Postoperative Delirium Research Articles

Predisposing and precipitating factors of post-operative delirium after transfemoral TAVI

Abstract Background Transcatheter aortic valve implantation (TAVI) represents the treatment of choice for aortic stenosis (AS) patients at higher age (> 75y) or with relevant comorbidities. Post-operative delirium (POD) is a frequent complication which has been associated with worse outcome. Thus, preventive options are highly needed. The aim of our single-center study was to investigate predisposing and precipitating factors of POD after transfemoral TAVI, with a focus on the influence of anaesthesia. Methods Risk factors for POD after TAVI were analysed in 2 merged cohorts of 480 study patients (43% women; mean age 80 years), enrolled in 2017-2022 (n=375, TAVI in 95% in general anaesthesia) and in 2022-2024 (n=105, TAVI in 91% in local anaesthesia). Incidence of POD was evaluated retrospectively by nursing documentation, medical records, and DRG coding. The association of demographics, comorbidities, echo parameters, procedural parameters, anaesthesia, and peri-procedural complications with POD incidence was investigated. Results In total, 29 patients (6%) developed POD, with a tendency towards a lower incidence in the later cohort (6.7% vs. 3.8%; p=0.28). Regarding baseline characteristics, patients experiencing POD were more likely to be male (p=0.03), frail (Katz Index <6, p=0.049), and to suffer from low-gradient AS (p=0.005 for paradoxical, p=0.02 for classical low-flow, low-gradient AS; see also fig. 1A). Total procedure time was significantly longer in patients with POD (median, 86 vs. 62 min, p=0.004; fig 1B), and a tendency towards a more frequent implantation of other than ballon-expandable valves could be observed (p=0.07). Concerning the role of anaesthesia, POD did not differ significantly after general anaesthesia (n=24/360, 6.7%), conscious sedation (n=1/19, 5.3%), and local anaesthesia (n=4/100, 4%) (p=0.38). Regarding procedural complications, POD patients were characterized by lower minimum hemoglobin post-TAVI (9.3 vs. 10.1 g/dl, p=0.05; fig. 1C) and higher incidences of intra-procedural resuscitation (11% vs. 2%, p=0.03), cerebrovascular accidents (10% vs. 2%, p=0.04) and new permanent pacemaker implantations (25% vs. 10%, p=0.02). In POD patients, long-term survival after TAVI was significantly reduced, with a median survival of only 2 years (Kaplan-Meier curves in fig. 2; p=0.001). Conclusions POD after TAVI stays common and unfavourable. The role of anaesthesia seems less pronounced than expected. Total procedure time and relevant anaemia after TAVI emerged as most important modifiable risk factors. Future research is warranted, since strategies to reduce precipitating factors for POD may have a significant impact on post-TAVI outcomes.Selected risk factors for PODConsequence of POD: Reduced Survival

The correlation between the confusion assessment method for intensive care units 7-item, the intensive care delirium screening checklist and adverse outcomes after post-cardiac surgery delirium

Abstract Background Postoperative Delirium(POD) and Subsyndromal Delirium(SSD) remain prevalent, particularly among the cardiovascular surgical population due to the utilization of cardiopulmonary bypass. Adverse outcomes, such as prolonged ICU stay, extended length of stay, and increased incidence of adverse events, are associated with individuals diagnosed with Postoperative Delirium or those experiencing fluctuations between Postoperative Delirium and Subsyndromal Delirium during ICU stays. Therefore, early delirium screening is of utmost importance. The Intensive Care Delirium Screening Checklist(ICDSC) and the Confusion Assessment Method for the Intensive Care Unit 7-item(CAM-ICU-7) are validated delirium screening instruments for critical patients. Purpose This study aims to determine whether the ICDSC or the CAM-ICU-7 is the superior predictor for adverse outcomes following Postoperative Delirium among the cardiovascular population. Methods In this prospective cohort study, 84 patients who underwent elective cardiovascular surgery underwent a total of 833 paired assessments(ICDSC and CAM-ICU-7) twice daily by the researcher. The correlation between the results of ICDSC and CAM-ICU-7 was evaluated. Multiple linear regression was employed to explore associations between ICDSC and CAM-ICU-7 and length of ICU stay, length of overall stay, and the total number of adverse events. The best model was selected after testing with Pearson's correlation coefficient, Hotelling's t, and Steiger's Z tests. Logistic regression explored associations between ICDSC and CAM-ICU-7 and adverse events. Results Postoperative Delirium incidence evaluated by the ICDSC and CAM-ICU-7 was 47.61% and 45.23%, respectively. The incidence of fluctuations between Postoperative Delirium and Subsyndromal Delirium evaluated by the ICDSC and CAM-ICU-7 was 34.52% and 21.43%, respectively. The agreement between the ICDSC and CAM-ICU-7 is high(kappa = 0.835, p<0.001) in detecting Postoperative Delirium but fair in detecting Subsyndromal Delirium(kappa = 0.213, p<0.001). Our research revealed that the length of ICU stay can be predicted by POD(detected by ICDSC and CAM-ICU-7) and fluctuated POD and SSD(detected by ICDSC but not CAM-ICU-7). However, only fluctuated POD and SSD detected by ICDSC could predict hospital length of stay. The total number of adverse events and incidence could be predicted by POD either detected by ICDSC or CAM-ICU-7 but only fluctuated POD and SSD detected by ICDSC, not CAM-ICU-7, could predict the total number of adverse events. Conclusions Both ICDSC and CAM-ICU-7 can detect Postoperative Delirium with high agreement. However, ICDSC could identify more individuals with both Postoperative Delirium and Subsyndromal Delirium, thus predicting more adverse outcomes than CAM-ICU-7. Therefore, ICDSC emerges as the superior delirium screening instrument for the cardiovascular population.

