Availability of preoperative neutrophil-lymphocyte ratio to predict postoperative delirium after head and neck free-flap reconstruction: A retrospective study

A novel risk assessment tool for postoperative delirium in vascular surgery: The stress model (Siena posTopeRative dElirium in vaScular Surgery)

OBJECTIVE

Postoperative delirium (POD) is a common complication with a high health-related impact. The creation of a model (Siena posTopeRative dElirium in vaScular Surgery) to identify high-risk patients with consecutive prompt diagnosis and correct management.

METHODS

This is an observational retrospective study to evaluate POD incidence in patients who underwent elective vascular surgery procedures between 2018 and 2020. POD was detected using CAM and defined as the onset of an acute confusional state, clinically manifesting as a disturbed state of consciousness, cognitive dysfunction, or alteration in perception and behavior. The total population was divided in the development and validation subsamples. Multivariable logistic regression analysis was performed, identifying variables related to the occurrence of POD. An additive score was created and the STRESS score was internally validated using the Validation subgroup.

RESULTS

A total of 1067 patients were enrolled. POD occurred in 111 cases (10.4%). Multivariable logistic regression analysis for POD occurrence revealed as significant predictors: age>75 years, CKD, dyslipidaemia, psychiatric disease, CAD, hospitalization in the previous month, preoperative NLR >3.59, preoperative Hb < 12 g/dl, preoperative Barthel score <75, major amputation, CLTI revascularization, general anesthesia, and postoperative urinary catheter. These variables were used to create the STRESS score. The model was applied to both development and validation subgroups; AUC was respectively 0.7079 (p < .0001) and 0.7270 (p < .0001).

CONCLUSION

The STRESS score has a good predictive potentiality for POD occurrence in elective vascular surgery procedures. However, implementation and external validation are needed to be correctly used in everyday clinical practice.

The impact of preoperative psychiatric intervention for postoperative delirium after major oral and maxillofacial surgery with free flap reconstruction

BACKGROUND

Postoperative delirium (POD) is a severe complication associated with various adverse outcomes, especially in older patients. Although the incidence and risk factors for POD have been explored in general surgery, they have not been fully elucidated. Early identification of high-risk patients and active preoperative intervention are considered essential for the prevention of POD. Recently, psychiatric consultation intervention have been shown to prevent delirium. This study investigated the effect of preoperative psychiatric interventions on preventing POD in our specific surgical context.

MATERIALS AND METHODS

This retrospective, single-center observational study included 86 patients who underwent major oral and maxillofacial surgery with free flap reconstruction between 2016 and 2023. The effect of psychiatric intervention were compared between patients with and without delirium.

RESULTS

Preoperative psychiatric intervention did not reduce the incidence of POD. The incidence of POD was 29.1 %. Univariate analyses showed no significant associations between POD and any clinical variables.

CONCLUSION

There was no difference in the incidence of POD between patients who received preoperative psychiatric intervention and those who did not, and further investigation is needed to determine the efficacy of preoperative psychiatric intervention in the prevention of POD.

Recent developments in delirium after oral and maxillofacial free-flap reconstruction

Postoperative delirium (POD), a common complication following surgery and anesthesia, is particularly prone to occur after reconstruction surgery in the oral and maxillofacial region. The occurrence of POD seriously affects the incidence of postoperative complications, the survival of free flaps, the length of hospital stays, and brings great pain to patients and their families, and even increases perioperative mortality. Currently, a large number of studies have reported on the risk factors for POD after oral and maxillofacial free-flap reconstruction. Multiple independent risk factors have been identified, including age, history of excessive alcohol consumption, and perioperative nutritional status. This review summarizes the relevant literature and hopes to provide insights for the prevention of POD in high-risk patients.

Sex-Specific Validity of the PRE-DELIRIC Model and the E-PRE-DELIRIC Model for Predicting Delirium in Patients After Cardiac Surgery

BACKGROUND

Several risk prediction models are used in intensive care units (ICUs) to detect delirium risk.

OBJECTIVE

The aim of this study was to compare the sex-specific validity of the Prediction of Delirium in ICU patients (PRE-DELIRIC) and Early Prediction of Delirium in ICU patients (E-PRE-DELIRIC) models for predicting delirium in ICU patients after cardiac surgery.

METHODS

Retrospective data from electronic medical records of ICU patients who underwent cardiac surgery between January 2019 and December 2022 were examined. Both models were evaluated using sensitivity, specificity, and positive and negative predictive values based on the highest Youden index for female and male patients. Receiver operating characteristic curve analysis was performed.

RESULTS

Delirium incidence was 30.7% and 27.5% in female and male patients, respectively. In the PRE-DELIRIC model, the highest Youden index scores for female and male patients were 67.00 and 57.54, respectively, with sensitivities and specificities of 61% and 88%, and 72% and 79%, respectively. In the E-PRE-DELIRIC model, the highest scores for female and male patients were 14.25 and 14.05, with sensitivities and specificities of 78% and 50%, and 70% and 53%, respectively. The area under the curve of the PRE-DELIRIC model for female and male patients was 0.77 and 0.78, respectively, and that of the E-PRE-DELIRIC model was 0.67 and 0.63, respectively.

CONCLUSIONS

The PRE-DELIRIC model showed higher specificity and was more reliable for male patients, whereas the E-PRE-DELIRIC model demonstrated better sensitivity for female patients due to its inclusion of more female-sensitive factors. A combined approach is recommended for improved reliability and validity in delirium risk assessment in clinical settings.

Can Neutrophil-to-Lymphocyte Ratio, Platelet Volume, and Platelet Distribution Width Be Used as Indicators of Delirium?

