Risk and Consequences of Postoperative Delirium in Cardiac SurgeryFunding None.
26 October 2019
16 January 2020
29 March 2020 (online)
Background Delirium is a common complication after cardiac surgery that leads to increased costs and worse outcomes. This retrospective study evaluated the potential risk factors and postoperative impact of delirium on cardiac surgery patients.
Methods One thousand two hundred six patients who underwent open-heart surgery within a single year were included. Uni- and multivariate analyses of a variety of pre, intra-, and postoperative parameters were performed according to differences between the delirium (D) and nondelirium (ND) groups.
Results The incidence of delirium was 11.6% (n = 140). The onset of delirium occurred at 3.35 ± 4.05 postoperative days with a duration of 5.97 ± 5.36 days. There were two important risk factors for postoperative delirium: higher age (D vs. ND, 73.1 ± 9.04 years vs. 69.0 ± 11.1 years, p < 0.001) and longer aortic cross-clamp time (D vs. ND, 69.8 ± 49.9 minutes vs. 61.6 ± 53.8 minutes, p < 0.05). We found that delirious patients developed significantly more frequent postoperative complications, such as myocardial infarction (MI) (D vs. ND, 1.43% [n = 3] vs. 0.28% [n = 2], p = 0.05), cerebrovascular accident (D vs. ND, 10.7% [n = 15] vs. 3.75% [n = 40], p < 0.001), respiratory complications (D vs. ND, 16.4% [n = 23] vs. 5.72% [n = 61], p < 0.001), and infections (D vs. ND, 36.4% [n = 51] vs. 16.0% [n = 170], p < 0.001). The hospital stay was longer in cases of postoperative delirium (D vs. ND, 23.2 ± 13.6 days vs. 17.4 ± 12.8 days, p < 0.001), and fewer patients were discharged home (D vs. ND, 56.0% [n = 65] vs. 66.8% [n = 571], p < 0.001).
Conclusions Because the propensity for delirium-related complications is high after cardiac surgery, a practical, preventative strategy should be developed for patients with perioperative risk factors, including higher age and a longer cross-clamp time.
Conceptualization, U.B. and H.D.;methodology, U.B. and H.D.; software, Y.S. and M.C.A.; validation, U.B., B.K., H.D. and A.L.; formal analysis, Y.S. and M.C.A.; investigation, M.C.A.; data curation, Y.S. and M.C.A.; writing—original draft preparation, Y.S. and M.C.A.; writing—review and editing, N.F.S, A.M., G.P. and J.P.M; visualization, Y.S.; supervision, U.B., B.K., H.D. and A.L.; project administration, H.D.
- 1 McPherson JA, Wagner CE, Boehm LM. , et al. Delirium in the cardiovascular ICU: exploring modifiable risk factors. Crit Care Med 2013; 41 (02) 405-413
- 2 Ogawa M, Izawa KP, Satomi-Kobayashi S. , et al. Impact of delirium on postoperative frailty and long term cardiovascular events after cardiac surgery. PLoS One 2017; 12 (12) e0190359
- 3 Marcantonio ER. Delirium in hospitalized older adults. N Engl J Med 2017; 377 (15) 1456-1466
- 4 Lei L, Katznelson R, Fedorko L. , et al. Cerebral oximetry and postoperative delirium after cardiac surgery: a randomised, controlled trial. Anaesthesia 2017; 72 (12) 1456-1466
- 5 Djaiani G, Silverton N, Fedorko L. , et al. Dexmedetomidine versus propofol sedation reduces delirium after cardiac surgery: a randomized controlled trial. Anesthesiology 2016; 124 (02) 362-368
- 6 Saczynski JS, Marcantonio ER, Quach L. , et al. Cognitive trajectories after postoperative delirium. N Engl J Med 2012; 367 (01) 30-39
- 7 Steiner LA. Postoperative delirium. Part 1: pathophysiology and risk factors. Eur J Anaesthesiol 2011; 28 (09) 628-636
- 8 van Gool WA, van de Beek D, Eikelenboom P. Systemic infection and delirium: when cytokines and acetylcholine collide. Lancet 2010; 375 (9716): 773-775
- 9 Dilger RN, Johnson RW. Aging, microglial cell priming, and the discordant central inflammatory response to signals from the peripheral immune system. J Leukoc Biol 2008; 84 (04) 932-939
