Quetiapine for delirium prophylaxis in high-risk critically ill patients

BackgroundDelirium is common in patients admitted to the surgical trauma intensive care unit (ICU), and the risk factors for these patients differ from medical patients. Given the morbidity and mortality associated with delirium, efforts to prevent it may improve patient outcomes, but previous efforts pharmacologically have been limited by side effects and insignificant results. We hypothesized that scheduled quetiapine could reduce the incidence of delirium in this population.MethodsThe study included 71 adult patients who were at high-risk for the development of delirium (PRE-DELIRIC Score ≥50%, history of dementia, alcohol misuse, or drug abuse). Patients were randomized to receive quetiapine 12.5 mg every 12 h for delirium or no pharmacologic prophylaxis within 48 h of admission to the ICU. The primary end point was the incidence of delirium during admission to the ICU. Secondary end points included time to onset of delirium, ICU and hospital length of stay (LOS), ICU and hospital mortality, duration of mechanical ventilation, and adverse events.ResultsThe incidence of delirium during admission to the ICU was 45.5% (10/22) in the quetiapine group and 77.6% (38/49) in the group that did not receive pharmacological prophylaxis. The mean time to onset of delirium was 1.4 days for those who did not receive prophylaxis versus 2.5 days for those who did (p = 0.06). The quetiapine group significantly reduced ventilator duration from 8.2 days to 1.5 days (p = 0.002).ConclusionsThe findings suggested that scheduled, low-dose quetiapine is effective in preventing delirium in high-risk, surgical trauma ICU patients.     

Delirium in hospitalised adults with acute burns – A systematic review

IntroductionDelirium is a potentially modifiable, acutely altered mental state, commonly characterised as a hospital-acquired complication. Studies of adult inpatients with acute burns with and without delirium identify causative risks related to the injury or treatment and outcomes related to the patient and healthcare system. We compare patients with and without delirium, providing a high-level quantitative synthesis of delirium risks and outcomes to inform guidelines and future research.MethodsA systematic review, meta-analysis and GRADE evaluation of risks and outcomes associated with delirium in adults with acute burns was conducted using PRISMA guidelines and PROSPERO protocol CRD42021283055. The Newcastle-Ottawa Scale was used to assess quality.ResultsInvestigators reviewed ten studies. ASA score ≥ 3, Total Body Surface Area Percentage (TBSA)> 10%, surgery done, ICU admission, hospital and also Intensive Care Unit (ICU) lengths of stay all had statistically significant associations with delirium, with low-very low certainty on GRADE evaluation. Limitations were heterogeneous studies, review methodology and study bias.ConclusionDelirium represents a significant risk to comorbid patients with burns that are hospitalised, receive ICU care, and surgery. Further research is indicated to precisely categorise delirium along the clinical journey to identify modifiable factors, prevention, and proactive therapy.     

Effect of dexmedetomidine on delirium during sedation in adult patients in intensive care units: A systematic review and meta-analysis

Study objectiveTo compare the effect of sedation protocols with and without dexmedetomidine on delirium risk and duration in adult patients in intensive care units (ICUs).DesignA meta-analysis of randomized controlled trials.Review methodsWe searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and ISI Web of Science from inception to September 3, 2020. We included studies comparing the effect of dexmedetomidine-based sedation on delirium risk with non-dexmedetomidine-based sedation in adult patients in ICUs. We pooled the data using a random-effects model using Review Manager 5.2, and assessed publication bias using Stata 11.0. The quality of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation system.Main resultsWe included 36 studies involving 9623 participants. The use of dexmedetomidine was associated with reduced risk of delirium (risk ratio [RR], 0.63; 95% confidence interval [CI], 0.54–0.75; very low-quality evidence), but higher incidences of hypotension and bradycardia during hospital stay. Dexmedetomidine was also associated with shorter durations of ICU stay, hospital stay and mechanical ventilation. Dexmedetomidine did not affect ICU mortality (RR, 1.01; 95% CI, 0.89–1.14; low-quality evidence), hospital mortality (RR, 1.01; 95% CI, 0.91–1.12; very low-quality evidence), or 30-day mortality (RR, 0.77; 95% CI, 0.58–1.01; moderate-quality evidence), or duration of delirium (mean difference, −0.74 days; 95% CI, −1.83 to 0.36 days; very low-quality evidence). We identified publication bias for risk and duration of delirium, length of ICU stay, and hospital stay.ConclusionsLow- or very low-quality evidence suggests that dexmedetomidine was associated with a clinically-small reduction of delirium risk, ICU/hospital stay and mechanical ventilation duration, but were not associated with improved mortality or shorter delirium duration in ICU patients. These findings were inconclusive because of publication bias, heterogeneity, and limited sample size. Significant adverse effects of dexmedetomidine include hypotension and bradycardia.PROSPERO registration number: CRD42018095358.     

