Search Results (172)

Background/Objectives: Hip fractures are highly prevalent worldwide, primarily affecting frail elderly patients. Frailty increases the risk of complications like postoperative delirium, which negatively impacts outcomes, including morbidity and mortality. Current recommendations favor a multidisciplinary approach and effective pain control, often using preoperative peripheral nerve blocks. We aimed to evaluate a multimodal approach’s efficacy in reducing postoperative delirium and complications in geriatric hip fracture patients. Methods: This study was conducted between March 2020 and June 2022. A total of 144 patients evaluated prior to the implementation of an optimized clinical pathway protocol (OCPP) were compared to 117 patients evaluated following its implementation. The protocol included early preoperative evaluation, streamlined medication adjustments, prompt surgical intervention and fascia iliaca compartment block (FICB) for analgesia. In addition, early patient mobilization and resumption of oral intake were promoted. The primary outcome was the incidence of delirium during hospitalization. Secondary outcomes were a composite of 30-day mortality or major complications, duration of stay, hospital readmission after discharge and 1-year mortality. Results: The OCPP intervention significantly reduced the incidence of postoperative delirium from 44% to 29% (a 33% relative reduction; p = 0.017), the rate of major complications or death was 14.5% in OCPP group and 25.7% in the control group (p = 0.02). Significantly more patients in the OCPP group were mobilized within 24 h (74.4% vs. 41.3% in the control group, p < 0.001). The median time to ambulation was also shorter in the OCPP group: 65 h (IQR: 39–115) compared to 72 h (IQR: 48–119.75) in the control group (p = 0.028). No differences were observed on hospital stay and 1-year mortality. Conclusions: Among patients undergoing hip fracture repair the implementation of a OCPP significantly reduced the incidence of postoperative delirium and the rate of major complications or death. This improvement was associated with significantly earlier patient mobilization and ambulation. The OCPP was not associated with a lower hospital stay and lower rate of one-year mortality. Full article

Background: Postoperative delirium (POD) is a neurocognitive syndrome affecting patients undergoing surgery. It is a frequent complication of coronary artery bypass grafting (CABG) and is associated with higher morbidity, mortality and treatment costs. This study aimed to investigate the relationship between gaseous microemboli (GME) load during cardiopulmonary bypass (CPB) and subsequent POD in patients undergoing CABG. Methods: In total, 102 patients undergoing elective on-pump CABG were evaluated in this observational study. An ultrasonic microbubble counter, with probes placed on the arterial and venous lines, was used during CPB to evaluate the GME load for each patient. During the first postoperative week, the patients were examined for the presence of POD. Results: Patients diagnosed with POD had higher number of bubbles in the arterial CPB line (5382.8 (4127.8–6637.8) vs. 2389.4 (2033.9–2745.0), p < 0.001), higher volume of bubbles in both the venous (24.2 µL (16.8–31.6) vs. 12.4 µL (9.7–15.1), p = 0.004) and arterial lines (1.82 µL (1.43–2.21) vs. 0.29 µL (0.22–0.36), p < 0.001), lower quality factor (QF) values (p = 0.039), a lower venoarterial reduction in bubble number (83.0% (77.8–88.1) vs. 92.4% (90.9–93.8), p = 0.001) and a lower venoarterial reduction in bubble volume (88.8% (85.4–92.2) vs. 96.3% (95.2–97.3), p < 0.001) compared to the patients without POD. Older age (p = 0.005), a lower reduction in bubble volume (p < 0.001) and lower QF values (p = 0.004) were significant independent predictors of POD. Conclusions: Our findings indicate a strong association between GME and the occurrence of POD, which entails that all available actions should be implemented to prevent their generation and facilitate the elimination of GME from the CPB circuit. Full article

