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6800$5< 2EMHFWLYH 3RVWRSHUDWLYH GHOLULXP 3' DIWHU FDUGLDF VXUJHU\ LV D VHULRXV FRPSOLFDWLRQ DQG FRPPRQO\ RFFXUV LQ FULWLFDOO\ LOO SDWLHQWV DGPLWWHGLQWKHLQWHQVLYHFDUHXQLW ,&8 7KLVVWXG\VRXJKWWRDVVHVVWKHLQFLGHQFHDQGULVNIDFWRUVRISRVWRSHUDWLYHGHOLULXPDIWHUFDUGLDFVXUJHU\ 0HWKRGV 'DWDREWDLQHGIURPSDWLHQWVDIWHUHOHFWLYHFDUGLDFVXUJHU\RQFDUGLRSXOPRQDU\E\SDVV &3% ZHUHSURVSHFWLYHO\DQDO\]HG Delirium was diagnosed postoperatively by the attending physician according to the criteria of the Intensive Care Delirium Screening Checklist ,&'6& 5LFKPRQG$JLWDWLRQ6HGDWLRQ6FDOH 5$66 &RQIXVLRQ$VVHVVPHQW0HWKRGIRUWKH,QWHQVLYH&DUH8QLW &$0,&8 DQG1XUVLQJ 'HOLULXP6FUHHQLQJ6FDOH 18'(6& 5HVXOWV 7KHLQFLGHQFHRI3'ZDV$YHUDJHDJHRIGHOLULRXVSDWLHQWVZDVVLJQL¿FDQWO\KLJKHUWKDQQRQGHOLULRXVSDWLHQWV \HDUVYV\HDUVS $SDVWKLVWRU\RIVWURNHZDVVLJQL¿FDQWO\PRUHIUHTXHQWYVS DQGLQWUDRSHUDWLYHXVH RIVRGLXPWKLRSHQWDOZDVORZHU PJYV PJS LQGHOLULRXVSDWLHQWVWKDQQRQGHOLULRXVSDWLHQWV3'ZDV DVVRFLDWHGZLWKORQJHU,&8VWD\ YV GD\VS DQGZLWKORQJHUVWD\LQWKHKRVSLWDODIWHUWUDQVIHUIURP,&8 YV GD\VS ,QPXOWLYDULDWHUHJUHVVLRQDQDO\VLVLQGHSHQGHQWSUHGLFWRUVIRU3'ZHUHDJH!\HDUV 25 &, S SUHYLRXVVWURNHV 25 &,S OHQJWKRIVWD\LQWKHKRVSLWDOEHIRUHVXUJHU\!GD\V 25 &, S GRVHRILQWUDRSHUDWLYHVRGLXPWKLRSHQWDORI PJ 25 &,S DQGUHLQWXEDWLRQ 25 &, S Conclusions. Our data suggests that PD is a common complication after elective cardiac surgery and is associated with longer hospital and ICU stay following cardiac surgery. Older age, previous strokes, longer pre-operative hospital stay, dose of intra-operative sodium thiopental RI PJDQGUHLQWXEDWLRQZHUHDVVRFLDWHGZLWKLQFUHDVHG3'ULVN&HUWDLQLGHQWL¿HGULVNIDFWRUVIRU3'VXFKDVLQWUDRSHUDWLYHWKLRSHQWDO GRVHDQGSUHRSHUDWLYHKRVSLWDOVWD\FDQEHSRWHQWLDOO\PRGL¿HGLQRUGHUWRUHGXFH3'ULVN .H\ZRUGV delirium, postoperative delirium, post-cardiotomy delirium, post-cardiac surgery delirium, cardiac surgery.