Systemic immune inflammatory index (SII) and systemic inflammatory response index (SIRI) as predictors of postoperative delirium in patients undergoing off-pump coronary artery bypass grafting (OPCABG) with cerebral infarction

ObjectivePostoperative delirium (POD) is a common complication following off-pump coronary artery bypass grafting (OPCABG) and is associated with significant morbidity. This study aims to evaluate the correlation of systemic immune inflammatory index (SII) and systemic inflammatory response index (SIRI) with postoperative delirium (POD) in patients with cerebral infarction undergoing OPCABG.MethodsThe perioperative cohort study included 321 patients who underwent OPCABG. Patients were divided into two groups based on the occurrence of POD: the delirium group (n = 113) and the non-delirium group (n = 208). Baseline characteristics, including gender, left ventricular ejection fraction (LVEF), surgery duration, hypertension, age, and smoking history were analyzed. SII and SIRI values were calculated preoperatively, and their association with POD was assessed using univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curves were used to evaluate the predictive accuracy of SII and SIRI.ResultsStatistical differences between SII and SIRI in the two groups (P < 0.05) were observed. Multivariate analysis confirmed that SII and SIRI, age and preoperative smoking history were predictors of POD. ROC curve analysis demonstrated that SII and SIRI had considerable predictive power, with AUC values of 0.73 (0.67–0.79) for SII and 0.75 (0.69–0.81) for SIRI.ConclusionSII and SIRI were found to be associated with an increased risk of POD in patients undergoing OPCABG, but further research is needed to confirm these findings and determine their independence as risk factors.

Hip fracture in elderly: malnutrition and health outcomes. A systematic review and meta-analysis

Abstract Background Hip fracture is a common condition among elderly and one of the leading causes of disability. Malnutrition is widely present in older patients and has been identified in several studies as an important and modifiable prognostic factor for several medical conditions, including hip fracture. The aim of the present study is to evaluate the association between malnutrition, assessed by validated tools, and selected health outcomes for different follow-up intervals from hip fracture, in particular: mortality, changes in mobility/living arrangements and postoperative delirium. Methods A literature search on PubMed, Web of Science and Scopus databases up to September 2023, was conducted to identify all studies involving older subjects that reported an association between MNA/GNRI/PNI/CONUT score and health outcome after hip fracture. Meta-analysis was performed by a random-effects model using risk values (RR/OR/HR) extracted from 14 eligible selected studies. Results Malnutrition significantly increased the risk of any adverse outcome by 70% at 1 month, and up to 250% at 1 year, showing an increasing trend with longer follow-up periods. One month after hip fracture, malnutrition significantly increased the risk of postoperative delirium by 275% (OR = 2.75; 95% CI 1.80-4.18; p ≤ 0.05), mortality by 342% (OR = 3.42; 95% CI 2.14-5.48; p ≤ 0.05) and mortality hazard risk by 351% (HR = 3.51; 95% CI 1.63-7.55; p ≤ 0.05). One year after hip fracture, malnutrition significantly increased the risk of transfer to more supported living arrangements by 218% (OR = 2.18; 95% CI 1.58-3.01; p ≤ 0.05), declined mobility by 41% (OR = 1.41; 95% CI 1.14-1.75; p ≤ 0.05), mortality by 368% (OR = 3.68; 95% CI 3.00-4.52; p ≤ 0.05) and mortality hazard risk by 234% (HR = 2.34; 95% CI 1.91-2.87; p ≤ 0.05). Conclusions These findings underscore that malnutrition worsens outcomes after hip fracture in elderly, emphasizing the importance of nutritional assessment to mitigate potential adverse consequences. Key messages • The results of the present study underscore that malnutrition increases the risk of death and worsens mobility and independence after hip fracture in older adults. • Routine nutritional status evaluation could prove beneficial in the management of hip fracture older patients in order to prevent potential adverse outcomes.

