Delirium in the cardiac surgical ICU

Brown, IV Charles H.

doi:10.1097/aco.0000000000000061

Cited by 144 publications

(125 citation statements)

References 74 publications

(56 reference statements)

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“…For patients at high risk for delirium based on preoperative assessment, tailored perioperative strategies are crucial, and general principles include avoidance of precipitating agents, such as benzodiazepines, emphasis on mobilization, screening for the development of delirium, and consideration of avoiding excessive depth of anesthesia. 40,41 Although brain imaging is not practical in all surgical patients, it is noteworthy that in this study ventricular size was linearly associated with baseline cognitive performance. Thus, although brain MRI scans may not be available on all patients, formal cognitive assessment may shed insight into important brain pathology and inform postoperative management.…”

Section: Discussionmentioning

confidence: 67%

The Association of Brain MRI Characteristics and Postoperative Delirium in Cardiac Surgery Patients

Brown¹,

Faigle²,

Klinker

et al. 2015

Clinical Therapeutics

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Purpose Delirium is common after cardiac surgery, and it is associated with short- and long-term consequences, including cognitive decline. Identification of patients who are vulnerable to delirium might allow for early implementation of delirium-prevention strategies in older adults undergoing surgery. Brain MRI findings provide insight into structural brain changes that may identify vulnerable patients. The purpose of this study was to examine the association between brain MRI characteristics potentially associated with delirium vulnerability and the development of postoperative delirium in a nested cohort of patients undergoing cardiac surgery. Methods We identified 79 cardiac surgery patients who had brain MRI imaging after cardiac surgery, as part of an ongoing randomized trial evaluating the efficacy of blood pressure management based on cerebral autoregulation monitoring versus standard management for improving neurological outcomes. Cerebral lateral ventricular size, cortical sulcal width, and white matter hyperintensities (WMH) on brain MRI scans were graded on a validated 0 to 9 scale, and categorized into tertiles. New ischemic lesions were characterized as present or absent. Delirium was assessed using a validated chart-review. Neuropsychological testing performed before surgery was used to establish preoperative cognitive baseline. Multivariable logistic regression was used to assess the independent association between MRI characteristics and postoperative delirium. Findings Twenty-eight of 79 (35.4%) patients developed postoperative delirium. Patients with delirium had higher unadjusted ventricular size (median 4 vs. 3, p=0.003), and there was a trend towards higher sulcal sizes and WMH grades. Increasing tertiles of ventricular size (Odds Ratio [OR] 3.59; 95% Confidence Interval [CI] 1.59–8.12; p=0.002) and sulcal size (OR 2.15; 95%CI 1.13–4.12; p=0.02) were associated with postoperative delirium, with a trend for tertiles of WMH grade (OR 1.91; 95%CI 0.99–3.68; p=0.05). In multivariable models adjusted for logistic EuroSCORE, baseline cognitive status, bypass time, and any postoperative complication, each tertile of ventricular size was associated with increased odds of postoperative delirium (OR 3.23 per tertile increase in ventricular size; 95%CI 1.21–8.60; p=0.02). There were no differences in odds of delirium by tertiles of sulcal grade, tertiles of white matter grade, or presence of new ischemic lesions, in adjusted models. Implications Increased brain ventricular size was independently associated with delirium after cardiac surgery. These results suggest that cerebral atrophy may contribute to increased vulnerability for postoperative delirium. Baseline brain MRIs may be useful in identifying cardiac surgery patients at high risk for postoperative delirium, who might benefit from targeted perioperative approaches to prevent delirium.

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Section: Discussionmentioning

confidence: 67%

The Association of Brain MRI Characteristics and Postoperative Delirium in Cardiac Surgery Patients

Brown¹,

Faigle²,

Klinker

et al. 2015

Clinical Therapeutics

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“…(DSM-V), delirium has an organic cause and is therefore a direct consequence of a general medical condition or its treatment (12). Although the pathophysiology of pediatric post-cardiotomy delirium has not yet been clarified, it is likely a syndrome resulting from a multifactorial process involving pre-operative patient vulnerability, perioperative insults, and iatrogenic factors related to post-operative PCICU care (26,27). This study suggests that pre-operative patient vulnerability is a risk factor, as children with poor nutrition (represented in this cohort as those patients with albumin <3 mg/dL) and atypical brains (developmental delay) were at higher risk for delirium.…”

Section: Discussionmentioning

confidence: 99%

Delirium in Children After Cardiac Bypass Surgery*

Patel

Biagas

Clarke

et al. 2017

Pediatric Critical Care Medicine

115

101

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Background Delirium is acute brain dysfunction associated with serious illness. Emerging data indicate that delirium occurs in greater than 20% of children in pediatric intensive care units. Cardiac bypass surgery is a known risk factor for delirium in adults, but has never been systematically studied in pediatrics. Objectives To describe the incidence of delirium in pediatric patients after cardiac bypass surgery, and explore associated risk factors and effect of delirium on in-hospital outcomes. Design Prospective observational single-center study. Setting Fourteen-bed pediatric cardiothoracic intensive care unit (PCICU). Patients One hundred and ninety four consecutive admissions following cardiac bypass surgery, age one day to 21 years. Interventions Subjects were screened for delirium daily using the Cornell Assessment of Pediatric Delirium. Measurements and Main Results Incidence of delirium in this sample was 49%. Delirium most often lasted 1–2 days, and developed within the first 1–3 days after surgery. Age less than two years, developmental delay, higher RACHS-1 score, cyanotic disease, and albumin less than three were all independently associated with development of delirium in a multivariable model (all p values <0.03). Delirium was an independent predictor of prolonged ICU LOS, with patients who were ever delirious having a 60% increase in ICU days compared to patients who were never delirious (p<0.01). Conclusions In our institution, delirium is a frequent problem in children after cardiac bypass surgery, with identifiable risk factors. Our study suggests that cardiac bypass surgery significantly increases children’s susceptibility to delirium. This highlights the need for heightened, targeted delirium screening in all PCICUs to potentially improve outcomes in this vulnerable patient population.

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“…To the best of our best knowledge, this is the largest study that examined the association of delirium with worse in‐hospital clinical outcomes in patients with MI. Previous studies examined the impact of delirium in limited populations, including those with cardiogenic shock, in the cardiac ICU, undergoing transcatheter aortic valve replacement, or CABG, with an emphasis on elderly populations . The analysis used the strength of the NIS, with large sample sizes and the ability to adjust for several confounding variables.…”

Section: Discussionmentioning

confidence: 99%