Development Of Postoperative Delirium Research Articles

Risk factors and outcomes of postoperative delirium in colorectal cancer patients over 60 years

To determine the incidence, risk factors and clinical outcomes of postoperative delirium in colorectal cancer patients over 60 years. Consecutive 382 patients older than 60 years undergoing colorectal cancer surgery at Shenzhen Second People's Hospital from June 2013 to June 2016 were recruited prospectively in this study. These patients were evaluated daily after surgery for 7 days by confusion assessment method. Clinical outcomes were compared between patients with and without postoperative delirium, including postoperative complications, length of hospital stay, and mortality within 30 days. Logistic regression analysis was used to identify independent predictors of postoperative delirium. There were 230 male and 152 female patients with median age of 67(range 60 to 92) years. Among them, 213 had colon cancer and 169 had rectal cancer. Postoperative delirium developed in 46(12.0%) patients, and most deliriums (78.3%) were diagnosed within 3 days after surgery. Patients with postoperative delirium had more complications [30.4%(14/46) vs. 17.3%(58/336), P=0.032], higher mortality [6.5%(3/46) vs. 1.8%(6/336), P=0.047], and longer postoperative hospital stay (median 14 days vs. 9 days, P=0.008). Univariate analysis revealed that advanced age, male, higher Charlson comorbidity index, higher American Society of Anesthesiologists Classification, lower preoperative blood albumin concentration, history of psychiatric disease, history of cerebrovascular disease, alcohol abuse, emergent operation, and perioperative blood transfusion were significantly related to the development of postoperative delirium. Logistic regression analysis identified that advanced age (OR=1.06, 95%CI: 1.01 to 1.13), history of psychiatric disease (OR=10.89, 95%CI: 2.73 to 41.59) and perioperative blood transfusion (OR=2.37, 95%CI: 1.11 to 7.32) were independent risk factors of postoperative delirium. Postoperative delirium is relatively common in elderly patients over 60 years undergoing colorectal cancer surgery. The high morbidity of postoperative complication and mortality associated with postoperative delirium warrant implementation of preoperative risk assessment and postoperative screening protocol for postoperative delirium. Comprehensively preventive strategies should be carried out for high-risk patients, e.g. advanced age, history of psychiatric disease, and perioperative blood transfusion.

Association between baseline cognitive impairment and postoperative delirium in elderly patients undergoing surgery for adult spinal deformity.

OBJECTIVE Postoperative delirium is common in elderly patients undergoing spine surgery and is associated with a longer and more costly hospital course, functional decline, postoperative institutionalization, and higher likelihood of death within 6 months of discharge. Preoperative cognitive impairment may be a risk factor for the development of postoperative delirium. The aim of this study was to investigate the relationship between baseline cognitive impairment and postoperative delirium in geriatric patients undergoing surgery for degenerative scoliosis. METHODS Elderly patients 65 years and older undergoing a planned elective spinal surgery for correction of adult degenerative scoliosis were enrolled in this study. Preoperative cognition was assessed using the validated Saint Louis University Mental Status (SLUMS) examination. SLUMS comprises 11 questions, with a maximum score of 30 points. Mild cognitive impairment was defined as a SLUMS score between 21 and 26 points, while severe cognitive impairment was defined as a SLUMS score of ≤ 20 points. Normal cognition was defined as a SLUMS score of ≥ 27 points. Delirium was assessed daily using the Confusion Assessment Method (CAM) and rated as absent or present on the basis of CAM. The incidence of delirium was compared in patients with and without baseline cognitive impairment. RESULTS Twenty-two patients (18%) developed delirium postoperatively. Baseline demographics, including age, sex, comorbidities, and perioperative variables, were similar in patients with and without delirium. The length of in-hospital stay (mean 5.33 days vs 5.48 days) and 30-day hospital readmission rates (12.28% vs 12%) were similar between patients with and without delirium, respectively. Patients with preoperative cognitive impairment (i.e., a lower SLUMS score) had a higher incidence of postoperative delirium. One- and 2-year patient reported outcomes scores were similar in patients with and without delirium. CONCLUSIONS Cognitive impairment is a risk factor for the development of postoperative delirium. Postoperative delirium may be associated with decreased preoperative cognitive reserve. Cognitive impairment assessments should be considered in the preoperative evaluations of elderly patients prior to surgery.

