Delirium Outcomes Research Articles

Poor olfaction prior to cardiac surgery: Association with cognition, plasma neurofilament light, and post-operative delirium.

Post-operative delirium (POD) affects up to 50% of cardiac surgery patients, with higher incidence in older adults. There is increasing need for screening tools that identify individuals most vulnerable to POD. Here, we examined the relationship between pre-operative olfaction and both incident POD and POD severity in patients undergoing cardiac surgery. We also examined cross-sectional relationships between baseline olfaction, cognition, and plasma neurofilament light (NfL). Individuals undergoing cardiac surgery (n=189; mean age=70years; 75% men) were enrolled in a clinical trial of cerebral autoregulation monitoring. At baseline, odor identification performance (Brief Smell Identification Test), cognitive performance, and plasma concentrations of NfL levels (Simoa™ NF-Light Assay) were measured. Delirium was assessed with the Confusion Assessment Method (CAM) or CAM-ICU, and delirium severity was assessed using the Delirium Rating Scale-Revised-98. The association of baseline olfaction, delirium incidence, and delirium severity was examined in regression models adjusting for age, duration of cardiopulmonary bypass, logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE), and baseline cognition. Olfactory dysfunction was present in 30% of patients, and POD incidence was 44%. Pre-operative olfactory dysfunction was associated with both incident POD (OR=3.17, p=0.001) and greater severity of POD after cardiac surgery (OR=3.94 p<0.001) in models adjusted for age, duration of bypass, and a surgical risk score. The addition of baseline cognition attenuated the strength of the association, but it remained significant for incident POD (OR=2.25, p=0.04) and POD severity (OR 2.10, p=0.04). Poor baseline olfaction was associated with greater baseline cognitive dysfunction (p<0.001) and increased baseline plasma NfL concentrations (p=0.04). Neither age, cognition, nor baseline NFL concentration modified the association of impaired olfaction and delirium outcomes. Olfactory assessment may be a useful pre-surgical screening tool for the identification of patients undergoing cardiac surgery at increased risk of POD. Identifying those at highest risk for severe delirium and poor cognitive outcomes following surgery would allow for earlier intervention and pre-operative rehabilitation strategies, which could ultimately impact the functional disability and morbidity associated with POD.

Effect of a Single-dose Dexmedetomidine on Postoperative Delirium and Intraoperative Hemodynamic Outcomes in Elderly Hip Surgery; A Randomized Controlled Trial Dexmedetomidine for Postoperative Delirium

Objective: Postoperative delirium (POD) is common in elderly patients. The growing evidences suggesting the potential benefits of dexmedetomidine (DEX) infusion in reducing POD. However, the administration of a singledose DEX remains controversial. This study aims to investigate the effect of a single-dose DEX on POD in elderlypatients undergoing hip surgery. Materials and Methods: This prospective, randomized, double-blinded trial enrolled patients aged over 65 years who underwent hip surgery under spinal anesthesia. Patients were assigned to either the DEX (received intravenous DEX 0.3-0.5 μg/kg after incision), or the normal saline solution (NSS). Delirium assessments were conducted at the post anesthetic care unit (PACU) and at 24, 48 and 72 hours postoperatively using the Confusion AssessmentMethod (CAM). Results: A total of 200 patients were randomized, with 100 in the DEX and 100 in the NSS. The incidence of POD was significantly lower in the DEX compared to the NSS (P &lt; 0.001, RR 0.45, 95%CI: 0.28, 0.73). This difference remained significant at each postoperative assessment time point. There was no significant difference in sedation score and perioperative hemodynamics, except for a slightly lower intraoperative heart rate (P=0.015) and systolic blood pressure (P=0.029) observed at the PACU in the DEX, but these differences were not clinically significant. Additionally, the length of stay after surgery in the DEX was significantly shorter compare to the NSS (P=0.006). Conclusion: A single-dose dexmedetomidine can reduce the incidence of POD within 72 hours postoperatively in elderly patients undergoing hip surgery without compromising intraoperative hemodynamic stability.

The effectiveness of preoperative delirium prevention in intermediate to high-risk older surgical patients: A systematic review.

