Vol. 24 No. 2 (2020)
ANESTHESIOLOGY & RESUSCITATION

Perioperative risk factors for delirium development after elective cardiovascular surgery

PDF (Русский)
  • V. Pasyuga,
  • D. Demin,
  • I. Nudel,
  • E. Demina,
  • A. Kadykova,
  • D. Tarasov,
  • I. Leiderman
V. Pasyuga
Federal Center for Cardiovascular Surgery, Astrakhan
Bio
D. Demin
Federal Center for Cardiovascular Surgery, Astrakhan
I. Nudel
Federal Center for Cardiovascular Surgery, Astrakhan
E. Demina
Federal Center for Cardiovascular Surgery, Astrakhan
A. Kadykova
Federal Center for Cardiovascular Surgery, Astrakhan
D. Tarasov
Federal Center for Cardiovascular Surgery, Astrakhan
I. Leiderman
Almazov National Medical Research Centre, Saint Petersburg
DOI: https://doi.org/10.21688/1681-3472-2020-2-83-94

Published 2020-07-03

Keywords

  • cardiac surgery,
  • critical illness,
  • delirium

How to Cite

Pasyuga, V., Demin, D., Nudel, I., Demina, E., Kadykova, A., Tarasov, D., & Leiderman, I. (2020). Perioperative risk factors for delirium development after elective cardiovascular surgery. Patologiya Krovoobrashcheniya I Kardiokhirurgiya, 24(2), 83–94. https://doi.org/10.21688/1681-3472-2020-2-83-94

Copyright (c) 2020 Pasyuga V.V., Demin D.A., Nudel I.L., Demina E.V., Kadykova A.V., Tarasov D.G., Leiderman I.N.

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Abstract

Aim. This study was conducted to determine the incidence of delirium after cardiac surgery and its effect on the length of the patient’s stay in the ICU and to identify the perioperative risk factors.
Methods. This research was a retrospective assessment of 1941 medical records and the course of the perioperative period in patients subjected to elective cardiac surgery.
Results. Delirium developed in 193 cases (9.94%); whereas, hyperactive, hypoactive and mixed delirium was observed in 13%, 43% and 44% of the patients, respectively. Most often (26% of the cases), delirium occurred after complex combined surgeries. Independent risk factors for the development of delirium were older age (OR 1.041, 95% CI [1.002–1.081], p = 0.038), EuroSCORE II score (OR 1.286, 95% CI [1.093–1.731], p = 0.025), acute kidney injury (OR 1.306, 95% CI [1.107–1.942], p = 0.0018) and renal replacement therapy (OR 1.399 95% CI [1.361–2.792], p = 0.001). Cardiopulmonary bypass duration and time of clamping of the aorta, postoperative serum creatinine level, need for blood transfusions and duration of mechanical ventilation and duration of ICU stay were identified as predictors and were also significantly higher in the delirium group. Delirium was closely associated with critical illness polyneuropathy (OR 9.201, 95% CI [2.13–38.826], p < 0.001) and neurogenic dysphagia (OR 7.48, 95% CI [1.12–56.07], p = 0.022).
Conclusion. The key factors for delirium development in the postoperative period include advanced age, high EuroSCORE II scale and acute kidney injury requiring continuous renal replacement therapy. Delirium significantly increases the duration of mechanical ventilation and the duration of ICU stay.

Received 30 January 2020. Revised 18 March 2020. Accepted 24 March 2020.

Funding: The study did not have sponsorship.

Conflict of interest: Authors declare no conflict of interest.

Author contributions
Conception and design: V.V. Pasyuga, I.N. Leiderman
Data collection: D.A. Demin, E.V. Demina, I.L. Nudel, V.V. Pasyuga
Data analysis: V.V. Pasyuga, I.N. Leiderman, D.A. Demin, D.G. Tarasov
Drafting the article: V.V. Pasyuga, D.A. Demin
Critical revision of the article: I.N. Leiderman, A.V. Kadykova
Final approval of the version to be published: V.V. Pasyuga, D.A. Demin, I.L. Nudel, E.V. Demina, A.V. Kadykova, D.G. Tarasov, I.N. Leiderman

PDF (Русский)