Effects of different sedation depths of propofol on postoperative delirium in patients undergoing cardiac valve replacement under cardiopulmonary bypass: the relationship with regional cerebral oxygen saturation

Objective To evaluate the effects of different sedation depths of propofol on postoperative delirium in patients undergoing cardiac valve replacement under cardiopulmonary bypass(CPB)and the relationship with regional cerebral oxygen saturation(rSO2). Methods Forty American Society of Anesthesiologists physical status Ⅲ or Ⅳ patients of both sexes, aged 26-64 yr, with body mass index of 17-25 kg/m2, scheduled for elective aortic valve replacement with CPB, were divided into A and B groups(n=20 each)using a random number table.The infusion rate of propofol was adjusted to maintain the corresponding anesthetic depth with 50≤BIS value 20% of the baseline)was observed.Postoperative delirium was evaluated using Confusion Assessment Method for the Intensive Care Unit(ICU)from 12 h after admission to ICU until discharge from ICU. Results The incidence of postoperative delirium, low cerebral oxygen saturation and minimum rSO2 were significantly lower in group B than in group A(P<0.05). Conclusion Maintaining 35≤ BIS value< 45 during CPB can reduce the development of postoperative delirium and is related to improving intraoperative rSO2 in patients undergoing cardiac valve replacement. Key words: Propofol; Heart valuve, prosthesis; Cardiopulmonary bypass; Delirium

Incidence and predictors of postoperative delirium after cytoreduction surgery-hyperthermic intraperitoneal chemotherapy.

Incidence of, and baseline characteristics associated with delirium in patients after cytoreduction surgery-hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), were subject of investigation. The study was conducted among a consecutive series of prospectively included patients who underwent CRS-HIPEC at the University Medical Center Groningen, Groningen, the Netherlands, between February 2006 and January 2015. A chart-based instrument for delirium during hospitalization was used to identify patients with symptoms of delirium who were not diagnosed by a psychiatrist during admission. Uni- and multivariate logistic regression analyses were performed. Data of 136 patients were included in the analysis. Median age was 60 years (range: 18-76) and 50 (37%) patients were male. During hospitalization, 38 (28%) patients were diagnosed with delirium. Factors that differed significantly between the patients with and without delirium by univariate analysis were included in multivariate analysis. Multivariate analysis showed that after adjustment for age and complications other than delirium, having three or more organs resected and the CRP serum levels were independent predictors for delirium (OR: 3.97; 95% 1.24-12.76; OR: 1.01; 95% 1-1.01, respectively). This report shows an incidence of 28% of delirium, occurring after CRS-HIPEC and suggests a role for systemic inflammation in the development of postoperative delirium.

Postoperative delirium in elderly patients is associated with subsequent cognitive impairment

BackgroundWe examined the risk for postoperative delirium (POD) in patients with mild cognitive impairment (MCI) or dementia, and the association between POD and subsequent development of MCI or dementia in cognitively normal elderly patients. MethodsPatients ≥65 yr of age enrolled in the Mayo Clinic Study of Aging who were exposed to any type of anaesthesia from 2004 to 2014 were included. Cognitive status was evaluated before and after surgery by neuropsychological testing and clinical assessment, and was defined as normal or MCI/dementia. Postoperative delirium was detected with the Confusion Assessment Method for the intensive care unit. Logistic regression analyses were performed. ResultsAmong 2014 surgical patients, 74 (3.7%) developed POD. Before surgery, 1667 participants were cognitively normal, and 347 met MCI/dementia criteria. The frequency of POD was higher in patients with pre-existing MCI/dementia compared with no MCI/dementia {8.7 vs 2.6%; odds ratio (OR) 2.53, [95% confidence interval (CI) 1.52–4.21]; P<0.001}. Postoperative delirium was associated with lower education [OR, 3.40 (95% CI, 1.60–7.40); P=0.002 for those with <12 vs ≥16 yr of schooling]. Of the 1667 patients cognitively normal at their most recent assessment, 1152 returned for postoperative evaluation, and 109 (9.5%) met MCI/dementia criteria. The frequency of MCI/dementia at the first postoperative evaluation was higher in patients who experienced POD compared with those who did not [33.3 vs 9.0%; adjusted OR, 3.00 (95% CI, 1.12–8.05); P=0.029]. ConclusionsMild cognitive impairment or dementia is a risk for POD. Elderly patients who have not been diagnosed with MCI or dementia but experience POD are more likely to be diagnosed subsequently with MCI or dementia.