Background/Objectives: Postoperative delirium is a frequent complication in children undergoing general anesthesia. It has been suggested that inflammation and oxidative stress contribute to the pathophysiology of delirium. The aim of our study was to investigate the relationship between inflammatory markers and delirium. Methods: A total of 221 children in the ASA 1-3 risk group who underwent adenoidectomy, tonsillectomy, and/or ventilation tube application were included in our single-center, prospective, and observational study approved by the Ethics Committee, numbered E1-23-3197. Patients whose parental consent was obtained were either premedicated with oral midazolam preoperatively or taken to surgery without premedication, depending on the anesthesiologist's preference. After induction with sevoflurane, rocuronium and fentanyl were administered intravenously. Sevoflurane and infusion of remifentanil were administered for maintenance. At the end of the operation, patients were transferred to the recovery unit and followed up for 30 min. They were evaluated with the Face, Legs, Activity, Cry, and Consolability (FLACC) Scale and Pediatric Anesthesia Emergence Delirium (PAED) Scale. Results: Delirium was observed in 80 patients. There was no significant difference between patients with and without delirium in terms of neutrophil/lymphocyte ratio, mean platelet volume, or platelet distribution volume. Lymphocyte count, PAED score, and FLACC score were statistically higher in patients with delirium (W = 4407.5, p-value = 0.006997; W = 0, p-value < 2.2 × 10-16; W = 9489, p-value < 2.2 × 10-16, respectively). Conclusions: No statistically significant relationship was found between hematologic inflammatory markers and delirium. Controlled studies with larger sample sizes are needed to determine whether these markers have strong predictive value.

Comprehensive geriatric assessment for predicting postoperative delirium in oral and maxillofacial surgery: a prospective cohort study

Identifying high-risk patients for developing postoperative delirium (POD) is essential for optimizing the medical field's human and financial resources through specialty-relevant geriatric assessments that can aid in establishing prehabilitation strategies. This study aims to identify geriatric screening tools to predict preoperative delirium and explore the high-risk elderly patients undergoing oral maxillofacial surgery. A comprehensive geriatric assessment encompassing 23 instruments was used to evaluate inpatients undergoing surgery under general anaesthesia, preoperatively and postoperatively. Selective intraoperative and postoperative variables were also assessed for their relation to POD occurrence. This prospective study included 90 patients (mean age 79.0 years) from August 2022 to August 2023. The POD rate in this cohort was (8.9% n = 8). The Clock-Drawing Test (CDT) was significantly associated with POD occurrence (p = 0.005). Significant associations were found between POD occurrence and operation type (p = 0.018), duration (p = 0.026), length of stay ( p = 0.002), and postoperative hemoglobin levels (p = 0.027). This study highlights the importance of comprehensive geriatric assessments in predicting POD in elderly patients. Future research should build on these findings to enhance preoperative care strategies and improve outcomes.Trial registration: German Register of Clinical Studies, DRKSID DRKS00028614.

Prevalence and risk factors of postoperative delirium in tumor patients after free flap reconstruction: A systematic review and meta-analysis of case-control studies

BACKGROUND

Postoperative delirium is a severe complication of flap transplantation surgery, adversely affecting surgical prognoses. The intricate pathophysiology of postoperative delirium renders the elucidation of its risk factors challenging. This research aims to delineate the prevalence and the specific risk factors of postoperative delirium in patients with cancer undergoing free flap reconstruction through a systematic review and meta-analysis to enlighten proactive prevention measures.

METHODS

The researchers systematically queried both the international and Chinese databases. Searches were performed for publications from inception until September 14, 2023, using the terms "free tissue flaps," "delirium," "neoplasms," and "risk factors." Data synthesis and statistical analysis were conducted using Stata SE (version 15.0) to calculate the combined effect size for identified risk factors. Reported outcomes included weighted mean differences or odds ratios with their respective 95% confidence intervals.

RESULTS

Twelve case-control studies were included (ntotal = 3,256). Among them, 515 patients developed postoperative delirium after free flap surgery, compared with 2,741 patients who did not. The outcomes suggest that the risk factors include but are not limited to age, male, late neoplasm staging, use of hypnotic or antipsychotic, history of background diseases, psychiatric review, tracheotomy, and impaired wound healing. In contrast, early neoplasm staging and others are the protective factors with statistical significance. Multivariate analysis further identified significant correlations between preoperative albumin, perioperative blood transfusion, sleep disturbance, postoperative visual analog scale, postoperative albumin, smoking, and the appearance of postoperative delirium.

CONCLUSION

The determined risk factors were grouped into preoperative, intraoperative, and postoperative categories substantiated by current data to present instructions for postoperative delirium prevention.

Predictive value of the Naples prognostic score on postoperative delirium in the elderly with gastrointestinal tumors: a retrospective cohort study

BACKGROUND

Postoperative delirium (POD) is a common complication among elderly patients after surgery. The Naples Prognostic Score (NPS), a novel prognostic marker based on immune-inflammatory and nutritional status, was widely used in the assessment of the prognosis of surgical patients. However, no study has evaluated the relationship between NPS and POD. The aim of this article was to investigate the association between NPS and POD and test the predictive efficacy of preoperative NPS for POD in elderly patients with gastrointestinal tumors.

MATERIALS AND METHODS

In the present study, we retrospectively collected perioperative data of 176 patients (≥ 60 years) who underwent elective gastrointestinal tumor surgery from June 2022 to September 2023. POD was defined according to the chart-based method and the NPS was calculated for each patient. We compared all the demographics and laboratory data between POD and non-POD groups. Univariate and multivariate logistic regression analysis was used to explore risk factors of POD. Moreover, the accuracy of NPS in predicting POD was further assessed by utilizing receiver operating characteristic (ROC) curves.

RESULTS

20 had POD (11.4%) in a total of 176 patients, with a median age of 71 (65-76). The outcomes by univariate analysis pointed out that age, ASA status ≥ 3, creatinine, white blood cell count, fasting blood glucose (FBG), and NPS were associated with the risk of POD. Multivariate logistic regression analysis further showed that age, ASA grade ≥ 3, FBG and NPS were independent risk factors of POD. Additionally, the ROC curves revealed that NPS allowed better prognostic capacity for POD than other variables with the largest area under the curve (AUC) of 0.798, sensitivity of 0.800 and specificity of 0.667, respectively.