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,1752'8&7,21 LQÀXHQFH RQ WKH LQFLGHQFH GXUDWLRQ DQG VHYHULW\ RI 3' Although the pathophysiology of delirium remains largely Postoperative delirium is a common perioperative unknown, it is generally accepted that the etiology involves complication frequently observed in patients undergoing cardiac surgery. Delirium is a neuropsychiatric syndrome PXOWLSOHIDFWRUVRIGLIIHUHQWVLJQL¿FDQFH> @7KHLGHQWL¿FDWLRQ of predisposing factors in cardiac surgery patients enables the FKDUDFWHUL]HG E\ ÀXFWXDWLRQV LQ FRJQLWLRQ DQG DWWHQWLRQ implementation of prevention strategies. The recognition of [1]. Delirium has been described from the early beginnings SUHFLSLWDWLQJIDFWRUVIDFLOLWDWHVWKHSHULRSHUDWLYHPRGL¿FDWLRQ RI FDUGLRSXOPRQDU\ E\SDVV &3% DQG ZDV GHVFULEHG DV of these strategies. SRVWRSHUDWLYH GHOLULXP 3' >@ &3% LV FRPPRQO\ XVHG The aim of our study was to assess the incidence and risk during the heart surgery. The incidence of PD in the patients factors for postoperative delirium after cardiac surgery at our with CPB surgery is higher than the patients without CPB institution according to the criteria of different screening tests. [2]. Delirium occurring after cardiac surgery is associated with many negative consequences, such as prolonged and 0$7(5,$/$1'0(7+2'6 PRUH FRVWO\ KRVSLWDO VWD\ >@ KLJKHU SRVVLELOLW\ RI HDUO\ Patient Selection and Study Design postoperative death, impaired postoperative cognition function, lower overall postoperative quality of life and The prospective study was performed in the Department greater social dependency [4]. of Cardiac, Thoracic and Vascular Surgery of the Hospital of The reported incidence of PD after cardiac surgery varies the Lithuanian University of Health Sciences Kaunas Clinics IURPWR>@EXWLQROGHUSDWLHQWVXQGHUJRLQJFDUGLDF /8+6.& /LWKXDQLDEHWZHHQ1RYHPEHUDQG0DUFK VXUJHU\LWPD\EHDVKLJKDVGHSHQGLQJRQVFUHHQLQJ 6WXG\SURWRFROZDVDSSURYHGE\/8+6.&LQVWLWXWLRQDO DQGGLDJQRVWLFPHWKRGVXVHG> @7KHFDXVHRISRVWRSHUDWLYH bioethics committee. GHOLULXPLVQRWIXOO\FOHDUDQGLVSUREDEO\PXOWLIDFWRULDO> @ 'XULQJWKLVSHULRGSDWLHQWVFRQVHFXWLYHO\DGPLWWHGWR WKDWKLGHVYDULRXVW\SHVRISUHH[LVWLQJ SUHGLVSRVLQJ LQÀLFWHG the ICU after elective cardiac surgery on CPB were included brain injuries and side-effects of the medical management LQWKHVWXG\$SDUWIURPDJH !\HDUV DQGDPLQLPXPOHQJWK SUHFLSLWDWLQJ >@ 0DQ\ VWXGLHV KDYH EHHQ FRQGXFWHG WR RI ,&8 VWD\ K WKHUH ZHUH QR RWKHU LQFOXVLRQ FULWHULD identify possible risk factors for PD. However, study results Patients with established PD risk factors, such as cognitive YDU\DQGVRPHWLPHVDUHFRQWUDGLFWRU\> @7KHUHDUHPDQ\ impairment, dementia and depression, diagnosed prior to the LGHQWL¿HG3'ULVNIDFWRUVVXFKDVROGHUDJHGHPHQWLDKHDULQJ surgery and patients who have developed cerebrovascular or vision disorders, reduced left ventricle ejection fraction GLVRUGHUV VWURNHV RU WUDQVLHQW LVFKHPLF DWWDFNV GXULQJ WKH /9() HOHFWURO\WHGLVRUGHUVDUWHULDOK\SHUWHQVLRQ FKURQLF postoperative period have been excluded from the study. REVWUXFWLYHSXOPRQDU\GLVHDVH &23' SQHXPRQLDH[LVWLQJ )LQDOO\ SDWLHQWV ZHUH VWXGLHG 3DWLHQWV ZHUH DVVHVVHG