Protocol for an observational study of delirium in the post-anaesthesia care unit (PACU) as a potential predictor of subsequent postoperative delirium

IntroductionPostoperative delirium can be a serious consequence of major surgery, associated with longer hospital stays, readmission, cognitive and functional deterioration and mortality. Delirium is an acute, reversible disorder characterised by...

NeurimmiRs and Postoperative Delirium in Elderly Patients Undergoing Total Hip/Knee Replacement: A Pilot Study.

Objective: Postoperative delirium (POD) is a frequent complication after surgery and its occurrence is associated with poor outcomes. The pathophysiology of this complication is not clear, but identification of risk factors is important for positive postoperative outcomes. The purpose of this study was to investigate the associations between the preoperative expression levels of microRNA (miR)-146a, miR-125b, and miR-181c in cerebrospinal fluid (CSF) and serum and the development and severity of POD.Methods: Forty elderly patients aged 65 years old and older admitted for elective total hip/knee replacement under spinal anesthesia. Preoperatively, baseline cognitive function was assessed using the Mini-Mental State Examination. Each patient was interviewed daily on the first and second postoperative days. Delirium was diagnosed using the Confusion Assessment Method, and delirium severity was measured using the Memorial Delirium Assessment Scale (MDAS). Preoperative serum and CSF miR levels were determined by quantitative real-time PCR (qRT-PCR).Results: POD was detected in 27.5% (11/40) of patients. Up-regulation of miR-146a and miR-181c in CSF and down-regulation of miR-146a in serum were observed preoperatively in patients who developed POD, while patients with and without POD did not differ in serum or CSF levels of miR-125b. Delirious patients had higher CSF/serum ratios of miR-146a and miR-181c levels than non-delirious patients. The lower CSF miR-146a and CSF/serum miR-146a ratios were significantly associated with milder POD severity, represented by a lower MDAS score.Conclusion: The dysregulation of preoperative miR-146a and miR-181c in CSF and serum was associated with the development and severity of POD. These NeurimmiRs might participate in the neuropathogenesis of POD, pending further investigations.Clinical trial registration: this study was registered at ClinicalTrials.gov (NCT02817386).

Incidence and Risk Factors for Postoperative Delirium in Patients After Hepatectomy.

Postoperative delirium is a common complication after surgery. However, the incidence and risk factors associated with delirium after liver resection have not been clarified. Thus, this study aimed to investigate the incidence and risk factors for delirium in patients that underwent liver resections. This study included 196 consecutive patients that underwent a liver resection. Groups with and without delirium were compared to identify differential patient characteristics. Multivariate regression analysis was used to identify independent factors that significantly influenced the development of postoperative delirium. Postoperative delirium developed in 44 (22.4%) of the 196 patients. Majority of incidents occurred on postoperative day 2, and mean duration was 4.2±5.5days. Patients with delirium exhibited the following features: advanced age, low serum albumin levels, a high probability of a positive test for anti-hepatitis C virus antibody, cerebrovascular disorders, cardiovascular diseases, diabetes mellitus, use of benzodiazepines, and previous history of delirium. Multivariate analysis revealed that the delirium development was significantly correlated with age, serum albumin level, presence of cerebrovascular disorder, use of benzodiazepines, and a previous history of delirium. This study clarified the incidence and risk factors for delirium after liver resection. These results would contribute to prediction and treatment of delirium.

