Metabolomic Analysis in Saliva and Different Brain Regions of Older Mice with Postoperative Delirium Behaviors

Objective Postoperative delirium(POD)has become a critical challenge with severe consequences and increased incidences as the global population ages.However,the underlying mechanism is yet unknown.Our study aimed to explore the changes in metabolites in three specific brain regions and saliva of older mice with postoperative delirium behavior and to identify potential non-invasive biomarkers.Methods Eighteen-month-old male C57/BL6 mice were randomly assigned to the anesthesia/surgery or control group.Behavioral tests were conducted 24 h before surgery and 6,9,and 24 h after surgery.Complement C3(C3)and S100 calcium-binding protein B protein(S100beta)levels were measured in the hippocampus,and a metabolomics analysis was performed on saliva,hippocampus,cortex,and amygdala samples.Results In total,43,33,38,and 14 differential metabolites were detected in the saliva,hippocampus,cortex,and amygdala,respectively.“Pyruvate”“alpha-linolenic acid”and“2-oleoyl-1-palmitoy-snglycero-3-phosphocholine”are enriched in one common pathway and may be potential non-invasive biomarkers for POD.Common changes were observed in the three brain regions,with the upregulation of 1-methylhistidine and downregulation of D-glutamine.Conclusion Dysfunctions in energy metabolism,oxidative stress,and neurotransmitter dysregulation are implicated in the development of POD.The identification of changes in the level of salivary metabolite biomarkers could aid in the development of noninvasive diagnostic methods for POD.

Predictive modeling for postoperative delirium in elderly patients with abdominal malignancies using synthetic minority oversampling technique

BACKGROUND Postoperative delirium,particularly prevalent in elderly patients after abdominal cancer surgery,presents significant challenges in clinical management.AIM To develop a synthetic minority oversampling technique(SMOTE)-based model for predicting postoperative delirium in elderly abdominal cancer patients.METHODS In this retrospective cohort study,we analyzed data from 611 elderly patients who underwent abdominal malignant tumor surgery at our hospital between September 2020 and October 2022.The incidence of postoperative delirium was recorded for 7 d post-surgery.Patients were divided into delirium and non-delirium groups based on the occurrence of postoperative delirium or not.A multivariate logistic regression model was used to identify risk factors and develop a predictive model for postoperative delirium.The SMOTE technique was applied to enhance the model by oversampling the delirium cases.The model’s predictive accuracy was then validated.RESULTS In our study involving 611 elderly patients with abdominal malignant tumors,multivariate logistic regression analysis identified significant risk factors for postoperative delirium.These included the Charlson comorbidity index,American Society of Anesthesiologists classification,history of cerebrovascular disease,surgical duration,perioperative blood transfusion,and postoperative pain score.The incidence rate of postoperative delirium in our study was 22.91%.The original predictive model(P1)exhibited an area under the receiver operating characteristic curve of 0.862.In comparison,the SMOTE-based logistic early warning model(P2),which utilized the SMOTE oversampling algorithm,showed a slightly lower but comparable area under the curve of 0.856,suggesting no significant difference in performance between the two predictive approaches.CONCLUSION This study confirms that the SMOTE-enhanced predictive model for postoperative delirium in elderly abdominal tumor patients shows performance equivalent to that of traditional methods,effectively addressing data imbalance.

Implications of Elevated Serum Cortisol in the Onset of Postoperative Delirium Following Off-Pump Coronary Artery Bypass Grafting: Insights from a Bangladesh-Based Single Center Experience