Few reviews have addressed delirium prevention among intermediate to high-risk older surgical patients. To map preoperative delirium prevention interventions for older surgical patients at intermediate to high risk of developing delirium, assess outcomes and identify gaps in knowledge. Systematic narrative review of randomised controlled trials reported following the PRISMA checklist. A systematic search was conducted of the literature published from 1990 to October 2022 in Medline, CINAHL and Ageline and of the grey literature in Google Scholar. Randomised controlled trials were retrieved that assessed the effectiveness of preoperative delirium prevention interventions for older surgical patients at intermediate to high risk of delirium. Data were extracted using a data extraction tool, and results were tabulated. Studies were assessed for bias using the Cochrane Collaboration Risk of Bias tool. Twenty-one studies met the selection criteria including N = 5096 participants. Two studies tested cognitive training, two studies tested fascia iliaca compartment block and one study assessed femoral nerve block. Ten studies tested prophylactic medications including methylprednisolone. Five studies investigated geriatric assessment and management. One study assessed transcutaneous electrical acupoint stimulation. In the two studies testing fascia iliaca compartment block, there was a reduction in postoperative delirium for orthopaedic patients. Methylprednisolone reduced postoperative delirium in orthopaedic patients and in those undergoing gastrointestinal surgery. Results of all other interventions on the occurrence of postoperative delirium and additional outcomes including the severity and duration of delirium were inconclusive. Despite the promising results for fascia iliaca compartment block and methylprednisolone, there is limited knowledge regarding evidence-based delirium prevention interventions. Most studies had small sample sizes indicating that the current evidence is exploratory. There is an urgent need for the funding and conduct of trials to test preventative interventions for older surgical patients at intermediate to high risk of developing delirium.

Effect of Optimizing Regional Cerebral Oxygen Saturation during Infant Cardiac Surgery on the Incidence of Postoperative Delirium: A Retrospective Study.

To investigate the effect of optimizing regional cerebral oxygen saturation (rScO2) on the incidence of postoperative delirium and surgical outcome in infants with congenital heart disease. Sixty-one infants experienced desaturation in rScO2 of 10% from baseline for more than 30 seconds during surgery between January 2020 and January 2022. Among them, 32 cases (Group A) received the corresponding treatment in the process of desaturation and 29 cases (Group B) were observed without receiving any treatment. General information, cerebral oxygen saturation, the incidence of postoperative delirium, and other relevant clinical data were collected. The duration and severity of intraoperative rScO2 desaturation in Group A were significantly lower than those in Group B. The incidence of postoperative delirium in Group A was significantly lower than that in Group B. There was no significant difference in the positive screening score for delirium between the two groups. Binary logistic regression analysis showed that the aortic cross-clamp time, mechanical ventilation duration, and severity of intraoperative rScO2 desaturation were significantly correlated with the occurrence of postoperative delirium. Aggressive rScO2 desaturation treatment is associated with a lower incidence of postoperative delirium and improved surgical outcomes.

“Beyond Feasibility”: A Qualitative Study of Patients, Their Whānau (Family) and Staff Perspectives and Experiences of a Non- Pharmacological Delirium-Prevention Intervention in Two Aotearoa/New Zealand Hospices

ContextDelirium is prevalent in the hospice population. Despite causing significant distress to patients and families, delirium is under-recognised. There is a need to better understand delirium prevention and outcomes in this population including people's experiences of delirium-prevention strategies in different cultural contexts. ObjectivesTo determine whether the "PRESERVE Aotearoa" delirium prevention intervention was feasible and acceptable for Māori (indigenous peoples of Aotearoa/ New Zealand) and non-Māori patients with advanced cancer, their families (called whānau in this paper), and clinical staff. MethodsA qualitative semistructured interview substudy of a cohort PRESERVE Aotearoa feasibility study codesigned with a Māori partner to ensure inclusion of Māori-centred values. The study was underpinned conceptually by He Awa Whiria (braided rivers)—combining Western and Māori knowledges. Data were analysed using Hopwood and Srivasta's framework. ResultsTwenty-six patients and their whānau, 21 clinical staff and five researchers from two stand-alone hospices in the North Island, Aotearoa/New Zealand. Finding showed that, for the most part, participants considered the study interventions feasible and acceptable. Inductive analysis resulted in four themes highlighting the importance to whānau of their participation in the study: benefits of learning about delirium; the affirmation of the caregiver role and whānau-centred care; valuing fundamentals of care; and research as legacy. ConclusionThis qualitative study found that it is feasible and acceptable to study multicomponent nonpharmacological delirium-prevention interventions in Aotearoa/New Zealand hospice inpatient units. The study also highlights the value of Māori-centred approaches and whānau involvement in these settings.