Depression as an independent predictor of postoperative delirium in spine deformity patients undergoing elective spine surgery.

OBJECTIVE Depression is the most prevalent affective disorder in the US, and patients with spinal deformity are at increased risk. Postoperative delirium has been associated with inferior surgical outcomes, including morbidity and mortality. The relationship between depression and postoperative delirium in patients undergoing spine surgery is relatively unknown. The aim of this study was to determine if depression is an independent risk factor for the development of postoperative delirium in patients undergoing decompression and fusion for deformity. METHODS The medical records of 923 adult patients (age ≥ 18 years) undergoing elective spine surgery at a single major academic institution from 2005 through 2015 were reviewed. Of these patients, 255 (27.6%) patients had been diagnosed with depression by a board-certified psychiatrist and constituted the Depression group; the remaining 668 patients constituted the No-Depression group. Patient demographics, comorbidities, and intra- and postoperative complication rates were collected for each patient and compared between groups. The primary outcome investigated in this study was rate of postoperative delirium, according to DSM-V criteria, during initial hospital stay after surgery. The association between depression and postoperative delirium rate was assessed via multivariate logistic regression analysis. RESULTS Patient demographics and comorbidities other than depression were similar in the 2 groups. In the Depression group, 85.1% of the patients were taking an antidepressant prior to surgery. There were no significant between-group differences in intraoperative variables and rates of complications other than delirium. Postoperative complication rates were also similar between the cohorts, including rates of urinary tract infection, fever, deep and superficial surgical site infection, pulmonary embolism, deep vein thrombosis, urinary retention, and proportion of patients transferred to the intensive care unit. In total, 66 patients (7.15%) had an episode of postoperative delirium, with depressed patients experiencing approximately a 2-fold higher rate of delirium (10.59% vs 5.84%). In a multivariate logistic regression analysis, depression was an independent predictor of postoperative delirium after spine surgery in spinal deformity patients (p = 0.01). CONCLUSIONS The results of this study suggest that depression is an independent risk factor for postoperative delirium after elective spine surgery. Further studies are necessary to understand the effects of affective disorders on postoperative delirium, in hopes to better identify patients at risk.

Effects of nimodipine on postoperative delirium in elderly under general anesthesia: A prospective, randomized, controlled clinical trial.

Nimodipine is a clinical commonly used calcium antagonistscan lowering the apoptosis rate of hippocampal neuron to reduce the incidence of postoperative cognitive dysfunction (POCD). This study was designed to evaluate the effects of nimodipine on postoperative delirium in elderly under general anesthesia.Sixty patients shceduced spine surgery under general anesthesia were randomly assigned into 2 groups using a random number table: control group (Group C) and nimodipine group (Group N). In Group N, nimodipine 7.5 μg/(kg × h) was injected continually 30 minutes before anesthesia induction, while the equal volume of normal saline was given in Group C. At 0 minute before injection, 0 minute after tracheal intubation, 1 hour after skin incision and surgery completed (T1–4), blood samples were taken from the radial artery and jugular bulb for blood gas analysis. Cerebral oxygen metabolism-related indicators were calculated at the same time. Concentration of S100β and glial fibrillary acidic protein (GFAP) were tested by ELISA. The incidence of postoperative delirium within 7 days after surgery was recorded.Cerebral oxygen metabolism-related indicators fluctuationed in the normal range in 2 groups at different time points and the difference were not statistically significant. Compared with Group C, S100β and GFAP decreased and incidence of postoperative delirium reduced at T3–4 in Group N, the difference was statistically significant (P<.05).The present study suggests that nimodipine can reduce the development of postoperative delirium in elderly patients under general anesthesia, the reduction of brain injury and improvement of cerebral oxygen metabolism may be involved in the mechanism.