Background: Following coronary artery bypass grafting (CABG), delirium emerges as a prevalent complication. This study aimed to assess the correlation between elevated serum cortisol levels and the occurrence of postoperative delirium subsequent to off-pump CABG. Methods: Conducted in the Department of Cardiac Surgery at BSMMU from October 2020 to September 2022, this comparative cross-sectional study included a total of 44 participants. Subjects, meeting specific criteria, were purposefully assigned to two groups based on off-pump CABG. Group A (n = 22) consisted of patients with normal serum cortisol levels, while Group B (n = 22) comprised individuals with high serum cortisol levels on the first postoperative day. Delirium onset was assessed at the bedside in the ICU on the 1st, 2nd, 3rd, 4th, and 5th postoperative days using standard tools, namely the Richmond Agitation Sedation score (RASS) and The Confusion Assessment Method (CAM-ICU). Data were collected based on the presence or absence of delirium. Statistical analysis utilized SPSS version 26.0, employing an independent Student’s t-test for continuous data and chi-square and Fischer’s exact test for categorical data. A p-value ≤ 0.05 was considered statistically significant. Results: Group-A had a mean age of 54.50 ± 17.97, and Group-B had a mean age of 55.22 ± 15.45, both with a male predominance (81.81% and 86.36% respectively). The mean serum cortisol level was significantly higher in Group B (829.71 ± vs. 389.98 ± 68.77). Postoperative delirium occurred in 27.3% of Group B patients, statistically significant compared to the 4.5% in Group A. However, patients in Group B who developed delirium experienced significantly longer postoperative ICU and hospital stays (79.29 ± 12.27 vs. 11.44 ± 2.85, p ≤ 0.05). There was one mortality in Group B, which was statistically not significant. Conclusion: This study observed a significant association between elevated serum cortisol levels in the postoperative period and the occurrence of postoperative delirium after off-pump coronary artery bypass grafting.

Incidence and Risk Factors of Sub-syndromal Delirium in Patients after Cardiac Surgery

[Objectives]This study aimed to investigate the incidence and risk factors associated with SSD in patients following cardiac surgery.[Methods]A total of 378 patients who underwent cardiac surgery in Taihe Hospital were recruited and screened.Diagnosis of delirium was made using evaluation methods and DSM-5 criteria.SSD was defined as the presence of one or more core features of delirium without meeting the full diagnostic criteria.Statistical analysis included independent samples t-test for group comparisons and binary logistic regression analysis to identify independent risk factors for SSD after cardiac surgery.[Results]Among the 378 subjects,112(29.63%)had SSD,28(7.41%)had delirium,and the remaining 238 patients(62.96%)did not present with delirium.Univariate analysis revealed that age,APACHE II score,duration of aortic clamping,length of ICU stay,duration of sedation use,and daily sleep time were significant risk factors for the occurrence of SSD(P<0.05).Logistic regression analysis identified age>70 years old,APACHE II score>20 points,length of ICU stay>5 d,and duration of sedation use>24 h as independent risk factors for SSD after cardiac surgery(P<0.05).A functional model was fitted based on the analysis results of the binary logistic regression model,yielding the equation logit P=1.472X_(1)+2.213X_(2)+3.028X_(3)+1.306X_(4).[Conclusions]Comprehensive clinical assessment is crucial for patients undergoing cardiac surgery,and appropriate preventive measures should be taken for patients with identified risk factors.Close monitoring of the patient s consciousness should be implemented postoperatively,and timely interventions should be conducted.Further research should focus on model validation and optimization.

Scopolamine causes delirium-like brain network dysfunction and reversible cognitive impairment without neuronal loss

Delirium is a severe acute neuropsychiatric syndrome that commonly occurs in the elderly and is considered an independent risk factor for later dementia.However,given its inherent complexity,few animal models of delirium have been established and the mechanism underlying the onset of delirium remains elusive.Here,we conducted a comparison of three mouse models of delirium induced by clinically relevant risk factors,including anesthesia with surgery(AS),systemic inflammation,and neurotransmission modulation.We found that both bacterial lipopolysaccharide(LPS)and cholinergic receptor antagonist scopolamine(Scop)induction reduced neuronal activities in the delirium-related brain network,with the latter presenting a similar pattern of reduction as found in delirium patients.Consistently,Scop injection resulted in reversible cognitive impairment with hyperactive behavior.No loss of cholinergic neurons was found with treatment,but hippocampal synaptic functions were affected.These findings provide further clues regarding the mechanism underlying delirium onset and demonstrate the successful application of the Scop injection model in mimicking delirium-like phenotypes in mice.

