Impact of intraoperative blood pressure, blood pressure fluctuation, and pulse pressure on postoperative delirium in elderly patients with hip fracture: A prospective cohort study

Research progress of postoperative delirium in neurosurgery

Delirium is a transient and acute syndrome of encephalopathy, characterized by disturbances in consciousness, orientation, cognition, perception, and emotional regulation, often accompanied by hallucinations, illusions, psychomotor agitation, and restlessness. Postoperative delirium (POD), a common complication particularly in elderly patients, significantly impacts recovery by prolonging mechanical ventilation, neurosurgical intensive care unit stays, and overall hospitalization durations, while severely diminishing patients’ quality of life after discharge. Despite its prevalence, POD remains underrecognized in clinical practice, with significant gaps in its diagnosis and management. This review explores the definition, diagnostic criteria, underlying pathogenesis, and associated risk factors of POD in neurosurgical patients, aiming to offer valuable insights for improving clinical diagnosis and therapeutic strategies.

Association between periprocedural cerebral desaturation during transcatheter aortic valve implantation and postprocedural delirium: a prospective observational study

BACKGROUND

The aim of this study was to investigate whether the level of decrease in cerebral oxygen saturation during the valve placement phase of the transcatheter aortic valve implantation (TAVI) procedure under sedation has an effect on postoperative delirium (POD).

METHODS

The study initially assessed 50 patients between the ages of 50 and 90 years with an indication for TAVI by the cardiac team. Regional cerebral oxygen saturation (rScO2) was measured using Near-infrared spectroscopy (NIRS) before the procedure (T1), during surgical field sterilization (T2), catheter placement (T3), wire manipulation (T4), valve placement (T5) and access site artery repair (T6). Confusion Assessment Method for The Intensive Care Unit (ICU-CAM) test was performed on intensive care unit and the presence of POD was questioned. Patients were divided into two groups as those without POD (Group 1) and those with POD (Group 2).

RESULTS

The study was completed with 41 patients in total. While POD was present in 12 (29.3%) of the patients evaluated intensive care unit, POD was not observed in 29 (70.7%) patients. The rScO2 value measured at T5 was significantly lower in Group 2 compared to Group 1 (p < 0.001).

CONCLUSIONS

In our study, the rate of POD after TAVI was as high as 29.3%. Low rScO2 during valve placement was associated with delirium. Our findings indicate that NIRS devices could be a useful tool for assessing the risk of POD during the TAVI procedure; however, further research is needed to validate their routine clinical use.

Personalised blood pressure management during major noncardiac surgery and postoperative neurocognitive disorders: a randomised trial

Background

It remains unknown whether there is a causal relationship between intraoperative hypotension and postoperative neurocognitive disorders. We tested the hypothesis that personalised-compared to routine-intraoperative blood pressure management reduces the incidence of postoperative neurocognitive disorders in patients having major noncardiac surgery.

Methods

In this single-centre trial, 328 elective major noncardiac surgery patients were randomly allocated to receive personalised blood pressure management (i.e. maintaining intraoperative mean arterial pressure [MAP] above preoperative baseline MAP from automated 24-h blood pressure monitoring) or routine blood pressure management (i.e. maintaining MAP above 65 mm Hg). The primary outcome was the incidence of neurocognitive disorders (composite of delayed neurocognitive recovery and delirium) between postoperative days 3 and 7.

Results

The primary outcome, neurocognitive disorders, occurred in 18 of 147 patients (12%) assigned to personalised and 21 of 148 patients (14%) assigned to routine blood pressure management (odds ratio [OR]=0.84, 95% confidence interval [CI]: 0.40-1.75, P=0.622). Delayed neurocognitive recovery occurred in 17 of 146 patients (12%) assigned to personalised and 17 of 145 patients (12%) assigned to routine blood pressure management (OR=0.99, 95% CI: 0.45-2.17, P=0.983). Delirium occurred in 2 of 157 patients (1%) assigned to personalised and 4 of 158 patients (3%) assigned to routine blood pressure management (OR=0.50, 95% CI: 0.04-3.53, P=0.684).

Conclusions

Personalised intraoperative blood pressure management maintaining preoperative baseline MAP neither reduced the incidence of the composite primary outcome neurocognitive disorders between postoperative days 3 and 7 nor the incidences of the components of the composite primary outcome-delayed neurocognitive recovery and delirium-compared to routine blood pressure management in patients having major noncardiac surgery.

Clinical trial registration

ClinicalTrials.gov (NCT03442907).

PeriOperative Quality Initiative (POQI) international consensus statement on perioperative arterial pressure management

Arterial pressure monitoring and management are mainstays of haemodynamic therapy in patients having surgery. This article presents updated consensus statements and recommendations on perioperative arterial pressure management developed during the 11th POQI PeriOperative Quality Initiative (POQI) consensus conference held in London, UK, on June 4-6, 2023, which included a diverse group of international experts. Based on a modified Delphi approach, we recommend keeping intraoperative mean arterial pressure ≥60 mm Hg in at-risk patients. We further recommend increasing mean arterial pressure targets when venous or compartment pressures are elevated and treating hypotension based on presumed underlying causes. When intraoperative hypertension is treated, we recommend doing so carefully to avoid hypotension. Clinicians should consider continuous intraoperative arterial pressure monitoring as it can help reduce the severity and duration of hypotension compared to intermittent arterial pressure monitoring. Postoperative hypotension is often unrecognised and might be more important than intraoperative hypotension because it is often prolonged and untreated. Future research should focus on identifying patient-specific and organ-specific hypotension harm thresholds and optimal treatment strategies for intraoperative hypotension including choice of vasopressors. Research is also needed to guide monitoring and management strategies for recognising, preventing, and treating postoperative hypotension.