References

  1. МКБ 10 - Международная классификация болезней 10-го пересмотра. Классы МКБ-10/F00-F99/F00-F09/F05. Режим доступа: https://mkb-10.com/index.php?pid=4024 [ICD 10 - International Statistical Classification of Diseases and Related Health Problems 10th Revision Codes: F00-F99/F00-F09/F05 (In Russ.) Available from: https://mkb-10.com/index.php?pid=4024]
  2. Association A.P. Diagnostic and statistical manual of mental disorders. 5th ed. American Psychiatric Publishing; 2013.
  3. Rudolph J.L., Inouye S.K., Jones R.N., Yang F.M., Fong T.G., Levkoff S.E., Marcantonio E.R. Delirium: An independent predictor of functional decline after cardiac surgery. J Am Geriatr Soc. 2010;58(4):643-649. PMID: 20345866, PMCID: PMC2856754. https://doi.org/10.1111/j.1532-5415.2010.02762.x
  4. Schoen J., Meyerrose J., Paarmann H., Heringlake M., Hueppe M., Berger K.-U. 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(5):R218. PMID: 21929765, PMCID: PMC3334763. https://doi.org/10.1186/cc10454
  5. Plaschke K., Fichtenkamm P., Schramm C., Hauth S., Martin E., Verch M., Karck M., Kopitz J. Early postoperative delirium after open-heart cardiac surgery is associated with decreased bispectral EEG and increased cortisol and interleukin-6. Intensive Care Med. 2010;36(12):2081-2089. PMID: 20689917. https://doi.org/10.1007/s00134-010-2004-4
  6. Liptzin B., Levkoff S.E. An empirical study of delirium subtypes. Br J Psychiatry. 1992;161(6):843-845. PMID: 1483173. https://doi.org/10.1192/bjp.161.6.843
  7. Evans A.S., Weiner M.M., Arora R.C., Chung I., Deshpande R., Varghese R., Augoustides J., Ramakrishna H. Current approach to diagnosis and treatment of delirium after cardiac surgery. Ann Card Anaesth. 2016;19(2):328-337. PMID: 27052077, PMCID: PMC4900348. https://doi.org/10.4103/0971-9784.179634
  8. Brown Ch.H. Delirium in the Cardiac Surgical ICU. Current Opinion in Anaesthesiology. 2014;27(2):117-122. https://doi.org/10.1097/ACO.0000000000000061
  9. McPherson J.A., Wagner C.E., Boehm L.M., Hall J.D., Johnson D.C., Miller L.R., Burns K.M., Thompson J.L., Shintani A.K., Ely E.W., Pandharipande P.P. Delirium in the cardiovascular ICU. Crit Care Med. 2013;41(2):405-413. PMID: 23263581, PMCID: PMC3557701. https://doi.org/10.1097/CCM.0b013e31826ab49b
  10. Cole M., McCusker J., Dendukuri N., Han L. The prognostic significance of subsyndromal delirium in elderly medical inpatients. J Am Geriatr Soc. 2003;51(6):754-760. PMID: 12757560. https://doi.org/10.1046/j.1365-2389.2003.51255.x
  11. Martin B.-J., Buth K.J., Arora R.C., Baskett R.J.F. Delirium: a cause for concern beyond the immediate postoperative period. Ann Thorac Surg. 2012;93(4):1114-1120. PMID: 22200370. https://doi.org/10.1016/j.athoracsur.2011.09.011
  12. Saczynski J.S., Marcantonio E.R., Quach L., Fong T.G., Gross A., Inouye S.K., Jones R.N. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367(1):30-39. PMID: 22762316, PMCID: PMC3433229. https://doi.org/10.1056/NEJMoa1112923
  13. Gottesman R.F., Grega M.A., Bailey M.M., Pham L.D., Zeger S.L., Baumgartner W.A., Selnes O.A., McKhann G.M. Delirium after coronary artery bypass graft surgery and late mortality. Ann Neurol. 2010;67(3):338-344. PMID: 20373345, PMCID: PMC3723404. https://doi.org/10.1002/ana.21899
  14. Лихванцев В.В. Неспецифический делирий в отделении интенсивной терапии и реанимации. Анестезиология и реаниматология. 2015;60(2):55-59. [Likhvantsev V.V. Nonspecific delirium in the intensive care unit. Anesteziologiya i reanimatologiya = Anesthesiology and resuscitation. 2015;60(2):55-59. (In Russ.)]