Explainable artificial intelligence to predict the risk of side-specific extraprostatic extension in pre-prostatectomy patients

IntroductionWe aimed to develop an explainable machine learning (ML) model to predict side-specific extraprostatic extension (ssEPE) to identify patients who can safely undergo nerve-sparing radical prostatectomy using preoperative clinicopathological variables.MethodsA retrospective sample of clinicopathological data from 900 prostatic lobes at our institution was used as the training cohort. Primary outcome was the presence of ssEPE. The baseline model for comparison had the highest performance out of current biopsy-derived predictive models for ssEPE. A separate logistic regression (LR) model was built using the same variables as the ML model. All models were externally validated using a testing cohort of 122 lobes from another institution. Models were assessed by area under receiver-operating-characteristic curve (AUROC), precision-recall curve (AUPRC), calibration, and decision curve analysis. Model predictions were explained using SHapley Additive exPlanations. This tool was deployed as a publicly available web application.ResultsIncidence of ssEPE in the training and testing cohorts were 30.7 and 41.8%, respectively. The ML model achieved AUROC 0.81 (LR 0.78, baseline 0.74) and AUPRC 0.69 (LR 0.64, baseline 0.59) on the training cohort. On the testing cohort, the ML model achieved AUROC 0.81 (LR 0.76, baseline 0.75) and AUPRC 0.78 (LR 0.75, baseline 0.70). The ML model was explainable, well-calibrated, and achieved the highest net benefit for clinically relevant cutoffs of 10–30%.ConclusionsWe developed a user-friendly application that enables physicians without prior ML experience to assess ssEPE risk and understand factors driving these predictions to aid surgical planning and patient counselling (https://share.streamlit.io/jcckwong/ssepe/main/ssEPE_V2.py).     

Clinical benefits of dexmedetomidine versus propofol in adult intensive care unit patients: a meta-analysis of randomized clinical trials

Background

This meta-analysis was performed to assess the influence of dexmedetomidine and propofol for adult intensive care unit (ICU) sedation, with respect to patient outcomes and adverse events.

Materials and methods

A systematic review was conducted of all randomized controlled trials exploring the clinical benefits of dexmedetomidine versus propofol for sedation in adult intensive care patients. The primary outcomes of this study were length of ICU stay, duration of mechanical ventilation, and risk of ICU mortality. Secondary outcomes included risk of delirium, hypotension, bradycardia and hypertension.

Results

Ten randomized controlled trials, involving 1202 patients, were included. Dexmedetomidine significantly reduced the length of ICU stay by <1 d (five studies, 655 patients; mean difference, −0.81 d; 95% confidence interval [CI], −1.48 to −0.15) and the incidence of delirium (three studies, 658 patients; relative risk [RR], 0.40; 95% CI, 0.22–0.74) in comparison with propofol, whereas there was no difference in the duration of mechanical ventilation (five studies, 895 patients; mean difference, 0.53 h; 95% CI −2.66 to 3.72) or ICU mortality (five studies, 267 patients; RR, 0.83; 95% CI, 0.32–2.12) between these two drugs. Dexmedetomidine was associated with an increased risk of hypertension (three studies, 846 patients; RR, 1.56; 95% CI, 1.11–2.20) compared with propofol. Other adverse event rates were similar between dexmedetomidine and propofol groups.

