Preoperative Risk Factors and Early Outcomes of Delirium in Valvular Open-Heart Surgery

Abstract

Background Compared with coronary artery bypass grafting surgery, data regarding postoperative delirium are scant in valvular open-heart surgery. Therefore, the goal of this retrospective study was to investigate the incidence, preoperative risk factors, and early outcomes of delirium in a large group of patients undergoing valvular open-heart surgery.

Methods In 13,229 patients with isolated valvular or combined valvular and bypass surgery, the incidence of postoperative delirium was assessed until discharge. Independent risk factors of delirium were evaluated by multivariable logistic regression analysis. Moreover, we assessed the multivariable-adjusted risk of prolonged intensive care unit (ICU) stay (>48 hours) and in-hospital mortality in patients with delirium.

Results Overall, the incidence of postoperative delirium was 8.4%. The incidence in patients experiencing a postoperative stroke or seizure was 23.1 and 29.7%, respectively. Twelve preoperative risk factors, mostly nonmodifiable, were independently associated with the risk of delirium, including advanced age, renal impairment, stroke, the need for emergency surgery, and severe preoperative anemia (hemoglobin < 9 g/dL). Postoperative delirium was associated with an adjusted odds ratio (OR) of prolonged ICU stay of 9.48 (95% confidence interval [CI]: 7.96–11.30). Adjusted in-hospital mortality was, however, significantly lower in patients with delirium versus patients without delirium (OR, 0.56; 95% CI: 0.38–0.83).

Conclusion In valvular open-heart surgery, postoperative delirium is a frequent neurological complication that is associated with other postoperative neurological complications and several, mostly nonmodifiable, preoperative risk factors. Although postoperative delirium was associated with a significantly increased risk of prolonged ICU stay, this did not translate into an increased short-term mortality.

Keywords

delirium - etiology - valvular open-heart surgery - in-hospital mortality - risk factors