  15. Гельфанд Б.Р., Линев Д.В., Ярошецкий А.И., Проценко Д.Н., Краснов В.Г., Краснов В.Н. Делирий у больных в критических состояниях: критерии оценки тяжести, прогноз, лечение. Анналы хирургии. 2016;21(1-2):60-73. [Gel'fand B.R., Linev D.V., Yaroshetskiy A.I., Protsenko D.N., Krasnov V.G., Krasnov V.N. Delirium in patients in critical conditions: criteria for assessing the severity, prognosis, treatment. Annaly khirurgii = Annals of Surgery. 2016;21(1-2):60-73. (In Russ.)] https://doi.org/10.18821/1560-9502-2016-21-1-60-73
  16. Ely E.W., Margolin R., Francis J., May L., Truman B., Dittus R., Speroff T., Gautam S., Bernard G.R., Inouye S.K. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2001;29(7):1370-1379. PMID: 11445689. https://doi.org/10.1097/00003246-200107000-00012
  17. Лихванцев В.В., Улиткина О.Н., Резепов Н.А. Послеоперационный делирий: что нового предлагает нам новое руководство ESA-2017? Вестник анестезиологии и реаниматологии. 2017;14(2):41-47. [Likhvantsev V.V., Ulitkina O.N., Rezepov N.A. Postoperative Delirium: what New Does Novel Guidelines by ESA-2017 offer? Vestnik anesteziologii i reanimatologii = Messenger of Anesthesiology and Resuscitation. 2017;14(2):41-47. (In Russ.)] https://doi.org/10.21292/2078-5658-2017-14-2-41-47
  18. van Eijk M.M.J., van Marum R.J., Klijn I.A.M., de Wit N., Kesecioglu J., Slooter A.J.C. Comparison of delirium assessment tools in a mixed intensive care unit. Crit Care Med. 2009;37(6):1881-1885. PMID: 19384206. https://doi.org/10.1097/CCM.0b013e3181a00118
  19. Inouye S.K., van Dyck Ch.C., Alessi C.A., Balkin S., Siegal A.P., Horwitz R.I. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948. PMID: 2240918. https://doi.org/10.7326/0003-4819-113-12-941
  20. Rudolph J.L., Jones R.N., Levkoff S.E., Rockett C., Inouye S.K., Sellke F.W., Khuri S.F., Lipsitz L.A., Ramlawi B., Levitsky S., Marcantonio E.R. Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Circulation. 2009;119(2):229-236. PMID: 19118253, PMCID: PMC2735244. https://doi.org/10.1161/CIRCULATIONAHA.108.795260
  21. Rudolph J.L., Marcantonio E.R. Postoperative delirium: acute change with long-term implications. Anesth Analg. 2011;112(5):1202-1211. PMID: 21474660, PMCID: PMC3090222. https://doi.org/10.1213/ANE.0b013e3182147f6d
  22. Inouye S.K., Westendorp R.G.J., Saczynski J.S. Delirium in elderly people. Lancet. 2014;383(9920):911-922. PMID: 23992774, PMCID: PMC4120864. https://doi.org/10.1016/S0140-6736(13)60688-1
  23. Hshieh T.T., Fong T.G., Marcantonio E.R., Inouye S.K. Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. J Gerontol A Biol Sci Med Sci. 2008;63(7):764-772. PMID: 18693233, PMCID: PMC2917793. https://doi.org/10.1093/gerona/63.7.764
  24. Adamis D., van Munster B.C., Macdonald A.J.D. The genetics of deliria. Int Rev Psychiatry. 2009;21(1):20-29. PMID: 19219710. https://doi.org/10.1080/09540260802675510
  25. Kazmierski J., Banys A., Latek J., Bourke J., Jaszewski R. Cortisol levels and neuropsychiatric diagnosis as markers of postoperative delirium: a prospective cohort study. Crit Care. 2013;17(2):R38. PMID: 23452669, PMCID: PMC3733427. https://doi.org/10.1186/cc12548
  26. Perry V.H., Cunningham C., Holmes C. Systemic infections and inflammation affect chronic neurodegeneration. Nat Rev Immunol. 2007;7(2):161-167. PMID: 17220915. https://doi.org/10.1038/nri2015
  27. Cunningham C. Systemic inflammation and delirium: important co-factors in the progression of dementia. Biochem Soc Trans. 2011;39(4):945-953. PMID: 21787328, PMCID: PMC4157218. https://doi.org/10.1042/BST0390945
  28. Gosselt A.Nc., Slooter A.Jc., Boere P.Rq., Zaal I.J. Risk factors for delirium after on-pump cardiac surgery: a systematic review. Crit Care. 2015;23(19):346. PMID: 26395253, PMCID: PMC4579578. https://doi.org/10.1186/s13054-015-1060-0
  29. Brown C.H. Delirium in the cardiac surgical intensive care unit. Current opinion in anaesthesiology. 2014;27:117-122.