Heart rate response and recovery during exercise predict future delirium risk——A prospective cohort study in middle-to older-aged adults

Background:Delirium is a neurocognitive disorder characterized by an abrupt decline in attention,awareness,and cognition after surgical/illness-induced stressors on the brain.There is now an increasing focus on how cardiovascular health interacts with neurocognitive disorders given their overlapping risk factors and links to subsequent dementia and mortality.One common indicator for cardiovascular health is the heart rate response/recovery(HRR)to exercise,but how this relates to future delirium is unknown.Methods:Electrocardiogram data were examined in 38,740 middle-to older-aged UK Biobank participants(mean age=58.1 years,range:40-72 years;47.3%males)who completed a standardized submaximal exercise stress test(15-s baseline,6-min exercise,and 1-min recovery)and required hospitalization during follow-up.An HRR index was derived as the product of the heart rate(HR)responses during exercise(peak/resting HRs)and recovery(peak/recovery HRs)and categorized into low/average/high groups as the bottom quartile/middle 2 quartiles/top quartile,respectively.Associations between 3 HRR groups and new-onset delirium were investigated using Cox proportional hazards models and a2-year landmark analysis to minimize reverse causation.Sociodemographic factors,lifestyle factors/physical activity,cardiovascular risk,comorbidities,cognition,and maximal workload achieved were included as covariates.Results:During a median follow-up period of 11 years,348 participants(9/1000)newly developed delirium.Compared with the high HRR group(16/1000),the risk for delirium was almost doubled in those with low HRR(hazard ratio=1.90,95%)confidence interval(95%CI):1.30-2.79,p=0.001)and average HRR(hazard ratio=1.54,95%CI:1.07-2.22,p=0.020)).Low HRR was equivalent to being 6 years older,a current smoker,or>3 additional cardiovascular disease risks.Results were robust in sensitivity analysis,but the risk appeared larger in those with better cognition and when only postoperative delirium was considered(n=147;hazard ratio=2.66,95%CI:1.46-4.85,p=0.001).Conclusion:HRR during submaximal exercise is associated with future risk for delirium.Given that HRR is potentially modifiable,it may prove useful for neurological risk stratification alongside traditional cardiovascular risk factors.

Sleeping Conditions of Older Adults with Delirium Receiving Home Care

We aimed to clarify the sleep status before delirium onset among older adults receiving home care. The sleep status of 21 participants aged ≥65 years was monitored while they slept with a sensor placed under their bedding, after ruling out insomnia and dementia. The incidence of delirium was 28.6%;delirium onset occurred within an average of 2.7 (SD = 12) days after the start of home care among those whose care environment was changed due to hospital discharge or moving. Increased interrupted sleep and activity during sleep indicated that sleep fragmentation occurred before delirium onset. In conclusion, individuals aged ≥65 years and those whose care environment has changed should be screened for delirium because the time to delirium onset is short. Further, interventions to monitor the sleep status and prevent delirium onset should be implemented from the day home care begins.

Risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium in elderly patients

Delirium is an acute reversible neuropsychiatric syndrome caused by multiple factors.It is associated with many adverse clinical outcomes including cognitive impairment,functional decline,prolonged hospitalization,and increased nursing service.The prevalence of delirium was high in department of cardiology,geriatric,and intensive care unit of hospital.With the increase in the aged population,further increases in delirium seem likely.However,it remains poorly recognized in the clinical practice.This article comprehensively discusses the latest research perspectives on the epidemiological data,risk factors,preventive interventions,overlapping symptoms,and clinical measures of delirium,including specific measures to manage delirium in clinical real-world situations.This article helps readers improve their knowledge and understanding of delirium and helps clinicians quickly identify and implement timely therapeutic measures to address various delirium subtypes that occur in the clinical settings to ensure patients are treated as aggressively as possible.

