Predicting postoperative delirium after vascular surgical procedures

Visser, Linda; Prent, Anna; Laan, Maarten J. van der; Leeuwen, Barbara L. van; Izaks, Gerbrand J.; Zeebregts, Clark J.; Pol, Robert A.

doi:10.1016/j.jvs.2015.01.041

Cited by 60 publications

(76 citation statements)

References 41 publications

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“…As an endpoint, LOS is important due to its association with increased costs, morbidities as well risk of nosocomial sequelae including infection and delirium, complications exacerbated in AKA patients. 27, 28 Median post-operative LOS for AKA patients has been reported at 5 days, similar to patients who undergo BKA or transmetatarsal amputation. 23 Our median LOS was 6 days, with a mean of 9.3 days.…”

Section: Discussionmentioning

confidence: 90%

Preoperative Predictors of 30-Day Mortality and Prolonged Length of Stay after Above-Knee Amputation

Wise

McMaster

Williamson

et al. 2016

Annals of Vascular Surgery

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Background The above-knee amputation (AKA) is an operation of last resort with high post-operative morbidity and mortality. This study identifies pre-operative risk factors predictive of both 30-day mortality and extended length of stay (LOS) in AKA patients. Materials and Methods Two hundred and ninety-five AKA patients from 2004-2013 from a single institution were retrospectively reviewed using a de-identified electronic medical record. Rationally selected factors potentially influencing 30-day mortality and LOS were chosen, including demographics, etiologies, vascular surgical history, lifestyle factors, comorbidities and laboratory values. Variables trending with one of the endpoints on bivariate analysis (P ≤ .10) were entered into multivariate forward stepwise regression models to determine independence as a risk factor (P ≤ .05). Subgroup analysis of AKA patients without a traumatic, burn or malignant etiology was similarly conducted. Results Within the 295 patient cohort, 60% of patients were male, 18% were African-American, mean age was 58 years old and mean body-mass index was 28 kg/m2. The 30-day mortality rate was 9%, and mean post-operative LOS of discharged patients was 9.3 days. Upon logistic regression, thrombocytopenia (platelet count < 250 ×106/mL; P < .001, odds ratio 6.1) and pre-operative septic shock (P = .02, odds ratio 5.1) were identified as independent risk factors for 30-day mortality. Upon linear regression, burn etiology (P < .001, B = 15.8 days), leukocytosis (white blood cell count < 12 ×106/mL; P < .001, B = 6.2 days) and guillotine amputation (P < .001, B = 7.6 days) were independently associated with prolonged LOS. Excluding patients with AKAs due to trauma, burn or malignancy, only thrombocytopenia (platelet count < 250 ×106/mL; P < .001, odds ratio 10.2) and leukocytosis (white blood cell count > 12 ×106/mL; P = .01, B = 5.2 days) were independent risk factors for in-hospital mortality and prolonged LOS, respectively. Conclusions Pre-operative septic shock and thrombocytopenia are independent risk factors for 30-day mortality after AKA, while burn etiology, leukocytosis and guillotine amputation contribute to prolonged LOS. Awareness of these risk factors may help enhance both pre-operative decision-making and expectations of the hospital admission.

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Section: Discussionmentioning

confidence: 90%

Preoperative Predictors of 30-Day Mortality and Prolonged Length of Stay after Above-Knee Amputation

Wise

McMaster

Williamson

et al. 2016

Annals of Vascular Surgery

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“…Research into delirium following several types of major vascular surgery have identified incidence of delirium of up to 46% following open AAA repair compared with only 2% after EVAR. 11 Factors relating to delirium include pre-existing cognitive impairment and age, and it has been shown to relate to higher rates of discharge to nursing care (38% vs. 8%) and reduction in scores for activities of daily living with effects persisting out to 6 months. 3 This shows a significant overlap for risk factors and consequences of the two phenomenon, suggesting they could share common pathophysiology.…”

