Perioperative predictors of delirium and incidence factors in adult patients post cardiac surgery

Stavros Theologou, Konstantinos Giakoumidakis, Christos Charitos, Stavros Theologou, Konstantinos Giakoumidakis, Christos Charitos

Abstract

Background: Delirium is a quite common complication in adult patients post-cardiac surgery. The purpose of our study was to identify perioperative characteristics and also focus on incidence factors that could predict delirium in the cardiac surgery intensive care unit (CICU) postoperatively.

Methods: We conducted a prospective study of 179 consecutive patients, who underwent open-heart surgical operation and were admitted to the CICU of a general tertiary hospital in Athens, Greece. The patients were screened for delirium by using the diagnostic tools of Rich-mond Agitation Sedation Scale (RASS score) and the Confusion Assessment Method - ICU (CAM-ICU). The delirium assessment was carried out on the 1st and the 2nd postoperative day, and was conducted twice every nursing shift. A short questionnaire on sociodemographics and clinical patient characteristics was used for data collection purposes.

Results: A total of 179 patients who underwent open-heart surgical operation with cardiopulmonary bypass (CPB) were enrolled in our study. The 2-day incidence of postoperative delirium in ICU was 11.2% (n=20/179). The main independent predictors of delirium on the 2nd postoperative day were neutrophil-to-lymphocyte ratio (p=0.001) and urea levels (p=0.016). Additionally, increased perioperative creatinine (p=0.006) and sodium (p=0.039) levels were significantly associated with delirium occurrence. Furthermore, elevated EuroSCORE (p=0.001), extended length of stay (LOS) in ICU (p<0.001), and extended LOS with endotracheal tube (p=0.001) were also statistically significant indicators.

Conclusion: Patients with extended LOS with endotracheal tube and prolonged stay in ICU in accordance with peaked urea, neutrophil-to-lymphocyte ratio, creatinine, and sodium levels seem to have a significantly greater probability of developing delirium in the ICU. Further research is needed in the field of postoperative cardiac patients in order to determine the causality and etiology of certain risk factors for delirium.

Keywords: delirium biomarkers; early recognition of delirium; intubation length of stay.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

References

    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 5th ed. Washington, DC: American Psychiatric Publishing; 2013.
    1. Norkiene I, Ringaitiene D, Misiuriene I, et al. Incidence and precipitating factors of delirium after coronary artery bypass grafting. Scand Cardiovasc J. 2007;41(3):180–185.
    1. Meagher D. Motor subtypes of delirium: past, present and future. Int Rev Psychiatry. 2009;21(1):59–73.
    1. Stransky M, Schmidt C, Ganslmeier P, et al. Hypoactive delirium after cardiac surgery as an independent risk factor for prolonged mechanical ventilation. J Cardiothorac Vasc Anesth. 2011;25(6):968–974.
    1. Arend E, Christensen M. Delirium in the intensive care unit: a review. Nurs Crit Care. 2009;14(3):145–154.
    1. Adamis D, Dimitriou C, Anifantaki S, et al. Validation of the Greek version of confusion assessment method for the intensive care unit (CAM-ICU) Intensive Crit Care Nurs. 2012;28(6):337–343.
    1. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation – Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338–1344.
    1. American Psychiatric Association . Practice guideline for the treatment of patients with delirium. 1999.
    1. Li HC, Chen YS, Chiu MJ, Fu MC, Huang GH, Chen CC. Delirium, subsyndromal delirium, and cognitive changes in individuals undergoing elective coronary artery bypass graft surgery. J Cardiovasc Nurs. 2015;30(4):340–345.
    1. 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(3):544–549.
    1. Weinrebe W, Johannsdottir E, Karaman M, Füsgen I. What does delirium cost ? An economic evaluation of hyperactive delirium. Z Gerontol Geriatr. 2016;49(1):52–58.
    1. Lee E, Kim J. Cost-benefit analysis of a delirium prevention strategy in the intensive care unit. Nurs Crit Care. 2014 Oct 29; Epub.
    1. Franco K, Litaker D, Locala J, Bronson D. The cost of delirium in the surgical patient. Psychosomatics. 2001;42(1):68–73.
    1. Androsova G, Krause R, Winterer G, Schneider R. Biomarkers of postoperative delirium and cognitive dysfunction. Front Aging Neurosci. 2015;7:112.
    1. Rudolph JL, Ramlawi B, Kuchel GA, et al. Chemokines are associated with delirium after cardiac surgery. J Gerontol A Biol Sci Med Sci. 2008;63(2):184–189.
    1. Zhang Z, Pan L, Deng H, Ni H, Xu X. Prediction of delirium in critically ill patients with elevated C-reactive protein. J Crit Care. 2014;29(1):88–92.
    1. Shadvar K, Baastani F, Mahmoodpoor A, Bilehjani E. Evaluation of the prevalence and risk factors of delirium in cardiac surgery ICU. J Cardiovasc Thorac Res. 2013;5(4):157–161.
    1. Sunbul EA, Sunbul M, Yanartas O, et al. Increased neutrophil/lymphocyte ratio in patients with depression is correlated with the severity of depression and cardiovascular risk factors. Psychiatry Investig. 2016;13(1):121–126.
    1. Giakoumidakis K, Fotos NV, Patelarou A, et al. Perioperative neutrophil to lymphocyte ratio as a predictor of poor cardiac surgery patient outcomes. Pragmat Obs Res. 2017;8:9–14.
    1. Tan TP, Arekapudi A, Metha J, Prasad A, Venkatraghavan L. Neutrophil-lymphocyte ratio as predictor of mortality and morbidity in cardiovascular surgery: a systematic review. ANZ J Surg. 2015;85(6):414–419.
    1. Egberts A, Mattace-Raso FUS. Increased neutrophillymphocyte ratio in delirium: a pilot study. Clin Interv Aging. 2017;12:1115–1121.
    1. Kulaksizoglu B, Kulaksizoglu S. Relationship between neutrophil/lymphocyte ratio with oxidative stress and psychopathology in patients with schizophrenia. Neuropsychiatr Dis Treat. 2016;12:1999–2005.
    1. van den Boogaard M, Kox M, Quinn KL, et al. Biomarkers associated with delirium in critically ill patients and their relation with long-term subjective cognitive dysfunction; indications for different pathways governing delirium in inflamed and noninflamed patients. Crit Care. 2011;15(6):R297.
    1. Rudolph JL, Jones RN, Levkoff SE, et al. Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Circulation. 2009;119(2):229–236.
    1. Tsuruta R, Oda Y. A clinical perspective of sepsis-associated delirium. J Intensive Care. 2016;4:18.
    1. Eden BM, Foreman MD. Problems associated with underrecognition of delirium in critical care: a case study. Heart Lung. 1996;25(5):388–400.
    1. Steiner LA. Postoperative delirium. Part 1: pathophysiology and risk factors. Eur J Anaesthesiol. 2011;28(9):628–636.
    1. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients. JAMA. 2011;286(21):2703–2710.

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