Postoperative delirium in patients with history of alcohol abuse

Abstract Introduction Postoperative delirium (POD) is an acute confusional state characterized by changes in consciousness and cognition, which may be fluctuating, developing in a small period of time. The aim of this study was to evaluate the relationship between alcohol abuse and the development of POD. Methods We prospectively evaluated consecutively all postoperative patients admitted in the Post-anaesthesia Care Unit over a 1-month period for delirium, using the Portuguese versions of the Nursing Delirium Screening Scale. Before surgery, alcohol consumption was inquired and alcohol abuse was assessed by the CAGE (Cutting Down, Annoyance, Guilt and Eye-opener) questionnaire; a score ≥2 defined alcohol abuse. Fischer exact test or chi-square was applied for comparisons. Risk factors were analyzed in a multivariate analysis using a logistic regression with odds ratios (OR) and 95% confidence intervals (95% CI). Results Two hundred twenty-one patients were enrolled. Delirium was seen in 11% patients. The incidence of alcohol abuse was 10%. Patients with alcohol abuse were more frequently men ( p p = 0.021). POD was more frequent in patients with alcohol abuse (30% vs. 9%; p = 0.002). Age (OR: 5.9; 95% CI: 2.2–15.9; p p = 0.002) and alcohol abuse (OR: 4.2; 95% CI: 1.4–12.9; p = 0.013) were found to be independent predictors for POD. Conclusions Older patients, higher ASA physical status and alcohol abuse were more frequent in patients with POD. Alcohol abuse was considered an independent risk factor for POD.

Independent Predictors of the Duration and Overall Burden of Postoperative Delirium After Cardiac Surgery in Adults: An Observational Cohort Study

Postoperative delirium (POD) is a common complication after cardiac surgery and is associated with increased patient morbidity and mortality. The objective of this study was to identify risk factors for long duration and overall burden of POD after cardiac surgery. One-year, single-center, retrospective, observational cohort study. University hospital. Adult patients undergoing cardiac surgery with cardiopulmonary bypass in 2013. None. Patients were screened for POD using the Intensive Care Delirium Screening Checklist. The primary outcome measure was the incidence of POD. Secondary outcome measures were the duration of POD and the area under the curve determined using the Intensive Care Delirium Screening Checklist score over time. Independent predictors of POD were estimated in multivariable logistic regression models. Hospital length of stay, medications, and outcome data also were analyzed. Among the 656 patients included in the cohort, 618 were analyzed. The overall incidence of POD was 39%. Older patient age (odds ratio [95% confidence interval]) 1.06 [1.04-1.09] for an increase of 1 year, p < 0.001); low preoperative serum albumin (1.08 [1.03-1.13] for a decrease of 1 g/L, p < 0.001); a history of atrial fibrillation (2.30 [1.30-4.09], p = 0.004); perioperative stroke (6.27 [1.54-43.64], p = 0.008); ascending aortic replacement surgery (2.99 [1.50-6.05], p = 0.002); longer duration of procedure (1.37 [1.16-1.63] for an increase of 1 hour, p < 0.001); and increased postoperative C-reactive protein concentration (2.16 [1.49-3.16] for a 2-fold increase, p < 0.001) were associated with higher odds of POD. Among patients affected by POD, older age, perioperative stroke, longer procedure time, and increased postoperative C-reactive protein were consistently predictive of longer duration of POD and greater area under the curve. Known risk factors for the development of POD after cardiac surgery also are predictive of prolonged duration and high overall burden of POD.

Preoperative Serum Metabolites Are Associated With Postoperative Delirium in Elderly Hip-Fracture Patients.

Hypotheses on the development of postoperative delirium (PD) include "neuroinflammatory," "neuronal aging," "oxidative stress," "neurotransmitter deficiency," and "neuroendocrine." Here, we employed metabolomics to determine the serum metabolites in the baseline associated with an increased risk of PD. Two hundred and nine elderly hip-fracture patients who had undergone hemiarthroplasty and had completed our assessments were selected. Fasting venous blood was collected at 7:00 on the morning of surgery and a serum sample bank was created for analysis. On the first 3 postoperative days, the patients were assessed twice daily using the Confusion Assessment Method - Chinese Revision. Ultimately, 43 patients were diagnosed with PD, who comprised the PD group. Meanwhile, 43 matched non-PD patients were selected based on age, sex, and body mass index. Serum samples from the two groups were analyzed by gas chromatography-time-of-flight mass spectrometry and Acquity ultra-performance liquid chromatography-quadrupole time-of-flight mass spectrometry. The demographic characteristics of the groups were matched. Four metabolites associated with an increased risk of PD were identified, including S-methylcysteine, linolenic acid, eicosapentaenoic acid, and linoleic acid. Multiple metabolic pathways in the PD group altered before surgery, including deficiency of ω3 and ω6 fatty acids, energy metabolism and oxidative stress with interactions between hypoxia and mitochondrial dysfunction, in addition to glutamate-glutamine cycle dysfunction. These metabolic abnormalities could possibly increase the fragility of the brain and then contribute to PD.

