Postoperative Neurocognitive Disorders in Cardiac Surgery: Investigating the Role of Intraoperative Hypotension. A Systematic Review

Impact of risk mitigation strategies on non-fatal injuries in the construction sector in qatar: a retrospective analysis

PURPOSE

The construction sector has the highest risk of fatal and non-fatal injuries worldwide. This study examined the impact of risk mitigation strategies implemented in Qatar's construction sector between 2013 and 2021 on non-fatal injuries.

METHODS

This study employed quantitative and qualitative methods. Data on implemented strategies were gathered through a systematic website search and structured interviews with Safety and Occupational Health officers. Retrospective injury data were obtained from Hamad Trauma Center medical records. Systematic website search identified key legislation and guidelines. Interview transcripts were analyzed using qualitative content analysis. Injury data were categorized into pre- and post-implementation data. Differences were assessed using means, standard deviations, percentages, effect sizes, and confidence intervals.

RESULTS

Eight safety legislation/policies and guidelines were issued. Interview analysis identified technical, behavioral, and organizational measures as key themes in risk mitigation strategies. Comparing pre- and post-implementation data, non-fatal injury incidence (effect size (ES): 0.21, 95% CI 0.19-0.28) and severity (ES: 0.32, 95% CI 0.25-0.40) were reduced. Hospital and ICU stays were shorter post-implementation (ES: 0.2, 95% CI 0.12-0.27 and 0.014, 95% CI 0.010-0.021). Injury reductions were observed across major affected areas, except for the chest and skin. Non-fatal injuries remained more common among general laborers (ES: - 0.26, 95% CI - 0.34, 0.18) and those wearing protective devices (ES; - 0.1, CI - 0.12, - 0.07).

CONCLUSION

Implemented risk mitigation strategies collectively reduced non-fatal injury incidence and severity and improved outcomes in the construction sector. Future research should explore observed trends through prospective studies and job hazard analysis.

Current Progress on Postoperative Cognitive Dysfunction: An Update

Postoperative cognitive dysfunction (POCD) represents a significant clinical concern, particularly among elderly surgical patients. It is characterized by a decline in cognitive performance, affecting memory, attention, coordination, orientation, verbal fluency, and executive function. This decline in cognitive abilities leads to longer hospital stays and increased mortality. This review provides a comprehensive overview of the current progress in understanding the relevant pathogenic factors, possible pathogenic mechanisms, diagnosing, prevention and treatment of POCD, as well as suggesting future research directions. It discusses neuronal damage, susceptible genes, central cholinergic system, central nervous system (CNS) inflammation, stress response and glucocorticoids, and oxidative stress in the development of POCD, aiming to uncover the pathological mechanism and develop effective treatment strategies for POCD.

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.

Histidine-Tryptophan-Ketoglutarate Cardioplegia Yields Different Results in Aortic Valve Surgery Depending on Patient Gender: A Pilot Study

BACKGROUND

Histidine-tryptophan-ketoglutarate (HTK) cardioplegia induces cardiac arrest through membrane hyperpolarization. Aortic valve pathology leads to pathophysiological changes in left ventricular vascularization that may prevent adequate cardioplegic distribution. The objective of the study was to ascertain whether the use of Bretschneider cardioplegia in aortic valve surgery yields different outcomes for male and female patients.

METHODOLOGY

Our study compares the perioperative data of 300 adult patients who underwent aortic valve replacement between June 2023 and June 2024 at the Emergency Cardiac Disease and Transplant Institute, Tîrgu Mures, Romania. Concomitant procedures, age under 18 years, retrograde or combined cardioplegia, and emergency surgery were excluded. The main outcome was operative mortality, and secondary outcomes were postoperative complications and paraclinical data such as ejection fraction and cardiac enzymes.

RESULTS

Male patients comprised 190 (62%) of the sample. The most common age group was 61-70 years in both groups. The mortality rate was 6 (5.4%) for women compared to 9 (4.7%) for men. Preoperative left ventricular ejection fraction was the primary covariate determining 30-day postoperative mortality. Left ventricular ejection fraction decreased by 2.2% in men and 1.1% in women 30 days after surgery.

CONCLUSIONS

The myocardial adaptation to aortic valve pathology exhibits gender-specific differences. However, the utilization of HTK cardioplegia obviates this disparity.