Multicentre implementation of a quality improvement initiative to reduce delirium in adult intensive care units: An interrupted time series analysis

PurposeThe ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada. Material and methodsWe conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record. Results44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18–0.50%, p < 0.01) from 33.48% (95%CI 29.64–37.31%) in 2017 to 28.74% (95%CI 25.22–32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00–11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events. ConclusionsAn ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium.

Augmented Reality Improves Pediatric Mask Induction: A Prospective, Matched Case-Control Study.

Introduction: Pediatric perioperative anxiety is a significant problem during mask induction for general anesthesia. Immersive technologies, such as extended reality headsets, are a promising strategy for alleviating anxiety. Our primary aim was to investigate mask acceptance during inhalational induction utilizing augmented reality (AR). Methods: This was a prospective, matched case-control study at a quaternary academic hospital. Fifty pediatric patients using AR for mask induction were matched to 150 standard-of-care (SOC) controls. The primary outcome was measured with the Mask Acceptance Scale (MAS). Secondary outcomes of cooperation and emergent delirium (ED) were assessed. Results: MAS scores ≥2 occurred at 4% (95% CI [0, 9.4%]) with AR versus 19.3%, (95% CI [13%, 25.7%]) with SOC (RR 0.21, 95% CI [0.05, 0.84], P = .027). Ninety-eight percent of AR patients were cooperative versus 91.3% with SOC (P = .457). Zero percent had ED with AR versus 0.7% with SOC (P = 1.000). Conclusions: AR during mask induction improved mask acceptance compared to SOC. No relationship was observed between AR and cooperation or ED. Future research will investigate the integration of AR into clinical practice as a nonpharmacologic intervention.

Does pain optimisation impact delirium outcomes in critically ill patients? A systematic review and meta-analysis protocol

BackgroundUntreated pain is associated with short-term and long-term consequences, including post-traumatic stress disorder and insomnia. Side effects of some analgesic medications include dysphoria, hallucinations and delirium. Therefore, both untreated pain...

NCI-Delirium Model: Co-caring to decrease the incidence of delirium among hospitalized older adults.

Delirium negatively impacts the health and wellbeing of older adults and their family carers and contributes to unnecessary high healthcare costs, estimated at $8.8 billion per year in Australia. Improvements to clinical practice are urgently needed, particularly now, as the COVID-19 pandemic is placing an enormous burden on our hospitals. &#x0D; Innovative strategies that support partnerships with family carers have been reported as key to improved patient outcomes and satisfaction with care, particularly for older adults unable to participate in their own care. This is because carers have intimate knowledge of a family member’s cognitive state to identify early subtle changes others might not. Carers also provide valuable reassurance and familiarity to the older adults during their treatment and can orient them to place and time. &#x0D; Founded on our clinical observations, informed by a scoping review of the literature (in press) and co-designed with carers, consumers, clinicians and policy analysts, we developed a new model of delirium care: NCI-Delirium. NCI-Delirium is a validated, scalable, low risk model that values the lived experience of older adults and carers. NCI-Delirium supports the integration of carers as partners in the care of the older adult from admission into the acute care setting. To support the integration of carers as partners, they are offered a web-based Delirium Toolkit that contains: an education package to build awareness and skill development (e.g., delirium risk factors, therapeutic and preventive strategies and non-pharmacological interventions to manage the reorientation of the hospitalised older adult); a 7-item psychometrically tested screening tool designed for carers to identify delirium symptoms and people at risk of delirium; access to support resources (e.g., counselling, social prescriptions, peer-support); and a co-designed discharge plan with the health team. &#x0D; Preliminary results suggest that NCI-Delirium improves health service delirium outcomes. Carer involvement in this research, and the introduction of their perspectives, has elevated carers’ key relationships with clinicians. Our co-designed solution to support the integration of carers as partners in delirium management has improved carers’ caregiving burden, psychological wellbeing and knowledge of delirium. This translatable co-designed model of care provides the much needed rich and robust clinical, implementation and economic evidence, to address the risk factors associated with the prevalence of delirium in hospitalised older adults. It is anticipated that the model will transform how we integrate carers as partners in care to improve clinical practice, patient and carer experiences; and reduce caregiving burden.&#x0D; Globally, the identification and management of risk for delirium is imperative. Delirium is a potentially life-threatening condition, and not well detected in the acute or community care setting. If carers are integrated and supported as partners in care, the capacity to identify symptoms and support the diagnosis of delirium should increase, potentially reducing functional decline, transition to residential aged care facilities and mortality rates. The next steps are to evaluate this co-designed web-based delirium model of care for use by carers in the community and residential aged care setting.&#x0D;