CONCLUSION

Age, ASA grade ≥ 3, and FBG were independent risk factors for POD in the elderly underwent gastrointestinal tumor surgery. Notably, the preoperative NPS was a more effective tool in predicting the incidence of POD, but prospective trials were still needed to further validate our conclusion.

TRIAL REGISTRATION

The registration information for the experiment was shown below. (date: 3rd January 2024; number: ChiCTR2400079459).

Association between increased systemic immune-inflammation index and postoperative delirium in older intertrochanteric fracture patients

BACKGROUND AND PURPOSE

The systemic immune-inflammation index (SII), a novel inflammation index derived from the counts of circulating platelets, neutrophils and lymphocytes, has been studied in the treatment of acute cancer and ischemic stroke (AIS). However, the clinical value of the SII in postoperative delirium patients has not been further investigated. The purpose of our research was to study the incidence and preoperative risk factors for postoperative delirium (POD) and verify whether the SII could serve as a potential marker for POD in older intertrochanteric fracture patients. Finally, we created a novel nomogram for predicting POD in older patients with intertrochanteric fractures.

METHODS

We enrolled elderly patients with intertrochanteric fractures who underwent proximal femoral nail antirotation (PFNA) between February 2021 and April 2023. Univariate and multivariate logistic analyses were subsequently performed to confirm the risk factors and construct a nomogram model.Calibration curve and clinical decision curve analysis (DCA) were used to assess the model's fitting performance. The performance of the nomogram was evaluated for discrimination, calibration, and clinical utility.

RESULTS

A total of 293 patients were eligible for inclusion in the study, 25.6% (75/293) of whom had POD. The POD patients had higher SII values than the non-POD patients. The SII was strongly correlated with POD in older intertrochanteric fracture patients, and the optimal cutoff value was 752.6 × 109. Multivariate analysis revealed that age, diabetes, total albumin, SII > 752.6 × 109 and a CRP > 20.25 mg/L were independent risk factors for POD patients. By incorporating these 5 factors, the model achieved a concordance index of 0.745 (95% CI, 0.683-0.808) and had a well-fitted calibration curve and good clinical application value.

CONCLUSION

The SII is a simple and valuable biomarker for POD, and the new nomogram model can be used to accurately predict the occurrence of POD. They can be utilized in clinical practice to identify those at high risk of POD in older intertrochanteric fracture patients.

Neutrophil to Lymphocyte Ratio and Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) has shown promising results as a diagnostic tool for periprosthetic joint infection (PJI) after total joint arthroplasty. We conducted a systematic review and meta-analysis to determine the utility of NLR in the diagnosis of PJI.

METHODS

We searched PubMed, Scopus, and Web of Science from inception up to 2022 and evaluated the quality of the included literature.

RESULTS

Based on the 12 eligible studies, NLR levels were significantly higher in patients who had PJI compared to those who had aseptic loosening (standard mean difference (SMD) = 1.05, 95% Confidence Interval (CI) = 0.71 to 1.40, P < .001). In the subgroup analysis according to type of PJI, NLR levels were significantly higher in patients who had either acute (SMD = 1.04, 95% CI = 0.05 to 2.03, P < .001) or chronic PJI (SMD = 1.08, 95% CI = 0.55 to 1.61, P < .001), compared to those who had aseptic loosening. According to type of arthroplasty, NLR levels were significantly higher in patients who had either total knee arthroplasty (SMD = 1.81, 95% CI = 1.48 to 2.13, P < .001) or total hip arthroplasty (SMD = 1.76, 95% CI = 1.54 to 1.98, P < .001) compared to aseptic loosening. The pooled sensitivity of the 12 studies was 0.73 (95% CI, 0.65 to 0.79), and the pooled specificity was 0.75 (95% CI, 0.71 to 0.78). The pooled positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of NLR were 2.94 (95% CI = 2.44 to 3.54), 0.35 (95% CI = 0.27 to 0.46), and 8.26 (95% CI = 5.42 to 12.58), respectively.

CONCLUSION

In summary, this meta-analysis indicates that NLR is a reliable marker in the diagnosis of PJI.

Association between preoperative neutrophil-lymphocyte ratio, uric acid, and postoperative delirium in elderly patients undergoing degenerative spine surgery

PURPOSE

There are few reports regarding the association between the neutrophil-lymphocyte ratio (NLR), uric acid, and the development of postoperative delirium (POD) in patients who are undergoing spine surgeries. We investigated the associations between the NLR, uric acid as a natural antioxidant, and POD in elderly patients undergoing degenerative spine surgery.

PATIENTS AND METHODS

This was a single-center, observational, and retrospective study conducted in Japan. We enrolled 410 patients who underwent degenerative spine surgery. POD was diagnosed after the surgeries by psychiatrists, based on the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). We performed a multivariable logistic regression analysis to clarify whether the NLR and uric acid values were associated with the development of POD in the patients.

RESULTS

129 of the 410 patients were excluded from the analysis. Of the 281 patients (137 females, 144 males), 32 patients (11.4%) were diagnosed with POD. The multivariable logistic regression analysis revealed that the preoperative uric acid level (adjusted odds ratio [aOR]: 0.67, 95% confidence interval [CI]: 0.49-0.90, p = 0.008) and age (aOR: 1.09, 95% CI: 1.02-1.16, p = 0.008) were significantly associated with POD. The preoperative NLR (aOR: 0.82, 95% CI: 0.60-1.13, p = 0.227) and antihyperuricemic medication (aOR: 0.97, 95% CI: 0.24-3.82, p = 0.959) were not significantly associated with POD.

CONCLUSION

Our results demonstrated that in elderly patients undergoing degenerative spine surgery, the preoperative NLR was not significantly associated with POD, but a lower preoperative uric acid value was an independent risk factor for developing POD. Uric acid could have a neuroprotective impact on POD in patients with degenerative spine diseases.

Thoracic delirium index for predicting postoperative delirium in elderly patients following thoracic surgery: A retrospective case-control study

BACKGROUND

Postoperative delirium (POD) is an acute neurological complication in the elderly undergoing thoracic surgery and can result in serious adverse consequences.