cerebrovascular pathology, longer duration of surgery, CPB, and monitored preoperatively, during surgery and in the early blood transfusions, postoperative hypertension, postoperative postoperative period. Preoperative evaluation, premedication, DWULDO¿EULOODWLRQRUWDFK\FDUGLD> @ the anaesthetic regimen, cardiac surgery procedures and PD is a frequently occurring but often under-diagnosed postoperative management were performed according to the and under-treated problem in the ICU patient populations institutional protocols. Medical, social and functional status > @7KLVFRPSOLFDWLRQLVRIWHQDFFRPSDQLHGE\DGGLWLRQDO data were collected by interviewing the patient on admission. symptoms, especially when no verbal contact with the patients Additional data were retrieved from medical records and from is possible, e.g. in cases of hypoactive delirium, mechanical the local clinical database. OXQJYHQWLODWLRQRULIVHGDWLYHPHGLFDWLRQLVXVHG> @'XH Postoperative Delirium Screening to the variety of its symptoms, PD is frequently missed after Delirium was diagnosed postoperatively by an attending FDUGLDFVXUJHU\RULVGLDJQRVHGWRRODWH>@3'LGHQWL¿FDWLRQ and detection is also complicated by scarce knowledge of SK\VLFLDQ LQWHQVLYHFDUHVSHFLDOLVW DFFRUGLQJWRWKH,QWHQVLYH WKHPHGLFDOVWDIIUHJDUGLQJWKLVSDWKRORJ\> @/LWHUDWXUH &DUH 'HOLULXP 6FUHHQLQJ &KHFNOLVW ,&'6& 5LFKPRQG sources indicate that the fundamental reason of PD is hypo- $JLWDWLRQ6HGDWLRQ 6FDOH 5$66 &RQIXVLRQ $VVHVVPHQW GLDJQRVWLFV RI XQGHUO\LQJ EUDLQ GLVRUGHU ± DV LQDGHTXDWH 0HWKRGIRUWKH,QWHQVLYH&DUH8QLW &$0,&8 DQG1XUVLQJ central nervous system risk monitoring at the ICU while the 'HOLULXP6FUHHQLQJ6FDOH 18'(6& FKHFNOLVWV> @ functions of other organs are thoroughly observed in order to If the level of sedation permitted delirium screening SUHYHQWWKHGHYHORSPHQWRIWKHLUGH¿FLHQFLHV EORRGJDVEORRG 5$66í WKHEHGVLGHQXUVHGRFXPHQWHGWKHVFRUHLQWKH patients’ medical records. For the diagnosis of delirium after SUHVVXUH(&*GLXUHVLVHWF >@7KHUHDUHQRVSHFL¿FDQG worldwide accepted tests or schemes to determine delirium VXUJHU\,&'6&18'(6&DQG&$0,&8FULWHULD> @ were used to assess whether delirium had developed. ICDSC DIWHUFDUGLDFVXUJHU\LQ,&87KHUHIRUHLWLVVWLOOGLI¿FXOWWR diagnose this serious complication. However delirium rating LVEDVHGRQ¿HOGV SRLQWHDFK DQG18'(6&LVEDVHG scales and checklists application increases the percentage of RQ¿HOGV SRLQWVHDFKGHSHQGVRQWKHLQWHQVLW\RIWKH recognition and ensures a better quality of early treatment. V\PSWRP 7KHVHWHVWVHYDOXDWHDOWHUHGOHYHORIFRQVFLRXVQHVV inattention, disorientation, hallucination-delusion-psychosis, ,WLVGLI¿FXOWWRGHWHUPLQHZKHWKHUFHUWDLQFRPRUELGLWLHV inappropriate speech or mood, psychomotor agitation/ KDYH PRUH LQÀXHQFH WRZDUGV 3' GHYHORSPHQW WKDQ RWKHUV There is no doubt that the severity of a patient’s illness UHWDUGDWLRQ VOHHSZDNH F\FOH GLVWXUEDQFH DQG ÀXFWXDWLQJ has an impact on PD development. The complexity of the FRXUVHRIDIRUHPHQWLRQHGLWHPV$Q,&'6&VFRUHRIDQG intervention and perioperative complications also have an 18'(6&VFRUHRILQGLFDWHGHOLULXP> @ PD screening was started 8 hours after the surgery and