Modification in ICU Design May Affect Delirium and Circadian Melatonin: A Proof of Concept Pilot Study.

Nonpharmacologic delirium management is recommended by current guidelines, but studies on the impact of ICU design are still limited. The study's primary purpose was to determine if a multicomponent change in room design prevents ICU delirium. Second, the influence of lighting conditions on serum melatonin was assessed. Prospective observational cohort pilot study. The new design concept was established in two two-bed ICU rooms of a university hospital. Besides modifications aimed at stress relief, it includes a new dynamic lighting system. Seventy-four adult critically ill patients on mechanical ventilation with an expected ICU length of stay of at least 48 hours, treated in modified or standard rooms. None. The clinical examination included a prospective assessment for depth of sedation, delirium, and pain every 8 hours using validated scores. Blood samples for serum melatonin profiles were collected every 4 hours for a maximum of three 24-hour periods. Seventy-four patients were included in the analysis. Seventy-six percent ( n = 28) of patients in the standard rooms developed delirium compared with 46% of patients ( n = 17) in the modified rooms ( p = 0.017). Patients in standard rooms (vs. modified rooms) had a 2.3-fold higher delirium severity (odds ratio = 2.292; 95% CI, 1.582-3.321; p < 0.0001). Light intensity, calculated using the measure of circadian effective irradiance, significantly influenced the course of serum melatonin ( p < 0.0001). Significant interactions ( p < 0.001) revealed that differences in serum melatonin between patients in standard and modified rooms were not the same over time but varied in specific periods of time. Modifications in ICU room design may influence the incidence and severity of delirium. Dedicated light therapy could potentially influence delirium outcomes by modulating circadian melatonin levels.

Incidence, associated factors, and outcomes of delirium in critically ill children in china: a prospective cohort study

BackgroundDelirium occurs frequently in critically ill children and has been reported in many countries, but delirium is not well-characterized in China. The aim of this study was to represent the incidence of delirium in critically ill children in China, its associated factors, and the influence of delirium on in-hospital outcomes.MethodsThis observational prospective cohort study was set up in a large academic medical center with a 57-bed PICU in southwestern China. Critically ill children who required PICU stays over 24 h and were admitted between November 2019 and February 2022 were included in this study. The Cornell Assessment of Pediatric Delirium was used twice daily for delirium evaluation by bedside nurses, and twenty-four clinical features were collected from medical and nursing records during hospitalization.ResultsThe incidence of delirium was 26.0% (n = 410/1576). Multivariate analysis revealed that seven independent risk factors including days of mechanical ventilation and physical restraints, admission diagnosis (neurologic disorder), sleep deprivation, use of benzodiazepines and dexmedetomidine, liver failure/liver dysfunction associated with delirium in critically ill children. One potentially protective factor was the watching television /listening to music/playing with toys. Children with delirium had longer lengths of stay in the PICU (median 11 vs. 10 days, p < 0.001) and hospital (median 18 vs. 15 days, p < 0.001) compared to those without delirium. Additionally, the in-hospital mortality rates were 4.63% and 0.77% in patients with and without delirium (p < 0.05).ConclusionsDelirium is common in critically ill children in China and related to poor outcomes. Interventional studies are warranted to determine the best practices to reduce delirium exposure in at-risk children.

The frail patient undergoing cardiac surgery: lessons learned and future perspectives.

Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.