- 10 Terrando N, Monaco C, Ma D, Foxwell BM, Feldmann M, Maze M. Tumor necrosis factor-alpha triggers a cytokine cascade yielding postoperative cognitive decline. Proc Natl Acad Sci U S A 2010; 107 (47) 20518-20522
- 11 Cerejeira J, Firmino H, Vaz-Serra A, Mukaetova-Ladinska EB. The neuroinflammatory hypothesis of delirium. Acta Neuropathol 2010; 119 (06) 737-754
- 12 Qin L, Wu X, Block ML. , et al. Systemic LPS causes chronic neuroinflammation and progressive neurodegeneration. Glia 2007; 55 (05) 453-462
- 13 Zhang WY, Wu WL, Gu JJ. , et al. Risk factors for postoperative delirium in patients after coronary artery bypass grafting: a prospective cohort study. J Crit Care 2015; 30 (03) 606-612
- 14 Martin KK, Wigginton JB, Babikian VL, Pochay VE, Crittenden MD, Rudolph JL. Intraoperative cerebral high-intensity transient signals and postoperative cognitive function: a systematic review. Am J Surg 2009; 197 (01) 55-63
- 15 Schoen J, Meyerrose J, Paarmann H, Heringlake M, Hueppe M, Berger KU. Preoperative regional cerebral oxygen saturation is a predictor of postoperative delirium in on-pump cardiac surgery patients: a prospective observational trial. Crit Care 2011; 15 (05) R218
- 16 Kazmierski J, Kowman M, Banach M. , et al; IPDACS Study. Incidence and predictors of delirium after cardiac surgery: results from The IPDACS study. J Psychosom Res 2010; 69 (02) 179-185
- 17 Filomena J, Riba-Llena I, Vinyoles E. , et al; ISSYS Investigators. Short-term blood pressure variability relates to the presence of subclinical brain small vessel disease in primary hypertension. Hypertension 2015; 66 (03) 634-640 , discussion 445
- 18 Rudolph JL, Babikian VL, Birjiniuk V. , et al. Atherosclerosis is associated with delirium after coronary artery bypass graft surgery. J Am Geriatr Soc 2005; 53 (03) 462-466
- 19 Bakker RC, Osse RJ, Tulen JH, Kappetein AP, Bogers AJ. Preoperative and operative predictors of delirium after cardiac surgery in elderly patients. Eur J Cardiothorac Surg 2012; 41 (03) 544-549
- 20 Lahariya S, Grover S, Bagga S, Sharma A. Delirium in patients admitted to a cardiac intensive care unit with cardiac emergencies in a developing country: incidence, prevalence, risk factor and outcome. Gen Hosp Psychiatry 2014; 36 (02) 156-164
- 21 Afonso A, Scurlock C, Reich D. , et al. Predictive model for postoperative delirium in cardiac surgical patients. Semin Cardiothorac Vasc Anesth 2010; 14 (03) 212-217
- 22 Tully PJ, Baker RA, Winefield HR, Turnbull DA. Depression, anxiety disorders and type D personality as risk factors for delirium after cardiac surgery. Aust N Z J Psychiatry 2010; 44 (11) 1005-1011
- 23 Andrejaitiene J, Sirvinskas E. Early post-cardiac surgery delirium risk factors. Perfusion 2012; 27 (02) 105-112
- 24 Loponen P, Luther M, Wistbacka JO. , et al. Postoperative delirium and health related quality of life after coronary artery bypass grafting. Scand Cardiovasc J 2008; 42 (05) 337-344
- 25 Bucerius J, Gummert JF, Borger MA. , et al. Predictors of delirium after cardiac surgery delirium: effect of beating-heart (off-pump) surgery. J Thorac Cardiovasc Surg 2004; 127 (01) 57-64
- 26 Jodati A, Safaie N, Raoofi M. , et al. Prevalence and risk factors of postoperative delirium in patients undergoing open heart surgery in northwest of Iran. J Cardiovasc Thorac Res 2013; 5 (03) 97-99
- 27 Siepe M, Pfeiffer T, Gieringer A. , et al. Increased systemic perfusion pressure during cardiopulmonary bypass is associated with less early postoperative cognitive dysfunction and delirium. Eur J Cardiothorac Surg 2011; 40 (01) 200-207
- 28 Sanders RD, Pandharipande PP, Davidson AJ, Ma D, Maze M. Anticipating and managing postoperative delirium and cognitive decline in adults. BMJ 2011; 343: d4331
- 29 Martin BJ, Buth KJ, Arora RC, Baskett RJ. Delirium: a cause for concern beyond the immediate postoperative period. Ann Thorac Surg 2012; 93 (04) 1114-1120