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ZDVUHSHDWHGHYHU\KRXUVGXULQJWKHGD\VRIWKHSDWLHQWV¶ GXUDWLRQRI&3%ZDVPLQXWHVPHDQGRVH RI ICU stay. This study was designated to investigate early onset LQWUDRSHUDWLYUH VRGLXP WKLRSHQWDO ZDV PJ of delirium following cardiac surgery, therefore screening 7KHPHDQOHQJWKRIVWD\DWWKH,&8ZDV GD\VDQG SHULRGZDVOLPLWHGWRGD\V PHDQVWD\LQWKHKRVSLWDODIWHU,&8GLVFKDUJHZDV days. Assessment of Postoperative Delirium Risk Factors The univariate analysis showed that delirious patients ,GHQWLI\LQJULVNIDFWRUVIRU3'DW,&8DGPLVVLRQLVWKH¿UVW UHODWLYH WR QRQGHOLULRXV SDWLHQWV ZHUH VLJQL¿FDQWO\ ROGHU step in improving the outcomes of delirium by prevention and PHDQDJH \HDUVYV\HDUVS early detection. These risk factors can be divided into baseline DQG KDG ORZHU /9() YV SUHGLVSRVLQJ DQG KRVSLWDOUHODWHG SUHFLSLWDWLQJ IDFWRUV S 3UHYLRXV VWURNHV ZHUH PRUH IUHTXHQW YV Predisposing factors are related to a patient’s underlying S WKH OHQJWK RI VWD\ LQ WKH KRVSLWDO EHIRUH FKDUDFWHULVWLFVDQGFRPRUELGLWLHVDQGDUHGLI¿FXOWWRPRGLI\ VXUJHU\ ZDV ORQJHU GD\V YV GD\V IRU H[DPSOH DJH VH[ DQG FRPRUELGLWLHV VXFK DV FKURQLF S LQWUDRSHUDWLYHXVHRIVRGLXPWKLRSHQWDOZDVORZHU obstructive pulmonary disease [COPD], diabetes mellitus, PJ YV PJ S LQ UHQDO LQVXI¿FLHQF\ 3UHFLSLWDWLQJ IDFWRUV DUH UHODWHG WR WKH delirious patients than in non-delirious patients. However, the patient’s acute illness, its treatment and ICU management, XVHRIIHQWDQ\O PJYVPJS and act as triggering factors for delirium, some of which can SRVWRSHUDWLYH VHGDWLRQ YV S DQG SRVW EHPRGL¿HGWKURXJKSUHYHQWLYHPHDVXUHV7KHLGHQWL¿FDWLRQ RSHUDWLYHSDLQFRQWUROZLWKRSLRLGV YVS of predisposing factors in cardiac surgery patients enables the ZHUHQRWVLJQL¿FDQWO\GLIIHUHQWLQ3'DQGLQQRQ3'SDWLHQWV implementation of prevention strategies. The recognition of 3'WUHDWPHQWZLWKKDORSHULGROZDVDGHTXDWHS 7KH SUHFLSLWDWLQJIDFWRUVIDFLOLWDWHVWKHSHULRSHUDWLYHPRGL¿FDWLRQ DQDO\VLV VKRZHG WKDW 3' VLJQL¿FDQWO\ SURORQJHG WKH OHQJWK RIWKHVHVWUDWHJLHV> @ RIWKH,&8VWD\ GD\VYV GD\VS Statistical Analysis DQGWKHOHQJWKRIVWD\LQWKHKRVSLWDODIWHU,&8 GD\VYV GD\VS 3DWLHQWVDIWHU3'PRUH Statistical analysis was performed by using the statistical IUHTXHQW UHTXLUHG UHLQWXEDWLRQ 25 &, ± VRIWZDUH SDFNDJHV 6366 IRU :LQGRZV 4XDQWLWDWLYH S variables were described as mean and a standard deviation ,QPXOWLYDULDWHDQDO\VLV 7DEOH LQGHSHQGHQWSUHGLFWRUV 06' 9DULDEOHV ZHUH UHYLHZHG IRU QRUPDOLW\ RXWOLHUV IRU3'ZHUHDJHRI!\HDUV 25 &,± and dependencies. Kolmogorov-Smirnov test was used for S SUHYLRXV VWURNHV 25 &, ± determination of quantitative data distribution. When the S OHQJWK RI VWD\ LQ WKH KRVSLWDO EHIRUH VXUJHU\ ! GLVWULEXWLRQ RI YDULDEOHV ZDV QRUPDO 6WXGHQW¶V W WHVW ZDV GD\V 25 &,±S GRVHRIVRGLXP used for comparison of quantitative sizes of two independent WKLRSHQWDORI PJ 25 &,±S samples, and the non-parametric Mann-Whitney U test was DQGUHLQWXEDWLRQ 25 &,± S used to compare non-normally distributed variables. The dependence of qualitative variables was evaluated by chi- ',6&866,21 VTXDUHG Ȥ 2 FULWHULRQ7KHOLQHDUGHSHQGHQFHRIWKHYDULDEOHV 2XU GDWD FRQ¿UPV WKH ¿QGLQJV RI SUHYLRXV VWXGLHV ZDVDVVHVVHGE\WKHFRUUHODWLRQFRHI¿FLHQW7DNLQJLQWRDFFRXQW