Extremes of baseline cognitive function determine the severity and outcomes of delirium: findings from a prospective longitudinal cohort study

AbstractBackgroundEpidemiological studies have shown the bidirectional relationship between dementia and delirium to be complex and non‐linear. This has implications for mechanistic studies investigating the extent to which any pathophysiology might be specific to delirium, or shared with dementia. While delirium is associated with long‐term dementia risk and cognitive decline, this association may be independent of classical Alzheimer’s pathology in oldest‐old patients.MethodThe Delirium and Population Health informatics (DELPHIC) study prospectively followed a population‐representative sample of 1510 individuals aged ≥70 years living in London, UK. We performed cognitive assessments at baseline, two years, and ascertained delirium symptoms during incident hospitalisation in 209 participants across 371 episodes.ResultBetter baseline cognitive function was generally associated with a lower likelihood of delirium. However, during delirium episodes, there was a U‐shaped relationship between baseline cognition and delirium symptom severity; participants with the lowest and highest baseline cognition experienced the most severe delirium and arousal deficits (baseline z‐score ‐2: mean MDAS 15; baseline z‐score +2: mean MDAS 11). At follow‐up, we observed the largest cognitive decline in participants with better baseline cognition experiencing delirium (2.2SD decline vs 0.8SD without delirium).ConclusionThese findings imply that delirium pathophysiology research should take into account differences in baseline cognition, for example by defining pre‐existing subclinical dementia pathology. We suggest the need for prospective, serial pathophysiological studies to consider the temporal sequence of delirium‐related neural damage. In this way, we could differentiate which mechanisms are unique to delirium, and which might interact with pre‐existing dementia pathophysiology to result in long‐term cognitive deficits.

Brain metabolism during delirium

AbstractBackgroundAltered cerebral glucose metabolism manifested by increased cerebrospinal fluid (CSF) lactate and decreased neuron specific enolase during delirium has been found in CSF analyses in multiple settings, although without change in CSF or blood glucose. These changes correlate with markers of delirium severity and outcomes of delirium.However, patients with delirium are acutely unwell in hospital and have multiple comorbidities. The contribution of acute illness and dementia have not been excluded.MethodWe studied two groups of acutely unwell older people in hospital after excluding underlying dementia by history and the Informant Questionnaire on Cognitive Decline in the Elderly. The first group had delirium and the second group had no delirium. All patients underwent a 18F‐fluorodeoxyglucose positron emission tomography (FDG‐PET) scan in hospital while unwell, and during delirium for the first group. Confounders on FDG‐PET such as structural brain lesions and medications that affect brain metabolism were excluded.Then we also compared the delirium FDG‐PET scans to a group with Alzheimer’s dementia.ResultPatients with delirium demonstrated a unique, novel pattern of brain hypometabolism that reflected symptoms of delirium. The affected areas included: bilateral thalami; right posterior cingulate cortex (PCC); right superior frontal, right infero‐lateral anterior temporal and left superior parietal cortices. The areas highly negatively correlated with delirium severity scores (Spearman’s rank correlation coefficients between ρ = ‐0.39 and ‐0.71; p values from 0.089 to 0.001) and performance on a range of relevant neuropsychological tests, for example thalami and Trail Making Test B (Spearman’s ρ = ‐0.52; p = 0.028). Direct comparison to AD scans significant thalamic hypometabolism (p&lt;0.01) in delirium, but the PCC was not different.ConclusionIn patients with acute illness but without dementia, delirium is accompanied by regional cerebral hypometabolism in a distribution that is not consistent with any known pattern of dementia. While there is some overlap with AD, thalamic hypometabolism is atypical of AD and consistent with the clinical features of delirium.ReferencesNitchingham AR, Pereira JV‐B, Wegner EA, Oxenham V, Close J Caplan GA. Regional cerebral hypometabolism on 18F‐FDG PET/CT scan in delirium is independent of acute illness and dementia. Alzheimers &amp; Dementia 2022; 1‐10.

