Postoperative Delirium: Risk Factors, Prevention, and Treatment

Trabold, Benedikt; Metterlein, Thomas

doi:10.1053/j.jvca.2014.03.017

Cited by 61 publications

(53 citation statements)

References 114 publications

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“…And although the list of possible risk factors for PD after SAVR remains long, the variables identified in this study such as age, a history of coronary artery disease, a need for an intra-aortic balloon pump preoperatively, and greater PRBC transfusions have all previously been cited as candidate risk factors for PD with on-pump surgery. 3,6,8,10,19 And although there are only a few studies available describing PD after TAVR, the data available thus far are consistent with those from this investigation suggesting that PD is an equally prevalent complication for TAVR, particularly when performed using alternative access techniques, 20,21 It is possible that despite the fact that TAVR may be a less-invasive procedure than SAVR, given the high-risk patient population for whom TAVR is currently restricted to as a procedural option, the incidence of PD following TAVR will remain high. The results from propensity-matched patients within this study suggest that a typical patient undergoing TAVR, with numerous comorbidities, would likely have an even higher likelihood of PD if offered an SAVR approach.…”

Section: Discussionmentioning

confidence: 99%

Delirium after surgical and transcatheter aortic valve replacement is associated with increased mortality

Maniar

Lindman

Escallier

et al. 2016

The Journal of Thoracic and Cardiovascular Surgery

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Objective The purpose of this study was to determine the incidence and clinical significance of postoperative delirium (PD) in patients with aortic stenosis undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). Method Between 2010 and 2013, 427 patients underwent TAVR (n = 168) or SAVR (n = 259) and were screened for PD using the Confusion Assessment Method for the Intensive Care Unit. The incidence of PD in both treatment groups was determined and its association with morbidity and mortality was retrospectively compared. Results PD occurred in 135 patients (32%) with a similar incidence between SAVR (33% [86 out of 259]) and TAVR (29% [49 out of 168]) (P = .40). TAVR by transfemoral approach had the lowest incidence of PD compared with SAVR (18% vs 33%; P = .025) or TAVR when performed by alternative access techniques (18% vs 35%; P = .02). Delirium was associated with longer initial intensive care unit stay (70 vs 27 hours), intensive care unit readmission (10% [14 out of 135] vs 2% [6 out of 292]), and longer hospital stay (8 vs 6 days) (P < .001 for all). PD was associated with increased mortality at 30 days (7% vs 1%; P < .001) and 1 year (21% vs 8%; P < .001). After multivariable adjustment, PD remained associated with increased 1-year mortality (hazard ratio, 3.02; 95% confidence interval, 1.75–5.23; P < .001). There was no interaction between PD and aortic valve replacement approach with respect to 1-year mortality (P = .12). Among propensity-matched patients (n = 170), SAVR-treated patients had a higher incidence of PD than TAVR-treated patients (51% vs 29%; P = .004). Conclusions PD occurs commonly after SAVR and TAVR and is associated with increased morbidity and mortality. Given the high incidence of PD and its associated adverse outcomes, further studies are needed to minimize PD and potentially improve patient outcomes.

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Section: Discussionmentioning

confidence: 99%

Delirium after surgical and transcatheter aortic valve replacement is associated with increased mortality

Maniar

Lindman

Escallier

et al. 2016

The Journal of Thoracic and Cardiovascular Surgery

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“…Proposed mechanisms include pre-existing brain inflammation exacerbated by surgery; induced immunologic perturbations; ischemic brain injury; hypoxia; and an imbalance of neurotransmitters, including cholinergic deficiency. 5 Several risk factors have been identified for delirium, including older age, preexisting cognitive impairment, depression, history of stroke, atrial fibrillation, anemia, infection, preoperative treatment with beta-blockers, alcohol, benzodiazepines, and nicotine abuse. 6–9 …”

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confidence: 99%

Blood Pressure Deviations From Optimal Mean Arterial Pressure During Cardiac Surgery Measured With a Novel Monitor of Cerebral Blood Flow and Risk for Perioperative Delirium: A Pilot Study

