Postoperative delirium in patients undergoing tumor resection with reconstructive surgery for oral cancer

Identification of risk factors for postoperative delirium in patients following intraoral reconstruction with microvascular free flaps: a matched-pair analysis

Postoperative delirium (POD) following microvascular head and neck reconstruction negatively impacts patient outcomes, and only a few risk factors have been identified. The aim of this study was to identify additional risk factors for POD after intraoral reconstruction with microvascular free flaps. Data from 377 patients who underwent intraoral microvascular free flap reconstruction between 2011 and 2019 were analysed retrospectively. Preoperative, intraoperative, and postoperative variables were compared between 40 patients with POD and 40 patients without POD who were matched for previously identified risk factors (i.e., sex, age, American Society of Anesthesiologists class, preoperative arterial hypertension, tracheotomy, operation time, and blood transfusion). A multivariable regression analysis was then performed to identify risk factors associated with POD. POD occurred in 50 (13.3%) of the 377 cases studied; the median time of onset was postoperative day 2. Excessive preoperative alcohol consumption (odds ratio 9.22, 95% confidence interval 1.09-77.97; P = 0.041) and postoperative transplant revision (odds ratio 25.72, 95% confidence interval 1.26-525.43; P = 0.035) were identified as risk factors for POD. The identification of patients at high risk of POD based on these two risk factors may allow early adjustment of diagnostic and therapeutic modalities to improve outcomes and reduce healthcare costs.

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.

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.

Postoperative Delirium in Patients with Oral Cancer: Is Intraoperative Fluid Administration a Neglected Risk Factor?

Simple Summary

Squamous cell carcinoma is the most typical malignant tumor of the oral cavity (OSCC) and surgery, including tumor resection and neck dissection with an appropriate reconstruction, remains the first line of treatment. Postoperative complications delay the healing process, and can have negative consequences for the patient. This study aimed to evaluate the impact of intraoperative fluid administration on developing postoperative delirium, and to identify other parameters leading to an increased risk of delirium.

Abstract

Squamous cell carcinoma (SCC) is a malignant tumor derived from squamous cells and can be found in different localizations. In the oral cavity especially, it represents the most common type of malignant tumor. First-line therapy for oral squamous cell carcinoma (OSCC) is surgery, including tumor resection, neck dissection, and maybe reconstruction. Although perioperative mortality is low, complications such as delirium are very common, and may have long-lasting consequences on the patient’s quality of life. This study examines if excessive fluid administration, among other parameters, is an aggravating factor for the development of postoperative delirium. A total of 198 patients were divided into groups concerning the reconstruction technique used: group A for primary wound closure or reconstruction with a local flap, and group B for microsurgical reconstruction. The patients with and without delirium in both groups were compared regarding intraoperative fluid administration, fluid balance, and other parameters, such as blood loss, duration of surgery and overall ventilation, alcohol consumption, and creatinine, albumin, natrium, and hematocrit levels. The logistic regression for group A shows that fluid intake (p = 0.02, OR = 5.27, 95% CI 1.27–21.8) and albumin levels (p = 0.036, OR = 0.22, CI 0.054–0.908) are independent predictors for the development of delirium. For group B, gender (p = 0.026, OR = 0.34, CI 0.133–0.879) with a protective effect for females, fluid intake (p = 0.003, OR = 3.975, CI 1.606–9.839), and duration of ventilation (p = 0.025, OR = 1.178, CI 1.021–1.359) are also independent predictors for delirium. An intake of more than 3000 mL for group A, and 4150 mL for group B, increases the risk of delirium by approximately five and four times, respectively. Fluid management should be considered carefully in patients with OSCC, in order to reduce the occurrence of postoperative delirium. Different factors may become significant for the development of delirium regarding different surgical procedures.

Early Ambulation to Prevent Delirium After Long-Time Head and Neck Cancer Surgery

Objective

Postoperative delirium is known to have various adverse effects on head and neck surgery patients. This study was designed to identify possible risk factors of delirium following long periods of head and neck cancer surgery and to help prevent postoperative delirium.

Methods

We enrolled 197 patients who underwent long-time (>6 h) head and neck surgery at the Asan Medical Center from January 2017 to December 2018 in this study. Clinical covariates that may be associated with delirium were analyzed retrospectively using univariate and multivariate analyses.

Results

Delirium occurred in 18 patients (9.1%). Within the first 7 days, 16 patients (88.9%) experienced delirium. Upon univariate analysis, delirium was associated with old age (≥75, p = 0.001), past neurological history (p = 0.019), time to ambulation (p = 0.014), and postoperative hospital day (p = 0.048). In multivariate analysis, old age (≥75, odds ratios (OR) 6.16, CI 2.00–19.00, p = 0.002), time to ambulation (OR 1.04, CI 1.01–1.07, p = 0.017), and past neurological history (OR 5.26, CI 1.09–25.37, p = 0.039) were significant risk factors associated with postoperative delirium.

Conclusions

Older patients or patients with neurologic history must be attended with care, especially early after surgery. Encouraging early ambulation might lower the incidence of postoperative delirium and, subsequently, reduce adverse effects. This result could benefit patients by helping them avoid undesirable outcomes.