Knowledge mapping and research trends on perioperative neurocognitive disorder from 1990 to 2022: a bibliometric analysis

Introduction

Perioperative neurocognitive disorder (PND) has attracted consistently increasing attention worldwide. However, there are few bibliometric studies that systematically evaluate this field. This study aimed to visualize the knowledge structure and research trends in PND through bibliometrics to help understand the future development of basic and clinical research.

Methods

Literature related to PND in Web of Science and PubMed from 1990 to 2022 were collected through keywords retrospectively. Additionally, the source information, citation information, etc. of these publications were extracted. Finally, bibliometric analysis was performed by visualization software and statistical software.

Results

There were 2837 articles and reviews in total. An exponential rise in PND-related publications was observed. China had the most publication, followed by the US and Germany. The institution with the most output and citations was Harvard University (149 papers, 8966 citations). The most prominent author was Marcantonio Edward R with 66 publications and 5721 citations. The journal with the highest productivity for PND research was Frontiers in Aging Neuroscience followed by Anesthesia and Analgesia. Keywords were identified as six topics, including postoperative delirium, postoperative neurocognitive disorder, cardiac surgery, anaesthesia, orthopedic surgery, and dementia. According to keyword analysis, the most recent popular keywords in PND research were prevention, older patients, emergence delirium, orthopedic surgery, and dexmedetomidine.

Conclusions

Publications on PND are increasing at an alarming rate from 1990 to 2022. Current research and future trends will concentrate on the prevention and treatment of PND, as well as PND associated with orthopedic surgery in older adults.

Effect of percutaneous cerebral oximetry-guided anaesthetic management on postoperative delirium in older adults undergoing off-pump coronary artery bypass grafting: study protocol for a single-centre prospective randomised controlled trial in a tertiary academic hospital in China

INTRODUCTION

Postoperative delirium is a prominent and clinically important complication in older adults after coronary artery bypass grafting (CABG) surgery, resulting in prolonged hospital stay, long-term cognitive impairment and increased morbidity and mortality. Many studies have shown that cerebral desaturation is associated with increased risk of postoperative delirium during on-pump cardiac surgery. However, few studies have focused on the effect of optimising regional cerebral oxygen saturation (rSO2) on postoperative delirium during off-pump CABG. The purpose of this study is to investigate whether intraoperative anaesthetic management based on percutaneous cerebral oximetry monitoring decreases the incidence of postoperative delirium in older adults undergoing off-pump CABG.

METHODS

This single-centre randomised controlled trial will randomly assign 200 patients to the intervention group or the control group at a ratio of 1:1. The patients in the intervention group will be observed by percutaneous cerebral oximetry monitoring that the desaturation (a drop of more than 20% from baseline value or rSO2 less than 55% for >60 consecutive seconds at either probe) during the procedure triggered the intervention strategies, while the cerebral oximetry data of the control group will be hidden from the clinical team and patients will be anaesthetised by the usual anaesthetic management. The primary outcome will be the incidence of postoperative delirium during the first 7 days after off-pump CABG. Delirium will be comprehensively evaluated by the combination of the Richmond Agitation Sedation Scale and the Confusion Assessment Method for the intensive care unit. The secondary outcomes will include the incidence of postoperative acute kidney injury and myocardial infarction during the hospital stay, as well as the intensive care unit and hospital length of stay.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the Chinese Academy of Medical Sciences, Fuwai Hospital (No 2022-1824). Written informed consent will be obtained from each patient or their legal representatives before enrolment. The results of this trial will be published in an international peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

ChiCTR2300068537.

Incidence and Factors Related to Prolonged Postoperative Cognitive Decline (POCD) in Elderly Patients Following Surgery and Anaesthesia: A Systematic Review

Aim

The aim of this systematic review is to explore the current literature to provide evidence regarding the incidence and risk factors of prolonged POCD in elderly patients following cardiac and non-cardiac surgical interventions.

Methods

The PubMed and Google Scholar databases were searched using appropriate keywords and search engines for adequate evidence from studies meeting the inclusion criteria so as to reveal the end-point, which was the presence of prolonged POCD in elderly patients following surgery and anaesthesia. The incidence of POCD at different time intervals and the variables predicting the occurrence of POCD were analysed.