showing that patients undergoing open heart surgery are in the distribution of the variables we used Pearson’s r correlation HOHYDWHGULVNIRUGHYHORSLQJ3')RUH[DPSOH-DQQDWL<HWDO FRHI¿FLHQW )RU QRUPDO YDULDEOHV 3HDUVRQ¶V U FRUUHODWLRQ IRXQGGHOLULXPLQFLGHQFHRI 6KDGYDU.HWDOUHSRUWHG FRHI¿FLHQWZDVDSSOLHG LIDWOHDVWRQHYDULDEOHGLVWULEXWLRQ WKHSUHYDOHQFHRIGHOLULXPRIDQG1RUNLHQH,HWDO was asymmetric, Spearman’s rho nonparametric analogue IRXQGWKDWWKHLQFLGHQFHRISRVWRSHUDWLYHGHOLULXPZDV was used. All tests were two-tailed. Receiver Operating > @ ,Q RXU SRSXODWLRQ WKH LQFLGHQFH RI SRVWRSHUDWLYH &KDUDFWHULVWLF FXUYH 52& ZDV XVHG WR ¿QG TXDQWLWDWLYH delirium, as established using the CAM-ICU, ICDSC, RASS variables separation critical point. Using univariate logistic DQG18'(6&FKHFNOLVWVZDVDQGFRUUHVSRQGVWR WKH UHJUHVVLRQ DQDO\VLV RGGV UDWLRV 25 ZLWK FRQ¿GHQFH literature. Compared with our previous retrospective study LQWHUYDOV &, ZHUH FDOFXODWHG 7KH LQFLGHQFH RI GHOLULXP [22], the incidence of PD increased from previously reported DFFRUGLQJWRDFRPSDUDWLYHDQDO\VLVRIVLJQL¿FDQWGLVWLQFWLYH 7KHVH¿QGLQJVVXJJHVWWKDW3'LGHQWL¿FDWLRQDIWHUFDUGLDF values of the variables used the binary logistic regression surgery depends on employed delirium detection methods. analysis. The difference between the two independent groups :HKDYHIRXQGWKDWDJHJUHDWHUWKDQ\HDUVLVDULVN RIGDWDZDVFRQVLGHUHGWREHVWDWLVWLFDOO\VLJQL¿FDQWZKHQWKH factor for PD. According to the literature data, the highest VLJQL¿FDQFHOHYHORIS risk of postoperative delirium is found in older patients. Older age is also associated with more aortic and carotid artery 5(68/76 atherosclerosis and increased risk of cerebral embolization, 7KHLQFLGHQFHRI3'ZDVDQGLWZDVPRVWFRPPRQ HVSHFLDOO\GXULQJDRUWLFPDQLSXODWLRQV> @$OVRZHKDYH GD\V DIWHU VXUJHU\ 3DWLHQW FKDUDFWHULVWLFV DUH GHWHUPLQHG WKDW SUHYLRXV VWURNH ZDV VWDWLVWLFDOO\ VLJQL¿FDQW SUHVHQWHGLQ7DEOH3DWLHQWVZHUHDJHGIURPWR \HDUV as predictor for PD. In other studies, cerebrovascular disease PHGLDQ \HDUV 7KHUHZHUH IHPDOHDQG or history of stroke were also proven as predisposing risk PDOH SDWLHQWV 0HDQ OHIW YHQWULFXODU HMHFWLRQ factors for PD, presumably due to its close association with IUDFWLRQ /9() ZDV DQGPHDQOHQJWKRIVWD\ WKHDWKHURVFOHURWLFGLVHDVHSURFHVV> @ LQ WKH KRVSLWDO EHIRUH VXUJHU\ ZDV GD\V 0HDQ ,QRXUVWXG\WKH/9()LQWKH3'JURXSZDVVLJQL¿FDQWO\
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Table 1. 3DWLHQWFKDUDFWHULVWLFVLQSHULRSHUDWLYHSHULRG $
Variable ' 1 1' 1 p Baseline $JH \HDUV *HQGHU PDOHIHPDOH %0, NJP /9() $6$FODVVL¿FDWLRQ FODVV,,,,9 Active smoker /HQJWKRIVWD\LQWKHKRVSLWDOEHIRUHVXUJHU\ GD\V Comorbidities Chronic obstructive pulmonary disease Diabetes mellitus Thyroid disorder Aortic sclerosis Arterial hypertension Rhythm disorders Previous strokes Hyperlipidaemia Renal disease Visual impairment Hearing impairment Preoperative medications Thyroxin administration Angiotensin receptor blockers administration Beta blockers administration Calcium channel blockers administration At operation $RUWLFFURVVFODPSWLPH PLQ &3%WLPH PLQ 'RVHRIVRGLXPWKLRSHQWDOL PJ LQWUDRSHUDWLYHO\ 'RVHRIIHQWDQ\O PJNJ LQWUDRSHUDWLYHO\ 