Conclusions

For ICU patient sedation, dexmedetomidine may offer advantages over propofol in terms of decrease in the length of ICU stay and the risk of delirium. However, transient hypertension may occur when dexmedetomidine is administered with a loading dose or at high infusion rates.     

Association between obstructive sleep apnea and atrial fibrillation and delirium after cardiac surgery. Sub-analysis of DECADE trial

BackgroundAtrial 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.MethodsSub-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.Results590 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).ConclusionIn 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.     

Optimal interval and duration of CAM-ICU assessments for delirium detection after cardiac surgery

Study objectiveOur goal was to determine when postoperative delirium first occurs, and to assess evaluation strategies that reliably detect delirium with lowest frequency of testing’.DesignThis was a retrospective study that used a database from a five-center randomized trial.SettingPostoperative cardiothoracic ICU and surgical wards.ParticipantAdults scheduled for elective coronary artery bypass and/or valve surgery.Intervention and measurementsPostoperative delirium was assessed using CAM-ICU questionnaires twice daily for 5 days or until hospital discharge. Data were analyzed using frequency tables and Kaplan-Meier time-to-event estimators, the latter being used to summarize time to first positive CAM-ICU over POD1–5 for all patients for various evaluation strategies, including all assessments, only morning assessment, and only afternoon assessments. Sensitivity for various strategies were compared using McNemar's test for paired proportions.Main resultsA total of 95 of 788 patients (12% [95% CI, 10% to 15%]) had at least 1 episode of delirium within the first 5 postoperative days. Among all patients with delirium, 65% were identified by the end of the first postoperative day. Delirium was detected more often in the mornings (10% of patients) than evenings (7% of patients). Compared to delirium assessments twice daily for five days, we found that twice daily assessments for 4 days detected an estimated 97% (95% CI 91%, 99%) of delirium. Measurements twice daily for three days detected 90% (82%, 95%) of delirium.ConclusionsPostoperative delirium is common, and CAM-ICU assessments twice daily for 4 days, versus 5 days, detects nearly all delirium with 20% fewer assessments. Four days of assessment may usually be sufficient for clinical and research purposes.     

Association between perioperative hypotension and postoperative delirium and atrial fibrillation after cardiac surgery: A post-hoc analysis of the DECADE trial

Study objectiveTo test the hypotheses that in adults having cardiac surgery with cardio-pulmonary bypass, perioperative hypotension increases the risk of delirium and atrial fibrillation during the initial five postoperative days.DesignSub-analysis of the DECADE multi-center randomized trial.SettingPatients who had cardiac surgery with cardiopulmonary bypass at the Cleveland Clinic.InterventionsIn the underlying trial, patients were randomly assigned 1:1 to dexmedetomidine or normal saline placebo.MeasurementsIntraoperative mean arterial pressures were recorded at 1-min intervals from arterial catheters or at 1–5-min intervals oscillometrically. Postoperative blood pressures were recorded every half-hour or more often. The co-primary outcomes were atrial fibrillation and delirium occurring between intensive care unit admission and the earlier of postoperative day 5 or hospital discharge. Delirium was assessed twice daily during the initial 5 postoperative days while patients remained hospitalized with the Confusion Assessment Method for the intensive care unit. Assessments were made by trained research fellows who were blinded to the dexmedetomidine administration.Main resultsThere was no significant association between intraoperative hypotension and delirium, with an adjusted odds ratio of 0.94 (95% CI: 0.81, 1.09; P = 0.419) for a doubling in AUC of mean arterial pressure (MAP) <60 mmHg. An increase in intraoperative AUC of MAP <60 mmHg was not significantly associated with the odds of atrial fibrillation (adjusted odds ratio = 0.99; 95% CI: 0.87, 1.11; P = 0.819). Postoperative MAP <70 mmHg per hour 1.14 (97.5% CI: 1.04,1.26; P = 0.002) and MAP <80 mmHg per hour 1.05 (97.5%: 1.01, 1.10; P = 0.010) were significantly associated with atrial fibrillation.ConclusionsIn patients having cardiac surgery with cardio-pulmonary bypass, neither intraoperative nor postoperative hypotension were associated with delirium. Postoperative hypotension was associated with atrial fibrillation, although intraoperative hypotension was not.     