Effects of surgical treatment modalities on postoperative cognitive function and delirium in elderly patients with extremely unstable hip fractures

BACKGROUND As the perioperative risk of elderly patients with extremely unstable hip fractures(EUHFs)is relatively high and therapeutic effect is not satisfactory,new therapeutic strategies need to be proposed urgently to improve the efficacy and clinical outcomes of such patients.AIM To determine the influence of two surgical treatment modalities on postoperative cognitive function(CF)and delirium in elderly patients with EUHFs.METHODS A total of 60 elderly patients consecutively diagnosed with EUHF between September 2020 and January 2022 in the Chongqing University Three Gorges Hospital were included.Of them,30 patients received conventional treatment(control group;general consultation+fracture type-guided internal fixation),and the other 30 received novel treatment(research group;perioperative multidisciplinary treatment diagnosis and treatment+individualized surgical plan+risk prediction).Information on hip function[Harris hip score(HHS)],perioperative risk of orthopedic surgery[Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity(POSSUM)],CF[Montreal cognitive assessment scale(MoCA)],postoperative delirium[mini-cognitive(Mini-Cog)],adverse events(AEs;internal fixation failure,infection,nonunion,malunion,and postoperative delirium),and clinical indicators[operation time(OT),postoperative hospital length of stay(HLOS),ambulation time,and intraoperative blood loss(IBL)]were collected from both groups for comparative analyses.RESULTS The HHS scores were similar between both groups.The POSSUM score at 6 mo after surgery was significantly lower in the research group compared with the control group,and MoCA and Mini-Cog scores were statistically higher.In addition,the overall postoperative complication rate was significantly lower in the research than in the control group,including reduced OT,postoperative HLOS,ambulation time,and IBL.CONCLUSION The new treatment modality has more clinical advantages over the conventional treatment,such as less IBL,faster functional recovery,more effectively optimized perioperative quality control,improved postoperative CF,mitigated postoperative delirium,and reduced operation-related AEs.

Effects of Coronavirus Disease 2019 and Frailty on Delirium in the Intensive Care Unit: A Propensity Score Analysis

Purpose: The association between frailty and delirium has emerged as a research topic. Neurological symptoms have been reported among patients with coronavirus disease 2019 (COVID-19), but its effects on delirium remain unclear. This study aimed to compare the incidence of delirium between patients with COVID-19 and those without COVID-19, and to evaluate the impact of COVID-19 and frailty on delirium. Methods: This retrospective study included patients aged ≥ 20 years who were admitted to our intensive care unit (ICU) between January 2020 and February 2022. An inverse probability of treatment weighting using stabilized inverse propensity scores was adopted to minimize bias. After patient demographics were adjusted, the incidence of delirium, assessed using the Confusion Assessment Method for ICU, was compared between patients with COVID-19 and those without COVID-19. The effects of COVID-19 and the Clinical Frailty Scale score on delirium were analyzed by adjusting some covariates, including the sequential organ failure assessment (SOFA) score, using a generalized estimating equation. Results: Among 260 eligible patients, 226 patients were included. The weighted incidence of delirium was 56.9% and 61.9% in patients with and without COVID-19, respectively (p = 0.67). The generalized estimating equation revealed that the odds ratios (95% confidence interval) for COVID-19, the CFS score, and the SOFA score were 1.49 (0.62 - 3.57), 1.46 (1.11 - 1.91), and 1.22 (1.10 - 1.36), respectively. Conclusion: CFS and SOFA scores on ICU admission may be associated with delirium, with no significant difference between patients with COVID-19 and those without COVID-19.

