Abstract
Postoperative delirium (POD) is a significant clinical problem in neurosurgical patients after intracranial surgery. Identification of high-risk patients may optimize perioperative management, but an adequate risk model for use at early phase after operation has not been developed. In the secondary analysis of a prospective cohort study, 800 adult patients admitted to the ICU after elective intracranial surgeries were included. The POD was diagnosed as Confusion Assessment Method for the ICU positive on postoperative day 1 to 3. Multivariate logistic regression analysis was used to develop early prediction model (E-PREPOD-NS) and the final model was validated with 200 bootstrap samples. The incidence of POD in this cohort was19.6%. We identified nine variables independently associated with POD in the final model: advanced age (OR 3.336, CI 1.765–6.305, 1 point), low education level (OR 2.528, 1.446–4.419, 1), smoking history (OR 2.582, 1.611–4.140, 1), diabetes (OR 2.541, 1.201–5.377, 1), supra-tentorial lesions (OR 3.424, 2.021–5.802, 1), anesthesia duration > 360 min (OR 1.686, 1.062–2.674, 0.5), GCS < 9 at ICU admission (OR 6.059, 3.789–9.690, 1.5), metabolic acidosis (OR 13.903, 6.248–30.938, 2.5), and neurosurgical drainage tube (OR 1.924, 1.132–3.269, 0.5). The area under the receiver operator curve (AUROC) of the risk score for prediction of POD was 0.865 (95% CI 0.835–0.895). The AUROC was 0.851 after internal validation (95% CI 0.791–0.912). The model showed good calibration. The E-PREPOD-NS model can predict POD in patients admitted to the ICU after elective intracranial surgery with good accuracy. External validation is needed in the future.
Highlights
Postoperative delirium (POD) is a significant clinical problem in neurosurgical patients after intracranial surgery
Compared with non-POD group, POD was more likely to occur in patients who were female, older than 65 years, and education level less than 9 years, had history of alcohol abuse and smoking, had history of hypertension, diabetes and stroke, American Society of Anesthesiologists (ASA) physical status III – IV, supra-tentorial lesions, intraoperative use of steroid, intraoperative transfusion, and anesthesia duration > 6 hours, as well as had Glasgow Coma Scale (GCS) < 9, metabolic acidosis, use of patient-controlled intravenous analgesia (PCIA), and positioning of neurosurgical drainage tube at intensive care unit (ICU) admission (Table 1)
We developed and internally validated a practical prediction model for POD in neurosurgical patients admitted to the ICU after elective craniotomy, consisting of 9 clinical factors: age, education level, history of smoking, history of diabetes, supra-tentorial lesions, anaesthesia duration, GCS at ICU admission, metabolic acidosis, and positioning of neurosurgical drainage tubes
Summary
Postoperative delirium (POD) is a significant clinical problem in neurosurgical patients after intracranial surgery. There has been increased attention to the postoperative management of neurosurgical patients to improve long-term neurocognitive, and reducing POD has been identified as an important target for surgical quality improvement (Berian et al 2018). Identifying high-risk patients for POD and early intervention for high-risk subjects may reduce the occurrence of delirium. There are a few studies developed risk models to predict POD in neurosurgical patients, but each of these models has its own limitation, including small sample size, only involving single disease, or predictors unavailable at intensive care unit (ICU) admission (Wang et al 2020b; Zhan et al 2020; Harasawa et al 2014; Flanigan et al 2018). We developed, internally validated, and tested a risk score model for POD in neurosurgical patients using data from our previous prospective cohort study of adult patients after elective craniotomy (Wang et al 2020a)
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