The interrelationship between multiple long-term conditions (MLTC) and delirium: a scoping review

INTRODUCTION

Delirium and multiple long-term conditions (MLTC) share numerous risk factors and have been shown individually to be associated with adverse outcomes following hospitalisation. However, the extent to which these common ageing syndromes have been studied together is unknown. This scoping review aims to summarise our knowledge to date on the interrelationship between MLTC and delirium.

METHODS

Searches including terms for delirium and MLTC in adult human participants were performed in PubMed, EMBASE, Medline, Psycinfo and CINAHL. Descriptive analysis was used to summarise findings, structured according to Synthesis Without Meta-analysis reporting guidelines.

RESULTS

After removing duplicates, 5256 abstracts were screened for eligibility, with 313 full-texts sought along with 17 additional full-texts from references in review articles. In total, 140 met inclusion criteria and were included in the final review. Much of the literature explored MLTC as a risk factor for delirium (n = 125). Fewer studies explored the impact of MLTC on delirium presentation (n = 5), duration (n = 3) or outcomes (n = 6) and no studies explored how MLTC impacts the treatment of delirium or whether having delirium increases risk of developing MLTC. The most frequently used measures of MLTC and delirium were the Charlson Comorbidity Index (n = 98/140) and Confusion Assessment Method (n = 81/140), respectively.

CONCLUSION

Existing literature largely evaluates MLTC as a risk factor for delirium. Major knowledge gaps identified include the impact of MLTC on delirium treatment and the effect of delirium on MLTC trajectories. Current research in this field is limited by significant heterogeneity in defining both MLTC and delirium.

Mortality following noncardiac surgery assessed by the Saint Louis University Score (SLUScore) for hypotension: a retrospective observational cohort study

BACKGROUND

The Saint Louis University Score (SLUScore) was developed to quantify intraoperative blood pressure trajectories and their associated risk for adverse outcomes. This study examines the prevalence and severity of intraoperative hypotension described by the SLUScore and its relationship with 30-day mortality in surgical subtypes.

METHODS

This retrospective analysis of perioperative data included surgical cases performed between January 1, 2010, and December 31, 2020. The SLUScore is calculated from cumulative time-periods for which the mean arterial pressure is below a range of hypotensive thresholds. After calculating the SLUScore for each surgical procedure, we quantified the prevalence and severity of intraoperative hypotension for each surgical procedure and the association between intraoperative hypotension and 30-day mortality. We used binary logistic regression to quantify the potential contribution of intraoperative hypotension to mortality.

RESULTS

We analysed 490 982 cases (57.7% female; mean age 57 yr); 33.2% of cases had a SLUScore>0, a median SLUScore of 13 (inter-quartile range [IQR] 7-21), with 1.19% average mortality. The SLUScore was associated with mortality in 12/14 surgical groups. The increases in the odds ratio for death within 30 days of surgery per SLUScore increment were: all surgery types 3.5% (95% confidence interval [95% CI] 3.2-3.9); abdominal/transplant surgery 6% (95% CI 1.5-10.7); thoracic surgery1.5% (95% CI 1-3.3); vascular surgery 3.01% (95% CI 1.9-4.05); spine/neurosurgery 1.1% (95% CI 0.1-2.1); orthopaedic surgery 1.4% (95% CI 0.7-2.2); gynaecological surgery 6.3% (95% CI 2.5-10.1); genitourinary surgery 4.84% (95% CI 3.5-6.15); gastrointestinal surgery 5.2% (95% CI 3.9-6.4); gastroendoscopy 5.5% (95% CI 4.4-6.7); general surgery 6.3% (95% CI 5.5-7.1); ear, nose, and throat surgery 1.6% (95% CI 0-3.27); and cardiac electrophysiology (including pacemaker procedures) 6.6% (95% CI 1.1-12.4).

CONCLUSIONS

The SLUScore was independently, but variably, associated with 30-day mortality after noncardiac surgery.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Blood Pressure Fluctuation Pattern Associated with 90-Day Ischemic Stroke and Transient Ischemic Attack After Total Knee Arthroplasty-A Retrospective Study

OBJECTIVE

Blood pressure (BP) fluctuation has been demonstrated to be closely associated with stroke. However, at present, no attention is paid to the BP fluctuation following total knee arthroplasty (TKA). The aim of this study is to investigate what is BP fluctuation patterns in stroke and transient ischemic attack (TIA) patients after primary TKA, compare clinical characteristics among different BP fluctuation patterns and determine whether it could predict the occurrence of a 90-day stroke.

METHODS

A retrospective study was conducted from February 1, 2011 to February 15, 2021. Stroke or TIA patients within 90 days after TKA were included. Data from a hospitalization management system were analyzed, including demographics, smoking status, comorbidities, medications, surgical variables, and 90-day stroke, mortality, and readmission rates. BP fluctuation patterns were defined based on the average BP in the first 3 days after TKA. A logistic regression analysis model was used to identify risk factors for 90-day stroke or TIA following TKA.

RESULTS

Of the 1687 patients who underwent primary TKA, 4.0% (68/1687) experienced a 90-day stroke or TIA. A total of 63 patients met the inclusion criteria, with an average age of 67.5 years and 55.6% (35/63) female. The number of stroke or TIA patients in each BP fluctuation pattern (T1-T5) was 6 (9.5%), 5 (7.9%), 4 (6.3%), 13 (20.6%), and 35 (55.6%) respectively. Patients with a T5 pattern tended to be older and had a greater reduction in average systolic blood pressure (SBP) 3 days after surgery compared to other patterns. The T5 pattern was associated with a higher occurrence of stroke and a lower occurrence of TIA. Patients with a T5 pattern also had a longer length of stay within 90 days following TKA. After adjusting for confounding factors, average SBP fluctuation ≥40 mmHg and the T5 pattern of BP fluctuation remained risk factors for 90-day stroke or TIA after TKA.