Publikationsverlauf

Eingereicht: 09. Juni 2021

Angenommen: 08. Oktober 2021

Artikel online veröffentlicht:
18. Januar 2022

• References

• 1 Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet 2014; 383 (9920): 911-922
• 2 Wilson JE, Mart MF, Cunningham C. et al. Publisher correction: delirium. Nat Rev Dis Primers 2020; 6 (01) 94
• 3 Greaves D, Psaltis PJ, Ross TJ. et al. Cognitive outcomes following coronary artery bypass grafting: a systematic review and meta-analysis of 91,829 patients. Int J Cardiol 2019; 289: 43-49
• 4 Greaves D, Psaltis PJ, Davis DHJ. et al. Risk factors for delirium and cognitive decline following coronary artery bypass grafting surgery: a systematic review and meta-analysis. J Am Heart Assoc 2020; 9 (22) e017275
• 5 Indja B, Woldendorp K, Vallely MP, Grieve SM. Silent brain infarcts following cardiac procedures: a systematic review and meta-analysis. J Am Heart Assoc 2019; 8 (09) e010920
• 6 Goldstone AB, Bronster DJ, Anyanwu AC. et al. Predictors and outcomes of seizures after cardiac surgery: a multivariable analysis of 2,578 patients. Ann Thorac Surg 2011; 91 (02) 514-518
• 7 McDonagh DL, Berger M, Mathew JP, Graffagnino C, Milano CA, Newman MF. Neurological complications of cardiac surgery. Lancet Neurol 2014; 13 (05) 490-502
• 8 Oldham MA, Vachon J, Yuh D, Lee HB. Cognitive outcomes after heart valve surgery: a systematic review and meta-analysis. J Am Geriatr Soc 2018; 66 (12) 2327-2334
• 9 Sauër AC, Veldhuijzen DS, Ottens TH, Slooter AJC, Kalkman CJ, van Dijk D. Association between delirium and cognitive change after cardiac surgery. Br J Anaesth 2017; 119 (02) 308-315
• 10 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
• 11 Krzych LJ, Wybraniec MT, Krupka-Matuszczyk I. et al. Complex assessment of the incidence and risk factors of delirium in a large cohort of cardiac surgery patients: a single-center 6-year experience. BioMed Res Int 2013; 2013: 835850
• 12 Hamiko M, Charitos EI, Velten M. et al. Mannitol is associated with less postoperative delirium after aortic valve surgery in patients treated with Bretschneider cardioplegia. Thorac Cardiovasc Surg 2020; (e-pub ahead of print).
• 13 Maschke M. et al. Delir und Verwirrtheitszustände inklusive Alkoholentzugsdelir. 1-Leitlinie, 2020, in: Deutsche Gesellschaft für Neurologie (Hrsg.), Leitlinien für Diagnostik und Therapie in der Neurologie. Accessed February 11, 2021 at: www.dgn.org/leitlinien
• 14 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Washington, DC: American Psychiatric Association; 1994
• 15 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Arlington, VA: American Psychiatric Association; 2013
• 16 Hargrave A, Bastiaens J, Bourgeois JA. et al. Validation of a nurse-based delirium-screening tool for hospitalized patients. Psychosomatics 2017; 58 (06) 594-603
• 17 Koster A, Börgermann J, Zittermann A, Lueth JU, Gillis-Januszewski T, Schirmer U. Moderate dosage of tranexamic acid during cardiac surgery with cardiopulmonary bypass and convulsive seizures: incidence and clinical outcome. Br J Anaesth 2013; 110 (01) 34-40
• 18 Hayhurst CJ, Pandharipande PP, Hughes CG. Intensive care unit delirium: a review of diagnosis, prevention, and treatment. Anesthesiology 2016; 125 (06) 1229-1241
• 19 Dubiel C, Hiebert BM, Stammers AN. et al. Delirium definition influences prediction of functional survival in patients one-year postcardiac surgery. J Thorac Cardiovasc Surg 2020; (e-pub ahead of print).
• 20 Sugimura Y, Sipahi NF, Mehdiani A. et al. Risk and consequences of postoperative delirium in cardiac surgery. Thorac Cardiovasc Surg 2020; 68 (05) 417-424
• 21 van der Zanden V, Beishuizen SJ, Swart LM, de Rooij SE, van Munster BC. The effect of treatment of anemia with blood transfusion on delirium: a systematic review. J Am Geriatr Soc 2017; 65 (04) 728-737
• 22 Lecker I, Wang DS, Whissell PD, Avramescu S, Mazer CD, Orser BA. Tranexamic acid-associated seizures: causes and treatment. Ann Neurol 2016; 79 (01) 18-26
• 23 Hedberg M, Engström KG. Stroke after cardiac surgery–hemispheric distribution and survival. Scand Cardiovasc J 2013; 47 (03) 136-144
• 24 Bladin CF, Alexandrov AV, Bellavance A. et al. Seizures after stroke: a prospective multicenter study. Arch Neurol 2000; 57 (11) 1617-1622
• 25 Shaw RC, Walker G, Elliott E, Quinn TJ. Occurrence Rate of delirium in acute stroke settings: systematic review and meta-analysis. Stroke 2019; 50 (11) 3028-3036
• 26 Falsini G, Grotti S, Porto I. et al. Long-term prognostic value of delirium in elderly patients with acute cardiac diseases admitted to two cardiac intensive care units: a prospective study (DELIRIUM CORDIS). Eur Heart J Acute Cardiovasc Care 2018; 7 (07) 661-670
• 27 Rizzi MA, Torres Bonafonte OH, Alquezar A. et al. Prognostic value and risk factors of delirium in emergency patients with decompensated heart failure. J Am Med Dir Assoc 2015; 16 (09) 799.e1-799.e6
• 28 Krzych LJ, Wybraniec MT, Krupka-Matuszczyk I. et al. Detailed insight into the impact of postoperative neuropsychiatric complications on mortality in a cohort of cardiac surgery subjects: a 23,000-patient-year analysis. J Cardiothorac Vasc Anesth 2014; 28 (03) 448-457
• 29 Hamilton GM, Wheeler K, Di Michele J, Lalu MM, McIsaac DI. A systematic review and meta-analysis examining the impact of incident postoperative delirium on mortality. Anesthesiology 2017; 127 (01) 78-88
• 30 Radtke FM, Franck M, Schust S. et al. A comparison of three scores to screen for delirium on the surgical ward. World J Surg 2010; 34 (03) 487-494