Section: Discussionmentioning

confidence: 99%

“…[15][16] This increased permeability might also explain why delirium has a lower incidence following minimally invasive aortic surgery compared with open repair. 11 Alternative biomarkers for monitoring the extent of neurological damage are now being investigated for their sensitivity in detecting subclinical injury and predicting cognitive outcomes, such as glial fibrillary acidic protein. 17 However, in order for them to be useful in the setting of future cognitive research, the link between serum levels and related outcomes needs to be more firmly established.…”

Section: Postoperative Neuroinflammationmentioning

confidence: 99%

A systematic review of postoperative cognitive decline following open and endovascular aortic aneurysm surgery

Matthews

et al. 2017

annals

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OBJECTIVES Postoperative cognitive decline (POCD) is a well-recognised neurological phenomenon following major surgery. Most commonly seen in elderly patients, it has direct links to increased long-term morbidity and reduced quality of life. Its incidence following open and endovascular abdominal and thoracic aneurysm surgery is unclear. The purpose of this systematic review is to collate available evidence for POCD following abdominal and thoracic aortic surgery, and to identify continuing controversies directing future research. METHODS A MEDLINE search was conducted following the recommendations of the PRISMA guidelines. Terms searched for included but were not limited to: aortic surgery, delirium, postoperative cognitive decline/dysfunction thoracic aortic surgery, abdominal aortic surgery. Reference lists were searched for additional studies. RESULTS Five observational studies were identified from the literature search. Variation in study methods, cognitive test batteries and thresholds set by the study coordinators did not allow for pooled results. In those studies that did find evidence of decline, risk was linked to age over 65 years, presence of postoperative delirium and decreased years in education. CONCLUSIONS Evidence thus far suggests that POCD can affect patients following major aortic, non-cardiothoracic as well as cardiothoracic surgery. Future research should focus on using a validated repeatable battery of cognitive tests and a single defined threshold for POCD to allow pooled analysis and more robust conclusions. Larger, adequately powered studies are required to reevaluate the effect of aortic aneurysm surgery on postoperative cognitive function.

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“…POD is independently associated with prolonged length of stay, increased mortality in hospital and at 6 months (Robinson et al 2009), increased levels of dependence with activities of daily living at discharge and at 6 months (Quinlan and Rudolph 2011), increased likelihood of discharge to an institution (Neufeld et al 2013; Visser et al 2015) and with an increased risk of re-admission and re-operation (Large et al 2013). It has also been associated with a decline in patient reported vitality, physical function and social function after discharge (Abelha et al 2013) and with the presence of post-traumatic stress disorder at 3 months after surgery (Drews et al 2015).…”

Section: Commentarymentioning

confidence: 99%

Preoperative discussion with patients about delirium risk: are we doing enough?

Tomlinson

Partridge

2016

Perioper Med

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Postoperative delirium is a common complication in the older surgical population, occurring in 10–50 % of cases. It is thought to be more common if an individual is identified as frail. Postoperative delirium is associated with poor outcome including higher mortality rates, prolonged length of hospital stay, increased care needs on discharge and longer term post-traumatic stress disorder.Guidelines from the American Geriatric Society and the National Institute for Health and Care Excellence highlight the importance of risk assessment at the time of the preoperative visit. This enables the perioperative team to plan a care pathway that minimises the risk of delirium occurring postoperatively. Risk assessment also informs a discussion with patient and family regarding their risk, as part of a process of informed patient consent. This is an essential step in conforming to current legal and General Medical Council guidance on the process of consent.

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Predicting postoperative delirium after vascular surgical procedures

Cited by 60 publications

References 41 publications

Preoperative Predictors of 30-Day Mortality and Prolonged Length of Stay after Above-Knee Amputation

Preoperative Predictors of 30-Day Mortality and Prolonged Length of Stay after Above-Knee Amputation

A systematic review of postoperative cognitive decline following open and endovascular aortic aneurysm surgery

Preoperative discussion with patients about delirium risk: are we doing enough?

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