Hori¹,

Max²,

Laflam³

et al. 2016

Journal of Cardiothoracic and Vascular Anesthesia

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Objective The aim of this study was to evaluate whether excursions of blood pressure from the optimal mean arterial pressure during and after cardiac surgery are associated with postoperative delirium identified using a structured examination. Design Prospective, observational study. Setting University hospital. Participants The study included 110 patients undergoing cardiac surgery. Interventions Patients were monitored using ultrasound-tagged near-infrared spectroscopy to assess optimal mean arterial pressure by cerebral blood flow autoregulation monitoring during cardiopulmonary bypass and the first 3 hours in the intensive care unit. Measurements and Main Results The patients were tested preoperatively and on postoperative days 1 to 3 with the Confusion Assessment Method or Confusion Assessment Method for the Intensive Care Unit, the Delirium Rating Scale-Revised-98, and the Mini Mental State Examination. Summative presence of delirium on postoperative days 1 through 3, as defined by the consensus panel following Diagnostic and Statistical Manual of Mental Disorders-IV-TR criteria, was the primary outcome. Delirium occurred in 47 (42.7%) patients. There were no differences in blood pressure excursions above and below optimal mean arterial pressure between patients with and without summative presence of delirium. Secondary analysis showed blood pressure excursions above the optimal mean arterial pressure to be higher in patients with delirium (mean ± SD, 33.2 ± 26.51 mmHgxh v 23.4 ± 16.13 mmHgxh; p ¼ 0.031) and positively correlated with the Delirium Rating Scale score on postoperative day 2 (r = 0.27, p = 0.011). Conclusions Summative presence of delirium was not associated with perioperative blood pressure excursions; but on secondary exploratory analysis, excursions above the optimal mean arterial pressure were associated with the incidence and severity of delirium on postoperative day 2.

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“…Although several efforts have attempted to determine its exact pathogenesis, POD is the consequence of interplay of different pathophysiologic mechanisms [9][10][11]. Among these, neuroinflammation is one of the most emerging causative hypotheses related to POD occurrence [23,24].…”

Section: Discussionmentioning

confidence: 99%

“…Several definitions of POD have been proposed along with different diagnostic tools [10]. POD is generally defined as an acute deterioration of brain function characterised by fluctuating mental status with inattention and disturbances in consciousness and presents clinically different subtypes, with or without accompanying agitation [11,12]. Hyperactive delirium is characterised by active symptoms such as agitation and restlessness, characterised by excessive motor or verbal behaviour that interfere with patient care, patient or staff safety, and medical therapy [6,11].…”

mentioning

confidence: 99%

“…Hyperactive delirium is characterised by active symptoms such as agitation and restlessness, characterised by excessive motor or verbal behaviour that interfere with patient care, patient or staff safety, and medical therapy [6,11]. Conversely, hypoactive delirium is characterised by unresponsiveness and motionlessness [11]. However, POD is often confounded with postoperative cognition dysfunction [9,13].…”

mentioning

confidence: 99%

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Effects of statins on delirium following cardiac surgery – evidence from literature

Mariscalco¹,

Mariani²,

Biancari³

et al. 2015

Psychiatr Pol

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SummaryDelirium is a common complication after cardiac surgery, being associated with significant mortality and morbidity. The pathogenesis of postoperative delirium (POD) is complex and multifactorial, involving an interaction of multiple predisposing and precipitating factors. There are several hypotheses regarding the underlying mechanisms of POD, and the most recent emerging one involves neuroinflammation, which is exacerbated by the cardiopulmonary bypass-induced systemic inflammatory response. Experimental and clinical studies have recently documented improved perioperative central neural protection exerted by statins because of their anti-inflammatory, immunomodulatory, and antithrombotic properties. The present review will focused on the possible protective effect exerted by preoperative statin administration on delirium following cardiac surgery.

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Postoperative Delirium: Risk Factors, Prevention, and Treatment

Cited by 61 publications

References 114 publications

Delirium after surgical and transcatheter aortic valve replacement is associated with increased mortality

Delirium after surgical and transcatheter aortic valve replacement is associated with increased mortality

Blood Pressure Deviations From Optimal Mean Arterial Pressure During Cardiac Surgery Measured With a Novel Monitor of Cerebral Blood Flow and Risk for Perioperative Delirium: A Pilot Study

Effects of statins on delirium following cardiac surgery – evidence from literature

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