Assessment scales for delirium: A review

Over the years many scales have been designed for screening, diagnosis and assessing the severity of delirium. In this paper we review the various instruments available to screen the patients for delirium, instruments available to diagnose delirium, assess the severity, cognitive functions, motoric subtypes, etiology and associated distress. Among the various screening instruments, NEECHAM confusion scale and delirium observation scale appear to be most suitable screening instrument for patients' in general medical and surgical wards, depending on the type of rater(physician or nurse). In general, the instruments which are used for diagnosis [i.e., confusion assessment method(CAM), CAM for intensive care unit(CAM-ICU), Delirium Rating Scale-revised version(DRS-R-98), memorial selirium assessment scale, etc. ] are based on various Diagnostic and Statistical Manual criteria and have good to excellent reliability and fair to good validity. Among the various diagnostic instruments, CAM is considered to be most useful instrument because of its accuracy, brevity, and ease of use by clinicians and lay interviewers. In contrast, DRS-R-98 appears to be a comprehensive instrument useful for diagnosis, severity rating and is sensitive to change and hence can be used for monitoring patients over a period. In the ICU setting, evidence suggests that CAM-ICU and Nursing Delirium Screening Scale had comparable sensitivities, but CAM-ICU has higher specificity. With regard to assessment of delirium in pediatric age group, certain instruments like Pediatric Anesthesia Emergence Delirium scale and pediatric CAM-ICU has been designed and have been found to be useful.

A qualitative study on experience of nurses caring for patients with delirium in ICUs in China:Barriers,burdens and decision making dilemmas

Purpose:The purpose was to explore the experiences of nurses caring for patients with delirium in ICU in China.Methods:Semi-structured qualitative interviews were conducted with 14 ICU nurses in Beijing,China.Audio recordings of the transcripts were coded and analysed thematically.Results:The emergent themes reflected clearly similar experiences and were titled as follows:Internal and external barriers to care;Care burden:workload,psychological pressure and injury;Dilemmas in decision-making:balancing risks and benefits.Conclusions:The results of this qualitative study have provided a rich description of the perceptions of a sample of nurses caring for patients with dementia in Beijing.Clearly,the nurses suffered from their work experiences in several aspects:they lacked the knowledge and skills required assessing and managing the patients as early as possible;they were physically and psychologically stressed while looking after the patients and faced with dilemmas and compromises in their decision-making.

Clinical and prognostic implications of delirium in elderly patients with non–ST-segment elevation acute coronary syndromes

Background Elderly patients with non-ST-segment elevation acute coronary syndromes(NSTE-ACS)may present delirium but its clinical relevance is unknown.This study aimed at detennining the clinical associated factors,and prognostic implications of delirium in old-aged patients admitted for NSTE-ACS.Methods LONGEVO-SCA is a prospective multicenter registry including unselected patients with NSTE-ACS aged>80 years.Clinical variables and a complete geriatric evaluation were assessed during hospitalization.The association between delirium and 6-month mortality was assessed by a Cox regression model weighted for a propensity score including the potential confounding variables.We also analysed its association with 6-month bleeding and cognitive or functional decline.Results Among 527 patients included,thirty-seven(7%)patients presented delirium during the hospitalization.Delirium was more frequent in patients with dementia or depression and in those from nursing homes(27.0%vs.3.1%,24.3%vs.11.6%,and 11.1%V5.2.2%,respectively;all P<0.05).Delirium was significantly associated with in-hospital infections(27.0%vs.5.3%,P<0.001)and usage of diuretics(70.3%vs.49.8%,P=0.02).Patients with delirium had longer hospitalizations[median 8.5(5.5-14)vs.6.0(4.0-10)days,P=0.02]and higher incidence of 6-month bleeding and mortality(32.3%vs.10.0%and 24.3%vs.10.8%,respectively;both P<0.05)but similar cognitive or functional decline.Delirium was independently associated with 6-month mortality(HR=1.47,95%CI:1.02-2.13,P=0.04)and 6-month bleeding events(OR=2.87;95%CI:1.98-4」6,P<0.01).Conclusions In-hospital delirium in elderly patients with NSTE-ACS is associated with some preventable risk factors and it is an independent predictor of 6-month mortality.