Background/Objectives: Obstructive sleep apnea is a prevalent, yet often underdiagnosed, condition characterized by recurrent upper airway obstruction during sleep, leading to significant perioperative risks in surgical patients. This systematic review aims to evaluate the incidence and impact of objectively diagnosed obstructive sleep apnea on postoperative outcomes across various surgical specialties—including bariatric, orthopedic, cardiac, and otorhinolaryngologic surgeries—and to assess the effectiveness of preoperative screening and perioperative management strategies. Methods: A comprehensive literature search of PubMed was conducted for studies published between January 2013 and December 2024, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies involved adult surgical patients with OSA confirmed by polysomnography or respiratory polygraphy. Studies were assessed for methodological quality using the Oxford Centre for Evidence-Based Medicine Levels of Evidence framework. Results: The findings consistently indicated that obstructive sleep apnea significantly increases the risk of postoperative complications, such as respiratory depression, atrial fibrillation, acute kidney injury, delirium, and prolonged hospital stay. Continuous positive airway pressure therapy demonstrated a protective effect in bariatric and cardiac surgeries, though its effectiveness in orthopedic and otorhinolaryngologic contexts was inconsistent, largely due to adherence variability and limited implementation. Preoperative screening tools such as the STOP-BANG questionnaire were widely used, but their utility depended on integration with confirmatory diagnostics. Conclusions: Obstructive sleep apnea represents a significant, modifiable risk factor in surgical populations. Preoperative identification and risk-adapted perioperative management, including CPAP therapy and multimodal analgesia, may substantially reduce postoperative morbidity. However, further randomized trials and cost-effectiveness studies are needed to optimize care pathways and ensure consistent implementation across surgical disciplines. Full article

Background: Minimized extracorporeal circulation (miECC) was developed to mitigate the adverse effects of cardiopulmonary bypass (CPB), yet its impact on soluble urokinase plasminogen activator receptor (suPAR) is unclear. SuPAR has been linked to adverse outcomes, including acute kidney injury (AKI). This study investigated perioperative suPAR kinetics in patients undergoing cardiac surgery with miECC or conventional CPB (cCPB) and explored its association with AKI, postoperative delirium (POD), and infections. Methods: This study is a secondary analysis of an observational cohort of 79 cardiac surgical patients. It evaluates perioperative suPAR levels and their association with the type of CPB used (miECC vs. cCPB) and postoperative adverse outcomes, including POD, AKI, and infections. Statistical analyses included repeated measures ANOVA, Wilcoxon tests, logistic regression, and ROC curve analysis to assess the predictive value of suPAR for these outcomes. Results: During surgery, suPAR significantly increased to higher levels with the use of cCPB compared to miECC (p = 0.027; odds ratio of 0.69 [0.57–0.84], p < 0.001). The use of miECC was an independent influencing factor on suPAR (−0.41 ± 0.1; p < 0.001). Regardless of the type of CPB, suPAR levels differed significantly between patients with and without kidney damage (n = 25; no AKI: 1.6 [1.1–2.0], AKI: 1.7 [1.3–2.4], p < 0.001). Multivariate regression analysis showed that AKI was an independent influencing factor on suPAR (−0.49 ± 0.1; p < 0.001). SuPAR demonstrated only low predictive value for AKI and could not predict POD. Conclusions: This study provides evidence that miECC is associated with lower intraoperative suPAR levels, suggesting a reduced inflammatory response compared to cCPB. While suPAR levels were significantly higher in patients with AKI, their predictive value for AKI remains limited. Furthermore, suPAR did not predict POD but was elevated in patients with pneumonia. Full article