'RVHRIPLGD]RODPXP PJ In the ICU 'XUDWLRQRIPHFKDQLFDOYHQWLODWLRQ K Repeated mechanical ventilation %OHHGLQJUHFRUGHGDWK PO /DERUDWRU\¿QGLQJV +DHPRJORELQ JO +DHPDWRFULW &53PD[ PJ/ *OXFRVHOHYHO PPROO Postoperative analgesia Epidural ,QWUDYHQRXVDQDOJHVLDGRVHRIRSLRLGV PJNJ NSAIDs %HQ]RGLD]HSLQHXVH¿UVWKRXUV PJ Histamine H2-receptor antagonist administration Nitroprussidum natrium required administration ,&8VWD\ GD\V /HQJWKRIVWD\LQWKHKRVSLWDODIWHU,&8 GD\V '±GHOLULXPJURXS 1'±QRQGHOLULXPJURXS %0,±ERG\PDVVLQGH[ $6$FODVVL¿FDWLRQ±$PHULFDQ6RFLHW\RI$QHVWKHVLRORJLVWVSK\VLFDOVWDWXVFODVVL¿FDWLRQ V\VWHP /9()±OHIWYHQWULFOHHMHFWLRQIUDFWLRQ &$%*±FRURQDU\DUWHU\E\SDVVJUDIWLQJ &3%±FDUGLRSXOPRQDU\E\SDVV &53±&UHDFWLYHSURWHLQ 16$,'± QRQVWHURLGDODQWLLQÀDPPDWRU\GUXJV ,&8±LQWHQVLYHFDUHXQLW ATXDQWLWDWLYHYDULDEOHVDUHSUHVHQWHGDVQXPEHU SHUFHQW DQGTXDOLWDWLYHYDULDEOHVDVPHDQVWDQGDUGGHYLDWLRQ
ORZHUWKDQLQWKHQRQ3'JURXS2WKHULQYHVWLJDWRUVLGHQWL¿HG LQÀXHQFHVWKHRFFXUUHQFHRI3'>@DQGSDWKRSK\VLRORJLFDO ORZ /9()DVDULVNIDFWRUIRUGHYHORSLQJGHOLULXP mechanism is based on chronic hypoxia that facilitates > @ :KHQ HYDOXDWLQJ RWKHU SUHRSHUDWLYH ULVN IDFWRUV mitochondrial dysfunction and promotes brain dysfunction and ZH KDYH IRXQG WKDW SDWLHQWV ZHUH RYHUZHLJKW PHDQ %0, FRJQLWLYH GHFOLQH > @ FHUHEURYDVFXODU GLVHDVHV >@ RI NJP EXW %0, GLG QRW KDYH FUXFLDO LQÀXHQFH RQ GLDEHWHVPHOOLWXV> @WKDWDUHDVVRFLDWHGZLWKLPSDLUHG the development of PD. According to the literature, COPD vascular reactivity and weakened protective reactions that
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Table 2. 0XOWLYDULDEOHORJLVWLFUHJUHVVLRQRISRVVLEOHULVNIDFWRUVIRUSRVWRSHUDWLYHGHOLULXP
Variable Categories OR &, P value Preoperative Age !\HDUV ± Strokes previous ± Length of stay in the hospital before surgery !GD\V ± Operative Intra-operative use of sodium thiopentali PJ ± Postoperative Re-intubation ±
25±RGGVUDWLR &,±FRQ¿GHQFHLQWHUYDO &3%±FDUGLRSXOPRQDU\E\SDVV &$%*±FRURQDU\DUWHU\E\SDVVJUDIWLQJ ,&8±LQWHQVLYHFDUHXQLW consequentially lead to increased central nervous system hand, it was established, that sodium thiopental is used to treat sensitivity to hypoxia and hypoperfusion resulting in elevated refractory intracranial hypertension by reducing intracranial 3'ULVN> @+RZHYHULQRXUVWXG\WKHUHZDVQRVWDWLVWLFDOO\ pressure and cerebral metabolic demands. Furthermore, it was VLJQL¿FDQWUHODWLRQRIGLDEHWHVPHOOLWXVDQG&23'ZLWK3' LGHQWL¿HGWKDWWKHUHDUHIXQGDPHQWDOQHXURSURWHFWLYHPROHFXODU :HKDYHPDQDJHGWR¿QGVWDWLVWLFDOO\VLJQL¿FDQWUHODWLRQ mechanisms mediated by thiopental and proved that thiopental between the length of hospital stay before surgery, when inhibits global protein synthesis and thus ameliorates hypoxic LW LV PRUH WKDQ GD\V DQG 3' :H FRQVLGHU WKDW ORQJHU FHOOGDPDJH>@,QRXUVWXG\ZHGHWHUPLQHGWKDWSDWLHQWV psychological stress before surgery could be associated with LQGHOLULXPJURXSUHFHLYHGVPDOOHUGRVH OHVVWKDQPJ this neuropsychiatric syndrome. of sodium thiopental to maintain anesthesia. We think that 'DWDRQWKHLQÀXHQFHRIDQHVWKHVLDRQ3'DUHFRQÀLFWLQJ KLJKHUGRVH PRUHWKDQPJ RIVRGLXPWKLRSHQWDOGXULQJ DQG KDYH EHHQ GLVFXVVHG > @ $QHVWKHVLD DORQH VHHPV WR anesthesia may be