Penehyclidine Hydrochloride Premedication Is Not Associated with Increased Incidence of Post-Operative Cognitive Dysfunction or Delirium:A Systemic Review and Meta-Analysis

Objective Post-operative cognitive dysfunction(POCD)and post-operative delirium(POD)are two common post-operative cerebral complications.The current meta-analysis was to systematically review the effects of penehyclidine hydrochloride(PHC)on POCD and POD in surgical patients.Methods Electronic databases were searched to identify all randomized controlled trials comparing PHC with atropine/scopolamine/placebo on POCD and POD in surgical patients.Primary outcomes of interest included the incidences of POCD and POD;the secondary outcomes of interest included peri-operative minimental state examination(MMSE)scores.Two authors independently extracted peri-operative data,including patients'baseline characteristics,surgical variables,and outcome data.For dichotomous data(POCD and POD occurrence),treatment effects were calculated as odds ratio(OR)and 95%confidential interval(Cl).Each outcome was tested for heterogeneity,and randomized-effects or fixed-effects model was used in the presence or absence of significant heterogeneity.For continuous variables(MMSE scores),treatment effects were calculated as weighted mean difference(WMD)and 95%CI.Statistical significance was defined as P<0.05.Results Our search yielded 33 studies including 4017 patients.Meta-analysis showed that,the incidence of POCD in PHC group was comparable to that in saline group(OR=0.97;95%Ck 0.S8-1.64;P=0.92),scopolamine group(OR=0.78;95%CI:0.48-1.27;P=0.32)and atropine group(0R=1.20;95%Ch 0.86-1.67;P=0.29).The incidence of POD in PHC group was comparable to that in saline group(OR=1.53;95%CI:0.81-2.90;P=0.19)and scopolamine group(OR=0.53;95%CI:0.06-4.56;P=0.56),but higher than that in atropine group(OR=4.49;95%CI:1.34-15.01;P=0.01).Conclusions PHC premedication was not associated with increased incidences of POCD or POD as compared to either scopolamine or placebo.

A nursing protocol targeting risk factors for reducing postoperative delirium in patients following coronary artery bypass grafting:Results of a prospective before-after study

Objective: The results of postoperative delirium (POD) warrant testing for prevention. The purpose of this study was to determine whether a nursing intervention targeting risk factors could decrease the inci-dence of POD among patients who had coronary artery bypass grafting (CABG) in China.Methods: A prospective before-after study was conducted between April 2014 and April 2015. A nursing delirium intervention protocol targeting risk factors for delirium was performed for 141 patients un-dergoing CABG in a cardiothoracic ICU from November 2014 to April 2015. Intervention consisted of screening for delirium risk factors, followed by targeted risk factor modification, including pain control, early catheter removal, patient orientation using the 5W1H procedure, increased family visits, mini-mizing care-related interruptions, comfortable nursing and monitoring for sleeping difficulties. Out-comes of the Intervention Group were compared with those of the Control Group for 137 CABG patients from April 2014 to October 2014. Delirium was assessed using the confusion assessment method for the intensive care unit (CAM-ICU). The sample size was justified by PASS2000, based on previous data of delirium incidence in our institution (30%). Main results: Delirium incidence during the first seven postoperative days was significantly lower in the Intervention Group at 13.48%(19/141) vs. 29.93%(41/137) for the Control Group (x2=11.112, P=0.001). In addition, POD in the Intervention Group occurred between the 3rd and 6th postoperative days, while POD in the Control Group mainly occurred on the first three days postoperatively. Delirium in the Intervention Group occurred later than delirium in the Control Group (x2=12.743, P<0.001). Length of ICU stay was reduced significantly (Z= -6.026, P<0.001). Conclusion: The application of a nursing protocol targeting risk factors in this study seems to be asso-ciated with a lower incidence of POD in patients after CABG. This finding suggests that managing the predictors properly is one of the effective strategies to prevent delirium.

Poor outcomes of delirium in the intensive care units are amplified by increasing age: A retrospective cohort study