AIMS

This study aimed to identify the related risk factors for POD following thoracic surgery, primarily focusing on preoperative serum biomarkers, and further to establish a novel delirium index to better predict POD.

METHODS

A total of 279 patients aged ≥60 years who underwent elective thoracic surgery from August 2021 to August 2022 were enrolled in this observational study. The platelet-to-white blood cell ratio (PWR) was calculated as number the of platelets divided by the number of white blood cells. POD was defined by the confusion assessment method twice daily during the postoperative first 3 days. Multivariate regression analysis was performed to identify all potential variables for POD. Moreover, a novel thoracic delirium index (TDI) was developed based on the related risk factors. The accuracy of TDI and its component factors in predicting POD was determined by the curve of receiver operating characteristic (ROC).

RESULTS

In total, 25 of 279 patients developed POD (8.96%). Age, PWR, and average pain scores within the first 3 days after surgery were regarded as the independent risk factors for POD. Moreover, the ROC analysis showed the TDI, including age, PWR, and average pain scores within the first 3 days after surgery, can more accurately predict POD with the largest area under the curve of 0.790 and the optimal cutoff value of 9.072, respectively.

CONCLUSION

The TDI can scientifically and effectively predict POD to provide optimal clinical guidance for older patients after thoracic surgery.

The Perioperative Frontal Relative Ratio of the Alpha Power of Electroencephalography for Predicting Postoperative Delirium After Highly Invasive Surgery: A Prospective Observational Study

BACKGROUND

We investigated the associations between postoperative delirium (POD) and both the relative ratio of the alpha (α)-power of electroencephalography (EEG) and inflammatory markers in a prospective, single-center observational study.

METHODS

We enrolled 84 patients who underwent radical cancer surgeries with reconstruction for esophageal cancer, oral floor cancer, or pharyngeal cancer under total intravenous anesthesia. We collected the perioperative EEG data and the perioperative data of the inflammatory markers, including neutrophil gelatinase-associated lipocalin, presepsin, procalcitonin, C-reactive protein, and the neutrophil-lymphocyte ratio (NLR). The existence of POD was evaluated based on the Intensive Care Delirium Screening Checklist. We compared the time-dependent changes in the relative ratio of the EEG α-power and inflammatory markers between the patients with and without POD.

RESULTS

Four of the 84 patients were excluded from the analysis. Of the remaining 80 patients, 25 developed POD and the other 55 did not. The relative ratio of the α-power at baseline was significantly lower in the POD group than the non-POD group (0.18 ± 0.08 vs 0.28 ± 0.11, P < .001). A time-dependent decline in the relative ratio of α-power in the EEG during surgery was observed in both groups. There were significant differences between the POD and non-POD groups in the baseline, 3-h, 6-h, and 9-h values of the relative ratio of α-power. The preoperative NLR of the POD group was significantly higher than that of the non-POD group (2.88 ± 1.04 vs 2.22 ± 1.00, P < .001), but other intraoperative inflammatory markers were comparable between the groups. Two multivariable logistic regression models demonstrated that the relative ratio of the α-power at baseline was significantly associated with POD.

CONCLUSIONS

Intraoperative frontal relative ratios of the α-power of EEG were associated with POD in patients who underwent radical cancer surgery. Intraoperative EEG monitoring could be a simple and more useful tool for predicting the development of postoperative delirium than measuring perioperative acute inflammatory markers. A lower relative ratio of α-power might be an effective marker for vulnerability of brain and ultimately for the development of POD.

Incidence and risk factors for postoperative delirium after head and neck cancer surgery: an updated meta-analysis

BACKGROUND

Postoperative delirium (POD) is a frequent neurologic dysfunction that often leads to more negative outcomes. Early identification of patients who are vulnerable to POD and early implementation of appropriate management strategies could decrease its occurrence and improve patient prognosis. Therefore, this meta-analysis comprehensively and quantitatively summarized the prevalence and related predictive factors of POD in head and neck cancer surgical patients.

METHODS

PubMed, Embase, and Cochrane Library were searched for observational studies that reported the prevalence and risk factors for POD after head and neck cancer surgery and were published from their inception until December 31, 2022. Two reviewers independently selected qualified articles and extracted data. The qualities of related papers were assessed using the Newcastle-Ottawa scale (NOS). RevMan 5.3 and Stata 15.0 were applied to analysis the data and conduct the meta-analysis.

RESULTS

Sixteen observational studies with 3289 inpatients who underwent head and neck cancer surgery were included in this review. The occurrence of POD ranged from 4.2 to 36.9%, with a pooled incidence of 20% (95% CI 15-24%, I2 = 93.2%). The results of this pooled analysis demonstrated that the statistically significant risk factors for POD were increased age (OR: 1.05, 95% CI: 1.03-1.07, P < 0.001), age > 75 years (OR: 6.52, 95% CI: 3.07-13.87, P < 0.001), male sex (OR: 2.29, 95% CI: 1.06-4.97, P = 0.04), higher American Society of Anesthesiologists grade (OR: 2.19, 95% CI: 1.44-3.33, P < 0.001), diabetes mellitus (OR: 2.73, 95% CI: 1.24-6.01, P = 0.01), and history of smoking (OR: 2.74, 95% CI: 1.13-6.65, P = 0.03).

CONCLUSIONS

POD frequently occurs after head and neck cancer surgery. Several independent predictors for POD were identified, which might contribute to identifying patients at high risk for POD and play a prominent role in preventing POD in patients following head and neck cancer surgery.

