Postoperative delirium in total knee and hip arthroplasty patients: a study of perioperative modifiable risk factors

Weinstein, Sarah M; Poultsides, Lazaros; Baaklini, Lila; Mörwald, Eva E.; Cozowicz, Crispiana; Saleh, Jawad N; Arrington, M.B.; Poeran, Jashvant; Zubizarreta, Nicole; Memtsoudis, Stavros G.

doi:10.1016/j.bja.2017.12.046

Cited by 107 publications

(84 citation statements)

References 41 publications

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“…The possibility is left open that if future studies consider additional covariates not measured in this study, OSA may indeed still emerge as a significant risk factor for delirium and/or increased pain perception. This is especially the case given the directionality of the effect estimate in this and other publications . Although hypothetical, this possibility finds support in mechanistic theories suggesting that OSA‐related pathophysiological processes lead to inflammatory changes in the brain.…”

Section: The Outcomes Of Pain and Deliriumsupporting

confidence: 75%

“…As in previous studies that did not purely relying on clinical judgement to identify the presence of delirium, the authors report an incidence that is alarmingly high – including in OSA patients. With one in five patients developing signs of this complication, it is much more common than appreciated by many clinicians in everyday practice and reported by studies using administrative datasets . The argument might be made that the sensitivity of this approach, which classifies patients with single episodes of inattention, for example, as delirious, may not be clinically relevant.…”

Section: The Outcomes Of Pain and Deliriummentioning

confidence: 99%

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The association between obstructive sleep apnoea, delirium and pain: does it exist or is it just in our heads?

Memtsoudis

2019

Anaesthesia

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The topic of obstructive sleep apnoea (OSA) in the perioperative period has received an increasing amount of attention in recent years. With growing acceptance of the notion that OSA is associated with increased peri-operative risk for a variety of adverse outcomes [1], focus has shifted to providing guidance on the identification and treatment of this patient population in the context of surgery [2, 3]. Despite numerous publications and the release of various guidelines by specialty societies, to date, information on the topic remains incomplete. Consequently, it is widely debated among researchers which peri-operative OSA phenotypes are prone to what type of complications and if these adverse outcomes are preventable through pre-operative identification and adjusted peri-operative management. This information is of major importance in order to help clinicians allocate scarce resources appropriately [4]. It is in this context that the study by Strutz et al. provides valuable information. In their retrospective analysis of data collected for three parent studies, the authors specifically sought to investigate the association between OSA and the occurrence of postoperative delirium as well as increased pain perception. After devising a thorough analysis protocol and employing state of the art methodology, the authors concluded that no such associations exist, at least within the framework of their analysis. They therefore suggested that screening for OSA may not be an effective tool to reduce the burden of these particular events, which are linked to further medical complications and higher resource utilisation. However, they do point out that the rate of delirium among patients with OSA is very high and therefore represents a considerable problem [5]. This publication adds to our knowledge on the subject of delirium and pain in OSA patients for which there is a paucity of literature [5]. The authors based their hypothesis on a relatively small number of previous studies suggesting OSA to be a risk factor for postoperative delirium and increased pain perception. Comparatively though, the data published in this edition of Anaesthesia represent the largest cohort in which these questions have been studied thus far [6, 7]. Qualitative assessment of the study and its design There are several points to be discussed about this remarkable publication. Strutz et al. present an example of how complex analyses of observational data can be conducted in a transparent way that increases confidence in the robustness of results.In an era where observational analyses of secondary data have become the source of much excitement but also significant criticism, it is important to note that in order to maintain the highest level of integrity, the authors have not only formulated and published their analysis plan a priori but also have opened it up to peer review [8]. This allowed for outside input and improvement of their protocol and goes beyond calls for registration of such investigations as suggested previously [9]. Although the c...

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Section: The Outcomes Of Pain and Deliriumsupporting

confidence: 75%

Section: The Outcomes Of Pain and Deliriummentioning

confidence: 99%

The association between obstructive sleep apnoea, delirium and pain: does it exist or is it just in our heads?

