Arterial pressure above the upper cerebral autoregulation limit during cardiopulmonary bypass is associated with postoperative delirium

Hori, Daijiro; Brown, Charles H.; Ono, M.; Rappold, Thomas; Sieber, Frederick E.; Gottschalk, Allan; Neufeld, Karin J.; Gottesman, Rebecca F.; Adachi, Hideo; Hogue, Charles W.

doi:10.1093/bja/aeu319

Cited by 163 publications

(123 citation statements)

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“…Previous studies among coronary artery bypass graft patients have also shown that intraoperative cerebral perfusion pressure changes exceeding the limits of cerebral autoregulation dramatically increase the risk of postoperative delirium (23). For example, Hori and colleagues (23) found that the presence of delirium was fourfold higher among coronary artery bypass graft patients whose MAP levels exceeded the upper limit of autoregulation capacity during surgery (13% vs. 3%) (23).…”

Section: Discussionmentioning

confidence: 99%

Reduced Cerebral Perfusion Pressure during Lung Transplant Surgery Is Associated with Risk, Duration, and Severity of Postoperative Delirium

et al. 2016

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Rationale: Delirium is common following lung transplant and is associated with poorer clinical outcomes. The extent to which intraoperative hemodynamic alterations may contribute to postoperative delirium among lung transplant recipients has not been examined. Objectives:To examine the impact of intraoperative hemodynamic changes on neurobehavioral outcomes among lung transplant recipients.Methods: Intraoperative hemodynamic function during lung transplant was assessed in a consecutive series of patients between March and November 2013. Intraoperative cerebral perfusion pressure was assessed every minute in all patients. Following lung transplant, patients were monitored for the presence and severity of delirium using the Confusion Assessment Method and the Delirium Rating Scale until hospital discharge.Measurements and Main Results: Sixty-three patients received lung transplants, of whom 23 (37%) subsequently developed delirium. Lower cerebral perfusion pressure was associated with increased risk of delirium (odds ratio [OR], 2.08 per 10-mm Hg decrease; 95% confidence interval [CI], 1.02-4.24; P = 0.043), longer duration of delirium (OR, 1.7 d longer per 10-mm Hg decrease; 95% CI, 1.1-2.7; P = 0.022), and greater delirium severity (b = 20.81; 95% CI, 21.47 to 20.15; P = 0.017).Conclusions: Poorer cerebral perfusion pressure during lung transplant is associated with greater risk for delirium following transplant, as well as greater duration and severity of delirium, independent of demographic and medical predictors. Author Contributions: Concept and design, J.A.B., S.K.R., R.D.D., S.M.P., J.P.M., and P.J.S. Data collection, P.J.S., J.P.M., B.M.H., and S.K.R. Analysis and interpretation of the data, P.J.S., J.P.M., and J.A.B. Drafting of the manuscript, P.J.S., J.P.M., S.M.P., and J.A.B. Critical revision of the article for important intellectual content, P

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Section: Discussionmentioning

confidence: 99%

Reduced Cerebral Perfusion Pressure during Lung Transplant Surgery Is Associated with Risk, Duration, and Severity of Postoperative Delirium

et al. 2016

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“…[8][9][10][11] Patients were eligible for enrolment if they were judged to be at high risk for stroke, as we have previously described. [8][9][10][11] Patients were excluded if they did not speak English, if they had visual impairment, or if there were contraindications to magnetic resonance imaging. The relationship between urine flow rate and MAP values below the lower limit of CBF autoregulation using this database has not been reported.…”

Section: Methodsmentioning

confidence: 99%

“…12 A continuous, moving Pearson's correlation coefficient between MAP and TCD blood flow velocity signals was then calculated to generate the variable mean velocity index (Mx). [8][9][10][11][12] When MAP is outside the limits of CBF autoregulation, Mx approaches 1, whereas it is close to 0 or negative when MAP is within the limits of autoregulation.…”

Section: Transcranial Doppler-based Autoregulation Monitoringmentioning

confidence: 99%

“…7 Our group has evaluated whether monitoring of cerebral blood flow (CBF) autoregulation provides a more precise approach for determining mean arterial pressure (MAP) targets during CPB than empirical targets. [8][9][10][11] We have found that the lower limits of CBF autoregulation vary widely between individuals and that the magnitude that MAP is below the lower limits of autoregulation influences the risk for AKI. [8][9][10]12 These findings indicate that the target MAP during CPB across individuals cannot necessarily be generalized and accurately empirically determined.…”

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confidence: 99%

“…18 Regardless, a strategy of merely increasing empiric MAP targets during CPB to 87 mmHg to maximize renal perfusion may result in a MAP above the upper limit of cerebral autoregulation in some patients, a situation that we have found is associated with delirium. 11 Perhaps individualized MAP management during CPB based on CBF autoregulation monitoring may ensure that BP targets based on urine flow rate are kept below the upper limit of autoregulation. Our study has several limitations in addition to the retrospective study design.…”

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confidence: 99%

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Defining oliguria during cardiopulmonary bypass and its relationship with cardiac surgery–associated acute kidney injury

Hori¹,

Katz²,

Fine³

et al. 2016

British Journal of Anaesthesia

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Effect of Targeting Mean Arterial Pressure During Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium Among Older Patients

et al. 2019

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; and the Cerebral Autoregulation Study Group IMPORTANCE Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. OBJECTIVE To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. INTERVENTION In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. MAIN OUTCOMES AND MEASURES The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. RESULTS Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P = .04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97; P = .04). CONCLUSIONS AND RELEVANCE The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00981474

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Arterial pressure above the upper cerebral autoregulation limit during cardiopulmonary bypass is associated with postoperative delirium

Abstract: clinicaltrials.gov NCT00769691 and NCT00981474.

Cited by 163 publications

References 34 publications

Reduced Cerebral Perfusion Pressure during Lung Transplant Surgery Is Associated with Risk, Duration, and Severity of Postoperative Delirium

Reduced Cerebral Perfusion Pressure during Lung Transplant Surgery Is Associated with Risk, Duration, and Severity of Postoperative Delirium

Defining oliguria during cardiopulmonary bypass and its relationship with cardiac surgery–associated acute kidney injury

Effect of Targeting Mean Arterial Pressure During Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium Among Older Patients

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