Factors predicting incidence of post-operative delirium in older people following hip fracture surgery: a systematic review and meta-analysis.

Delirium is one of the most common complications following hip fracture surgery in older people. This study identified pre- and peri-operative factors associated with the development of post-operative delirium following hip fracture surgery. Published and unpublished literature were searched to identify all evidence reporting variables on patient characteristics, on-admission, intra-operative and post-operative management assessing incident delirium in older people following hip fracture surgery. Pooled odds ratio (OR) and mean difference of those who experienced delirium compared to those who did not were calculated for each variable. Evidence was assessed using the Downs and Black appraisal tool and interpreted using the GRADE approach. A total of 6704 people (2090 people with post-operative delirium) from 32 studies were analysed. There was moderate evidence of nearly a two-times greater probability of post-operative delirium for those aged 80 years and over (OR: 1.77; 95% CI: 1.09, 2.87), whether patients lived in a care institution pre-admission (OR: 2.65; 95% CI: 1.79, 3.92), and a six-times greater probability of developing post-operative delirium with a pre-admission diagnosis of dementia (OR: 6.07, 95% CI: 4.84, 7.62). There was no association with intra-operative variables and probability of delirium. Clinicians treating people with a hip fracture should be vigilant towards post-operative delirium if their patients are older, have pre-existing cognitive impairment and poorer overall general health. This is also the case for those who experience post-operative complications such as pneumonia or a urinary tract infection. Copyright © 2017 John Wiley & Sons, Ltd.

Postoperative serum thioredoxin concentrations correlate with delirium and cognitive dysfunction after hip fracture surgery in elderly patients

BackgroundOxidative stress correlates with occurrence and development of postoperative delirium (POD) and cognitive dysfunction (POCD). Thioredoxin (TRX) is a potent anti-oxidant and its circulating concentrations reflect extent of brain injury. We determined the relation of serum TRX concentrations to POD and POCD in elderly patients undergoing hip fracture surgery. MethodsIn this prospective, observatory study, TRX concentrations in preoperative and postoperative serum from 192 patients and serum from 192 controls were measured using an enzyme-linked immunosorbent assay. The relationship between TRX concentrations and risk of POD and POCD was assessed using a multivariate analysis. ResultsAs compared to the controls, postoperative, but not preoperative serum TRX concentrations were significantly increased in the patients. Furthermore, postoperative TRX concentrations and age were identified as the independent predictors for POD and POCD. Also, area under receiver operating characteristic curve (AUC) of postoperative TRX concentrations was obviously higher than that of age in the prediction of POD and POCD. Additionally, in a combined logistic-regression model, TRX concentrations significantly improved the AUCs of age to predict POD and POCD. ConclusionsTRX in postoperative serum may be a potential biomarker to predict POD and POCD in elder patients undergoing hip fracture surgery.

Postoperative Delirium After Liver Transplantation is Associated With Increased Length of Stay and Lower Survival in a Prospective Cohort.