one of the factors that could reduce the have little to no effect on the development of postoperative incidence of PD. However, further studies must be done to cognitive dysfunction. Only the combination of surgical admit or decline this hypothesis. WUDXPDDQGDQHVWKHVLDOHDGVWRDUHOHYDQWG\VIXQFWLRQ> @ Why is it important to identify postoperative delirium The medications that cardiac surgery patients consume and to begin its treatment as soon as possible? The answer to before, during, and after surgery, are also important in this question is provided by Afonso A. et al. [7]: relationship GHYHORSPHQW RI GHOLULXP > @ 7KH SDWLHQWV ZHUH EHWZHHQGHOLULXPDQGGHPHQWLDLQ\HDUVZLWKSDWLHQWV premeditated with oral benzodiazepines and intramuscular DJHGLQPHGLFDOVHUYLFHVZDVSHU\HDULQSDWLHQW morphine routinely before anesthetic induction, and general ZLWKRXWGHOLULXPDQGSHU\HDULQGHOLULXPJURXS7KH anesthesia was induced with intravenously thiopentone and incidence of delirium is in all aspects unfavorable for the fentanyl, supplemented with small doses of midazolam when patient. Delirium after cardiac surgery is associated with required and anesthesia was maintained with additional PDQ\QHJDWLYHFRQVHTXHQFHV> @,QRXUVWXG\WKH IHQWDQ\ODQGLVRÀXUDQHLQDLUR[\JHQ analysis showed that patients who experienced postoperative In accordance with the literature data, the intraoperative delirium require re-intubation more frequently, PD prolonged use of long-lasting opioids is associated with an increased risk WKHOHQJWKRIWKH,&8VWD\IRUXSWRGD\VDQGWKHOHQJWKRIWKH of PD compared to short-acting substances. Correspondingly, SRVWRSHUDWLYHKRVSLWDOVWD\DIWHU,&8IRUXSWRGD\V2XU the amount of perioperatively used fentanyl has a quantitative ¿QGLQJVDUHVLPLODUWRUHVXOWVIURPRWKHUVWXGLHV$OVRLWLV HIIHFWRQWKHLQFLGHQFHRIGHOLULXP> @2XUVWXG\IRXQGWKDW established that hypoactive delirium itself is a strong predictor intraoperative use of fentanyl and post-operative pain control for a longer ICU stay and a prolonged period of mechanical with opioids were not different as a function of PD. In accordance YHQWLODWLRQ >@ KRZHYHU ZH KDYH QRW IRXQG GHOLULXP WR with literature data, benzodiazepines were independently prolong mechanical ventilation. We draw attention, that the DVVRFLDWHGZLWKDQLQFUHDVHGULVNRI3'> @,QFRQWUDVW treatment of postoperative delirium as recommended with ZH FRXOG QRW ¿QG VWDWLVWLFDOO\ VLJQL¿FDQW UHODWLRQ EHWZHHQ KDORSHULGRO>@ZDVHOLJLEOHDQGDGHTXDWH7KHNQRZOHGJHRI benzodiazepines and PD. Sedatives are commonly used the risk factors for delirium in cardiac surgical patients may be within the ICU and have also been implicated as the cause of KHOSIXOLQUDSLGLGHQWL¿FDWLRQDQGWUHDWPHQWRISRVWRSHUDWLYH paradoxical hostility, aggressiveness, confusion and agitation. delirium during ICU stay. This relatively infrequent response to therapy is thought to Although there are many tests and checklist that are used be due to anticholinergic activity, and there is evidence that WRLGHQWLI\GHOLULXPLQ,&8 ,&'6&&$0,&85$6618 anticholinergic medications are linked to delirium in older '(6& WKHUHLVQRVSHFL¿FDQGZRUOGZLGHDFFHSWHGWHVW WR SDWLHQWV> @3UHYLRXVO\LWKDVEHHQGHVFULEHGWKDWWKHUH