BACKGROUND: Delirium in patients in intensive care units(ICUs) is an acute disturbance and fluctuation of cognition and consciousness. Though increasing age has been found to be related to ICU delirium, there is limited evidence of the effect of age on delirium outcomes. The aim of this study is to investigate the relationship between age categories and outcomes among ICU delirium patients.METHODS: Data were extracted from the electronic ICU(e ICU) Collaborative Research Database with records from 3,931 patients with delirium. Patients were classified into non-aged(<65 years), youngold(65–74 years), middle-old(75–84 years), and very-old(≥85 years) groups. A Cox regression model was built to examine the role of age in death in ICU and in hospital after controlling covariates. RESULTS: The sample included 1,667(42.4%) non-aged, 891(22.7%) young-old, 848(21.6%) middle-old, and 525(13.3%) very-old patients. The ICU mortality rate was 8.3% and the hospital mortality rate was 15.4%. Compared with the non-aged group, the elderly patients(≥65 yeras) had higher mortality at ICU discharge(χ2=13.726, P=0.001) and hospital discharge(χ2=56.347, P<0.001). The Cox regression analysis showed that age was an independent risk factor for death at ICU discharge(hazard ratio [HR]=1.502, 1.675, 1.840, 95% confidence interval [CI] 1.138–1.983, 1.250–2.244, 1.260–2.687;P=0.004, 0.001, 0.002 for the young-, middle-and very-old group, respectively) as well as death at hospital discharge(HR=1.801, 2.036, 2.642, 95% CI 1.454–2.230, 1.638–2.530, 2.047–3.409;all P<0.001).CONCLUSIONS: The risks of death in the ICU and hospital increase with age among delirious patients.

Postoperative delirium after major orthopedic surgery

BACKGROUND Postoperative delirium(POD)is one of the most common complications in older adult patients undergoing elective surgery.Few studies have compared,within the same institution,the type of surgery,risk factors and type of anesthesia and analgesia associated with the development of POD.AIM To investigate the following three questions:(1)What is the incidence of POD after non-ambulatory orthopedic surgery at a high-volume orthopedic specialty hospital?(2)Does surgical procedure influence incidence of POD after nonambulatory orthopedic surgery?And(3)For POD after non-ambulatory orthopedic surgery,what are modifiable risk factors?METHODS A retrospective cohort study was conducted of all non-ambulatory orthopedic surgeries at a single orthopedic specialty hospital between 2009 and 2014.Patients under 18 years were excluded from the cohort.Patient characteristics and medical history were obtained from electronic medical records.Patients with POD were identified using International Classification of Diseases,9^th Revision(ICD-9)codes that were not present on admission.For incidence analyses,the cohort was grouped into total hip arthroplasty(THA),bilateral THA,total knee arthroplasty(TKA),bilateral TKA,spine fusion,other spine procedures,femur/pelvic fracture,and other procedures using ICD-9 codes.For descriptive and regression analyses,the cohort was grouped,using ICD-9 codes,into THA,TKA,spinal fusions,and all procedures.RESULTS Of 78492 surgical inpatient surgeries,the incidence from 2009 to 2014 was 1.2%with 959 diagnosed with POD.The incidence of POD was higher in patients undergoing spinal fusions(3.3%)than for patients undergoing THA(0.8%);THA patients had the lowest incidence.Also,urgent and/or emergent procedures,defined by femoral and pelvic fractures,had the highest incidence of POD(7.2%)than all other procedures.General anesthesia was not seen as a significant risk factor for POD for any procedure type;however,IV patient-controlled analgesia was a significant risk factor for patients undergoing THA[Odds ratio(OR)=1.98,95%confidence interval(CI):1.19 to 3.28,P=0.008].Significant risk factors for POD included advanced age(for THA,OR=4.9,95%CI:3.0-7.9,P<0.001;for TKA,OR=2.16,95%CI:1.58-2.94,P<0.001),American Society of Anesthesiologists score of 3 or higher(for THA,OR=2.01,95%CI:1.33-3.05,P<0.001),multiple medical comorbidities,hyponatremia(for THA,OR=2.36,95%CI:1.54 to 3.64,P<0.001),parenteral diazepam(for THA,OR=5.05,95%CI:1.5-16.97,P=0.009;for TKA,OR=4.40,95%CI:1.52-12.75,P=0.007;for spine fusion,OR=2.17,95%CI:1.19-3.97,P=0.01),chronic opioid dependence(for THA,OR=7.11,95%CI:3.26-15.51,P<0.001;for TKA,OR=2.98,95%CI:1.38-6.41,P=0.005)and alcohol dependence(for THA,OR=5.05,95%CI:2.72-9.37,P<0.001;for TKA,OR=6.40,95%CI:4.00-10.26,P<0.001;for spine fusion,OR=6.64,95%CI:3.72-11.85,P<0.001).CONCLUSION POD is lower(1.2%)than previously reported;likely due to the use of multimodal regional anesthesia and early ambulation.Both fixed and modifiable factors are identified.

