Subsyndromal delirium after cardiac surgery

Abstract

Objectives. To evaluate the incidence of subsyndromal delirium (SSD) after cardiac surgery and its impact on clinical outcome. Design. In this prospective study, 506 patients were screened for SSD and clinical delirium (CD) using the Intensive Care Delirium Screening Checklist. Results. 150 (34%) patients were classified as having SSD and 54 (12%) patients as having CD. 2% of SSD patients developed CD. Patients’ age, EuroSCORE, postoperative the Acute Physiology and Chronic Health Evaluation II, the incidences of emergency operations, and the number of aortic surgery increased from non-delirious (ND) to SSD. Intensive care unit (ICU) and hospital stays were longer in CD compared with SSD patients. ND patients did not differ from SSD patients regarding duration of ventilation, ICU stay, or hospital stay. The rate of home discharge decreased from ND over SSD to CD patients. Mortality in SSD patients did not differ from ND or CD patients. Conclusion. SSD showed a prevalence of 34% in patients after cardiac surgery. SSD occurred independent of CD for the majority of patients. Except for a lower rate of home discharge, the clinical outcome did not differ from that of ND patients. According to our data, SSD does not represent a preliminary or resolving stage of delirium.     

Predictors of delirium after cardiac surgery delirium: effect of beating-heart (off-pump) surgery

BACKGROUND: Despite improved outcomes after cardiac operations, postoperative delirium remains a common complication that is associated with increased morbidity and prolonged hospital stay. METHODS: Univariate and multivariate predictors of postoperative delirium were determined from prospectively gathered data on 16,184 patients undergoing cardiac operations with cardiopulmonary bypass (conventional, n = 14,342) and without cardiopulmonary bypass (beating-heart surgery, n = 1847) between April 1996 and August 2001. Delirium was defined as a transient mental syndrome of acute onset characterized by global impairment of cognitive functions, a reduced level of consciousness, attentional abnormalities, increased or decreased psychomotor activity, and a disordered sleep-wake cycle. RESULTS: The overall prevalence of postoperative delirium was 8.4%. Of 49 selected patient-related risk factors and treatment variables, 35 were highly associated with postoperative delirium by univariate analysis. Stepwise logistic regression revealed the following variables as independent predictors of delirium: history of cerebrovascular disease, peripheral vascular disease, atrial fibrillation, diabetes mellitus, left ventricular ejection fraction of 30% or less, preoperative cardiogenic shock, urgent operation, intraoperative hemofiltration, operation time of 3 hours or more, and a high perioperative transfusion requirement. Two variables were identified as having a significant protective effect against postoperative delirium: beating-heart surgery and younger patient age. CONCLUSIONS: Postoperative delirium is a common complication in cardiac operations. The increased use of beating-heart surgery without cardiopulmonary bypass may lead to a lower prevalence of this complication and thus improve patient outcomes.     

Hospital administrative database underestimates delirium rate after cardiac surgery

Purpose

Administrative electronic databases are highly specific for postoperative complications, but they lack sensitivity. The objective of this study was to determine the incidence of delirium after cardiac surgery using a targeted prospectively collected dataset and to compare the findings with the incidence of delirium in the same cohort of patients identified in a hospital administrative database.

Methods

Following Research Ethics Board approval, we compared delirium rates in a prospectively collected data research database with delirium rates in the same cohort of patients in an administrative hospital database where delirium was identified from codes entered by coding and abstracting staff. Every 12 hr postoperatively, delirium was assessed with a Confusion Assessment Method in the Intensive Care Unit. The administrative database contained the International Classification of Diseases version 10 (ICD-10) codes for patient diagnoses. The ICD-10 codes were extracted from the administrative database for each patient in the research database and were checked for the presence of the ICD-10 code for delirium.

Results

Data from a cohort of 1,528 patients were analyzed. Postoperative delirium was identified in 182 (11.9%) patients (95% confidence interval [CI], 10.3-13.5%) in the research dataset and 46 (3%) patients (95% CI, 2.2-3.8%) in the administrative dataset (P < 0.001). Thirteen (0.85%) patients who were coded for delirium in the administrative database were not identified in the research dataset. The median onset of postoperative delirium in these patients was significantly delayed (4 [3-9] days) compared with patients identified by both datasets (2 [1-9] days) and compared with patients from the research database only (1 [1-14] days) (P = 0.007).

Conclusion

Postoperative delirium rates after cardiac surgery are underestimated by the hospital administrative database.     