  30. Гороховатский Ю.И., Замятин М.Н., Седракян А.Р., Вахляев А.В., Борщев Г.Г. Профилактика делирия в кардиохирургии. Вестник Национального медико-хирургического центра им. Н.И. Пирогова. 2016;11(2):9-14. [Gorokhovatsky Yu.I., Zamyatin M.N., Sedrakyan A.R., Vachlyaev A.V., Borshchev G.G. Prevention in of Delirium in Cardiac Surgery. Vestnik Natsional'nogo mediko-khirurgicheskogo tsentra im. N.I. Pirogova = Bulletin of Pirogov National Medical and Surgical Center. 2016;11(2):9-14. (In Russ.)]
  31. Шевченко Ю.Л., Гороховатский Ю.И., Замятин М.Н., Седракян А.Р., Вахляев А.В., Борщев Г.Г. Фармакологическая профилактика делирия в кардиохирургии. Вестник хирургии им. И.И. Грекова. 2018;177(6):54-58. [Shevchenko Yu.L., Gorokhovatskii Yu.I., Zamiatin M.N., Sedrakian A.R., Vakhliaev A.V., Borshchev G.G. Pharmacological prophylaxis of delirium in cardiosurgery. Vestnik khirurgii im. I.I. Grekova = Grekov's Bulletin of Surgery. 2018;177(6):54-58. (In Russ.)]
  32. Базылев В.В., Евдокимов М.Е., Горностаев А.А., Фомина И.С.,Щегольков А.А., Булыгин А.В., Малярова Е.А. Влияет ли никотинзаместительная терапия на частоту развития делирия у пациентов после изолированной реваскуляризации миокарда? Патология кровообращения и кардиохирургия. 2018;22(1):29-35. [Bazylev V.V., Evdokimov M.E., Gornostaev A.A., Fomina I.S., Schegolkov A.A., Bulygin A.V., Malyarova E.A. Could nicotine replacement therapy affect the frequency of delirium in patients after isolated myocardial revascularization? Patologiya krovoobrashcheniya i kardiokhirurgiya = Circulation Pathology and Cardiac Surgery. 2018;22(1):29-35. (In Russ.)] https://doi.org/10.21688/1681-3472-2018-1-29-35
  33. Еременко А.А., Чернова Е.В. Лечение делирия в раннем послеоперационном периоде у кардиохирургических пациентов. Анестезиология и реаниматология. 2014;3:30-34. [Eremenko A.A., Chernova E.V. Treatment of delirium in cardio-surgical patients in early postoperative period. Anesteziologiya i reanimatologiya = Anesthesiology and resuscitation. 2014;3:30-34. (In Russ.)]
  34. Ng K.T., Shubash C.J., Chong J.S. The effect of dexmedetomidine on delirium and agitation in patients in intensive care: systematic review and meta-analysis with trial sequential analysis. Anaesthesia. 2019;74(3):380-392. PMID: 30367689. https://doi.org/10.1111/anae.14472
  35. Carrasco G., Baeza N., Cabre L., Portillo E., Gimeno G., Manzanedo D., Calizaya M. Dexmedetomidine for the treatment of hyperactive delirium refractory to haloperidol in nonintubated ICU patients: A nonrandomized controlled trial. Crit Care Med. 2016;44(7):1295-1306. PMID: 26925523. https://doi.org/10.1097/CCM.0000000000001622
  36. Flukiger J., Hollinger A., Speich B., Meier V., Tontsch J., Zehnder T., Siegemund M. Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis. Ann Intensive Care. 2018;8(1):92. PMID: 30238227, PMCID: PMC6148680. https://doi.org/10.1186/s13613-018-0437-z
  37. Shehabi Y., Grant P., Wolfenden H., Hammond N., Bass F., Campbell M., Chen J. Prevalence of delirium with dexmedetomidine compared with morphine based therapy after cardiac surgery: a randomized controlled trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study). Anesthesiology. 2009;111(5):1075-1084. PMID: 19786862. https://doi.org/10.1097/ALN.0b013e3181b6a783
  38. Pasin L., Landoni G., Nardelli P., Belletti A., Di Prima A.L., Taddeo D., Isella F., Zangrillo A. Dexmedetomidine reduces the risk of delirium, agitation and confusion in critically ill patients: A meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth. 2014;28(6):1459-1466. PMID: 25034724. https://doi.org/10.1053/j.jvca.2014.03.010