The efficacy of preemptive multimodal analgesia in elderly patients undergoing laparoscopic colorectal surgery: a randomized controlled trial

Objective To evaluate the effectiveness of preemptive multimodal analgesiain elderly patients undergoing laparoscopic colorectal surgery. Methods A prospective randomized controlled study was conducted in the Department of Gastrointestinal Surgery of the Second Hospital of Hebei Medical University from January 2022 to December 2022. A total of 133 patients were included according to the criteria and randomly divided into preemptive analgesia (PRA) group (test group, 67patients) and postoperative analgesia (POA) group (control group, 66patients). Results The Visual Analog Scale (VAS)scores of PRA group 24 h, 48 h, and 72 h after operation were lower than those of POA group, and the difference was statistically significant, P < 0.001.The incidences of postoperative gastrointestinal dysfunction (POGD) and postoperative delirium (POD)in PRA group were 13.43% and 8.98%, respectively, which were significantly lower than those in POA group (31.82% and 24.24%), P < 0.05. The levels of IL-6 and IL-10 in PRA group after the operation were 17.54 ± 2.13 ng/L and 15.57 ± 1.71 ng/L respectively, which were lower than those in POA group (25.45 ± 2.95 ng/L and 23.45 ± 1.88 ng/L), P < 0.05. The level of acetylcholinesterase(AchE) was 56.34 ± 5.62 nmol/L in the POA group, which was significantly higher than that in the POA group (49.59 ± 5.52 nmol/L), P < 0.001. Conclusion Preemptive multimodal analgesia can reduce the incidence of POGD and POD in elderly patients undergoing laparoscopic gastrocolic surgery, improve the recovery process of postoperative gastrointestinal function, increase the concentrations of propionic acid and butyric acid in short chain fatty acids (SCFAs) and the number of beneficial intestinal bacteria.

Incidence of Concurrent Cerebral Desaturation and Electroencephalographic Burst Suppression in Cardiac Surgery Patients.

Increased intraoperative electroencephalographic (EEG) burst suppression is associated with postoperative delirium. Cerebral desaturation is considered as one of the factors associated with burst suppression. Our study investigates the association between cerebral desaturation and burst suppression by analyzing their concurrence. Additionally, we aim to examine their association with cardiac surgical phases to identify potential for targeted interventions. We retrospectively analyzed intraoperative 1-minute interval observations in 51 patients undergoing cardiac surgery. Processed EEG and cerebral oximetry were collected, with the anesthesiologists blinded to the information. The associations between cerebral desaturation (defined as a 10% decrease from baseline) and burst suppression, as well as with phase of cardiac surgery, were analyzed using the Generalized Logistic Mixed Effect Model. The results were presented as odds ratio and 95% confidence intervals (CIs). A value of P < .05 was considered statistically significant. The odds of burst suppression increased 1.5 times with cerebral desaturation (odds ratio [OR], 1.52, 95% CI, 1.11-2.07; P = .009). Compared to precardiopulmonary bypass (pre-CPB), the odds of cerebral desaturation were notably higher during CPB (OR, 22.1, 95% CI, 12.4-39.2; P < .001) and post-CPB (OR, 18.2, 95% CI, 12.2-27.3; P < .001). However, the odds of burst suppression were lower during post-CPB (OR, 0.69, 95% CI, 0.59-0.81; P < .001) compared to pre-CPB. Compared to pre-CPB, the odds of concurrent cerebral desaturation and burst suppression were notably higher during CPB (OR, 52.3, 95% CI, 19.5-140; P < .001) and post-CPB (OR, 12.7, 95% CI, 6.39-25.2; P < .001). During CPB, the odds of cerebral desaturation (OR, 6.59, 95% CI, 3.62-12; P < .001) and concurrent cerebral desaturation and burst suppression (OR, 10, 95% CI, 4.01-25.1; P < .001) were higher in the period between removal of aortic cross-clamp and end of CPB. During the entire surgery, the odds of burst suppression increased 8 times with higher inhalational anesthesia concentration (OR, 7.81, 95% CI, 6.26-9.74; P < .001 per 0.1% increase). Cerebral desaturation is associated with intraoperative burst suppression during cardiac surgery, most significantly during CPB, especially during the period between the removal of the aortic cross-clamp and end of CPB. Further exploration with simultaneous cerebral oximetry and EEG monitoring is required to determine the causes of burst suppression. Targeted interventions to address cerebral desaturation may assist in mitigating burst suppression and consequently enhance postoperative cognitive function.

Nonpharmacological Prevention and Management of Delirium: Past, Present, and Future.