Postoperative delirium: An independent risk factor for poorer quality of life with long-term cognitive and functional decline after cardiac surgery

Study objectiveTo evaluate the influence of delirium on the functional and cognitive capacity of patients included in the DELIPRECAS study, as well as on their quality of life, in the 3–4 years after cardiac surgery.DesignProspective observational study.SettingAssessment of cognitive and functional status from hospital discharge to the present, 3 years after cardiac surgery.Patients313 patients undergoing cardiac surgery consecutively, aged 18 years or over.MeasurementsThe primary outcome measure was the cognitive and functional status of the patients 3 years after cardiac surgery, evaluated by telephone interview, and the possible influence on them of delirium diagnosed by the Confusion Assessment Method in Intensive Care Units (CAM-ICU) during their stay in the intensive care unit after cardiac surgery.Main resultsPostoperative delirium acts as an independent risk factor for the long-term development of memory problems (OR 6.11, 95% CI 2.54 to 14.68, p < 0.001), concentration (OR 11.20, 95% CI 3.58 to 35.09, p > 0.001), confusion/disorientation (OR 10.93, 95% CI 3.61 to 33.12, p > 0.001), sleep problems (OR 5.21, 95% CI 2 0.29 to 11.84, p < 0.001), nightmares (OR 8.99, 95% CI 1.98 to 40.90, p = 0.004), emotional problems (OR 4.30, 95% CI 1.87 to 9.91, p = 0.001) and poorer mobility after hospital discharge (OR 2.436, 95% CI 1.06 to 5.61, p = 0.037). The number of hospital readmissions was also significantly higher in those patients who developed delirium after cardiac surgery (27% vs 13.8%, p = 0.022).ConclusionPostoperative delirium is a risk factor for decreased quality of life in patients 3 years after heart surgery, being associated with greater cognitive and functional deterioration, as well as greater risk of hospital readmission. Therefore, emphasis should be placed on both prevention and early recognition and treatment of delirium to improve long-term outcomes for patients after cardiac surgery.     

Intensive glucose control during the perioperative period for diabetic patients undergoing surgery: An updated systematic review and meta-analysis

Study objectiveTo evaluate the impact of intensive glucose control on diabetic patients undergoing surgery.DesignA systematic review and meta-analysis of randomized controlled trials. PubMed, CENTRAL, EMBASE, ISI Web of Science, and CINAHL databases were searched from inception to 13 December 2020.SettingOperating room, postoperative recovery area and ward, up to 30 days after surgery.PatientsDiabetic patients undergoing surgery.InterventionsWe used Review Manager 5.4 to pool the data with a random-effects model. The quality of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation system.MeasurementsThe primary outcomes were infectious complications, postoperative mortality, and hypoglycaemia. The secondary outcomes included atrial fibrillation, myocardial infarction, stroke, delirium, renal failure, postoperative mechanical ventilation time, length of intensive care unit (ICU) stay, and hospital stay.Main resultsThirteen studies involving 1582 participants were included. Compared with conventional glucose control, intensive glucose control was associated with a lower risk of infectious complications (risk ratio [RR], 0.35; 95% confidence interval [CI], 0.19–0.63; low-quality evidence), atrial fibrillation (RR, 0.55; 95% CI, 0.42–0.71; high-quality evidence), and renal failure (RR, 0.38; 95% CI, 0.15–0.95; moderate-quality evidence), as well as a shorter length of stay in the ICU (mean difference (MD), −0.55 day; 95% CI, −1.05 to −0.05 days; very-low-quality evidence) and hospital (MD, −1.61 days; 95% CI, −2.78 to −0.44 days; very-low-quality evidence). However, intensive glucose control was associated with a higher risk of hypoglycaemia (RR, 3.00; 95% CI, 1.97–4.55; high-quality evidence). There were no significant differences in postoperative mortality, myocardial infarction, stroke, delirium, or postoperative mechanical ventilation time.ConclusionsIntensive glucose control in diabetic patients is associated with a reduction in some adverse postoperative outcomes including infectious complications, but also appears to increase the risk of hypoglycaemia. Further well-designed studies may be needed to determine appropriate regimens to reduce hypoglycaemia incidence.PROSPERO registration numberCRD42021226138.     

