Pharmacological Risk Factors for Delirium after Cardiac Surgery: A Review

Abstract

Purpose:The objective of this review is to evaluate the literature on medications associated with delirium after cardiac surgery and potential prophylactic agents for preventing it.Source:Articles were searched in MEDLINE, Cumulative Index to Nursing and Allied Health, and EMBASE with the MeSH headings: delirium, cardiac surgical procedures, and risk factors, and the keywords: delirium, cardiac surgery, risk factors, and drugs. Principle inclusion criteria include having patient samples receiving cardiac procedures on cardiopulmonary bypass, and using DSM-IV-TR criteria or a standardized tool for the diagnosis of delirium.Principal Findings:Fifteen studies were reviewed. Two single drugs (intraoperative fentanyl and ketamine), and two classes of drugs (preoperative antipsychotics and postoperative inotropes) were identified in the literature as being independently associated with delirium after cardiac surgery. Another seven classes of drugs (preoperative antihypertensives, anticholinergics, antidepressants, benzodiazepines, opioids, and statins, and postoperative opioids) and three single drugs (intraoperative diazepam, and postoperative dexmedetomidine and rivastigmine) have mixed findings. One drug (risperidone) has been shown to prevent delirium when taken immediately upon awakening from cardiac surgery. None of these findings was replicated in the studies reviewed.Conclusion:These studies have shown that drugs taken perioperatively by cardiac surgery patients need to be considered in delirium risk management strategies. While medications with direct neurological actions are clearly important, this review has shown that specific cardiovascular drugs may also require attention. Future studies that are methodologically consistent are required to further validate these findings and improve their utility.

Pharmacologic Agents for the Prevention and Treatment of Delirium in Patients Undergoing Cardiac Surgery

“…In considering whether the type of pharmacologic agent used to prevent delirium is clinically important, additional consideration should be given to the following issues. The effect of ketamine may be overestimated in the trial of Hudetz et al (15) because the total fentanyl dose per body weight was not taken into account in the analysis (40). The effect of ketamine may be overestimated in the trial of Hudetz et al (15) because the total fentanyl dose per body weight was not taken into account in the analysis (40).…”

Postoperative delirium following transcatheter aortic valve implantation: a historical cohort study

“…Les facteurs prédictifs indépendants de délirium après TAVI incluaient la coronaropathie (rapport de cotes [RC]: 12,7; intervalle de confiance [IC] à 95 %: 1,0 à 154, 9), les troubles cognitifs (RC: 6,5; IC à 95 %: 1,8 à 23,2) et l'arythmie cardiaque (RC: 3,5; IC à 95 %: 1,1 à 11,6). La TAVI par voie TA a augmenté de façon indépendante le risque de délirium par rapport à la voie TF (RC: 13,8; IC à 95 %: 3,3 à 59,0). Conclusions Les patients subissant une procédure par voie TA ont présenté une augmentation marquée de l'incidence du délirium postopératoire par rapport aux patients subissant une TAVI par voie TF.…”

“…6 Numerous risk factors for delirium following cardiac surgery have been identified, including several comorbidities 7 and perioperative medications. 8 Surgical factors in particular, such as cardiopulmonary bypass (CPB), 9 have been shown to modify the risk of developing delirium considerably. Bucerius et al reported that rates of delirium were approximately three times lower in coronary artery bypass graft (CABG) patients who had surgery without CPB than in those who had CABG with CPB.…”

Post-operative nausea and vomiting in the cardiac surgery population: Who is at risk?

“…7 Therefore, PONV has implications not only for immediate perioperative outcomes, but also for post-discharge quality of life, cardiac rehabilitation attendance, and return to work. Finally, side effects associated with anti-emetic medications, such as delirium, 22 as well as complications of PONV may result in extended lengths of stay, which in turn directly affect costs to the health care system.…”