Results

The results of 23 articles covering 5077 patients (3694 non cardiac and 1383 cardiac surgeries) were carefully analysed. POCD occurs from the first postoperative day and lasts for potentially long periods. The incidence of POCD in this review ranged from 2.2% to 35.7%. More specifically, it ranged from 2.2% to 31.5% in non-cardiac surgeries and 11.8% to 35.7% in patients who had undergone cardiac surgeries. Some of the independent risk factors (predictors) for the development of POCD were advanced age, high concentration of neuroinflammatory mediators detectable in plasma, low SpO2, longer anaesthetic and surgical duration, and depth of anaesthesia.

Conclusion

This review can only provide limited evidence of prolonged POCD (more than a year) and further research that involves better study designs, larger samples, involving longer follow-up, and at different sites (multicentre) is highly advised. This in turn may help researchers and clinicians to discover the actual causes and risk factors and develop appropriate preventive and treatment protocols to tackle POCD in the ageing surgical population.

Development and validation of a nomogram for predicting intraoperative hypotension in cardiac valve replacement

Background: Cardiac valve replacement risks include intraoperative hypotension, endangering organ perfusion. Our nomogram predicted hypotension risk in valve surgery, guiding early intervention. Methods: Analyzing 561 patients from July to November 2022, we developed a nomogram to predict hypotension in valve replacement patients, validated using data from December 2022 to January 2023 on 241 patients, with robust statistical confirmation. Results: Our study identified age, hypertension, left ventricular ejection fraction and serum creatinine as hypotension predictors. The resulting nomogram, validated with high concordance index and area under the curve scores, provided a clinically useful tool for managing intraoperative risk. Conclusion: For valve replacement patients, factors like age, hypertension, low left ventricular ejection fraction and high serum creatinine predicted hypotension risk. Our nomogram enabled clinicians to quantify this risk and proactively manage it.

Effects of anesthetic adjunctive agents on postoperative cognitive dysfunction in elderly patients undergoing noncardiac surgery: A Bayesian network meta-analysis

BACKGROUND

Elderly patients are prone to postoperative cognitive dysfunction (POCD). The comparison of the effects of anesthetic adjuvant drugs on POCD in elderly patients undergoing noncardiac surgery remains controversial.

METHODS

The final search took place on June 10, 2023. Randomized controlled trials including ketamine, ulinastatin, dexmedetomidine, parecoxib, and midazolam on the prevention and treatment of POCD in elderly undergoing noncardiac surgery were collected. A Bayesian network meta-analysis was performed to quantitatively combine the evidence.

RESULTS

A total of 35 randomized trials were finally included in this systematic review, and the overall risk of bias is Allocation concealment. These anesthetic adjuvant drugs did not show significant differences in preventing POCD on postoperative days 1 and 7 compared with each other, but ulinastatin may be more effective in preventing POCD than dexmedetomidine [odds ratio (OR) = 0.28, 95% confidence interval (CI) = (0.10, 0.71)] and parecoxib [OR = 0.3, 95% CI = (0.10, 0.82 on postoperative day 3. The efficiency ranking results also find that ulinastatin and ketamine might provide better effects regarding POCD prevention.

CONCLUSIONS

Ketamine and ulinastatin might have better effects in preventing POCD in elderly patients undergoing noncardiac surgery. Our meta-analysis provided evidence for the use of ulinastatin and ketamine in the prevention of POCD in elderly patients undergoing noncardiac surgery.

Two-stage prediction model for postoperative delirium in patients in the intensive care unit after cardiac surgery

OBJECTIVES

Postoperative delirium is a common severe complication in patients in the intensive care unit after cardiac surgery. We developed a two-stage prediction model and quantified the risk of developing postoperative delirium to assist in early prevention before and after surgery.

METHODS

We conducted a prospective cohort study and consecutively recruited adult patients after cardiac surgery. The Confusion Assessment Method for patients in the intensive care unit was used to diagnose delirium 5 days postoperatively. The stage I model was constructed using patient demographics, health conditions and laboratory results obtained preoperatively, whereas the stage II model was built on both pre- and postoperative predictors. The model was validated internally using the bootstrap method and externally using data from an external cohort.