Delirium has been recognized, documented, and examined for centuries. In 500 BC Hippocrates described hyper- and hypoactive forms of delirium. As medicine, surgery, and critical care have accelerated over the last century, so too has our understanding of delirium and its profound risks to patients, families, and health care teams. It has also been increasingly understood that it is the accumulation of risk factors that ultimately precipitates delirium and nonpharmacological interventions to reduce these risks remain the cornerstone of delirium prevention and management. However, over the last three decades, these nonpharmacological strategies have moved from a single-component approach to a multicomponent approach, targeting multiple risk factors. Additionally, our understanding of what constitutes a risk factor for delirium has evolved, and in particular, it has been recognized that delirium can sometimes be a byproduct of our interventions and health care systems. In the surgical setting, for example, optimization of risk factors prior to surgery, when possible, is now seen as a key way to prevent postoperative delirium. Similarly, critical care medicine now operates with the appreciation of the profound risk to patients of prolonged mechanical ventilation, sedation, and immobilization and seeks to minimize each to reduce the risk of delirium, among other negative effects. The future of delirium prevention and management lies in both better implementation of best practices that have been defined over the last three decades as well as taking more of a whole patient view. This includes harnessing the electronic medical record, artificial intelligence, and so on to risk assess and individualize care for each patient; restructuring care to reduce deliriogenic practices and care environments; redefining what usual care looks like (e.g., utilizing music and involving loved ones, etc.); policy changes to change systematic priorities. In this paper, we will explore the past, present, and future of nonpharmacological prevention and management of delirium across care settings.

Incidence and risk factors of postoperative delirium in lumbar spinal fusion patients: A National Database analysis

Postoperative delirium (POD) is a frequent complication observed in patients following spinal surgeries. The incidence of POD is particularly concerning for major procedures like lumbar spinal fusion, leading to a range of detrimental outcomes. However, existing research on the prevalence and risk factors associated with POD after lumbar spinal fusion is limited, especially when relying on data from large-scale national databases. This study employed a comprehensive analysis of the National Inpatient Sample (NIS) database, encompassing data from 2010 to 2019. The study population included patients who underwent primary lumbar spinal fusion surgery. We compared patients who did not experience POD with those who developed POD postoperatively, analyzing demographic characteristics, pre-existing comorbidities, and perioperative complications. Analysis of the NIS database identified a total of 493,481 patients who underwent lumbar spinal fusion. The overall incidence of POD following the procedure was 1.07%. Patients who experienced delirium postoperatively exhibited significantly longer hospital stays, incurred higher healthcare costs, and faced a heightened risk of in-hospital mortality (p < 0.001). Additionally, POD following lumbar spinal fusion was associated with various medical complications, including acute renal failure, myocardial infarction, pneumonia, pulmonary embolism, stroke, and urinary tract infections. Several independent predictors were identified as being significantly associated with postoperative delirium, including advanced age (≥65 years old), pre-existing neurological disorders, a history of alcohol or drug abuse, depression, psychotic disorders, fluid and electrolyte imbalances, diabetes, weight loss, deficiency anemia, coagulopathy, congestive heart failure, pulmonary circulation disorders, peripheral vascular disease, chronic renal insufficiency, and receiving treatment at a teaching hospital. Notably, neurological disorders demonstrated the strongest correlation with the development of postoperative delirium. Overall, our analysis revealed a relatively low prevalence of POD following lumbar spinal fusion surgery. Nevertheless, it is critical to investigate and understand the independent predictors of POD to effectively prevent and mitigate its negative impact on patient outcomes.

Role of Intraoperative Neurophysiological Monitoring in Predicting Postoperative Delirium in Patients Undergoing Carotid Endarterectomy Surgeries.

This study aims to evaluate the diagnostic utility of Electroencephalography (EEG) and Somatosensory Evoked Potentials (SSEP) as modalities of Intraoperative neurophysiological monitoring (IONM) in predicting Postoperative Delirium (POD) in patients who underwent Carotid Endarterectomy (CEA) surgery. A total cohort of 425 patients were included in this study. Medical record data was reviewed retrospectively and their documented significant IONM data were analyzed and integrated into the study for each patient. The study cohort was assessed for POD with Intensive Care Delirium Screening Checklist (ICDSC) and a score of &gt;4 was positive for delirium. Of the 425 patients that underwent CEA for carotid stenosis, 65/425 (15.29%) had documented significant IONM changes. Of those 65 patients with significant changes, 16 (24.61%) had POD. On the other hand, of the 360 patients without changes, 31 (8.61%) had POD. On performing multivariable analysis and adjusting for possible confounders, IONM changes were still significantly associated with POD (p value: &lt;0.001; 95% C.I. 1.91-7.98; OR: 3.94). Specifically, SSEP changes alone were significantly associated with POD (p value: &lt;0.001; 95% C.I. 2.36-11.08; OR: 5.15). Significant IONM changes increase the risk of developing POD in patients undergoing CEA. Despite the low overall risk of POD after CEA in our study, it is imperative to conclude that patients with POD are twice likely to exhibit changes.

Data-driven Machine Learning Models for Risk Stratification and Prediction of Emergence Delirium in Pediatric Patients Underwent Tonsillectomy/Adenotonsillectomy.