CONCLUSION

BP fluctuation patterns in the early postoperative period are associated with 90-day stroke and TIA following primary TKA.

Association of Blood Pressure Variability with Delirium in Patients with Critical Illness

BACKGROUND

The objective was to examine the association of blood pressure variability (BPV) during the first 24 h after intensive care unit admission with the likelihood of delirium and depressed alertness without delirium ("depressed alertness").

METHODS

This retrospective, observational, cohort study included all consecutive adult patients admitted to an intensive care unit at Mayo Clinic, Rochester, Minnesota, from July 1, 2004, through October 31, 2015. The primary outcomes were delirium and delirium-free days, and the secondary outcomes included depressed alertness and depressed alertness-free days. Logistic regression was performed to determine the association of BPV with delirium and depressed alertness. Proportional odds regression was used to assess the association of BPV with delirium-free days and depressed alertness-free days.

RESULTS

Among 66,549 intensive care unit admissions, delirium was documented in 20.2% and depressed alertness was documented in 24.4%. Preserved cognition was documented in 55.4% of intensive care unit admissions. Increased systolic and diastolic BPV was associated with an increased odds of delirium and depressed alertness. The magnitude of the association per 5-mm Hg increase in systolic average real variability (the average of absolute value of changes between consecutive systolic blood pressure readings) was greater for delirium (odds ratio 1.34; 95% confidence interval 1.29-1.40; P < 0.001) than for depressed alertness (odds ratio 1.06; 95% confidence interval 1.02-1.10; P = 0.004). Increased systolic and diastolic BPV was associated with fewer delirium-free days but not with depressed alertness-free days.

CONCLUSIONS

BPV in the first 24 h after intensive care unit admission is associated with an increased likelihood of delirium and fewer delirium-free days.

Association between intraoperative mean arterial pressure variability and postoperative delirium after hip fracture surgery: a retrospective cohort study

BACKGROUND

Postoperative delirium (POD) is a common complication in elderly patients after hip fracture surgery. Our study was to investigate whether intraoperative mean arterial pressure variability (MAPV) was associated with POD in elderly patients after hip fracture surgery.

METHODS

In this retrospective cohort study, patients aged 65 years and older undergoing hip fracture surgery were included. The correlation between MAPV and POD was investigated using univariate and multivariate logistic regression. Covariate-related confounding effects were eliminated with propensity score matching (PSM) analysis. Then, a subgroup analysis was conducted to further examine the associations between MAPV and POD.

RESULTS

Nine hundred sixty-three patients with a median age of 80 years (IQR: 73-84) were enrolled. POD occurred in 115/963 (11.9%) patients within 7 days after surgery. According to multivariate regression analysis, MAPV > 2.17 was associated with an increased risk of POD (OR: 2.379, 95% CI: 1.496-3.771, P < 0.001). All covariates between the two groups were well balanced after PSM adjustment. A significant correlation between MAPV and POD was found in the PSM analysis (OR: 2.851, 95% CI: 1.710-4.746, P < 0.001).

CONCLUSIONS

An increased intraoperative MAPV may be a predictor for POD.

Sevoflurane-induced hypotension causes cognitive dysfunction and hippocampal inflammation in mice

Sevoflurane commonly adopted for anesthetic in clinical practice, however, its influences on cerebral blood flow and cognitive function remain controversial. Herein, the sevoflurane-induced hypotension on arterial blood pressure, cerebral blood flow, cognitive function, and hippocampal inflammation was investigated in mice. A significant decrease in arterial blood pressure and cerebral blood flow was indicated by the sevoflurane anesthesia treatment. Moreover, sevoflurane-induced hypotension was associated with the impaired cognitive function and the increased levels of NLRP3 inflammasome activation and oxidative stress in hippocampus. These findings suggest that sevoflurane-induced hypotension may lead to the cognitive dysfunction and hippocampal inflammation.

Influence of perioperative blood pressure regulation on postoperative delirium in patients undergoing head and neck free flap reconstruction

BACKGROUND

Postoperative delirium (POD) is a serious complication in patients undergoing microvascular head and neck reconstruction. Whether intraoperative and postoperative blood pressure regulation are risk factors for POD remains unclear. This study aimed to highlight the relationships between intraoperative and postoperative blood pressure regulation and POD in microvascular head and neck reconstruction.

METHODS

Data from 433 patients who underwent microvascular head and neck reconstruction at our department of oral and maxillofacial surgery between 2011 and 2019 were retrospectively analyzed. The 55 patients with POD were matched with 55 patients without POD in terms of tracheotomy, flap type, and flap location, and the intraoperative and postoperative systolic and mean blood pressure values were compared between the two groups.

RESULTS

Patients with POD showed lower intraoperative and postoperative minimum mean arterial pressure (MAP) values than patients without POD (60.0 mmHg vs. 65.0 mmHg, p < 0.001; and 56.0 mmHg vs. 62.0 mmHg, p < 0.001; respectively). A lower intraoperative minimum MAP value was identified as predictor for POD (odds ratio [OR] 1.246, 95% confidence interval [CI] 1.057-1.472, p = 0.009). The cut-off value for intraoperative MAP for predicting POD was  ≤ 62.5 mmHg (area under the curve [AUC] 0.822, 95% CI 0.744-0.900, p < 0.001).

CONCLUSIONS

Maintaining a stable intraoperative minimum MAP of  > 62.5 mmHg could help to reduce the incidence of POD in microvascular head and neck reconstruction.

Incidence of intraoperative hypotension during non-cardiac surgery in community anesthesia practice: a retrospective observational analysis

BACKGROUND

Intraoperative hypotension (IOH) is well-described in the academic setting but not in community practice. IOH is associated with risk of postoperative morbidity and mortality. This is the first report of IOH in the community setting using the IOH measure definition from the Centers for Medicare and Medicaid Services Merit-based Incentive Payment System program.