Memtsoudis

2019

Anaesthesia

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“…In recent years, there have been reports that benzodiazepine receptor agonists (benzodiazepines and non-benzodiazepines) may cause cognitive decline, mental dependence, delirium, and muscle relaxation, with increased risks of falls and proximal femoral fractures. [15,27,28] New insomnia drugs, such as ramelteon and suvorexant, act selectively on the pineal and hypothalamic receptors (melatonin receptor and orexin receptor), respectively, potentially reducing the risk of delirium. Furthermore, Hatta et al reported in a randomized clinical trial, that ramelteon and suvorexant even showed suppressive effects against delirium.…”

Section: Discussionmentioning

confidence: 99%

Pre-operative hemoglobin level and use of sedative-hypnotics are independent risk factors for post-operative delirium following total knee arthroplasty

Kijima¹,

Kayama

Saito³

et al. 2020

Preprint

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Background: Delirium is a well-known complication following surgery, especially with the increasing age of patients undergoing surgery. The increasing demands resulting from a prolonged healthy life expectancy has resulted in more arthroplasties despite their age and existing comorbidities. The purpose of this study is to explore the various risk factors that may contribute to delirium in unilateral and bilateral total knee arthroplasties in the elderly population. Methods: 170 patients who underwent unilateral or bilateral total knee arthroplasties were analyzed retrospectively for delirium. Age, sex, comorbidities, use of sedative-hypnotics, peri-operative blood loss, pre- and post-operative laboratory blood test results were investigated and analyzed. Results: The incidence of post-operative delirium was 6.5% (11 out of 170 patients) with a mean age of 79.5 (± 6.9) years, compared to 73.0 (± 9.0) years in the non-delirium group. Higher age, use of sedative-hypnotics, low pre-operative Hb and Ht, low post-operative Hb, Ht and BUN were observed in the delirium group. Multivariate logistic regression analysis identified that the use of sedative-hypnotics and pre-operative Hb level were independent risk factors for post-operative delirium after TKA. The odds ratios for the use of sedative-hypnotics and pre-operative Hb level were 4.6 and 0.53, respectively. Receiver operating characteristic curve analysis showed that pre-operative Hb of less than 11.1 g/dL was a predictor for the development of delirium, with a sensitivity of 54.6% and a specificity of 91.6%. Conclusion: Patients with a pre-operative Hb level of <11.1 g/dL or those using sedative-hypnotics are associated with post-operative delirium. Peri-operative management and preventative measures are therefore needed to reduce the risks of post-operative delirium in such patients.

show abstract

Section: Discussionmentioning

confidence: 99%

Pre-operative hemoglobin level and use of sedative-hypnotics are independent risk factors for post-operative delirium following total knee arthroplasty.

Kijima¹,

Kayama

Saito³

et al. 2020

Preprint

View full text Add to dashboard Cite

Background: Delirium is a well-known complication following surgery, especially with the increasing age of patients undergoing surgery. The increasing demands resulting from a prolonged healthy life expectancy has resulted in more arthroplasties despite their age and existing comorbidities. The purpose of this study is to explore the various risk factors that may contribute to delirium in unilateral and bilateral total knee arthroplasties in the elderly population. Methods: 170 patients who underwent unilateral or bilateral total knee arthroplasties were analyzed retrospectively for delirium. Age, sex, comorbidities, use of sedative-hypnotics, peri-operative blood loss, pre- and post-operative laboratory blood test results were investigated and analyzed. Results: The incidence of post-operative delirium was 6.5% (11 out of 170 patients) with a mean age of 79.5 (± 6.9) years, compared to 73.0 (± 9.0) years in the non-delirium group. Higher age, use of sedative-hypnotics, low pre-operative Hb and Ht, low post-operative Hb, Ht and BUN were observed in the delirium group. Multivariate logistic regression analysis identified that the use of sedative-hypnotics and pre-operative Hb level were independent risk factors for post-operative delirium after TKA. The odds ratios for the use of sedative-hypnotics and pre-operative Hb level were 4.6 and 0.53, respectively. Receiver operating characteristic curve analysis showed that pre-operative Hb of less than 11.1 g/dL was a predictor for the development of delirium, with a sensitivity of 54.6% and a specificity of 91.6%.Conclusion: Patients with a pre-operative Hb level of <11.1 g/dL or those using sedative-hypnotics are associated with post-operative delirium. Peri-operative management and preventative measures are therefore needed to reduce the risks of post-operative delirium in such patients.

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Postoperative delirium in total knee and hip arthroplasty patients: a study of perioperative modifiable risk factors

Abstract: In this cohort of hip and knee arthroplasty patients, anaesthesia type and perioperative medications were associated with increased odds for postoperative delirium. Our results support the notion that modifiable risk factors may exacerbate or attenuate risk for postoperative delirium.

Cited by 107 publications

References 41 publications

The association between obstructive sleep apnoea, delirium and pain: does it exist or is it just in our heads?

The association between obstructive sleep apnoea, delirium and pain: does it exist or is it just in our heads?

Pre-operative hemoglobin level and use of sedative-hypnotics are independent risk factors for post-operative delirium following total knee arthroplasty

Pre-operative hemoglobin level and use of sedative-hypnotics are independent risk factors for post-operative delirium following total knee arthroplasty.

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