RESULTS

The two-stage model was developed with 654 patients and was externally validated with 214 patients undergoing cardiac surgery. The stage I model contained 6 predictors, whereas the stage II model included 10 predictors. The stage I model had an area under the receiver operating characteristic curve of 0.76 (95% confidence interval: 0.68-0.81), and the stage II model's area under the receiver operating characteristic curve increased to 0.85 [95% confidence interval (CI): 0.81-0.89]. The external validation resulted in an area under the curve of 0.76 (95% CI: 0.67-0.86) for the stage I model and 0.78 (95% CI: 0.69-0.86) for the stage II model.

CONCLUSIONS

The two-stage model assisted medical staff in identifying patients at high risk for postoperative delirium before and 24 h after cardiac surgery. This model showed good discriminative power and predictive accuracy and can be easily accessed in clinical settings.

TRIAL REGISTRATION

The study was registered with the US National Institutes of Health ClinicalTrials.gov (NCT03704324; registered 11 October 2018).

Timing, Threshold, and Duration of Intraoperative Hypotension in Cardiac Surgery: Their Associations With Postoperative Delirium

OBJECTIVES

To study the timing, threshold, and duration of intraoperative hypotension (IOH) associated with the risk of postoperative delirium (POD).

DESIGN

A single-center retrospective observational study.

SETTING

University teaching hospital.

PARTICIPANTS

A total of 503 adult patients who underwent cardiac valvular surgery that required cardiopulmonary bypass (CPB).

MEASUREMENTS AND MAIN RESULTS

The authors predefined the following 4 periods: (1) during surgery, (2) pre-CPB, (3) during CPB, and (4) post-CPB, and 8 thresholds of mean arterial pressure for IOH according to every 5 mmHg between 50 mmHg and 85 mmHg. The authors calculated the cumulative duration below the 8 thresholds in each period. The primary outcome was delirium defined as a score of ≥4 for at least one Intensive Care Delirium Screening Checklist assessment during 48 h after the surgery. Among 503 patients, POD occurred in 95 patients (18.9%). There was no significant association of POD with all of the thresholds of IOH in the periods of pre-CPB, during CPB, and during surgery. However, in the post-CPB period, the patients with POD had a significantly longer cumulative duration of IOH according to all of the thresholds of mean arterial pressure. In multivariate analyses, 4 IOH thresholds in the post-CPB period were associated independently with POD: <60 mmHg (odds ratio [OR] =1.84 [95% CI 1.10-3.10]), <65 mmHg (OR = 1.72 [1.01-2.92]), <70 mmHg (OR = 1.83 [1.03-3.26]), and <75 mmHg (OR = 1.94 [1.02-3.69]).

CONCLUSIONS

A longer cumulative duration of IOH with the threshold between <60 and <75 mmHg that occurred after CPB was independently associated with the risk of POD.

Stroke, Seizures, Hallucinations and Postoperative Delirium as Neurological Complications after Cardiac Surgery and Percutaneous Valve Replacement

(1) Background: Neurological complications such as acute ischemic stroke or postoperative delirium are frequent after cardiac surgery or percutaneous valve replacement. This study aimed to identify corresponding risk factors. (2) Methods: 297 patients with percutaneous valve replacement or cardiac surgery were postoperatively screened for neurological complications such as delirium, stroke, seizures and hallucinations twice daily for three days. Pre- and perioperative risk factors were evaluated in a multivariate model. (3) Results: Neurological complications occurred in 43.8% (n = 130) as composed of delirium (43.43%, n = 129), stroke (2.7%, n = 8), seizures (1.35%, n = 4) and real hallucinations (3.36%, n = 10). Multiple logistic regression revealed an association of neurological complications with lower Montreal Cognitive Assessment scores (Exp(B) 2.042; 95% CI, 1.183−3.525, p = 0.010), older age (Exp(B) 1.071; 95% CI, 1.036−1.107, p < 0.001), red blood cell transfusions until postoperative day 3 (Exp(B) 1.157; 95% CI, 1.030−1.300, p = 0.014), history of heart failure (Exp(B) 1.985; 95% CI, 1.130−3.487, p = 0.017) and increased CRP levels (Exp(B) 1.004; 95% CI, 1.000−1.008, p = 0.037). (4) Conclusions: Postoperative delirium remains a frequent complication after cardiac surgery, while stroke and seizures occur rarely. A preoperative risk profile including older age, history of heart failure and cognitive impairment was identified for a complicated postoperative course. However, the impact of an intense inflammatory response must not be neglected.

Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment

Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.

Survival of Frail Elderly with Delirium

This study aims to determine when frailty increases the risks of delirium mortality. Hospital patients falling into the elderly frail or pre-frail category were recruited, some without delirium, some with delirium at admission, and some who developed delirium during admission. We screened for frailty, cognitive status, and co-morbidities whenever possible and extracted drug information and mortality data from electronic health records. Kaplan–Meier estimates of survival probability functions were computed at four times, comparing delirium versus non delirium patients. Differences in survival were assessed by a log-rank test. Independent Cox’s regression was carried out to identify significant hazard risks (HR) at 1 month, 6 months, 1 year, and 2 years. Delirium predicted mortality (log-rank test, p < 0.0001) at all four censoring points. Variables with significant HRs were frailty indicators, comorbidities, polypharmacy, and the use of specific drugs. For the delirium cohort, variables with the most significant 2-year hazard risks (HR(95%CI)) were: male gender (0.43 20 (0.26,0.69)), weight loss (0.45 (0.26,0.74)), sit and stand up test (0.67 (0.49,0.92)), readmission within 30 days of discharge (0.50 (0.30,0.80)), cerebrovascular disease (0.45 (0.27,0.76)), head trauma (0.54 22 (0.29,0.98)), number of prescribed drugs (1.10 (1.03,1.18)), and the use of diuretics (0.57 (0.34,0.96)). These results suggest that polypharmacy and the use of diuretics increase mortality in frail elderly patients with delirium.

Incidence and factors associated with postoperative delirium in patients undergoing transurethral resection of bladder tumor

Background

Postoperative delirium is an important complication after surgery, including urological surgery. This study evaluated the incidence of postoperative delirium and its associated factors after transurethral resection of bladder tumor in adult patients.

Methods

Patients aged ≥20 years who underwent elective transurethral resection of bladder tumor under general anesthesia from April 2016 to November 2020 were included. Patient demographic and intraoperative data, including the administration of 5-aminolevulinic acid and hypotension, defined as a mean arterial pressure value < 60 mmHg, were evaluated. The primary outcome was the incidence of postoperative delirium assessed using a chart-based method. The factors associated with postoperative delirium were explored using multiple logistic regression analysis. Postoperative lengths of stay between patients with and without postoperative delirium were compared using the Mann–Whitney U-test.

Results

Of 324 eligible patients with a median age of 76, 26 patients experienced postoperative delirium, with an incidence rate of 8.0% (95% confidence interval, 5.06–10.9). Age (odds ratio 1.13, 95% confidence interval 1.05–1.22, p = 0.001) and body mass index (odds ratio 0.83, 95% confidence interval 0.71–0.97, p = 0.02) were associated with postoperative delirium. Postoperative length of stay between patients with or without postoperative delirium was not significantly different (6 vs 6 days, p = 0.18).

Conclusions

The incidence of postoperative delirium after transurethral resection of bladder tumor under general anesthesia in this study was 8.0%. Older age and low body mass index were associated with development of postoperative delirium.

An Update on Postoperative Cognitive Dysfunction Following Cardiac Surgery

Postoperative cognitive dysfunction is extremely prevalent following cardiac surgery. The increasing patient age and comorbidity profile increases their susceptibility to cognitive impairment. The underlying pathophysiological mechanisms leading to cognitive impairment are not clearly elucidated. Using the contemporary literature (2015-present), this narrative review has three aims. Firstly, to provide an overview of postoperative cognitive impairment. Secondly, to analyse the predominant pathophysiological mechanisms leading to cognitive dysfunction following cardiac surgery such as inflammation, cerebral hypoperfusion, cerebral microemboli, glycaemic control and anaesthesia induced neurotoxicity. Lastly, to assess the current therapeutic strategies of interest to address these pathophysiological mechanisms, including the administration of dexamethasone, the prevention of prolonged cerebral desaturations and the monitoring of cerebral perfusion using near-infrared spectroscopy, surgical management strategies to reduce the neurological effects of microemboli, intraoperative glycaemic control strategies, the effect of volatile vs. intravenous anaesthesia, and the efficacy of dexmedetomidine.