Although postoperative delirium (POD) is a common in-hospital complication associated with negative outcomes, evidence in liver transplantation (LT) is scarce. We examined the incidence and duration of POD, its impact on outcomes and health-care utilization, and described predisposing and precipitating factors favoring POD development. This prospective cohort study included adults undergoing transplantation in a tertiary hospital. Postoperative delirium was assessed 3 times daily until 24 days post-LT, with the Intensive Care Delirium Screening Checklist on the intensive care unit (ICU) and the Delirium Observation Screening Scale on the ward. Postoperative delirium was noted if any of the daily measurements was positive. Forty-two patients (69% male, mean age 55 years, median Model for End-Stage Liver Disease score 15 [interquartile range 8-26]) were included. The incidence of POD was 45.2%, with a median duration of 5 days. Patients with POD had longer ICU (median 8 vs 2 days, P = .000) and hospital stays (median 32 vs 14 days, P = .000) as well as shorter survival (Breslow test P = .045, log-rank test P = .150). Pre-LT comorbidities and perioperative factors might be related to POD development. Nurses are key persons in the detection of POD in the daily clinical routine. The high incidence of POD and its negative association with patient outcomes highlight not only the relevance of systematic assessment of POD after LT but also the need for preventive interventions.

Accuracy of plasma and urine neutrophil gelatinase-associated lipocalin concentrations in predicting postoperative delirium in elderly patients

Objective To evaluate the accuracy of plasma and urine neutrophil gelatinase-associated lipocalin (NGAL) concentrations in predicting postoperative delirium in elderly patients. Methods From November 2014 to March 2015, 70 patients of either sex who underwent total unilateral hip or knee replacement, aged 65-85 yr, with body mass index of 18-25 kg/m2, of American Society of Anesthesiologists physical status Ⅱ or Ⅲ, were selected.The Confusion Assessment Method for the Intensive Care Unit was used to assess the development of postoperative delirium at 24, 48 and 72 h after operation.The patients were divided into either delirium group or non-delirium group according to whether or not postoperative delirium occurred.At 5 min before anesthesia induction, immediately after extubation, and at 24 and 72 h after operation, the midstream urine samples and peripheral venous blood samples were collected for determination of the urine and plasma NGAL concentrations by immuno-enhanced turbidimetry.At 5 min before anesthesia induction, and 24 and 48 h after operation, the serum creatinine and cystatin C concentrations were detected, and the development of postoperative acute kidney injury was recorded.The receiver operating characteristic curve for urine and plasma NGAL concentrations in diagnosing postoperative delirium was plotted, and the area under the curve and 95% confidence interval were calculated.The critical value and sensitivity and specificity were calculated according to the corresponding concentrations of NGAL in urine and plasma when Youden index reached the maximal value. Results The incidence of postoperative delirium was 15%.Compared with non-delirium group, the plasma NGAL concentrations were significantly increased immediately after extubation, and the urine NGAL concentrations were significantly increased immediately after extubation and at 24 h after operation in delirium group(P 0.05). Postoperative acute kidney injury was not found in the two groups.The area under the curve (95% confidence interval) for urine NGAL concentrations measured immediately after extubation in predicting postoperative delirium was 0.736 (0.509-0.946), the critical value was 149.1 ng/ml, the sensitivity 60%, and the specificity 97%.The area under the curve (95% confidence interval) for urine NGAL concentrations measured at 24 h after operation in predicting postoperative delirium was 0.785 (0.565-0.998), the critical value was 131.5 ng/ml, the sensitivity 60%, and the specificity 82%.The area under the curve (95% confidence interval) for plasma NGAL concentrations measured immediately after extubation in predicting postoperative delirium was 0.772 (0.580-0.965), the critical value was 107.9 ng/ml, the sensitivity 80%, and the specificity 79%.The area under the curve (95% confidence interval) for plasma NGAL concentrations at 24 h after operation in predicting postoperative delirium was 0.679 (0.524-0.835), the critical value was 153.65 ng/ml, the sensitivity 70%, and the specificity 90%. Conclusion The plasma and urine NGAL concentrations measured immediately after extubation can accurately predict the development of postoperative delirium in elderly patients. Key words: Proto-oncogene proteins; Forecasting; Delirium; Postoperative complications; Aged

Blood transfusion strategy and risk of postoperative delirium in nursing homes residents with hip fracture. A post hoc analysis based on the TRIFE randomized controlled trial.