Effect of pharmacist-led intervention protocol on preventing postoperative delirium after elective cardiovascular surgery

Postoperative delirium (PD) is an acute brain dysfunction, with a particularly high incidence after cardiovascular surgery. Pharmacist-led interventions show limited evidence in attenuating PD in cardiovascular surgery. In this retrospective cohort study, we aimed to clarify the risk factors of PD for cardiovascular surgery focused on pharmacotherapy and elucidate the effect of pharmacist-led intervention on the PD attenuation rate based on protocol-based pharmaceutical management (PBPM). This study included 142 adult patients who underwent elective valve replacement or valvuloplasty. The risk factors for PD were investigated using multivariate logistic regression analysis. Taking risk factors into consideration, a protocol was developed to discontinue benzodiazepines prescriptions by ward pharmacists, and replace with ramelteon and suvorexant if all the following factors apply: 1) number of medications ≥ 6 drugs, 2) number of doses to take ≥ 4 times, and 3) regular use of benzodiazepines or insomnia. Subsequently, the PD rate was compared during a period of two years and 6 months between the pre-PBPM (n = 39) and post-PBPM (n = 62). The PD rate for elective valve replacement or valvuloplasty was 25% (35/142). The adjusted odds ratio for polypharmacy was 3.3 (95% confidence interval: 1.2-8.9, p = 0.016), suggesting that preoperative risk assessment may be essential for patients with polypharmacy. The PD rate significantly decreased to 13% (8/62) in the post-PBPM group compared with 33% (13/39) in the pre-PBPM group (p = 0.014). There was a significant decrease in benzodiazepines use in post-PBPM compared with pre-PBPM (p = 0.026); however, the rate of ramelteon and orexin receptor antagonists use increased by PBPM introduction (p < 0.001). Although the present PBPM still requires further modification, it is simple and potentially useful for pharmacists to assess the risk of patients undergoing any elective cardiovascular surgery.

Association of cervical atherosclerosis on Doppler ultrasonography and postoperative delirium in patients undergoing spinal surgery: a single-center, retrospective, observational study

PURPOSE

This study aimed to evaluate the association between cervical atherosclerosis on Doppler ultrasonography and postoperative delirium (POD) in patients undergoing spinal surgery.

METHODS

In this retrospective observational study using prospectively collected data, 295 consecutive patients aged > 50 years underwent spine surgery at a single institution between March 2015 and February 2021. Cervical atherosclerosis was defined as the intima-media thickness (IMT) of the common carotid artery (CCA) being ≥ 1.1 mm on pulsed-wave Doppler ultrasonography. Univariate and multivariate logistic regression analyses were performed with the prevalence of postoperative delirium as a dependent variable. Age, sex, body mass index, medical history, American Society of Anesthesiologists Physical Status (ASA-PS), CHADS2 score (an assessment score for stroke), instrumentation, duration of surgery, blood loss, and cervical arteriosclerosis were the independent variables.

RESULTS

Twenty-seven patients of 295 (9.2%) developed delirium postoperatively. Forty-one (13.9%) of the 295 patients had cervical atherosclerosis. Their univariate analyses showed that age (P = 0.001), hypertension (P = 0.016), cancer (P = 0.046), antiplatelet agent use (P < 0.001), ASA-PS ≥ 3 (P < 0.001), CHADS2 score (P < 0.001), cervical atherosclerosis (P = 0.008), and right CCA-IMT (P = 0.007) were significantly associated with POD. However, multivariate logistic regression analyses showed older age (odds ratio [OR], 1.109; 95% confidence interval [CI] 1.035-1.188; P = 0.03) and antiplatelet agent use (OR, 3.472; 95% CI 1.221-9.870; P = 0.020) to be significantly associated with POD.

CONCLUSIONS

There was a significant association between POD and the prevalence of cervical atherosclerosis using the univariate logistic regression analysis. Furthermore, multivariate logistic regression analyses showed that older age and antiplatelet agent use were independently associated with POD.

Hemoglobin-Albumin-Lymphocyte-Platelet (HALP) Score as a Predictive Model for the Success of Reconstruction of Head and Neck Defects with Free Microvascular Flaps

Significant advances in reconstructive head and neck surgery with free microvascular flaps have had a positive impact on esthetic outcomes and quality of life. However, complications still occur in some patients. This study investigated the influence of the Hemoglobin, Albumin, Lymphocyte, and Platelet Score (HALP score), an immunonutritive marker, on complications and flap success. The retrospective analysis included 194 patients who underwent reconstruction of head and neck defects with free microvascular flaps. The HALP score correlated strongly with overall complications, including flap necrosis, infection, fistula, and hematoma. Hemoglobin, albumin, lymphocytes, and platelets individually showed associations with specific complications. HALP score was an extremely strong predictor of complications (AUC = 0.85). HALP score may be valuable for assessing patient status and predicting complications in microvascular free-flap reconstruction to allow timely interventions and improve outcomes. Further research is needed to investigate additional predictors and improve postoperative care.

Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio as prognostic predictors for delirium in critically ill patients: a systematic review and meta-analysis

INTRODUCTION

In this systematic review and meta-analysis, we aim to analyze the current literature to evaluate neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) values among critically ill patients who develop delirium as compared to those who do not.

METHODS

PubMed, Web of Science, and Scopus were used to conduct a systematic search for relevant publications published before June 12, 2022. The Newcastle-Ottawa scale was used for quality assessment. Because a significant level of heterogeneity was found, we used the random-effects model to generate pooled effects.

RESULTS

Twenty-four studies including 11,579 critically ill patients, of whom 2439 were diagnosed with delirium, were included in our meta-analysis. Compared with the non-delirious group, the delirious group's NLR levels were significantly higher (WMD = 2.14; CI 95% = 1.48-2.80, p < 0.01). In the subgroup analysis according to the type of critical condition, the NLR levels in patients of delirious group were significantly more than those of non-delirious group in studies on POD, PSD and PCD (WMD = 1.14, CI 95% = 0.38-1.91, p < 0.01, WMD = 1.38, CI 95% = 1.04-1.72, p < 0.001, and WMD = 4.22, CI 95% = 3.47-4.98, p < 0.001, respectively). However, compared with the non-delirious group, the delirious group's PLR levels were not significantly different (WMD = 1.74; CI 95% = -12.39-15.86, p = 0.80).

CONCLUSION

Our findings support NLR to be a promising biomarker that can be readily integrated into clinical settings to aid in the prediction and prevention of delirium.