In the pediatric surgical population, Emergence Delirium (ED) poses a significant challenge. This study aims to develop and validate machine learning (ML) models to identify key features associated with ED and predict its occurrence in children undergoing tonsillectomy or adenotonsillectomy. The analysis involved data cleaning, exploratory data analysis (EDA), supervised predictive modeling, and unsupervised learning on a medical dataset (n = 423). After preliminary data cleaning, EDA encompassed plotting histograms, boxplots, pairplots, and correlation heatmaps to understand variable distributions and relationships. Four predictive models were trained including logistic regression (LR), random forest (RF), Support Vector Machine (SVM), and Gradient Boosting (XGBoost). The models were evaluated and compared using Receiver Operating Characteristic (ROC) Area Under the Curve (AUC), precision, recall, and feature importance. The RF model showed better performance and was used for the test (AUC-ROC 0.96, precision 1.00, and recall 0.92 on the validation set). K-means clustering was applied to find groups within the data. Elbow method and silhouette scores were used to determine the optimal number of clusters. The formed clusters were analyzed by aggregating features to understand the characteristics of each cluster. EDA revealed significant positive correlations between age, weight, American Society of Anesthesiologists (ASA) health score, and surgery duration with the risk of developing ED. Among the ML models, RF achieved the highest performance. Key predictive variables, based on the model's feature importance, included delirium screening scales, extubation time, and time to regain consciousness. Unsupervised K-means clustering identified 2-3 optimal clusters, which represented distinct patient subgroups: younger, healthier, low-risk individuals (cluster 0), and older patients with increasing chronic disease burden, higher delirium screening scores, and consequently higher post-operative delirium risk (clusters 1 and 2). ML techniques are valuable tools for extracting insights and making accurate predictions from healthcare data. High-performing algorithm-based models can be implemented for clinical decision support systems, facilitating early identification and intervention for ED in pediatric patients. By investigating various variables, it is possible to assess risk and implement preventive measures effectively. Furthermore, unsupervised clustering reveals distinct patient subgroups, enabling personalized perioperative management strategies and enhancing overall patient care.

A case report of benzodiazepine withdrawal delirium due to accidental discontinuation of benzodiazepines in cancer perioperative period.

Benzodiazepines are known for their possible risk of delirium, especially when administered to older adults or during the perioperative period. However, the risk of sudden discontinuation of benzodiazepines and subsequent withdrawal delirium seems to be underappreciated and not properly recognized in cancer treatment, even among healthcare workers. A man in his late 70s was diagnosed with rectal cancer and had a history of taking etizolam and alprazolam for over 15 years. After hospitalization for cancer, these benzodiazepines were discontinued abruptly 2 days before the surgery, due to concerns about benzodiazepine-related delirium. After half a day, severe benzodiazepine withdrawal symptoms, such as disorientation, agitation, tachycardia, diaphoresis, and muscle twitching, appeared. The patient was diagnosed with delirium associated with benzodiazepine withdrawal, and his symptoms subsided soon after re-administration of benzodiazepines. Despite development of mild postoperative delirium, the operation was performed safely. The rapid and abrupt discontinuation of benzodiazepines before cancer surgery could impose a high risk of benzodiazepine withdrawal delirium in patients, which makes the management of psychiatric symptoms in the perioperative period more complex and difficult. We believe that it is necessary to highlight the risks of withdrawal delirium and abrupt benzodiazepine discontinuation in cancer treatment. Moreover, re-education on this topic is essential for healthcare workers.

Understanding Barriers to Early Rehabilitation Following the Surgery for Fragility Hip Fractures: A Single-Centre Audit.

Introduction Hip fractures are amongst the most common reasons for geriatric patients' admission to the hospital; recovery of the hip fracture patient can be enhanced by an early rehabilitation program, which should start from the time of admission. This audit aims to study the hip fracture physiotherapy rehabilitation program at a local hospital to ensure compliance with the national guidelines and to identify any potential barriers to early mobilisation after a hip fracture operation. Methods The audit was approved by the trust's audit office. A retrospective study in the Queen Elizabeth The Queen Mother Hospital in Margate, Kent, UK, has been conducted including 113 patients admitted from April to August 2023 to our local hospital; the patientswere screened for the inclusion and exclusion criteria, and data collection started regarding the admitting wards and their physiotherapy assessments including the time they were first assessed by a physiotherapist and the time of first mobilisation after the hip fracture operation and any identified barriers to early mobilisation. Results There were 113 patients who underwent hip fracture surgery, including 23 males and 90 females. The mean age of the participants was 82.7 years.Ninety-three percent (n=106/113) of the patients were seen by a physiotherapist on the day or the day following the surgery for their hip fracture. Amongst the admitted patients, 40% (n=46/113) experienced delayed mobilisation. The reason for the delay was post-operative delirium (n=15/46), low haemoglobin (n=12/46), pain (n=10/46), dementia (n=2/46) and no documented reason (n=7/46). Conclusion The study outcomes emphasise the importance of admitting hip fracture patients into specialised orthopaedic wards. The study identified post-operative delirium, low haemoglobin, pain and pre-existing dementia as factors that delay rehabilitation. Most of these factors are preventable or manageable, which canfacilitate early rehabilitation and subsequently hospital discharge.