OBJECTIVES

To describe the incidence of IOH in the community setting; assess variation in IOH by patient-, procedure-, and facility-level characteristics; and describe variation in risk-adjusted IOH across clinicians.

METHODS

Design Cross-sectional descriptive analysis of retrospective data from anesthesia records in 2020 and 2021. Setting Forty-five facilities affiliated with two large anesthesia providers in the USA. Participants Patients aged 18 years or older having non-emergent, non-cardiac surgery under general, neuraxial, or regional anesthesia. Cases were excluded based on criteria for the IOH measure: baseline mean arterial pressure (MAP) below 65 mmHg prior to anesthesia induction; American Society of Anesthesiologists (ASA) physical status classification of I, V, or VI; monitored anesthesia care only; deliberate induced hypotension; obstetric non-operative procedures; liver or lung transplant; cataract surgery; non-invasive gastrointestinal cases. Main outcomes IOH, using four definitions. Primary definition: binary assessment of whether the case had MAP < 65 mmHg for 15 min or more. Secondary definitions: total number of minutes of MAP < 65 mmHg, total area under MAP of 65 mmHg, time-weighted average MAP < 65 mmHg.

RESULTS

Among 127,095 non-emergent, non-cardiac cases in community anesthesia settings, 29% had MAP < 65 mmHg for at least 15 min cumulatively, with an overall mean of 12.4 min < 65 mmHg. IOH was slightly more common in patients who were younger, female, and ASA II (versus III or IV); in procedures that were longer and had higher anesthesia base units; and in ambulatory surgery centers. Incidence of IOH varied widely across individual clinicians in both unadjusted and risk-adjusted analyses.

CONCLUSION

Intraoperative hypotension is common in community anesthesia practice, including among patients and settings typically considered "low risk." Variation in incidence across clinicians remains after risk-adjustment, suggesting that IOH is a modifiable risk worth pursuing in quality improvement initiatives.

Metabolic syndrome and the risk of postoperative delirium and postoperative cognitive dysfunction: a multi-centre cohort study

BACKGROUND

Metabolic syndrome and its components are risk factors for cognitive impairment, but their contribution to perioperative neurocognitive disorders is unknown. We examined their associations with the risk of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) in older patients.

METHODS

In 765 male and female participants aged ≥65 years, we measured preoperative metabolic parameters and screened for POD for 7 days or until discharge. POCD was defined through comparison of cognitive change on six neuropsychological tests with non-surgical controls. Multiple logistic regression analyses examined the association of metabolic parameters with risk of POD and POCD with adjustment for age, sex, and surgery type.

RESULTS

A total of 149 patients (19.5% of 765) developed POD and 53 (10.1% of 520 attendees) had POCD at 3 months. Patients with metabolic syndrome were at 1.85-fold higher risk of POD (95% confidence interval [CI] 1.26-2.70). Each 1 mmol L^-1 higher high-density lipoprotein cholesterol (HDL-C) was associated with a 0.47-fold lower POD risk (95% CI 0.30-0.74). Each 1 kg m^-2 higher body mass index (BMI) was associated with a 1.09-fold higher POCD risk (95% CI 1.02- 1.16).

CONCLUSIONS

Older surgical patients with metabolic syndrome were at increased risk of POD. Only reduced HDL-C was significantly associated with POD. For POCD, a higher preoperative BMI was identified as a risk factor. These findings add to mounting evidence of a distinct epidemiology of POD and POCD. Screening programmes taking advantage of HDL-C and BMI measurements and of metabolic interventions in reducing perioperative neurocognitive disorders should be evaluated.

CLINICAL TRIAL REGISTRATION

NCT02265263.

Postoperative delirium: identifying the patient at risk and altering the course: A narrative review

Postoperative delirium (POD) is a common neurocognitive syndrome seen in older patients after major surgery. POD is linked to longer stays in hospital and intensive care, a greater incidence of postoperative complications, worse functional outcome, and higher mortality. Researchers have not yet fully elucidated the exact pathophysiology of POD. Several risk factors that contribute to the development of POD have been identified, such as advanced age, cardiac or hip surgery, preoperative cognitive decline or delirium, disturbances in brain levels of neurotransmitters and information processing, oxidative stress and neuro-inflammation. Identifying patients at risk for POD enables a more precise and efficient allocation of medical resources and facilitates POD prevention and management. The present review addresses how to identify patients at risk of POD and summarizes the currently available evidence and best-practice recommendations for peri-operative management and prevention of POD.

The Efficacy of Low-Dose Risperidone Treatment for Post-Surgical Delirium in Elderly Orthopedic Patients

Background: Delirium is an acute and typically reversible failure of essential cognitive and attentional functions and is a growing public health concern, with an incidence of 20-50% in patients older than 65 after major surgery and 61% in patients undergoing hip fracture surgery. Numerous treatment strategies have been examined with no conclusive results. The purpose of this study is to assess the efficacy of a three-day low-dose risperidone treatment protocol, 0.5 mg BID, in treating delirium in elderly hospitalized orthopedic surgery department patients. Methods: This study is a prospective non-randomized study involving the senior patient population, older than 65, in an Orthopedic Surgery Department in 2019 and 2020. Delirium was diagnosed by a confusion assessment method (CAM) questionnaire. A three-day 0.5 mg risperidone BID treatment protocol was initiated following diagnosis. Patient data collected included age, gender, chronic diseases, type of surgery and anesthesia and delirium characteristics. Results: The delirium study group included 47 patients with an average age of 84.4 years (±8.6), of whom 53.2% were females. Delirium incidence was 3.7% in all patients older than 65 (1759 patients) and 9.3% in the proximal femoral fracture group. We did not correlate electrolyte imbalance, anemia, polypharmacy and chronic diseases to delirium onset characteristics. Following the three-day low-dose risperidone treatment protocol, 0.5 mg BID, 14.9% of the patients showed CAM score normalization after one day of treatment, and 93.6% within two days. Conclusions: We found our rigid three-day low-dose risperidone treatment protocol, 0.5 mg BID, efficacious in fast delirium resolution, without side effects.

Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review

Importance

Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups.

Objective

To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting.

Evidence Review

A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium.

Findings

A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity.

Conclusions and Relevance

In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.

Higher intraoperative mean arterial blood pressure does not reduce postoperative delirium in elderly patients following gastrointestinal surgery: A prospective randomized controlled trial

BACKGROUND

This study aimed to describe the relationship between the different levels of intraoperative mean arterial blood pressure (MAP) and postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery.

MATERIALS AND METHODS

This prospective controlled clinical trial enrolled 116 patients aged 65 to 85 years who underwent gastrointestinal laparoscopic surgery. These patients were randomized 1:1 to a MAP goal of 65 to 85 mmHg (L group) or an 86 to 100 mmHg (H group). The primary endpoint was the incidence of postoperative delirium, assessed twice daily with the Confusion Assessment Method (CAM) and Richmond Agitation-Sedation Scale (RASS) during the first five postoperative days. Delirium severity was evaluated with the Delirium-O-Meter (D-O-M).

RESULTS

108 patients (L group n = 55, H group n = 53) were eventually included in intention-to-treat analyses. Postoperative delirium occurred in 18 (32.7%) of 55 cases of L group and in 15 (28.3%) of 53 cases of H group. The incidence of delirium subtypes between the two groups: hypoactive delirium 14.5% (8/55) vs 11.3% (6/53); hyperactive delirium 7.3% (4/55) vs 3.8% (2/53); mixed delirium 10.9% (6/55) vs 13.2% (7/53). However, the L group showed higher D-O-M scores of the first episode of delirium: 14.5 (Q1 = 12, Q3 = 18.5) vs 12 (Q1 = 10, Q3 = 14), which means the delirium is more severe.

CONCLUSIONS

Compared with 65 to 85 mmHg, maintaining intraoperative MAP at 86-100 mmHg did not reduce the incidence of postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery. However, the severity of delirium could be reduced and blood loss is a risk factor for postoperative delirium.

Effect of systolic blood pressure fluctuations during resuscitation on postoperative complications following meningioma surgery: A retrospective observation study

It is unclear whether blood pressure variability in the post-anesthesia care unit is associated with postoperative complications. This study aims to characterize the impact of blood pressure fluctuations on postoperative complications and postoperative length of stay after meningioma surgery. Adult meningioma patients undergoing general anesthesia were retrospectively recruited. The principal exposure was blood pressure variability in the post-anesthesia care unit, calculated by noninvasive blood pressure measurements. The primary outcome was major postoperative complications, defined as II or higher in the Clavien-Dindo classification grades. Secondary outcomes included healthcare resource utilization parameters among patients. Multivariable logistic regression was used and adjusted for potential confounding variables. Data sensitivity analyses were performed via different variable transformations and propensity score matching analyses. A total of 578 patients qualified for the study, and 161 (27.9%) cases experienced postoperative complications. The multivariable analysis found that increased systolic blood pressure variability in the post-anesthesia care unit was associated with postoperative complications (adjusted odds ratio [aOR] = 1.15; 95% confidence interval [CI], 1.09-1.22, P < .001) and prolonged postoperative length of stay (adjusted regression coefficients [β] = 1.86; 95% CI, 0.58-3.13, P = .004). Patients with postoperative complications had a higher frequency of intensive care admission (44.1% vs 15.3%), major postoperative interventions (6.6% vs 0%), and 30-day readmission (5.0% vs 0.7%). Systolic blood pressure fluctuations during resuscitation have an independent impact on postoperative complications and postoperative length of stay following meningioma surgery.

The Impact of the Fascia Iliaca Block Beyond Perioperative Pain Control in Hip Fractures: A Retrospective Review

Background

Geriatric hip fractures are common injuries that are associated with high morbidity and mortality. Adequate pain control remains a challenge as the altered physiology in elderly patients makes use of traditional analgesics challenging. The use of regional anesthetics, specifically the fascia iliaca compartment block (FICB), in the perioperative period has been shown to decrease opioid use in this population. This study aimed to investigate the effect the FICB had on pain control, length of stay, readmissions, and complications in a 30-day postoperative period.

Methods

This was a retrospective cohort study comparing patients who sustained hip fractures; one cohort (110 patients) received a preoperative fascia iliaca block with continuous infusion (FICB), whereas the other cohort (110 patients) did not receive a block (NO-FICB). Both cohorts were from level II trauma centers. Data were collected between 2016 and 2019. Descriptive statistics was performed to describe and summarize the data. Bivariate analysis was performed using chi-square test, with 2 tailed P-values ≤ .05 were considered statistically significant.

Results

The FICB group had a lower length of stay (3.9 days vs 4.8 days; P < .001), and lower pain scores on post-operative days 2 and 3 (P = .019). There was no difference in time from admission to surgery (P = .112) or narcotic use between cohorts (P = .304). However, the FICB group was more likely to discharge to a skilled nursing facility (P=.002), and more likely to be readmitted within 30 days (P = .047). There were no differences in medical complications or mortality between the 2 groups.

Conclusions

The primary study endpoint, length of stay, was found to be significantly shorter in the patients who underwent the FICB vs the group who did not undergo the FICB. Pain scores on POD2 and POD3 were lower in patients who received a FICB. This study adds to the body of evidence that the FICB is an effective addition to a multimodal pain pathway.

Level of Evidence

Level III Evidence - Retrospective Cohort Study.