Postoperative delirium and neurocognitive disorders

PURPOSE OF REVIEW

Postoperative neurocognitive disorders (NCD) are significant causes of morbidity and mortality. In this paper, we will review our understanding and potential management of postoperative NCD.

RECENT FINDINGS

Postoperative delirium, delayed neurocognitive recovery and postoperative cognitive dysfunction (POCD) are recognized as a part of the continuous spectrum of postoperative NCD. Although the pathophysiology is still poorly understood, there is renewed focus on improving neurocognitive outcomes of aging surgical population. Novel methods of neurocognitive screening are developed and research in the prevention and management of NCD has gained traction.

SUMMARY

A spectrum of NCD exists in surgical patients ranging from postoperative delirium, delayed neurocognitive recovery, and POCD. Identification of patients at-risk for developing NCD can help target appropriate perioperative intervention. Also, specialized care teams and the implementation of standardized protocols are crucial for the successful management perioperative NCD. Finally, large, randomized, multicenter studies are needed to confirm benefits of preventive and treatment strategies.

Association between perioperative hypotension and postoperative delirium and atrial fibrillation after cardiac surgery: A post-hoc analysis of the DECADE trial

STUDY OBJECTIVE

To test the hypotheses that in adults having cardiac surgery with cardio-pulmonary bypass, perioperative hypotension increases the risk of delirium and atrial fibrillation during the initial five postoperative days.

DESIGN

Sub-analysis of the DECADE multi-center randomized trial.

SETTING

Patients who had cardiac surgery with cardiopulmonary bypass at the Cleveland Clinic.

INTERVENTIONS

In the underlying trial, patients were randomly assigned 1:1 to dexmedetomidine or normal saline placebo.

MEASUREMENTS

Intraoperative mean arterial pressures were recorded at 1-min intervals from arterial catheters or at 1-5-min intervals oscillometrically. Postoperative blood pressures were recorded every half-hour or more often. The co-primary outcomes were atrial fibrillation and delirium occurring between intensive care unit admission and the earlier of postoperative day 5 or hospital discharge. Delirium was assessed twice daily during the initial 5 postoperative days while patients remained hospitalized with the Confusion Assessment Method for the intensive care unit. Assessments were made by trained research fellows who were blinded to the dexmedetomidine administration.

MAIN RESULTS

There was no significant association between intraoperative hypotension and delirium, with an adjusted odds ratio of 0.94 (95% CI: 0.81, 1.09; P = 0.419) for a doubling in AUC of mean arterial pressure (MAP) <60 mmHg. An increase in intraoperative AUC of MAP <60 mmHg was not significantly associated with the odds of atrial fibrillation (adjusted odds ratio = 0.99; 95% CI: 0.87, 1.11; P = 0.819). Postoperative MAP <70 mmHg per hour 1.14 (97.5% CI: 1.04,1.26; P = 0.002) and MAP <80 mmHg per hour 1.05 (97.5%: 1.01, 1.10; P = 0.010) were significantly associated with atrial fibrillation.

CONCLUSIONS

In patients having cardiac surgery with cardio-pulmonary bypass, neither intraoperative nor postoperative hypotension were associated with delirium. Postoperative hypotension was associated with atrial fibrillation, although intraoperative hypotension was not.

Cefazolin Improves Anesthesia and Surgery-Induced Cognitive Impairments by Modulating Blood-Brain Barrier Function, Gut Bacteria and Short Chain Fatty Acids