心肺转流心脏手术术后谵妄的预防

术后谵妄是手术后常见的神经系统并发症,表现为急性发作的注意力不集中、思维混乱和意识水平的改变等.心肺转流心脏手术患者的术后谵妄发生率明显高于其他类型手术,严重影响患者术后恢复和生存质量.尽管不能完全避免术后谵妄的发生,但有效的预防措施可以明显降低心肺转流心脏手术患者术后谵妄的发生率.本文章回顾近年来国内外术后谵妄的相关...     

心脏手术后谵妄的危险因素分析及预测模型构建

目的 探讨心脏手术患者术后谵妄(POD)的危险因素,根据危险因素构建预测模型并评估其预测效能。
方法 本研究为回顾性病例-对照研究。收集2016年5月至2019年5月行心脏手术治疗的患者3 397例临床资料,提取性别、年龄、吸烟史、饮酒史、高血压病史、糖尿病史、高脂血症病史、脑血管疾病史、手术时间、心肺转流（CPB）时间、主动脉阻断时间、术中连续有创动脉血压值、术中出血量、术中麻醉药物使用情况、入ICU时Hb、白细胞计数、氧合指数（PaO2/FiO2）、血乳酸值、呼吸机使用时间、血管活性药物使用情况、术后左心室射血指数（LVEF）等临床指标,采用单因素分析评估上述指标与POD的相关性。采用逐步Logistic回归进行临床指标筛选并构建预测模型,绘制模型列线图,计算预测模型的受试者工作特征（ROC）曲线下面积（AUC）以及最佳阈值下的敏感性和特异性。
结果 有186例（5.48%）患者术后出现谵妄。与非谵妄患者比较,谵妄患者年龄、脑血管疾病和高血压病史比例、术中低血压比例、术中血压变异率、术中丙泊酚用量、术中出血量、术后乳酸值、术后白细胞显著增高的比例、术后左心室收缩功能不全（LVEF<50%）的比例以及术后应用肾上腺素和去甲肾上腺素比例明显增加（P<0.05）,手术时间和CPB时间、术中低血压时间以及术后机械通气时间明显延长（P<0.05）,术后氧合指数和Hb明显降低（P<0.05）。逐步Logistic回归分析显示,老年、脑血管疾病史、手术时间长、术中血压变异率大、术后Hb<100 g/L、机械通气时间延长以及左心室收缩功能不全、应用去甲肾上腺素是心脏手术后谵妄的独立危险因素。应用这些危险因素构建预测模型,AUC为0.932（95%CI 0.897～0.967）,敏感性78.2%,特异性93.5%。
结论 老年、脑血管疾病史、手术时间、术中血压变异率、术后Hb<100 g/L、机械通气时间延长以及左心室收缩功能不全、应用去甲肾上腺素是心脏手术后谵妄的独立危险因素,基于这些危险因素构建的模型可较好地预测心脏手术后谵妄的发生,为早期干预治疗提供参考。     

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。     

Cerebral oximetry and postoperative delirium after cardiac surgery: a randomised,controlled trial

Postoperative delirium is associated with increased morbidity and mortality. We hypothesised that restoration of regional cerebral oxygen desaturation would reduce the incidence of postoperative delirium in elderly patients after cardiac surgery. After institutional ethics review board approval and informed consent, a double‐blinded, prospective, randomised, controlled trial was conducted in patients ≥ 60 years of age undergoing cardiac surgery with cardiopulmonary bypass. In the intervention group, an algorithm was commenced if regional cerebral oxygen saturation decreased below 75% of baseline value for 1 min or longer. In the control group, the cerebral oximetry monitor screen was electronically blinded. Assessment of delirium was performed with confusion assessment method for intensive care unit or confusion assessment method after discharge from intensive care unit at 12‐h intervals for seven postoperative days. Postoperative delirium was present in 30 out of 123 (24.4%) and 31 out of 126 (24.6%) patients in the intervention and control groups, respectively, odds ratio 0.98 (95%CI 0.55–1.76), p = 0.97. Postoperative delirium was present in 20 (71%) out of 28 and in 41 (18%) out of 221 patients with baseline regional cerebral oxygen saturation ≤ 50, or > 50%, respectively, p = 0.0001. Higher baseline regional cerebral oxygen saturation and body mass index were protective against postoperative delirium. Restoration of regional cerebral oxygen desaturation did not result in lower postoperative delirium after cardiac surgery. Pre‐operative regional cerebral oxygen saturation ≤ 50% was associated with increased postoperative delirium rates in elderly patients following cardiac surgery.     

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.