diagnose postoperative delirium for patients after cardiac DUHVSHFL¿FFRQWUDLQGLFDWLRQVWRWKHXVHRIEDUELWXUDWHVVXFKDV surgery. This is the main reason why different tests are used thiopentone, with regard to the development of PD. Moreover, in other studies. Therefore, the results in some study may the authors recommend reconsidering the routine use of vary. There should be made special guidelines that could WKLRSHQWRQH VRGLXP WKLRSHQWDO DW OHDVW IRU VXEMHFWV ZLWK help screening postoperative delirium in patient after cardiac known risk factors for this cognitive dysfunction, because the VXUJHU\,WFRXOGEHXVHGWRDYRLGLQFRQVLVWHQFLHVLQVFLHQWL¿F use of this induction agent was shown to be associated with researches. an increased relative risk for developing this condition even LQDSRSXODWLRQZLWKRXWNQRZQULVNIDFWRUV> @2QWKHRWKHU
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&21&/86,216 $&.12:/('*(0(176 This prospective study demonstrates that PD is a common We are indebted to the nursing staff at the Kaunas clinics complication that worsens patient outcome following cardiac of Lithuanian University of Health Sciences for their untiring surgery. PD has many reasons and a multifactorial risk model assistance in the examination and assistance of our patients. should be applied to identify patients at an increased risk for &21)/,&762),17(5(67 developing PD. Our study and other examples in the literature suggest that many risk factors cannot be changed or avoided, $XWKRUVGHFODUHQRFRQÀLFWVRILQWHUHVW EXWVRPHFDQEHPRGL¿HG:HGHWHUPLQHGWKDWVKRUWHUOHQJWKRI VWD\LQWKHKRVSLWDOEHIRUHVXUJHU\ GD\VRUKLJKHUGRVHVRI VRGLXPWKLRSHQWDOGXULQJWKHPDLQWHQDQFHRIDQHVWKHVLD ! PJ PD\UHGXFH3'LQFLGHQFH+RZHYHUIXUWKHUVWXGLHVDUH required to clarify PD risk factors because controlling them will help preventing PD.
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1. Smulter N, Lingehall HC, Gustafson Y, Olofsson B, Engström KG. Delirium after cardiac surgery: Shadvar K, Baastani F, Mahmoodpoor A, Bilehjani E. Evaluation of the prevalence and risk LQFLGHQFHDQGULVNIDFWRUV,QWHUDFW&DUGLRYDVF7KRUDF6XUJ IDFWRUVRIGHOLULXPLQFDUGLDFVXUJHU\,&8-&DUGLRYDVF7KRUDF5HV 2. Shadvar K, Baastani F, Mahmoodpoor A, Bilehjani E. Evaluation of the prevalence and risk 21. 1RUNLHQơ , 5LQJDLWLHQơ ' .X]PLQVNLHQơ 9 âLS\ODLWơ - ,QFLGHQFH DQG 5LVN IDFWRUV RI HDUO\ IDFWRUVRIGHOLULXPLQFDUGLDFVXUJHU\,&8-&DUGLRYDVF7KRUDF5HV GHOLULXPDIWHUFDUGLDFVXUJHU\%LRPHG5HV,QW .RVWHU 6 +HQVHQV$* YDQ GHU 3DOHQ -7KH ORQJWHUP FRJQLWLYH DQG IXQFWLRQDO RXWFRPHV RI 22. $QGUHMDLWLHQH-6LUYLQVNDV((DUO\SRVWFDUGLDFVXUJHU\GHOLULXPULVNIDFWRUV3HUIXVLRQ SRVWRSHUDWLYHGHOLULXPDIWHUFDUGLDFVXUJHU\$QQ7KRUDF6XUJ 4. Mc Khann MG, Gottesmann RF, Grega MA et al. Neurological and cognitive sequelae of cardiac .U]\FK/-:\EUDQLHF070DWXV]F]\N,.6NU]\SHN0%HWDO&RPSOH[$VVHVVPHQWRIWKH VXUJHU\,Q %UDLQSURWHFWLRQLQFDUGLDFVXUJHU\6SULQJHU/RQGRQ Incidence and Risk Factors of Delirium in a Large Cohort of Cardiac Surgery Patients: A Single- &HQWHU Received 22 April 2015, accepted 15 June 2015 Straipsnis gautas 2015-04-22, priimtas 2015-06-15 9RO1R-XQH %,2/2*,&$/36<&+,$75<$1'36<&+23+$50$&2/2*<