Incidence and risk factors of delirium in the elderly general surgical patient

Background

This study evaluates the incidence of delirium and risk factors associated with delirium in elderly patients admitted to a general surgical ward.

Methods

Patients aged over 60 years who were admitted with an acute or elective general surgical diagnosis were eligible for this prospective cohort study. Risk factors associated with delirium were analyzed using univariate and multivariate analysis to identify those independently associated with delirium.

Results

A total of 209 patients were included in the study. The incidence of delirium was 16.9% (23.2% for acute admission, P < .001). Variables associated with delirium were dementia, presence of an urinary catheter, cognitive decline at admission measured with the mini-mental state examination, white blood cell count >10.0 × 10⁹/L, and urea >7.5 mmol/L. Median length of hospital stay was 13 days (range 3–85) for patients with delirium versus 7 (range 1–54) for patients without (P = .002).

Conclusions

The incidence of delirium is high in elderly patients, especially after an acute admission, leading to an increase in length of hospital stay. To minimize delirium, associated risk factors must be identified and, if possible, treated.     

Incidence of complications in the post-anesthesia care unit and associated healthcare utilization in patients undergoing non-cardiac surgery requiring neuromuscular blockade 2005–2013: A single center study

Study objectiveThe use of neuromuscular blockade agents (NMBA), had been associated with significant residual post-operative paralysis and morbidity. There is a lack of clinical evidence on incidence of postoperative complications within the post-anesthesia care unit (PACU) in patients exposed to intraoperative NMBA's. This study aims to estimate the incidence of post-operative complications associated with use of NMBAs and assessing its association with healthcare resource utilization.DesignRetrospective cohort.SettingPost-anesthesia care unit in tertiary care center.PatientsAdults having non-cardiac surgery and receiving NMBAs between April-2005 and December-2013MeasurementsWe assessed: 1) incidences of major and minor PACU complications, 2) incidence of any postoperative complication in patients receiving a NMBA reversal (neostigmine) vs. without. 3) We secondarily assessed the relationship between PACU complications and use of healthcare resources.Main resultsThe incidence of any major complications was 2.1% and that of any minor complication was 35.2%. ICU admission rate was 1.3% in patients without any complications, versus 5.2% in patients with any minor and 30.6% in patients with any major complication. ICU length of stay was prolonged in patients with any major (52.1 ± 203 h), compared to patients with any minor (6.2 ± 64 h) and with no complications (1.7 ± 28 h). Patients who received a NMBA and neostigmine, compared to without neostigmine, had a lower incidence of any major complication (1.7% vs. 6.05%), rate of re-intubation (0.8% vs. 4.6%) and unplanned ICU admission (0.8% vs. 3.2%).ConclusionsThis study documents that incidence of major PACU complications after non-cardiac surgery was 2.1%, with the most frequent complications being re-intubation and ICU admission. Patients receiving NMBA reversal were at a lower risk of re-intubation and unplanned ICU admission, justifying routine use of reversals. Complete NMBA reversals are crucial in reducing preventable patient harm and healthcare utilization.     