Risk factors and associated outcomes of postoperative delirium after open abdominal aortic aneurysm repair

ObjectiveOpen abdominal aortic aneurysm repair (OAR) is a major vascular procedure that incurs a large physiologic demand, increasing the risk for complications such as postoperative delirium (POD). We sought to characterize POD incidence, identify delirium risk factors, and evaluate the effect of delirium on postoperative outcomes. We hypothesized that POD following OAR would be associated with increased postoperative complications and resource utilization. MethodsThis was a retrospective study of all OAR cases from 2012 to 2020 at a single tertiary care center. POD was identified via a validated chart review method based on key words and Confusion Assessment Method assessments. The primary outcome was POD, and secondary outcomes included length of stay, non-home discharge, 90-day mortality, and 1-year survival. Bivariate analysis as appropriate to the data was used to assess the association of delirium with postoperative outcomes. Multivariable binary logistic regression was used to identify risk factors for POD and Cox regression for variables associated with worse 1-year survival. ResultsOverall, 198 OAR cases were included, and POD developed in 34% (n = 67). Factors associated with POD included older age (74 vs 69 years; P < .01), frailty (50% vs 28%; P < .01), preoperative dementia (100% vs 32%; P < .01), symptomatic presentation (47% vs 27%; P < .01), preoperative coronary artery disease (44% vs 28%; P = .02), end-stage renal disease (89% vs 32%; P < .01) and Charlson Comorbidity Index score >4 (42% vs 26%; P = .01). POD was associated with 90-day mortality (19% vs 5%; P < .01), non-home discharge (61% vs 30%; P < .01), longer median hospital length of stay (14 vs 8 days; P < .01), longer median intensive care unit length of stay (6 vs 3 days; P < .01), postoperative myocardial infarction (7% vs 2%; P = .045), and postoperative pneumonia (19% vs 8%; P = .01). On multivariable analysis, risk factors for POD included older age, history of end-stage renal disease, lack of epidural, frailty, and symptomatic presentation. A Cox proportional hazards model revealed that POD was associated with worse survival at 1 year (hazard ratio, 3.8; 95% confidence interval, 1.6-9.0; P = .003). ConclusionsPOD is associated with worse postoperative outcomes and increased resource utilization. Future studies should examine the role of improved screening, implementation of delirium prevention bundles, and multidisciplinary care for the most vulnerable patients undergoing OAR.

Evaluating the effects of S-ketamine on postoperative delirium in elderly patients following total hip or knee arthroplasty under intraspinal anesthesia: a single-center randomized, double-blind, placebo-controlled, pragmatic study protocol

IntroductionPostoperative delirium (POD) is an acute, transient brain disorder associated with decreased postoperative quality of life, dementia, neurocognitive changes, and mortality. A small number of trials have explored the role of S-ketamine in the treatment of POD due to its neuroprotective effects. Surprisingly, these trials have failed to yield supportive results. However, heterogeneity in delirium assessment methodologies, sample sizes, and outcome settings as well as deficiencies in S-ketamine use methods make the evidence provided by these studies less persuasive. Given the severe impact of POD on the health of elderly patients and the potential for S-ketamine to prevent it, we believe that designing a large sample size, and rigorous randomized controlled trial for further evaluation is necessary.MethodsThis is a single-center, randomized, double-blind, placebo-controlled, pragmatic study. Subjects undergoing total hip or knee arthroplasty will be randomized in a 1:1 ratio to intervention (n = 186) and placebo (n = 186) groups. This trial aims to explore the potential role of S-ketamine in the prevention of POD. Its primary outcome is the incidence of POD within 3 postoperative days. Secondary outcomes include the number of POD episodes, the onset and duration of POD, the severity and subtype of POD, pain scores and opioid consumption, sleep quality, clinical outcomes, and safety outcomes.DiscussionTo our knowledge, this is the first pragmatic study that proposes to use S-ketamine to prevent POD. We reviewed a large body of literature to identify potential preoperative confounding variables that may bias associations between the intervention and primary outcome. We will use advanced statistical methods to correct potential confounding variables, improving the test’s power and external validity of test results. Of note, the patient population included in this trial will undergo intraspinal anesthesia. Although large, multicenter, randomized controlled studies have found no considerable difference in the effects of regional and general anesthesia on POD, patients receiving intraspinal anesthesia have less exposure to at-risk drugs, such as sevoflurane, propofol, and benzodiazepines, than patients receiving general anesthesia. At-risk drugs have been shown to negatively interfere with the neuroprotective effects of S-ketamine, which may be the reason for the failure of a large number of previous studies. There is currently a lack of randomized controlled studies evaluating S-ketamine for POD prevention, and our trial helps to fill a gap in this area.Trial registration: http://www.chictr.org.cn, identifier ChiCTR2300075796.

Early incident and subsyndromal delirium in older patients undergoing elective surgical procedures: a randomized clinical trial of an avoid delirium protocol.