To investigate whether a liberal blood transfusion strategy [Hb levels ≥11.3g/dL (7mmol/L)] reduces the risk of postoperative delirium (POD) on day 10, among nursing home residents with hip fracture, compared to a restrictive transfusion strategy [Hb levels ≥9.7g/dL (6mmol/L)]. Furthermore, to investigate whether POD influences mortality within 90days after hip surgery. This is a post hoc analysis based on The TRIFE - a randomized controlled trial. Frail anemic patients from the Orthopedic Surgical Ward at Aarhus University Hospital were enrolled consecutively between January 18, 2010 and June 6, 2013. These patients (aged ≥65 years) had been admitted from nursing homes for unilateral hip fracture surgery. After surgery, 179 patients were included in this study. On the first day of hospitalization, all enrolled patients were examined for cognitive impairment (assessed by MMSE) and delirium (assessed by CAM). Delirium was also assessed on the tenth postoperative day. The prevalence of delirium was 10% in patients allocated to a liberal blood transfusion strategy (LB) and 21% in the group with a restrictive blood transfusion strategy (RB). LB prevents development of delirium on day 10, compared to RB, odds ratio 0.41 (95% CI 0.17-0.96), p=0.04. Development of POD on day 10 increased the risk of 90-day death, hazard ratio 3.14 (95% CI 1.72-5.78), p<0.001. In nursing home residents undergoing surgery for hip fracture, maintaining hemoglobin level above 11.3g/dL reduces the rate of POD on day 10 compared to a RB. Development of POD is associated with increased mortality.

Olfactory dysfunction is related to postoperative delirium in Parkinson's disease.

Operations often lead to delirium in elderly patients, particularly those with impaired cognition, suggesting that underlying neuropathology may play a role in the development of postoperative delirium. Olfactory dysfunction is a well-known marker of underlying Lewy body pathology in Parkinson's disease (PD). However, the prognostic value of olfaction for the development of postoperative delirium in PD remains unclear. 34 PD patients with or without postoperative delirium following surgery under general anesthesia were included in this study (n=17 for each group). Cross-Cultural Smell Identification scores were lower in PD patients with postoperative delirium (4.4±1.5) relative to the delirium-free controls (6.8±2.4, p<0.005). Multivariate logistic regression analysis revealed that olfaction and operation time were significant predictors of the development of postoperative delirium. Impaired olfaction is significantly associated with postoperative delirium in PD. Olfaction may be useful for identifying PD patients susceptible to postoperative delirium.

Review of Postoperative Delirium in Geriatric Patients Undergoing Hip Surgery

Postoperative delirium is a serious complication following hip surgery in elderly patients that can adversely affect outcomes in both hip fracture and arthroplasty surgery. Recently, the incidence of hip fracture in the Medicare population was estimated at approximately 500 000 patients per year, with the majority treated surgically. The annual volume of total hip arthroplasty is nearly 450 000 patients and is projected to increase over the next 15 to 20 years. Subsequently, the incidence of postoperative delirium will rise. The incidence of postoperative delirium after hip surgery in the elderly patients ranges between 4% and 53%, and it is identified as the most common surgical complication of older patients. The most common risk factors include advanced age, hip fracture surgery (vs elective hip surgery), and preoperative delirium/cognitive impairment. Exact pathophysiology has not been fully defined. It is hypothesized that imbalances in cortical neurotransmitters or inflammatory cytokine pathway mechanisms contribute to delirium. Development of postoperative delirium is associated with longer hospital stay, increased medical complications, and poorer short-term functional outcome. Patients who develop postoperative delirium are also at increased risk for cognitive decline beyond the acute phase. Following acute care, postoperative delirium is associated with the need for a higher level of care, an additional cost. Management of postoperative delirium centers on prevention and early recognition. Medical prophylaxis has been demonstrated to have limited utility. Utilization of delirium detection methods contributed to early recognition. The most effective means of prevention involved a multidisciplinary team focused on adequate hydration, optimization of analgesia, reduction in polypharmacy, aggressive physiotherapy, and early recognition of the delirium symptoms.