Effect of small dose esketamine on perioperative neurocognitive disorder and postoperative depressive symptoms in elderly patients undergoing major elective noncardiac surgery for malignant tumors: A randomized clinical trial.

Perioperative neurocognitive disorder and postoperative depressive symptoms are significant complications after surgery. Studies have indicated that esketamine possesses neuroprotective and antidepressant qualities. This trial included 209 patients aged 60 to 86 years undergoing tumor resection who received esketamine (Group E) or not (Group C) during and after surgery. In group E, patients were given an intravenous dose of 0.5 mg/kg of esketamine 10 minutes after induction of general anaesthesia. In addition, esketamine (2 mg/kg) in combination with sufentanil was used for PCIA during 48 hours postoperatively. On the other hand, saline was used as a substitute for esketamine in group C. Cognitive function was evaluated using neuropsychological tests and telephone interview for cognitive status-modified, and symptoms of depression were assessed using Hamilton Depression Rating Scale 17. Compared to Group C, patients in Group E exhibited lower rates of depressive symptoms at 3, 7, and 90 days post-surgery (53.9% vs 67.7%, 26.3% vs 47.9%, and 13.3% vs 28.4%). Group E also showed decreased time for Trail Making Test on days 7 and 90. However, there were no significant differences in the incidence of delirium 1 to 5 days post-surgery or cognitive impairment 90 days post-surgery between the 2 groups (12.1% vs 10.9% and 8.4% vs 9.7%). Intraoperative low-dose esketamine and postoperative low-dose esketamine combined with sufentanil for patient-controlled intravenous analgesia has been shown to improve postoperative analgesia, alleviate postoperative depressive symptoms, and aid in the recovery of social executive ability. However, this approach did not reduce the incidence of postoperative delirium or postoperative cognitive dysfunction.

Clinical investigation into risk factors for delirium post-cardiac surgery and its implications for nursing intervention guided by behavior change theory

BackgroundThis study explores the factors contributing to the occurrence of delirium following cardiac surgery and devises nursing strategies rooted in behavior change theory.MethodsA cohort of 320 cardiac surgery patients was selected, categorized into two groups: 93 cases where postoperative delirium (POD) was anticipated, and 227 cases where it was not. Preoperative, intraoperative, and postoperative factors of POD were scrutinized using single-factor analysis, while binary logistic regression analysis was employed to pinpoint risk factors.ResultsAmong the 320 patients, 93 displayed POD symptoms post-surgery, yielding an incidence of 29.06%. Preoperative univariate analysis disclosed significant differences in gender, age, smoking, hypertension, and diabetes (P < 0.05). Intraoperatively, significant differences were noted in the American Society of Anesthesiologists (ASA) anesthesia grade (II, III, and IV), surgery time, cardiopulmonary bypass duration, and aortic occlusion duration (P < 0.05). Post-surgery, significant differences were observed in the duration of Intensive Care Unit (ICU) stay, mechanical ventilation time, and visual analogue scale (VAS) scores (P < 0.05). Multivariate Logistic regression identified surgery time (OR = 2.334, P < 0.001), ICU admission duration (OR = 1.457, P < 0.001), mechanical ventilation time (OR = 1.235, P = 0.004), and VAS scores (OR = 2.986, P < 0.001) as independent risk factors for POD. ROC curve analysis indicated higher sensitivity and specificity in predicting POD with surgery time, ICU stay duration, mechanical ventilation time, and VAS scores.ConclusionIrrespective of the surgical intervention type, surgery time, ICU stay duration, mechanical ventilation time, and VAS scores are recognized as risk factors for POD in cardiac surgery patients. Hence, continuous patient monitoring and early intervention tailored to specific risk factors are essential in clinical practice to mitigate POD incidence.

A Comprehensive Intervention Program for Postoperative Delirium Prevention in Elderly Patients Undergoing Cardiac Surgery

PurposeTo explore the application effect of a comprehensive intervention program for postoperative delirium (POD) prevention. DesignDescriptive and comparative study. MethodsThis study included 82 elderly patients who underwent cardiac surgery as the control group to receive routine perioperative care. Seventy seven elderly patients who underwent cardiac surgery were selected as the observation group and received a comprehensive intervention program for POD prevention. This study further compared the length of stay in the hospital, nutritional status, pain score, and sleep quality between the two groups after intervention. FindingsThe postoperative length of stay in the hospital of the observation group was shorter than that of the control group (12.60 ± 2.97 vs 17.30 ± 7.10), and the incidence of POD was lower than that of the latter group (24.68% vs 47.56%, X2 = 8.976, P = .003). The pain scores of the observation group were lower than those of the control group (F = 195.381, P < .001). There was significant difference that the sleep quality score of the observation group was higher than that of the control group (F = 219.20, P < .001). The levels of albumin and hemoglobin in the observation group were higher than those in the control group (54.38 ± 5.87 vs 38.40 ± 3.11; 124.64 ± 13.18 vs 109.00 ± 10.20). The observation group had shorter mechanical ventilation duration, intensive care unit stay, and lower total hospital expenses compared with the control group (P < .05). ConclusionsThe comprehensive intervention program for POD prevention based on evidence-based medicine has a positive effect. In addition, it can also improve patients' pain, sleep quality, and nutritional status.