Emerging evidence suggests that anesthesia and surgery may induce gut dysbiosis. Gut dysbiosis leads to imbalance in circulating contents of microbiota-derived metabolites and disrupts the integrity of the blood-brain barrier (BBB), contributing to postoperative cognitive dysfunction (POCD). The composition of gut microbiota may be influenced by various antibiotics. However, how perioperative use of antibiotics affects POCD needs more explorations. In the present study, we explored the effect of cefazolin, a common antibiotic used in perioperative period, on cognitive function, BBB integrity, gut bacteria and short chain fatty acids (SCFAs), a group of widely studied metabolites in aged mice, using 18-month-old male mice. Significant BBB disruptions and decreased levels of tight junction proteins, zonula occludens-1 (ZO-1) and Occludin (OCLN) were seen in the mice of POCD model. Cefazolin treatment attenuated these changes induced by anesthesia and surgery. Furthermore, cefazolin reversed the changes in several fecal bacteria (β-, γ/δ-, ε-Proteobacteria, and Bacteroidetes) as determined by qPCR tests. Analysis of plasma SCFAs showed that almost all types of SCFAs were reduced in POCD and cefazolin administration reversed the changes in expression of the two most abundant SCFAs (acetic and propionic acids). In conclusion, this study demonstrated that cefazolin improved POCD. Mechanistically, cefazolin suppressed the disruption of BBB, gut microbiota or SCFAs, thereby ameliorating POCD.

Analysis of the Risk Factors for Hypotension in Laparoscopic Hiatal Hernia Repair

Objective

This study aimed to investigate the risk factors for hypotension in patients undergoing laparoscopic hiatal hernia repair.

Methods

The clinical data of patients who underwent laparoscopic repair of a hiatal hernia in the Beijing Chao-Yang Hospital of Capital Medical University between February 2018 and January 2021 were retrospectively collected, and their perioperative data were obtained by querying the electronic medical record system. The patients were divided into two groups—a hypotension group and a normal group—based on the occurrence of intraoperative hypotension, which was defined as a mean arterial pressure <65 mmHg and lasting ≥1 minute during the operation. The variables with a P value ≤0.1 in univariate regression analysis and clinically considered relevant variables were included in multivariate regression analysis in order to screen the risk factors for hypotension in these patients.

Results

A total of 114 patients were included in the analysis. The incidence of hypotension was 54.4%. Old age was identified as the only risk factor for hypotension during hiatal hernia surgery.

Conclusion

Old age is the only risk factor for intraoperative hypotension in patients undergoing laparoscopic hiatal hernia repair.

Validation of E-PRE-DELIRIC in cardiac surgical ICU delirium: A retrospective cohort study

BACKGROUND

The early prediction model for delirium in intensive care units (ICUs)-E-PRE-DELIRIC-has been created to predict delirium development during the length of stay in ICUs. However, there have been few early predictive models for delirium in the cardiac surgical ICU (CSICU), and the predictive ability of the E-PRE-DELIRIC among patients following cardiac surgeries is still unknown.

AIMS AND OBJECTIVES

To validate the performance of E-PRE-DELIRIC in CSICU.

DESIGN

A retrospective cohort study.

METHODS

Data were retrospectively extracted from the electronic records for patients admitted in CSICU from January 2018 to December 2018 in a tertiary teaching hospital in China. Adult patients were included following the criteria of the E-PRE-DELIRIC model. Predictors, including age, history of cognitive impairment, history of alcohol abuse, urgent admission, use of corticosteroids, respiratory failure, blood urea nitrogen, and mean arterial pressure, at the time of ICU admission were retrieved, and delirium was assessed twice a day using the Confusion Assessment Method for the ICU. The performance of the E-PRE-DELIRIC model was evaluated by area under receiver operator characteristic curve, precision-recall curve (AUPRC), Hosmer-Lemeshow (HL) test, and calibration belt.

RESULTS

Of the 725 patients included, 120 (16.6%) developed delirium. The AUROC was 0.54 (95% confidence interval [CI], 0.48-0.59), and the AUPRC was 0.18 (95% CI, 0.12-0.20). The HL test showed a significant difference between predicted probability and delirium occurrence (χ² = 17.326, P = .027), and the overestimation chance of the E-PRE-DELIRIC score was 0.24 to 0.43.

CONCLUSION

The E-PRE-DELIRIC model has poor-to-fair predictive value in this study; thus, its application among the CSICU patients is limited. Development of reliable and validated tools for early prediction of delirium in CSICU is required.

RELEVANCE TO CLINICAL PRACTICE

Early prediction of delirium risk at CSICU admission is of vital importance and could provide timely information to caregivers. However, the E-PRE-DELIRIC model should be applied cautiously in the CSICU because of the significant probability of over-estimating the risk of developing delirium.