Mannitol Is Associated with Less Postoperative Delirium after Aortic Valve Surgery in Patients Treated with Bretschneider Cardioplegia

Abstract

Background Heart surgery with extracorporeal circulation (ECC) often leads to postoperative delirium (POD). This is associated with increased morbidity resulting in longer hospital stay and associated costs. The purpose of our study was to analyze the effect of intraoperative mannitol application on POD in patients undergoing elective aortic valve replacement (AVR). Materials and Methods In our retrospective single-center study, 259 patients underwent elective AVR, using Bretschneider cardioplegic solution for cardiac arrest, between 2014 and 2017. Patients were divided in mannitol (n = 188) and nonmannitol (n = 71) groups. POD was assessed using the confusion assessment method for the intensive care unit (ICU). Statistical significance was assumed at p < 0.05. Results Baseline patient characteristics did not differ between the groups. Incidence of POD was significantly higher in the nonmannitol group (33.8 vs. 13.8%; p = 0.001). These patients required longer ventilation time (24.1 vs. 17.1 hours; p = 0.021), higher reintubation rate (11.3 vs. 2.7%; p = 0.009), ICU readmission (12.7 vs. 4.8%; p = 0.026), prolonged ICU (112 vs. 70 hours; p = 0.040), and hospital stay (17.8 vs. 12.6 days; p < 0.001), leading to higher expenses (19,349 € vs. 16,606 €, p < 0.001). A 30-day mortality was not affected, but nonmannitol group showed higher Simplified Acute Physiology Score II score (32.2 vs. 28.7; p < 0.001). Mannitol substitution was independently associated with lower incidence of POD (odds ratio: 0.40; 95% confidence interval: 0.18–0.89; p = 0.02). Conclusion Treatment with mannitol during ECC was associated with decreased incidence of POD. This was accompanied by shorter ventilation time, ICU and hospital stay, and lower treatment expenses.

Comparison of Robot-assisted versus Conventional Laparoscope on Incidence and Risk Factors of Postoperative Delirium for Patients undergoing radical prostatectomy: A single-center retrospective analysis

“…Small doses of mannitol have been successfully used to improve cerebral oxygen metabolism and protect cognitive function postoperatively [9]. Increased rates of reintubation, ICU readmission, and longer hospital stays were observed in patients who did not receive intraoperative mannitol and later developed postoperative delirium relative to patients who received mannitol and did not develop delirium [27]. In patients with severe delirium after surgery, we rst administered a small dose of mannitol.…”

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

“…The delirium incidence of 8.4% in our study is at the lower end of previously published results in patients undergoing open-heart surgery, which ranged from 4 to 34%. [10][11][12] Clinically, delirium presents in three motor subtypes: the hyperactive, the hypoactive, and the mixed. 18 Particularly, the less apparent hypoactive form requires active screening with special delirium assessment tools.…”

“…In addition, generalizability may be limited due to the singlecenter study design, since specific surgical and/or perfusion techniques may substantially influence the risk of delirium. 12 Another limitation is that due to deep sedation the risk of delirium may have been underestimated in patients with persisting severe life-threatening condition. Moreover, the DSM V criteria were not introduced until 2013.…”

“…Some small prospective studies reported incidence rates of 14 to 34%, whereas in a larger retrospective study the incidence of postoperative delirium was only 4.1%. [9][10][11][12] To the best of our knowledge, risk factors for the development of postoperative delirium have not been assessed systematically in large-scale valvular open-heart surgery.…”