Association of Inflammatory Biomarkers with Immunosuppression Management and Outcomes in Kidney Transplant Recipients with COVID-19

BackgroundKidney transplant recipients with coronavirus disease 2019 (COVID-19) are at increased risk for adverse outcomes, such as acute kidney injury (AKI), intensive care unit (ICU) admission, and death. The association of inflammatory biomarkers with outcomes and the impact of changes in immunosuppression on biomarker levels are unknown.MethodsWe investigated factors associated with a composite of AKI, ICU admission, or death, and whether immunosuppression changes correlated with changes in inflammatory biomarkers and outcomes in kidney transplant recipients with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction.ResultsOf 59 patients, 50% had estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m². Patients who discontinued calcineurin inhibitors (CNIs) had higher peak high-sensitivity C-reactive protein (hs-CRP) than those who maintained the same dose (median, 344; interquartile range [IQR], 145-374 vs median, 41; IQR, 22-116 mg/L, P = .03). Of the patients, 73% were hospitalized, 22% had admissions to the ICU, and 20% died. Of the 56% with AKI, 35% required dialysis. All patients with AKI but without pulmonary manifestations recovered to 10% of baseline creatinine levels. Factors associated with the composite outcome were eGFR <60 mL/min/1.73 m² (odds ratio [OR], 5.833; 95% confidence interval [CI], 1.880-18.099; P = .002), hs-CRP (OR, 1.011/unit increase; 95% CI, 1.002-1.021; P = .019), white blood cell count (OR, 1.173/unit increase; 95% CI, 1.006-1.368; P = .041), and decreased or discontinued CNI (OR, 4.286; 95% CI, 1.353-13.572; P = .013). eGFR<60 mL/min/1.73 m² (OR, 11.176; 95% CI, 1.581-79.001; P = .016), and peak hs-CRP (OR, 1.010/unit increase; 95% CI, 1.000-1.020; P = .049) remained associated with the composite in the multivariable model.ConclusionsKidney transplant recipients with COVID-19 have high rates of ICU admissions, AKI, and death. Those with eGFR<60 mL/min/1.73 m² are at highest risk. CNI reduction is associated with higher inflammatory biomarkers, correlating with worse outcomes. More studies are needed to determine if this association should drive clinical management.     

Influencia de la fragilidad en el pronóstico de pacientes quirúrgicos mayores de 70 años con criterios de ingreso en UCI

IntroductionFrailty degree can influence more than age or severity in the outcome of patients older than 70 years undergoing surgery of the digestive system that require immediate postoperative control in the ICU.MethodsA prospective and observational study of patients over 70 years of age who were admitted to the surgical ICU of a third level hospital immediately after an elective or emergent surgical intervention on the digestive system from June 1, 2018 until June 1, 2019. The variables age, frailty Clinical Frailty Scale (CFS), and modified Frailty Index (mFI), severity (APACHE II), type of surgery, surgical pathology were recorded upon admission. A bivariate analysis was performed to assess the influence of frailty and severity on hospital morbidity and mortality and baseline situation of the patient (in terms of dependence) at 6 months.ResultsA total of 90 patients were recruited, 54.4% of whom were reoperated; 74.4% were initially discharged from the ICU, with 28.4% of readmission and directly associated to frailty (CFS and mFI: P<0.01). The overall mortality at 6 months was 44.5% being CFS (OR = 64.3; P<0.05, 95% CI: 12.3-333.9) and APACHE II (OR = 1.17; P<0.05; 95% CI: 1.04-1.32) the covariates that best related.ConclusionsThe estimation of frailty by CSF and mFI is directly associated to the surgical morbidity and readmission of elderly and severe patients admitted to the ICU. In addition, CFS and mFI has been efficient as a predictive of mortality at 6 months.     

MRSA colonization and acquisition in the burn unit: A systematic review and meta-analysis

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) is one of the most commonly encountered bacteria in the burn unit. In order to investigate the magnitude of this challenge, we assessed the prevalence of MRSA colonization on admission and the incidence of MRSA acquisition within burn units.MethodsWe searched PubMed and EMBASE for studies reporting MRSA colonization among patients admitted in burn units.ResultsWe identified 16 articles that fulfilled our inclusion criteria and found an overall pooled prevalence of MRSA colonization upon the first 72 h of admission (colonization on admission) to the burn unit of 4.1% (95% CI: 2.7%–5.7%). MRSA acquisition in studies without a decolonization protocol was 21.2% (95% CI: 13.2%–30.5%) with a statistically significant downward trend over the years. Studies that implemented a decolonization protocol yielded a MRSA acquisition incidence rate of 4.5% (95% CI: 0.9%–10.6%). MRSA acquisition was higher among patients that have had inhalation injury (OR 3.96, 95% CI: 2.51–6.23), flame burns (OR 1.85, 95% CI: 1.25–2.73), or ICU admission (OR 3.12, 95% CI: 2.18–4.47).ConclusionOur study yielded that among burn victims, MRSA colonization prevalence on admission is not negligible and the risk of becoming MRSA colonized during hospitalization is higher when no decolonization protocols are implemented. Flame burns, admission to ICU, and inhalation injury were found to be associated with MRSA acquisition.     