The impact of intraoperative blood pressure variability on the risk of postoperative adverse outcomes in non-cardiac surgery: a systematic review

Hemodynamic stability during surgery seems to account for positive postoperative outcomes in patients. However, little is known about the impact of intraoperative blood pressure variability (IBPV) on the postoperative complications. The aim was to investigate whether IBPV is associated with the development of postoperative complications and what is the nature of this association. We conducted a systematic search in PubMed, Medical Subject Headings, Embase, Web of Science, SCOPUS, clinicaltrials.gov, and Cochrane Library on the 8th of April, 2021. We included studies that only focused on adults who underwent primarily elective, non-cardiac surgery in which intraoperative blood pressure variation was measured and analyzed in regard to postoperative, non-surgical complications. We identified 11 papers. The studies varied in terms of applied definitions of blood pressure variation, of which standard deviation and average real variability were the most commonly applied definitions. Among the studies, the most consistent analyzed outcome was a 30-day mortality. The studies presented highly heterogeneous results, even after taking into account only the studies of best quality. Both higher and lower IBPV were reported to be associated for postoperative complications. Based on a limited number of studies, IBPV does not seem to be a reliable indicator in predicting postoperative complications. Existing premises suggest that either higher or lower IBPV could contribute to postoperative complications. Taking into account the heterogeneity and quality of the studies, the conclusions may not be definitive.

Comparison of restrictive fluid therapy with goal-directed fluid therapy for postoperative delirium in patients undergoing spine surgery: a randomized controlled trial

Background

Postoperative delirium (POD) is a common phenomenon after spinal surgery. Intraoperative fluid management may affect POD. The aim of this study was to compare the effects of restrictive fluid therapy (RF) with those of goal-directed fluid therapy (GDT) on POD.

Methods

A total of 195 patients aged ≥ 50 years who underwent spinal surgery were randomly divided into two groups: the RF group and the GDT group. In group RF, a bolus of lactated Ringer’s solution was administered at a dose of 5 mL·kg^-1 before the induction of anesthesia, followed by a dose of 5 mL·kg^-1·h^-1 until the end of surgery. For patients in the GDT group, in addition to the initial administration of lactated Ringer’s solution at 5 mL·kg^-1, the subsequent fluid therapy was adjusted by using a continuous noninvasive arterial pressure (CNAP) monitoring system to maintain pulse pressure variation (PPV) ≤ 14%. The primary endpoint was the incidence of POD, assessed once daily with the Confusion Assessment Method-Chinese Reversion (CAM-CR) scale at 1–3 days postoperatively. The secondary endpoints were intraoperative fluid infusion volume, urine volume, mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), regional cerebral oxygen saturation (rSO₂) value, lactic acid value, and visual analog scale (VAS) pain score at 1–3 days after surgery. Moreover, postoperative complications and the length of hospital stay were recorded.

Results

The incidence of POD was lower in the GDT group than in the RF group (12.4% vs 4.1%; P = 0.035) in the first 3 days after spine surgery. Compared to group RF, group GDT exhibited a significantly increased volume of intraoperative lactated Ringer’s solution [1500 (interquartile range: 1128 to 1775) mL vs 1000 (interquartile range: 765 to 1300) mL, P < 0.001] and urine volume [398 (interquartile range: 288 to 600) mL vs 300 (interquartile range: 200 to 530) mL, P = 0.012]. Intraoperative MAP, CI and rSO₂ values were higher in the GDT group than in the RF group (P < 0.05). Moreover, the length of hospital stay [17.0 (14 to 20) days versus 14.5 (13 to 17.0) days, P = 0.001] was shorter in the GDT group than in the RF group.

Conclusions

GDT reduced the incidence of POD in middle- and old-aged patients undergoing spinal surgery possibly by stabilizing perioperative hemodynamic and improving the supply and demand of oxygen.

Trial registration

ChiCTR2000032603; Registered on May 3, 2020.

Effect of hypertension and medication use regularity on postoperative delirium after maxillofacial tumors radical surgery

The incidence of postoperative delirium (POD) after maxillofacial tumors radical surgery is relatively high. There are a number of evidences showing the relationship between hypertension and decreased cerebral blood flow, as well as the relationship between cerebral ischemia and postoperative cognitive impairment. However, the impact of hypertension in the process of POD and related mechanisms remain unclear.

This study included 98 elderly patients who underwent maxillofacial tumors radical surgery in our hospital, from June 2020 to December 2020. We collected the general condition of patients and related research factors before surgery, and also collected related intraoperative factors. After that, we would follow up the patients for POD evaluation.

The incidence of POD in the hypertension group was 41%, compared with 12% in the nonhypertension group (P < 0.05). The incidence of POD in the irregular medication group was 62%, compared with 26% in the regular medication group (P < 0.05). Both hypertension (OR = 2.45, 95% CI = 1.11–5.72) and irregular medication use (OR = 2.35, 95% CI = 0.87–5.69) were independent risk factors for POD after this type of surgery in elderly patients.

Hypertension and medication use regularity are closely related to POD. This may be related to the delayed postoperative response caused by intraoperative cerebral ischemia.

Management of delirium within intraoperative settings for older adults with hip fracture: a scoping review

BACKGROUND

Delirium is a common adverse event in older patients undergoing hip fracture repair surgery. The impact of hospital-acquired delirium during intraoperative phase of their treatment can have a significant impact on post-operative outcomes. While non-pharmacological, multicomponent delirium prevention interventions are considered standard practice in acute medical units, delirium management in the intraoperative setting is less clear.

OBJECTIVES

The aim was to identify evidence-based delirium management interventions which are, and could be, undertaken within the intraoperative setting for older patients undergoing hip fracture repair surgery.

DESIGN

A scoping review following the principles developed by Arksey and O'Malley (2005).