  39. Devlin J., Skrobik Y., Gélinas C., Needham D.M., Slooter A.J.C., Pandharipande P.P., Watson P.L., Weinhouse G.L., Nunnally M.E., Rochwerg B., Balas M.C., van den Boogaard M., Bosma K.J., Brummel N.E., Chanques G., Denehy L., Drouot X., Fraser G.L., Harris J.E., Joffe A.M., Kho M.E., Kress J.P., Lanphere J.A., McKinley S., Neufeld K.J., Pisani M.A., Payen J.-F., Pun B.T., Puntillo K.A., Riker R.R., Robinson B.R.H., Shehabi Y., Szumita P.M., Winkelman C., Centofanti J.E., Price C., Nikayin S., Misak C.J., Flood P.D., Kiedrowski K., Alhazzani W. Clinical Practice Guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Medicine. 2018;46(9):e825-e873. PMID: 30113379. https://doi.org/10.1097/CCM.0000000000003299
  40. Шишнева Е.В., Лебедева Е.В. Послеоперационный делирий у кардиохирургических пациентов: частота и предикторы развития. Комплексные проблемы сердечно-сосудистых заболеваний. 2013;3:82-83. [Shishneva E.V., Lebedeva E.V. Postoperative delirium in cardiosurgical patients: frequency and development predictors. Kompleksnyye problemy serdechno-sosudistykh zabolevaniy = Complex problems of cardiovascular disease. 2013;3:82-83. (In Russ.)]
  41. Koster S., Oosterveld F.G.J., Hensens Ab.G., Wijma A., van der Palen J. Delirium After Cardiac Surgery and Predictive Validity of a Risk Checklist. Ann Thorac Surg. 2008;86(6):1883-1887. PMID: 19022003. https://doi.org/10.1016/j.athoracsur.2008.08.020
  42. Järvelä K., Porkkala H., Karlsson S., Martikainen T., Selander T., Bendel S. Postoperative Delirium in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth. 2018;32(4):1597-1602. PMID: 29361457. https://doi.org/10.1053/j.jvca.2017.12.030
  43. Meadows K., Gibbens R., Gerrard C., Vuylsteke A. Prediction of patient length of stay on the intensive care unit following cardiac surgery: A logistic regression analysis based on the cardiac operative mortality risk calculator, EuroSCORE. J Cardiothorac Vasc Anesth. 2018;32(6):2676-2682. PMID: 29678435. https://doi.org/10.1053/j.jvca.2018.03.007
  44. Bucerius J., Gummert J.F., Borger M.A., Walther T., Doll N., Falk V., Schmitt D.V., Mohr F.W. Predictors of delirium after cardiac surgery delirium: effect of beating-heart (off-pump) surgery. J Thorac Cardiovasc Surg. 2004;127(1):57-64. PMID: 14752413. https://doi.org/10.1016/s0022-5223(03)01281-9
  45. Tilley E., Psaltis P.J., Loetscher T., Davis D.H., Harrison S.L., Kim S., Keage H.A.D. Meta-analysis of prevalence and risk factors for delirium after transcatheter aortic valve implantation. Am J Cardiol. 2018;122(11):1917-1923. PMID: 30293651, PMCID: PMC6269593. https://doi.org/10.1016/j.amjcard.2018.08.037
  46. O'Neal J.B., Billings F.T.4th, Liu X., Shotwell M.S., Liang Y., Shah A.S., Ehrenfeld J.M., Wanderer J.P., Shaw A.D. Risk factors for delirium after cardiac surgery: a historical cohort study outlining the influence of cardiopulmonary bypass. Can J Anaesth. 2017;64(11):1129-1137. PMID: 28718100. PMCID: PMC5693689. https://doi.org/10.1007/s12630-017-0938-5
  47. Bokeriia L.A., Golukhova E.Z., Poluninia A.G. Postoperative delirium in cardiac operations: Microembolic load is an important factor. Ann Thorac Surg. 2009;88(1):348-354. PMID: 19559271. https://doi.org/10.1016/j.athoracsur.2009.02.031
  48. Siew E.D., Fissell W.H., Tripp C.M., Blume J.D., Wilson M.D., Clark A.J., Vincz A.J., Ely E.W., Pandharipande P.P., Girard T.D. Acute kidney injury as a risk factor for delirium and coma during critical illness. Am J Respir Crit Care Med. 2017;195(12):1597-1607. PMID: 27854517, PMCID: PMC5476907. https://doi.org/10.1164/rccm.201603-0476OC
  49. Rudiger A., Begdeda H., Babic D., Krüger B., Seifert B., Schubert M., Spahn D.R., Bettex D. Intra-operative events during cardiac surgery are risk factors for the development of delirium in the ICU. Crit Care. 2016;20:264. PMID: 27544077, PMCID: PMC4992555. https://doi.org/10.1186/s13054-016-1445-8