Early injection laryngoplasty for acute unilateral vocal fold paralysis after thoracic aortic surgery

ObjectiveUnilateral vocal fold paralysis (UVFP) following open thoracic aortic surgery increases pulmonary complications and hospital stays. An intervention protocol with early injection laryngoplasty (IL) and swallowing maneuvers was developed for acute UVFP following thoracic aortic surgery. This study aimed to compare the incidence of complications and length of medical care between the non-VFP and the IL-UVFP group managed under this protocol. MethodsPatients who underwent open thoracic aortic surgery from March 2020 to February 2023 were included, excluding those with preoperative VFP or postoperative bilateral VFP. Under the protocol, patients with UVFP and incomplete glottic closure received IL and swallowing maneuvers within one week after diagnosis, while those without a glottic gap started a soft diet along with swallowing maneuvers. Postoperative complications, including reintubation, ICU re-transfer, pneumonia, stroke, delirium, wound infection, and bleeding, as well as hospital and ICU stay, were assessed. ResultsOf the 355 patients included in the study, 51 (14.4%) developed postoperative UVFP, while 304 (85.6%) had normal VF function. In the UVFP group, 42 patients underwent IL, while 9 patients without a glottic gap did not undergo IL. The incidence of complications and length of medical care were analyzed in the non-VFP and the IL-UVFP groups. The IL-UVFP group had a longer median hospital stay compared to the non-VFP group (20.5 vs. 16.0 days), though this difference was not statistically significant (P = .0681). ICU stay (P = .5396) and ICU re-transfer rates (P = 1.00) were also comparable between the groups. There was no significant difference in the incidence of pneumonia between the IL-UVFP group (4.8%) and the non-VFP group (9.5%) (P = .4003). Additionally, no significant differences were observed in the incidence of stroke, delirium, wound infection, or bleeding between the groups. No IL-related complications were reported. ConclusionsThe protocol with early IL appears to help reduce complication rates in acute UVFP patients following thoracic aortic surgery to levels comparable to those in patients without VFP. This protocol could serve as a guideline for otolaryngologists in managing UVFP patients. Level of evidence2b/Individual cohort study.

How to predict postoperative delirium in geriatric patients with hip fracture as soon as possible? A retrospective study

PurposeInflammation may play a role in the mechanism of postoperative delirium (POD), a severe complication among older postoperative patients. The purpose of this study was to investigate the risk factors of POD in postoperative patients with hip fracture, especially the inflammation marker– neutrophil–lymphocyte ratio (NLR).MethodsThis retrospective investigation utilized data from the Seventh Medical Center of People’s Liberation Army. 1,242 Eligible patients with hip fracture (829 females), median age 81 years, mean neutrophil-lymphocyte ratio (NLR) 5.28, were enrolled. Receiver operating characteristic (ROC) curve was performed to identify the optimal cut point of NLR for POD. The relationship between NLR and POD occurrence, NLR and POD duration were analyzed by multivariable analysis.ResultsROC curve showed that the optimal cut point of NLR for POD was NLR ≥ 7.6. Multivariate logistic regression analysis showed that NLR ≥ 7.6 (odds ratio [OR] 2.75, [95% confidence interval [CI] 1.51 to 5.02], p = 0.001), stroke (OR 1.05, [95% CI 1.02 to 1.09], p = 0.005), complications, general anesthesia, long length of stay were risk factors of POD, with the largest effect for NLR ≥ 7.6. NLR ≥ 7.6 (β 0.59, [95% CI 0.209 to 0.886], p = 0.038), older age (β 0.054, [95% CI 0.009 to 0.099], p = 0.019), previous stroke (β 0.908, [95% CI 0.085 to 1.731], p = 0.031), and previous heart failure (β 1.679, [95% CI 0.448 to 2.910], p = 0.008) suggested long POD duration.ConclusionsThis study demonstrates an association between NLR and postoperative delirium in geriatric hip fracture patients, and contribute new evidence to support NLR as a potential marker for prediction of POD and POD duration.

Association between intraoperative electroencephalogram burst suppression and postoperative delirium: A systematic review and meta-analysis.