Relationship between neutrophil/lymphocyte ratio and postoperative delirium in elderly patients with proximal femoral nail anti-rotation for intertrochanteric fractures

OBJECTIVE

Delirium is a common postoperative complication in elderly patients with intertrochanteric femur fracture. This study aimed at analyzing risk factors for postoperative delirium (POD) in patients after proximal femoral nail anti-rotation (PFNA).

METHODS

From February 2017 to February 2021, we included elderly patients with intertrochanteric fractures who underwent PFNA. The predictive ability and cut-off value of neutrophil/lymphocyte ratio (NLR) for POD were evaluated using receiver operating characteristic (ROC) curve. Univariate and multivariate analyses were used to investigate the association between NLR and POD.

RESULTS

We enrolled 315 patients. The ROC curve suggested that NLR ≥ 4.85 was the optimal cut-off value for POD. The POD and non-POD groups differed significantly in age, diabetes, time from injury to operation, preoperative albumin level, neutrophil count, and NLR (P < 0.05). Logistic regression indicated that NLR ≥ 4.85 (odds ratio [OR] = 3.491; 95% confidence interval [CI]: 1.731-5.982; P < 0.001), old age (OR = 1.921; 95% CI: 1.267-4.125; P < 0.001), time from injury to operation ≥ 48 h (OR = 1.733; 95% CI: 1.212-3.542; P = 0.007), and preoperative albumin level ≤ 35 g/L (OR = 2.274; 95% CI: 1.662-4.846; P = 0.001) increased the risk of POD.

CONCLUSION

Old age, time from injury to operation ≥ 48 h, preoperative albumin level ≤ 35 g/L, and NLR ≥ 4.85 were independent risk factors for POD. Thus, NLR may predict POD in elderly patients with intertrochanteric femur fractures after PFNA.

Risk factors and a nomogram model for postoperative delirium in elderly gastric cancer patients after laparoscopic gastrectomy

Background

To evaluate the risk factors of postoperative delirium (POD) in elderly gastric cancer (GC) patients after laparoscopic gastrectomy and construct a predictive model.

Methods

Elderly GC patients undergoing laparoscopic gastrectomy were enrolled and grouped based on the status of POD development within postoperative 7 days. Independent risk factors were selected out by univariate and multivariate logistic regression analyses and then enrolled in the nomogram prediction model.

Results

A total of 270 elderly GC patients were enrolled, and POD occurred in 74 (27.4%) patients within postoperative 7 days. The results of multivariate regression analysis indicated that age (OR: 3.30, 95% CI: 1.41–6.85, P < 0.001), sleeping pills (OR: 1.87, 95% CI: 1.12–3.09, P = 0.012), duration of ICU stay (OR: 1.55, 95% CI: 1.02–2.37, P = 0.029), albumin/fibrinogen ratio (AFR) (OR: 1.74, 95% CI: 1.03–2.76, P = 0.019), and neutrophils/lymphocytes ratio (NLR) (OR: 2.12, 95% CI: 1.11–4.01, P = 0.016) were five independent risk factors for POD in elderly GC patients. The AUC of the constructed nomogram model based on these five factors was 0.807.

Conclusions

This study highlighted that age, AFR, NLR, sleeping pills taking, and duration of ICU stay were independent risk factors for POD, and the nomogram model based on these factors could effectively predict POD in elderly GC patients.

The Predictive Role of Inflammatory Biochemical Markers in Post-Operative Delirium After Vascular Surgery Procedures

Background

Post-operative delirium (POD) is a common complication, especially in elderly patients who underwent vascular surgery procedures. The aim of this study was to evaluate the relation of inflammatory biochemical markers as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and systemic inflammation index (SII) with POD occurrence.

Methods

This was a single-center, retrospective, observational study. We analyzed the perioperative data of patients who had undergone elective vascular surgery procedures. The occurrence of delirium after procedure was used to divide the population in two groups: POD-pos and POD-neg group. ROC curves were performed to find the appropriate cut-off values of NLR, PLR and SII. Multivariate analysis was used to identify the independent predictors for POD.

Results

A total of 646 patients were enrolled. Mean age was 76.2±9.8 years, 68.4% were male. Seventy-three patients (11.3%) developed POD. Mean hospital stay was significantly increased in the POD-pos group (6.1±5.4 vs 3.2±2.8 days, p=0.0001). In-hospital reinterventions were more frequent in the POD-pos group (8.2% vs 3.8%). Blood values analysis reported significant differences: Hb, NLR, PLR, SII, creatinine and RCP were strongly increased (p<0.05) in the POD-pos group. ROC curves identified cut-off values for NLR>3.57, PLR>139.2 and SII>676.4. Multivariate analysis revealed that age, Renal Failure, peripheral revascularization procedures, major amputation, general anesthesia, hospitalization in the previous month, NLR>3.57 and SII>676.4 were independent risk factors for POD.

Conclusion

POD represents a common complication of vascular surgery patients. Our study demonstrated that NLR, PLR and SII are reliable and readily available laboratory predictors of POD in vascular surgery that could help in POD risk-stratification.

Lower preoperative serum uric acid level may be a risk factor for postoperative delirium in older patients undergoing hip fracture surgery: a matched retrospective case-control study

BACKGROUND

Postoperative delirium (POD) is a common complication after hip fracture surgery that is associated with various short- and long-term outcomes. The mechanism of POD may be associated with the oxidative stress process. Uric acid has been shown to provide a neuroprotective effect in various neurodegenerative diseases through its antioxidant properties. However, it is unclear whether lower preoperative serum uric acid levels are associated with the development of POD after hip fracture surgery. Therefore, this study assessed the association of lower preoperative uric acid levels in patients with POD during hospitalization.

METHODS

This is a matched retrospective case-control study that included 96 older patients (≥65 y) who underwent hip fracture surgery. POD was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Patients diagnosed with POD (cases) were matched 1:1 with patients without POD (controls) on the basis of age, sex, and anesthesia type. The relationship between preoperative uric acid and POD was analyzed by multivariable analysis.