Delay in Source Control in Perforated Peptic Ulcer Leads to 6% Increased Risk of Death Per Hour: A Nationwide Cohort Study

Background

Delay to theatre for patients with intra-abdominal sepsis is cited as a particular risk factor for death. Our aim was to evaluate the potential relationship between hourly delay from admission to surgery and post-operative mortality in patients with perforated peptic ulcer (PPU).

Methods

All patients entered in the National Emergency Laparotomy Audit who had an emergency laparotomy for PPU within 24 h of admission from December 2013 to November 2017 were included. Time to theatre from admission was modelled as a continuous variable in hours. Outcome was 90-day mortality. Logistic regression adjusting for confounding factors was performed.

Results

3809 patients were included, and 90-day mortality rate was 10.61%. Median time to theatre was 7.5 h (IQR 5–11.6 h). The odds of death increased with time to operation once adjustment for confounding variables was performed (per hour after admission adjusted OR 1.04 95% CI 1.02–1.07). In patients who were physiologically shocked (N = 334), there was an increase of 6% in risk-adjusted odds of mortality for every hour Em Lap was delayed after admission (OR 1.06 95% CI 1.01–1.11).

Conclusion

Hourly delay to theatre in patients with PPU is independently associated with risk of death by 90 days. Therefore, we suggest that surgical source control should occur as soon as possible after admission regardless of time of day.

     

Association of postoperative delirium with cognitive outcomes: A meta-analysis

Study objectiveTo determine the association between postoperative delirium (POD) and cognitive outcomes at least 1 month after surgery in elderly patients, and synthesize the dynamic risk trajectory of cognition impairment after POD.DesignMeta-analysis searching PubMed, Cochrane and EMBASE from inception to November 1, 2020. The terms postoperative delirium, delirium after surgery, postsurgical delirium, postoperative cogniti*, postoperative cognitive dysfunction, postoperative cognition decline, cognitive decline, cognitive impair* and dement* were searched alone or in combination.MeasurementsInclusion criteria were prospective cohort studies investigating the association between POD and cognitive outcomes in patients aged ≥60 years underwent surgery. The primary outcome was the association between POD and cognitive outcomes at 1 or more months after surgery. We considered cognitive outcomes measured up to 12 months after surgery as short-term and beyond 12 months as long-term. Two authors performed the study screening, data extraction and quality assessments. Effect sizes were calculated as Hedges g or Odds ratio (OR) based on random- and fixed-effects models. Meta-regression was conducted to analyze the role of potential contributors to heterogeneity.Main resultsEighteen studies were included. Our result showed a significant and medium association between POD and cognitive outcomes after at least 1 month postoperatively (g = 0.61 95% CI 0.43–0.79; I² = 65.1%), indicating that patients with POD were associated with worse cognitive outcomes. The association of POD with short- and long-term cognitive impairment were also both significant (short-term: g = 0.46 95% CI 0.24–0.68; I² = 53.1%; and long-term: g = 0.82 95% CI 0.57–1.06; I² = 57.1%). A multivariate meta-regression suggested that age and measure of delirium were significant sources of heterogeneity. POD was also associated with the significant risk for dementia (OR = 6.08 95% CI 3.80–9.72; I² = 0) as well as attention (OR = 1.74 95% CI 1.13–2.68; I² = 0), executive (OR = 1.33 95% CI 1.00–1.80; I² = 0) and memory impairment (OR = 1.59 95% CI 1.20–2.10; I² = 43.0%). Additionally, our results showed that the risk trajectory for cognitive decline associated with POD within five years after surgery revealed exponential growth.ConclusionsThis is the first meta-analysis quantifying the association between POD and cognitive outcomes. Our results showed that POD was significantly associated with worse cognitive outcomes, including short- and long-term cognitive outcomes following surgery.     