Pharmacological avoidance guidelines for preventing delirium have been suggested; however, there are limited pragmatic studies of these strategies. Early (<24 h) delirium can be observed in the postoperative care unit and is associated with an increased risk of subsequent delirium. We examined the effectiveness of an avoid delirium protocol (ADP) in older (>65 years) patients undergoing elective surgeries. The randomized controlled trial assessed an ADP developed using the American Geriatric Society's Clinical Practice Guidelines for Postoperative Delirium in Older Adults, on early (<24 h) incident or subsyndromal delirium. Delirium was assessed using the confusion assessment method before surgery, in the post-anesthesia care unit, and on postoperative day 1. The primary outcome of early delirium was the combined incidence of incident or subsyndromal delirium. Early delirium was identified in 24/235 patients (10.2%) with a risk ratio of 1.27 (95% CI 0.59-2.73, P = 0.667) for patients randomized to the ADP. In cases with protocol adherence and no benzodiazepine use, early delirium was present in 10/ 73 (13.7%) compared to 14/148 (9.5%) in non-adherent cases [risk ratio 1.45 (95% CI 0.57-3.10, P = 0.362)]. Lower American Society of Anesthesiologists physical class [odds ratio 3.31 (95% CI 1.35-8.92, P = 0.008)] and an inpatient admission [odds ratio 2.67 (95% CI 1.55-4.87, P = 0.0002)] were associated with early delirium. Our findings suggest that pharmacological avoidance protocols limiting or avoiding the use of specific classes of medications are not effective in reducing early incident or subsyndromal delirium in older patients undergoing elective surgery.

The risk factors for and the frequency and outcomes of subsyndromal delirium among patients who have undergone cardiac surgery: a protocol for systematic review and meta-analysis

IntroductionSeveral key symptoms must be present for the accurate diagnosis of patients with postoperative cardiac delirium. Some patients present with symptoms of delirium but do not meet the diagnostic criteria...

Peculiarities of Clinical Symptoms, Somatic Complications, Approaches to Therapy and Outcomes of Delirium Induced by Exposure to Synthetic Cannabinoids: Systematic Review

INTRODUCTION: The use of synthetic cannabinoids (SCs) is an urgent healthcare problem, due to, among other things, a high number of complications.&#x0D; AIM: To systematize the peculiarities of clinical presentation, somatic complications, effectiveness of empirical approaches to therapy, and probable outcomes of delirium induced by exposure to SCs.&#x0D; MATERIALS AND METHODS: The analysis of scientific publications selected by the keywords in eLibrary, СNKI, PubMed databases, was conducted. According to PRISMA recommendations, 20 articles were taken for analysis.&#x0D; RESULTS: Today, it is impossible to predict the period when SC-induced delirium may occur. It can start after one-time intake of even small dose, and can occur both due to intoxication and with the underlying withdrawal state on the 2nd4th days after the last use. Besides classic symptoms, the clinical picture of delirium is characterized by many symptoms of schizophrenic psychoses: hallucinations of threatening or drug-addicted content; secondary paranoid delusion, less expressed than hallucinations; aggressiveness and agitated behavior; some formal thinking disorders; rarely, KandinskiClerambault and oneiroid syndromes. There are reported cases of severe somatic complications in the form of depression of consciousness, rhabdomyolysis, acute renal failure, cardiomyopathy, myocardial infarction, epilepsy, infectious complications with the underlying weakened immunity. Therapy of SC-induced delirium includes detoxification and metabolic therapy, administration of antipsychotics and tranquilizers; use of resuscitation measures in case of depression of consciousness and development of life-threatening conditions. SC-induced delirium lasts from several hours to several days. In most cases, it terminates with complete recovery with amnesia of the period of confusion and asthenia, but in some cases fatal outcomes are reported caused not only by accidents such as road accidents or suicide, but also by somatic complications (most often of infectious character, or multi-organ failure).&#x0D; CONCLUSION: SСs remain relevant due to high frequency of their use and continuous emergence of new analogs to substances of this group. They have multidirectional effect, and so far it is difficult to predict at what period the delirium induced by them may occur.

3.26 Pediatric Delirium and Psychiatric Outcome in Children Under 12 Years

3.26 Pediatric Delirium and Psychiatric Outcome in Children Under 12 Years