >II) and an inability to mount a stress response (normal white blood cell count) may influence the patient's postoperative mental status. In particular, two of the risk factors we identified may be amenable to therapy and are abnormal serum sodium and lack of an increase in white blood cell count during the stress of trauma and surgery. IMPLICATIONS: This prospective study investigated preoperative variables that are predictive of postoperative delirium in geriatric patients undergoing surgical repair of hip fracture. The results suggest that the patient's preoperative medical condition and inability to mount a stress response influence postoperative delirium.     

Brief report: preoperative frailty in older surgical patients is associated with early postoperative delirium

We investigated whether preoperative frailty among older noncardiac surgical patients provides information about the development of postoperative delirium that is in addition to traditional geriatric risk factors. One-third of patients had a frailty score ≥3, which is considered "frail" in others' research. Twenty-five percent of patients developed postoperative delirium, which was measured using the confusion assessment method. Multivariable logistic regression showed that age, activities of daily living dependence, instrumental activities of daily living dependence, and cognitive functioning did not contribute significantly to the prediction of postoperative delirium. Only preoperative symptoms of depression (odds ratio=1.42; 95% confidence interval=1.06-1.91; P=0.018) and the frailty score (odds ratio=1.84; 95% confidence interval=1.07-3.1; P=0.028) were independently associated with the development of postoperative delirium.     

Multivariate analysis of predictors of late stroke after total aortic arch repair.

OBJECTIVE: The number of aortic surgeries has recently increased, with improvement of outcome due to the development of various novel operative techniques and adjuncts. Although the postoperative incidence of stroke, the most severe complication of aortic surgery, is still a matter of concern and has been described well previously, late stroke after aortic arch repair has not been described well. We assessed the incidence and predictors of late stroke after total aortic arch repair. METHODS: From January 1993 to December 2003, 470 patients underwent total aortic arch repair in our institution. All patients, whether undergoing elective, urgent, or emergent aortic arch repair, were included. Emergent operation was required for 115 patients because of rupture or acute type A dissection. For brain protection, retrograde cerebral perfusion was used in 27% (125) and selective cerebral perfusion in 75% (353) of cases. The follow-up period was 32.5+/-31.5 months. Late stroke was defined as stroke occurring more than 30 days postoperatively. RESULTS: The incidence of early postoperative stroke was 4.9% (23/470), while that of late postoperative stroke was 6.0% (28/470). On univariate analysis, postoperative atrial fibrillation (P=0.014), preoperative prevalence of craniocervical lesions (P=0.0001), and advanced age (P=0.046) were each significantly related to late stroke. A Cox proportional hazards model detected postoperative atrial fibrillation (P=0.013, OR=3.02, 95% CI: 1.26-7.24) and preoperative prevalence of craniocervical lesions (P=0.0001, OR=5.37, 95% CI: 2.30-12.52) as predictors of late stroke. CONCLUSIONS: Postoperative atrial fibrillation and preoperative prevalence of craniocervical lesions were found to be risk factors for late stroke after total aortic arch repair.