Incidence, risk factors, and cumulative risk of delirium among ICU patients: A case-control study

Objectives: Delirium is a common acute cognitive impairment syndrome among intensive care unit (ICU) patients.This study was aimed to investigate the incidence,risk factors,and cumulative risk of delirium among ICU patients.Methods: A case-control study including clinical records of 452 patients were retrospectively analyzed.Delirium was assessed using the Confusion Assessment Method for the ICU and Richmond Agitation -Sedation Scale.Results: We found that 163 out of the 452 patients (36.1%) had delirium.Multivariate analysis showed that use of sedatives,length of ICU hospitalization,and physical restraint were independent risk factors for delirium.The additive effect of all three factors resulted to an odds ratio of 30.950.Conclusion: The incidence of delirium remained high.Thus,nurses shall strengthen the monitoring of delirium,regularly access the patient's level of calmness,and limit the use of physical restraint.

Sepsis associated delirium mimicking postoperative delirium as the initial presenting symptom of urosepsis in a patient who underwent nephrolithotomy

We report a case of 70 years old male who underwent percutaneous nephrolithotomy for renal calculi.After an uneventful recovery from anaesthesia,the patient developed delirium which manifested as restlessness,agitation,irritability and combative behavior.All other clinical parameters including arterial blood gas,chest X-ray and core temperature were normal and the patient remained haemodynamically stable.But 45 min later the patient developed florid manifestations of septic shock.He was aggressively managed in a protocolized manner as per the Surviving Sepsis Guidelines in the Critical Care Unit and recovered completely.There are no case reports showing postoperative delirium as the only initial presentation of severe sepsis,with other clinical parameters remaining normal.Both urosepsis and sepsis associated delirium have very high mortality.High index of suspicion and a protocolized approach in the management of sepsis can save lives.

Risk factors for delirium after surgery for craniocerebral injury in the neurosurgical intensive care unit

BACKGROUND Postoperative delirium is common in patients who undergo neurosurgery for craniocerebral injury.However,there is no specific medical test to predict postoperative delirium to date.AIM To explore risk factors for postoperative delirium in patients with craniocerebral injury in the neurosurgery intensive care unit(ICU).METHODS A retrospective analysis was performed in 120 patients with craniocerebral injury admitted to Hainan People’s Hospital/Hainan Hospital Affiliated to Hainan Medical University,The First Affiliated Hospital of Hainan Medical University,and The Second Affiliated Hospital of Hainan Medical University between January 2018 and January 2020.The patients were categorized into groups based on whether delirium occurred.Of them,25 patients with delirium were included in the delirium group,and 95 patients without delirium were included in the observation group.Logistic regression analysis was used to explore the association between sex,age,educational level,Glasgow coma scale(GCS),complications(with or without concussion,cerebral contusion,hypoxemia and ventricular compression)and site of injury and delirium.RESULTS The GCS score above 8 and concomitant disease of cerebral concussion,cerebral contusion,hypoxemia and ventricular compression,and damage to the frontal lobe were associated with delirium in patients admitted to neurosurgical intensive care unit(ICU)(all P<0.05).However,age,sex,administration more than three medicines,and educational level were not significantly associated with the onset of delirium in patients with craniocerebral injury in the neurosurgical ICU(P<0.05).Multivariate logistic regression analysis showed that GCS score above 8,cerebral concussion,cerebral contusion,hypoxemia,ventricle compression,and frontal lobe disorders were independent risk factors for delirium in patients with craniocerebral injury in the neurosurgical ICU(P<0.05).CONCLUSION GCS score,concussive concussion,cerebral contusion,hypoxemia,ventricle compression,and damage to frontal lobe are risk factors of postoperative delirium.