RESULTS

The POD and non-POD groups each had 48 patients. In the univariate analysis, lower log preoperative serum uric acid value, higher neutrophil-to-lymphocyte ratio, and cerebrovascular disease were more likely in patients with POD than in those with no POD. Multivariable conditional logistic regression analysis showed that lower log preoperative serum uric acid (adjusted odds ratio [aOR], 0.028; confidence interval [CI], 0.001-0.844; p = 0.040), higher neutrophil-to-lymphocyte ratio (aOR, 1.314; 95% CI, 1.053-1.638; p = 0.015), and increased surgery duration (aOR, 1.034; 95% CI, 1.004-1.065; p = 0.024) were associated with increased risk of POD.

CONCLUSIONS

Lower preoperative serum uric acid levels may be an independent risk factor for POD after adjustment for possible confounding factors. However, large prospective studies are needed to confirm this finding.

Systemic immune-inflammation index predicts postoperative delirium in elderly patients after surgery: a retrospective cohort study

Background

Postoperative delirium (POD) is a common complication among elderly patients after surgery. It is unclear whether the systemic immune-inflammation index (SII) can be a predictor of POD. We explored the prognostic value of the SII in predicting POD in elderly patients undergoing non-neurosurgery and non-cardiac surgery in a large retrospective cohort.

Methods

We enrolled elderly patients undergoing non-neurosurgery and non-cardiac surgery between January 2014 and August 2019. Univariate and multivariate logistic regression analyses were performed to explore the correlation between POD and the SII value as both a continuous and categorical variable. Then, propensity score matching (PSM) analysis was applied to eliminate the confounding effect of covariates and prove our results. Subgroup analyses were then performed to discover the association between the SII and POD in different subgroups.

Results

A total of 29,608 patients with a median age of 70 years (IQR: 67–74) were enrolled in the retrospective cohort. The cut-off value of the SII was 650, which was determined by the receiver operating characteristic (ROC) curve. The ORs of an SII value > 650 was 2.709 (95% CI:2.373–3.092, P < 0.001), 1.615 (95% CI:1.384–1.882, P < 0.001), 1.855 (95% CI:1.602–2.146, P < 0.001), and 1.302 (95% CI:1.106–1.531, P = 0.001) for prediction of POD in univariate model and three multivariate regression models. After PSM, the OR of an SII value > 650 was 1.301 (95% CI: 1.062–1.598, P = 0.011). The subgroup analysis indicated that the SII indicates a significantly increased risk of POD in patients with Hb < 130 g/L, 4*10⁹/L < WBC ≤ 10*10⁹/L, albumin < 39 g/L, or duration of MAP < 60 mmHg ≥ 5 min. The SII was found to be a useful prognostic predictor of POD for patients of different ages, sexes, and ASA classifications.

Conclusions

The SII had a predictive value for POD in patients undergoing non-neurosurgery and non-cardiac surgery. As an index generated from routine blood tests, the SII has advantages regarding cost and time. After further validation, the SII may provide a new option for POD prediction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03418-4.

Preoperative Inflammatory Markers and the Risk of Postoperative Delirium in Patients Undergoing Lumbar Spinal Fusion Surgery

We investigated the possible associations between postoperative delirium (POD) and routinely available preoperative inflammatory markers in patients undergoing lumbar spinal fusion surgery (LSFS) to explore the role of neuroinflammation and oxidative stress as risk factors for POD. We analyzed 11 years’ worth of data from the Smart Clinical Data Warehouse. We evaluated whether preoperative inflammatory markers, such as the neutrophil-to-lymphocyte ratio (NLR), the monocyte-to-lymphocyte ratio (MLR), and the CRP-to-albumin ratio (CAR), affected the development of POD in patients undergoing LSFS. Of the 3081 subjects included, 187 (7.4%) developed POD. A significant increase in NLR, MLR, and CAR levels was observed in POD patients (p < 0.001). A multivariate analysis showed that the second, third, and highest quartiles of the NLR were significantly associated with the development of POD (adjusted OR (95% CI): 2.28 (1.25−4.16], 2.48 (1.3−4.73], and 2.88 (1.39−5.96], respectively). A receiver operating characteristic curve analysis showed that the discriminative ability of the NLR, MLR, and CAR for predicting POD was low, but almost acceptable (AUC (95% CI): 0.60 (0.56−0.64], 0.61 (0.57−0.65], and 0.63 (0.59−0.67], respectively, p < 0.001). Increases in preoperative inflammatory markers, particularly the NLR, were associated with the development of POD, suggesting that a proinflammatory state is a potential pathophysiological mechanism of POD.

Higher neutrophil-lymphocyte ratio is associated with depressive symptoms in Japanese general male population

Relationships between the neutrophil–lymphocyte ratio (NLR) and/or the platelet-lymphocyte ratio (PLR) and neuroinflammatory diseases have been reported. Depression is also associated with neuroinflammation. Here, we determined the association between the NLR, PLR, and depressive symptoms. This cross-sectional study is a secondary analysis of the data of the Iwaki Health Promotion Project 2017. We analyzed the characteristics and laboratory data of 1,015 Japanese subjects (597 females, 408 males) including their NLR and PLR values. We assigned the subjects with a Center for Epidemiologic Studies Depression Scale (CES-D) score ≥ 16 to the depressive symptoms group. We performed a multivariate logistic regression analysis to determine whether the NLR and/or PLR were associated with depressive symptoms (CES-D ≥ 16). Two hundred subjects (19.7%; 122 [20.4%] females, 78 [19.1%] males) were assigned to the depressive symptoms group. There were significant differences between the non-depressive symptoms and depressive symptoms groups in the NLR [median (25th to 75th percentile): 1.54 (1.24, 1.97) vs. 1.76 (1.32, 2.37), P = 0.005] and the PLR [median (25th to 75th percentile): 123.7 (102.0, 153.9) vs. 136.8 (107.0, 166.5), P = 0.047] in males, but not in females. The multivariate logistic regression analysis demonstrated that the NLR was significantly associated with depressive symptoms in males (adjusted odds ratio: per 1 increase, 1.570; 95% confidence interval: 1.120–2.220; P = 0.009). In conclusion, our findings indicate that higher NLR may be associated with depressive symptoms in males.