DATA SOURCES

Seven databases including Cochrane, CINAHL, Embase, MEDLINE, PsychINFO, PubMed and SCOPUS were systematically searched. The search was limited to the last 11 years (2009-2020). Research studies included both primary and secondary sources of evidence.

RESULTS

A total of 2464 articles were initially identified. These articles were further refined using keyword searches and exclusion criteria, with a final set of 16 articles meeting the inclusion criteria. Three main themes were as follows: anaesthetic-related interventions used to prevent delirium; recognising non-modifiable and potentially modifiable risk factors; and screening and diagnosis of delirium.

CONCLUSIONS

While there is a strong focus on anaesthetist-led interventions in the intraoperative setting, there are opportunities for more nurse-led interventions through adequate pain management and haemodynamic monitoring that require further research. Identifying the best test for screening and diagnosing delirium in the intraoperative setting requires further research.

Anaesthesia for the elderly: a narrative review

As octogenarians in the operation room are no longer an exemption but the norm, perioperative management needs to be adopted to meet the special requirements of this group of patients. Anaesthesia does not need to be re-invented to fit the elderly. However, as elderly patients are among those most affected by adverse postoperative outcomes, the same diligence that is as a matter of course exercised in anaesthesiologic care of the youngest patients needs to be exercised for the eldest as well. Aging is associated with characteristic physiologic changes and an overall reduction in compensation width. However, the individual relevance of these changes varies distinctly. A comprehensive preoperative assessment is therefore essential to identify those at high risk. Maintaining functionality and preventing cognitive decline are central elements of perioperative care for frail elders, often only requiring unspectacular, but effective adjustments to established routine care processes. This review focuses on current recommendations in the perioperative anaesthesiologic management of elderly patients with a view towards assisting clinical anaesthesiologists in implementing respective structures in their setting and adjusting care pathways to meet the needs of this vulnerable but growing group of patients and improve their postoperative outcome.

Successful peripheral nerve block under dexmedetomidine sedation for femoral neck fracture fixation in a 97-year-old patient

Hip fracture is a common injury in elderly patients. In Japan, the number of super-old patients-age >90 years-with hip fractures has increased drastically over time. Available strategies for anaesthetic management for hip fracture surgery include general anaesthesia, neuraxial anaesthesia and peripheral nerve block. However, general and neuraxial anaesthesia are often avoided for various reasons, particularly in elderly patients. In recent years, peripheral nerve block has proven effective in various surgical procedures. Additionally, dexmedetomidine exhibits neuroprotective effects and has been used safely in super-old patients. Herein, we demonstrate successful anaesthetic management with peripheral nerve block under dexmedetomidine sedation for open reduction and internal fixation of a femoral neck fracture in a 97-year-old patient.

Perioperative risk factors for recovery room delirium after elective non-cardiovascular surgery under general anaesthesia

Background

Although postoperative delirium is a frequent complication of surgery, little is known about risk factors for delirium occurring in the post-anaesthesia care unit (PACU). The aim of this study was to determine pre- and intraoperative risk factors for the development of recovery room delirium (RRD) in patients undergoing elective non-cardiovascular surgery.

Methods

RRD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We collected perioperative data in 228 patients undergoing elective non-cardiovascular surgery under general anaesthesia and performed univariate and multivariate logistic regression to identify risk factors related to RRD. PACU and postoperative events were recorded to assess the outcome of RRD.

Results

Fifty-seven patients (25%) developed RRD. On multivariate analysis, maintenance of anaesthesia with inhalation anaesthetic agents (OR = 6.294, 95% CI 1.4–28.8, corrected p = 0.03), malignant primary disease (OR = 3.464, 95% CI = 1.396–8.592, corrected p = 0.018), American Society of Anaesthesiologists Physical Status (ASA-PS) III–V (OR = 3.389, 95% CI = 1.401–8.201, corrected p = 0.018), elevated serum total or direct bilirubin (OR = 2.535, 95% CI = 1.006–6.388, corrected p = 0.049), and invasive surgery (OR = 2.431, 95% CI = 1.103–5.357, corrected p = 0.035) were identified as independent risk factors for RRD. RRD was associated with higher healthcare costs (31,428 yuan [17,872–43,674] versus 16,555 yuan [12,618–27,788], corrected p = 0.002), a longer median hospital stay (17 days [12–23.5] versus 11 days [9–17], corrected p = 0.002), and a longer postoperative stay (11 days [7–15] versus 7 days [5–10], corrected p = 0.002]).

Conclusions

Identifying patients at high odds for RRD preoperatively would enable the formation of more timely postoperative delirium management programmes.

Investigating Association between Intraoperative Hypotension and Postoperative Neurocognitive Disorders in Non-Cardiac Surgery: A Comprehensive Review

Postoperative delirium (POD) and postoperative cognitive decline (deficit) (POCD) are related to a higher risk of postoperative complications and long-term disability. Pathophysiology of POD and POCD is complex, elusive and multifactorial. Intraoperative hypotension (IOH) constitutes a frequent and vital health hazard in the perioperative period. Unfortunately, there are no international recommendations in terms of diagnostics and treatment of neurocognitive complications which may arise from hypotension-related hypoperfusion. Therefore, we performed a comprehensive review of the literature evaluating the association between IOH and POD/POCD in the non-cardiac setting. We have concluded that available data are quite inconsistent and there is a paucity of high-quality evidence convincing that IOH is a risk factor for POD/POCD development. Considerable heterogeneity between studies is the major limitation to set up reliable recommendations regarding intraoperative blood pressure management to protect the brain against hypotension-related hypoperfusion. Further well-designed and effectively-performed research is needed to elucidate true impact of intraoperative blood pressure variations on postoperative cognitive functioning.