Electroencephalogram burst suppression can be associated with postoperative delirium; however, the results of relevant studies are discrepant. This systematic review and meta-analysis aimed to assess the association between intraoperative burst suppression and postoperative delirium in adult surgical patients. PubMed, MEDLINE, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials were systematically searched and updated in May 2023. We included cohort studies, case-control studies, and randomized-controlled studies reporting on postoperative delirium incidence with documented intraoperative burst suppression in adults receiving general anesthesia for any surgery. The primary outcome was the pooled odds ratio (OR) for postoperative delirium in cases with intraoperative burst suppression compared to those without burst suppression, calculated using a random-effects model. Two independent investigators extracted the data. The protocol was prospectively registered in PROSPERO (registration number: CRD42022326479); the results were reported according to PRISMA guidelines. Fourteen studies (6435 patients) were included in the analysis. The overall incidence of postoperative delirium was 21.1% (1358/6435). Patients with intraoperative burst suppression had a higher incidence of postoperative delirium than those without burst suppression (pooled OR, 1.492; 95% confidence interval (CI) [1.022-2.178]; I2 =44%; 95% CI [0%-75%]; τ2 = 0.110). The intraoperative duration of burst suppression was significantly longer in patients who developed postoperative delirium (standardized mean difference [SMD] 0.462 [95% CI, 0.293-0.632]; I2 = 63%; 95% CI [16%-84%]; τ2 = 0.027). The burst suppression ratio was significantly higher in the delirium group (SMD 0.150; 95% CI [0.055-0.245]; I2 = 0%; 95% CI [0%-85%]; τ2 = 0.00). Our meta-analysis suggests an association between intraoperative burst suppression and postoperative delirium; however, the quality of evidence was very low. The limited number of studies and substantial heterogeneity across them emphasize the need for further high-quality studies to establish a more robust conclusion.

The association of pre-operative biomarkers of endothelial dysfunction with the risk of post-operative neurocognitive disorders: results fromthe BioCog study.

Endothelial dysfunction (ED) promotes the development of atherosclerosis, and studies suggest an association with age-related neurocognitive disorders. It is currently unclear whether ED is also associated with the risk of perioperative neurocognitive disorders. We included 788 participants aged ≥ 65 years of the BioCog study. Patients were scheduled to undergo elective surgery with expected duration > 60 min. Blood was collected before surgery for measurement of 5 biomarkers of ED: asymmetric and symmetric dimethylarginine (ADMA; SDMA), intercellular and vascular adhesion molecule (ICAM-1, VCAM-1), and von Willebrand factor (vWF). Patients were monitored for the occurrence of postoperative delirium (POD) daily until the 7th postoperative day. 537 (68.1%) patients returned for a 3-month follow-up. Post-operative cognitive dysfunction (POCD) was defined from the change in results on a battery of 6 neuropsychological tests between baseline and 3 months, compared to the change in results of a control group during the 3-month interval. The associations of each of the 5 ED biomarkers with POD and POCD respectively were determined using multiple logistic regression analyses with adjustment for age, sex, surgery type, pre-morbid IQ, body mass index,hypertension, diabetes,HbA1C, triglyceride, total and HDL cholesterol. 19.8% of 788 patients developed POD; 10.1% of 537 patientshad POCDat 3 months. Concentrations of ED biomarkers were not significantly associated with a POD. A higher VCAM-1 concentration was associated with a reduced POCD risk (adjustedodds ratio 0.55; 95% CI: 0.35-0.86). No further statistically significant results were found. Pre-operative concentrations of ED biomarkers werenot associated with POD risk. We unexpectedly found higher VCAM-1 to be associated with a reduced POCD risk. Further studies are needed to evaluate these findings.

Assessing the Risk of Postoperative Delirium Through Comprehensive Geriatric Assessment and Eastern Cooperative Oncology Group Performance Status of Elderly Patients With Gastric Cancer.

Postoperative delirium is especially common and often problematic among elderly patients undergoing surgery. This study aimed to explore factors that can predict postoperative delirium in elderly patients undergoing gastric cancer surgery. This cohort study included 255 patients age 75 years or older who underwent gastric cancer surgery between July 2010 and December 2020. All the patients underwent preoperative comprehensive geriatric assessment (CGA) evaluation by a geriatrician. In addition to the CGA items, this study investigated the association between postoperative delirium and clinicopathologic factors, including Eastern Cooperative Oncology Group performance status (ECOG-PS). The most common postoperative complication was delirium, present in 31 patients (12.2%). The group with delirium was significantly more likely to have ECOG-PS≥2, diabetes mellitus, cardiovascular disease, or cerebral infarction. The CGA showed frailty in the Instrumental Activities of Daily Living scale (IADL), the Mini-Mental State Examination (MMSE), the Vitality Index (VI), and the Geriatric Depression Scale 15 (GDS-15). In the multivariate analysis, the independent risk factors for delirium were ECOG-PS ≥2 (P=0.002) and MMSE-frailty (P<0.001). Using an MMSE score of ≤23 and an ECOG-PS score of ≥2 as cutoffs, postoperative delirium was predicted with a sensitivity of 80.7% and a specificity of 74.1%. Postoperative delirium might be more easily predicted based on the combination of MMSE and ECOG-PS for elderly patients with gastric cancer undergoing gastrectomy.