White-Cell Derived Inflammatory Biomarkers in Prediction of Postoperative Delirium in Elderly Patients Undergoing Surgery for Lower Limb Fracture Under Non-General Anaesthesia

Purpose

The aim of this study was to investigate whether white-cell derived biomarkers could serve as potential markers in prediction of postoperative delirium (POD) after lower limb fracture.

Patients and Methods

Elderly patients with surgery for lower limb fracture under non-general anaesthesia were included. Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and platelet-to-white cell ratio (PWR), which were most recently measured preceding surgery and measured within 24h after surgery, were calculated. Delirium was measured with Confusion Assessment Method (CAM) once daily from preoperative day 1 to postoperative day 3 or hospital discharge.

Results

The incidence of POD was 32.6% (60/184). Between patients with and those without POD, there were significant differences in preoperative hematological biomarkers (neutrophil count, lymphocyte count, NLR and PWR) and postoperative hematological biomarkers (white cell count, neutrophil count, lymphocyte count, NLR, PLR and PWR). More obvious changes before and after operation for NLR, PLR and C-reactive protein (CRP) were found in patients with POD. Multivariate logistic regression showed that benzodiazepines (OR, 7.912; 95% CI, 1.884–33.230; p = 0.005), change of CRP (OR, 1.017; 95% CI, 1.007–1.027; p = 0.001) and postoperative NLR (OR, 1.358; 95% CI, 1.012–1.823; p = 0.041) were associated with POD. When the changes of NLR, PLR and PWR entered multivariate logistic regression, older age (OR, 1.073; 95% CI, 1.001–1.149; p = 0.046), benzodiazepines (OR, 6.811; 95% CI, 1.652–28.081; p = 0.008), greater change of CRP (OR, 1.015; 95% CI, 1.006–1.023; p = 0.001) and greater change of NLR (OR, 1.266; 95% CI, 1.035–1.549; p = 0.022) were associated with increased risk of POD. Postoperative NLR had high accuracy to predict POD with area under curve (AUC) of 0.790 (95% CI 0.708 to 0.872).

Conclusion

Age, benzodiazepines, postoperative NLR, change of NLR and change of CRP were independent predictable markers for POD in elderly patients undergoing surgery for lower limb fracture under non-general anaesthesia. Early postoperative NLR may help to recognize POD as soon as possible.

Higher neutrophil-to-lymphocyte ratio, mean platelet volume, and platelet distribution width are associated with postoperative delirium in patients undergoing esophagectomy: a retrospective observational study

PURPOSE

We investigated whether preoperative inflammatory markers, i.e., the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), mean platelet volume (MPV), and platelet distribution width (PDW) can predict the development of postoperative delirium (POD) after esophagectomy.

PATIENTS AND METHODS

This single-center, retrospective, observational study included 110 patients who underwent an esophagectomy. We assigned the patients with the Intensive Care Delirium Screening Checklist score ≥ 4 to the POD group. We performed multivariable logistic regression analyses to determine whether the NLR, PLR, MPV, and PDW can be used to predict the development of POD.

RESULTS

The POD group had 20 patients; the non-POD group included the other 90 patients. Although only the preoperative NLR in the POD group was significantly higher than in the non-POD group (3.20 [2.52-4.30] vs. 2.05 [1.45-3.02], p = 0.001), multivariable logistic regression analyses showed that the following three parameters were independent predictors of POD: preoperative NLR ≥ 2.45 (adjusted odds ratio [aOR]: 8.68, 95%CI 2.33-32.4, p = 0.001), MPV ≥ 10.4 (aOR: 3.93, 95%CI: 1.37-11.2, p = 0.011), and PDW ≥ 11.8 (aOR: 3.58, 95%CI: 1.22-10.5, p = 0.020).

CONCLUSION

Our analysis results demonstrated that preoperative NLR ≥ 2.45, MPV ≥ 10.4, and PDW ≥ 11.8 were significantly associated with a higher risk of POD after adjustment for possible confounding factors. However, as the AUCs of the preoperative MPV and PDW for the prediction of the development of POD in univariable ROC analyses were low, large prospective studies are needed to confirm this result.

Neutrophil-Lymphocyte Ratio as a Potential Biomarker for Delirium in the Intensive Care Unit

Background: Recognition and early detection of delirium in the intensive care unit (ICU) is essential to improve ICU outcomes. To date, neutrophil-lymphocyte ratio (NLR), one of inflammatory markers, has been proposed as a potential biomarker for brain disorders related to neuroinflammation. This study aimed to investigate whether NLR could be utilized in early detection of delirium in the ICU. Methods: Of 10,144 patients who admitted to the ICU, 1,112 delirium patients (DE) were included in the current study. To compare among inflammatory markers, NLR, C-reactive protein (CRP), and white blood cell (WBC) counts were obtained: the mean NLR, CRP levels, and WBC counts between the initial day of ICU admission and the day of initial delirium onset within DE were examined. The inflammatory marker of 1,272 non-delirium patients (ND) were also comparatively measured as a supplement. Further comparisons included a subgroup analysis based on delirium subtypes (non-hypoactive vs. hypoactive) or admission types (elective vs. emergent). Results: The NLR and CRP levels in DE increased on the day of delirium onset compared to the initial admission day. ND also showed increased CRP levels on the sixth day (the closest day to average delirium onset day among DE) of ICU admission compared to baseline, while NLR in ND did not show significant difference over time. In further analyses, the CRP level of the non-hypoactive group was more increased than that of the hypoactive group during the delirium onset. NLR, however, was more significantly increased in patients with elective admission than in those with emergent admission. Conclusion: Elevation of NLR was more closely linked to the onset of delirium compared to other inflammatory markers, indicating that NLR may play a role in early detection of delirium.