Automated Blood Pressure Control

Arterial pressure management is a crucial task in the operating room and intensive care unit. In high-risk surgical and in critically ill patients, sustained hypotension is managed with continuous infusion of vasopressor agents, which most commonly have direct α agonist activity like phenylephrine or norepinephrine. The current standard of care to guide vasopressor infusion is manual titration to an arterial pressure target range. This approach may be improved by using automated systems that titrate vasopressor infusions to maintain a target pressure. In this article, we review the evidence behind blood pressure management in the operating room and intensive care unit and discuss current and potential future applications of automated blood pressure control.

Intraoperative hypotension is associated with increased postoperative complications in patients undergoing surgery for pheochromocytoma-paraganglioma: a retrospective cohort study

BACKGROUND

Dramatic hemodynamic fluctuation occurs frequently during surgery for pheochromocytoma or paraganglioma. However, the criteria of intraoperative hemodynamic instability vary widely, and most of them were defined arbitrarily but not according to patients' prognosis. The objective was to analyze the relationship between different thresholds and durations of intraoperative hyper-/hypotension and the risk of postoperative complications in patients undergoing surgery for pheochromocytoma or paraganglioma.

METHODS

This was a retrospective single-center cohort study performed in a tertiary care hospital from January 1, 2005 to December 31, 2017. Three hundred twenty-seven patients who underwent surgery for pheochromocytoma or paraganglioma, of which the diagnoses were confirmed by postoperative pathologic examination, were enrolled. Those who were less than 18 years, underwent surgery involving non-tumor organs, or had incomplete data were excluded. The primary endpoint was a composite of the occurrence of AKI or other complications during hospital stay after surgery. Multivariate Logistic regression models were used to analyze the association between different thresholds and durations of intraoperative hyper-/hypotension and the development of postoperative complications.

RESULTS

Forty three (13.1%) patients developed complications during hospital stay after surgery. After adjusting for confounding factors, intraoperative hypotension, defined as systolic blood pressure (SBP) of ≤95 mmHg for ≥20 min (OR 3.211; 99% CI 1.081-9.536; P = 0.006), SBP of ≤90 mmHg for ≥20 min (OR 3.680; 98.8% CI 1.107-12.240; P = 0.006), SBP of ≤85 mmHg for ≥10 min (OR 3.975; 98.3% CI 1.321-11.961; P = 0.003), and SBP of ≤80 mmHg for ≥1 min (OR 3.465; 95% CI 1.484-8.093; P = 0.004), were associated with an increased risk of postoperative complications. On the other hand, intraoperative hypertension was not significantly associated with the development of postoperative complications.

CONCLUSIONS

For patients undergoing surgery for pheochromocytoma or paraganglioma, intraoperative hypotension is associated with increased postoperative complications; and the harmful effects are level- and duration-dependent. The effects of intraoperative hypertension need to be studied further.

Pre-emptive analgesia with continuous fascia iliaca compartment block reduces postoperative delirium in elderly patients with hip fracture. A randomized controlled trial

OBJECTIVES

  To evaluate whether pre-emptive analgesia is an effective technique to reduce postoperative delirium (PD) in geriatric patients with hip fracture.

METHODS

This is a double-blind randomized clinical trial. Ninety elderly patients scheduled for hipfracture surgery at HongHui Hospital, Xi'an Jiaotong University, Xi'an, China  between March 2018 and January 2019 were divided into 2 groups. On arrival at the emergency department, the experimental group (n=44) received ultrasound-guided continuous fascia iliaca compartment block (FICB) for preoperative analgesia, while the control group (n=46) received fake (or generic) continuous FICB. All patients received spinal anaesthesia and postoperative patient controlled epidural analgesia (PCEA). We compared the change in preoperative and postoperative pain scores, the incidence of PD, and the consumption of opioids between the 2 groups. Results: Five patients did not meet the participation requirements; therefore, 85 patients were included in the study. Patients in the experimental group experienced less preoperative pain (p less than 0.05). Between the 2 groups, no significant differences were found for postoperative pain scores. The incidence of PD was lower in the experimental group (13.9% versus 35.7%, p=0.018). In addition, before the surgery, a drop in consumption of fentanyl was noted in the experimental group (0.08±0.21 versus 0.28±0.13, p=0.037).Conlusion: Pre-emptive analgesia with continuous FICB is an effective technique to reduce PD in geriatric patients with hip fracture.

Perioperative blood pressure in the elderly

PURPOSE OF REVIEW

Hemodynamic instability is common in the perioperative period because of obligate physiologic changes that occur with surgery. Despite the frequency of such hemodynamic changes and the potential harm associated with them, particularly in the elderly, guidelines to optimize perioperative blood pressure are lacking. The present review examines recent evidence for perioperative blood pressure management in the elderly.

RECENT FINDINGS

Hypotension has been associated with poor outcomes, particularly renal injury, myocardial injury, and increased mortality, in the perioperative period. Hypertension, tachycardia, frequency of blood pressure monitoring, and management of chronic antihypertensive medications may also affect patient outcomes. Elderly patients may be especially prone to adverse events associated with perioperative hemodynamic instability.

SUMMARY

Precise and intentional management of hemodynamic parameters, medication regimens, and blood pressure monitoring may reduce adverse events in elderly patients undergoing surgery. Further investigation is required to identify the exact hemodynamic parameters that mitigate risk.

["Emergency anesthesia" in geriatric patients]

BACKGROUND

The share of elderly patients undergoing emergency surgery is constantly increasing. Their postoperative outcome remains poor, even if surgery itself is survived in the short or medium term.

OBJECTIVES

Important aspects of anesthesiologic care for older emergency patients based upon recent literature and guideline recommendations are presented.

METHODS

Selective review of the literature, considering national and international guidelines, meta-analysis and Cochrane reviews.

CONCLUSION

Anesthesiologic care can significantly influence the perioperative outcome of elderly emergency surgery patients. In this context, emergency anesthesiology exceeds mere anesthesia itself and applies to the overall perioperative management.