Bilateral erector spinae plane blocks in children undergoing cardiac surgery: A randomized,controlled study

Study objectiveWe aimed to test the hypothesis that erector spinae plane block (ESPB) provides efficient analgesia and reduces postoperative morphine consumption in children undergoing cardiac surgery with median sternotomy.DesignA prospective, blinded, randomized, controlled study.SettingA tertiary university hospital, operating room and intensive care unit.PatientsForty children aged 2–10 years, who underwent cardiac surgery with median sternotomy. The patients were randomly divided into the block group (Group B) and the control group (Group C).InterventionsGroup B (n = 20) were treated with ultrasound-guided bilateral ESPB at the level of the T4-T5 transverse process, whereas no block was administered in Group C (n = 20). In all children, intravenous morphine at 0.05 mg/kg was used whenever the modified objective pain score (MOPS) ≥4 for postoperative analgesia.MeasurementsThe MOPS and Ramsay sedation score (RSS) were assessed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20 and 24 h postoperatively. Total morphine consumption at 24 h, extubation time and length of intensive care unit (ICU) stay was also evaluated and recorded.Main resultsBilateral ESPB significantly decreased the consumption of morphine in the first 24 h, postoperatively. During the postoperative 24-h follow-up, 11 children in Group C requested morphine and the cumulative dose of morphine was 0.83 ± 0.91 mg, while 4 children in Group B requested morphine and the cumulative dose of morphine was 0.26 ± 0.59 mg (p = 0.043). There was no significant difference between Groups B and C in terms of MOPS and RSS values, extubation time or length of ICU stay.ConclusionUltrasound-guided bilateral ESPB with bupivacaine provides efficient postoperative analgesia and reduces postoperative morphine consumption at 24 h in children undergoing cardiac surgery.     

Preoperative screening of patients at high risk of obstructive sleep apnea and postoperative complications: A systematic review and meta-analysis

Study objectiveTo determine the association between postoperative complications and a high versus low risk of obstructive sleep apnea (OSA) as determined via screening tools.DesignSystematic review and meta-analysis of cohort studies. PubMed, EMBASE, Web of Science, and the Cochrane Library were searched from their inception to January 5, 2021.SettingOperating room, postoperative recovery area, and ward.PatientsAdult patients scheduled for surgery.InterventionsWe used Review Manager 5.4 to pool the data. The quality of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation system.MeasurementsThe primary outcome was the composite endpoint of postoperative respiratory complications. The secondary outcomes were postoperative cardiac and neurological complications, intensive care unit (ICU) admission, and mortality.Main resultsTwenty-six studies with 50,592 patients were included. A STOP-Bang score ≥ 3 (versus <3) was associated with higher incidences of postoperative respiratory (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.66–2.68) and neurological complications (OR, 3.60; 95% CI, 1.56–8.31). A STOP-Bang score ≥ 5 (versus <5) was associated with higher incidences of postoperative respiratory (OR, 2.37; 95% CI, 1.11–5.04) and cardiac complications (OR, 4.95; 95% CI, 1.22–20.00) and higher in-hospital mortality (OR, 26.39; 95% CI, 2.89–241.30). A Berlin score ≥ 2 (versus <2) was not associated with the incidence of postoperative complications, ICU admission, or mortality. The quality of evidence for all outcomes was very low.ConclusionsVery low-quality evidence suggested that a high risk of OSA, as assessed using the STOP-Bang questionnaire, was associated with a higher incidence of postoperative respiratory complications, and may also be associated with higher incidences of postoperative cardiac and neurological complications than a low risk of OSA. Since most of the included studies did not adjust for confounding factors, our findings need to be interpreted with caution.PROSPERO registration number: CRD42021220236.