Objectives: The incidence of postoperative pain in patients that undergo spinal interventions is significantly increased, affecting their functional outcomes and quality of life. Dexmedetomidine (DEX) belongs to the category of centrally acting nonopioid agents with highly selective α2 adrenoreceptor agonist activity that are frequently applied in spinal surgery based on its antinociceptive and anxiolytic properties. Although many studies displayed the effectiveness of DEX in postoperative pain management, the impact of DEX on functional improvement after spinal surgeries is still debatable. Purpose: This systematic review focuses on the intraoperative and postoperative role of dexmedetomidine (DEX) as an analgesic agent in elective and emergency adult spine surgery. Methods: An electronic literature review search was conducted via Web of Science and PubMed to assess the impact of DEX on postoperative pain management, postoperative delirium (POD), and postoperative cognitive dysfunction (POCD). Discussion: Twenty-one studies were retrieved, three of which were review articles. The effects of DEX were studied for up to 48 h postoperatively. In most cases, its administration was associated with reduced intraoperative and postoperative opioid consumption. However, findings on pain control were less conclusive due to heterogeneity in dosing protocols, concomitant medications, the timing of administration, and pain scoring systems. DEX appears to reduce the incidence of POD and POCD, particularly when used in combination with other drugs. Conclusions: Although the present study supports that the intraoperative administration of dexmedetomidine decreases the pain intensity and/or opioid consumption as well as the development of POD and POCD in patients undergoing spinal surgeries during the first 24 h postoperatively, the current literature should be expanded to allow for the safe generalisation of findings over longer follow-up periods. Further research into the neuroprotective, analgesic, and anti-inflammatory roles of DEX is warranted. Full article

Introduction: Postoperative delirium (POD) remains a major complication in geriatric surgical care, with poorly understood molecular mechanisms. Emerging evidence links cardiac surgery to elevated markers of neurologic injury, even in cognitively intact individuals. While neuroinflammation is the prevailing model, a more detailed characterization of the systemic inflammatory and metabolic response to surgery may offer deeper insights into POD pathogenesis. Methods: We used the 7K SomaLogic proteomic platform to analyze preoperative and postoperative day-one serum samples from 78 patients undergoing cardiac surgery with cardiopulmonary bypass. We compared proteomic profiles within individuals (pre- vs. post-surgery) and between those who developed POD and those who did not. Functional analyses were performed to identify relevant biological pathways. A composite metabo-inflammatory score (MIF) was derived to quantify systemic derangement. We modeled the association between POD and age, sex, baseline cognition, and MIF score. Results: Cardiac surgery with CPB was associated with marked inflammatory responses across all subjects, including increased IL-6, CRP, and serum amyloid A. Compared to controls, POD cases showed greater metabo-inflammatory shifts from baseline (average logFC = 2.56, p < 0.001). Lower baseline cognitive scores (OR = 0.74, p = 0.019) and higher MIF scores (OR = 1.03, p = 0.013) were independently associated with increased POD risk. Conclusions: Cardiac surgery with CPB elicits a significant metabo-inflammatory response in all patients. However, those who develop POD exhibit disproportionately greater dysregulation. Full article

Background/Objectives: The use of opioid drugs in the elderly population is characterized by an increased risk of sedation and respiratory depression, and in the immediate postoperative period, it is associated with a higher incidence of postoperative delirium. The dilemma of opioid use as an element of acute postoperative pain therapy is crucial in elderly patients. Methods: This study was conducted in 80 patients qualified for laparoscopic cholecystectomy under general combined anesthesia. Two methods of analgesia were performed—Low-Opioid Analgesia (LOA) and Opioid-Based Analgesia (OBA)—and pain intensity based on the Numerical Rating Scale (NRS) was assessed at 0–2, 2–6, 6–12, and 12–24 h after surgery. The mean NRS in LOA and OBA was compared in age categories. Pain trajectory in patients over 60 years old was compared between LOA and OBA. Results: The trajectory of analgesia presented a negative slope in LOA for patients over 60 years of age, with reductions in pain intensity of 33%, 25%, and 66%. In OBA, a positive slope trajectory was noted, and pain intensity was higher within 12–24 h after surgery than within 0–2 and 2–6 h. Conclusions: Opioid analgesia in patients over 60 years of age presented a better effect in the immediate postoperative period. Non-opioid analgesia is indicated for patients over 60 years old in the later postoperative period. The model of combined minimal opioid anesthesia and non-opioid postoperative analgesia presents a favorable therapeutic effect for patients over 60 years old. Full article

Background: Postoperative delirium is associated with an increased number of different complications, such as prolonged hospital stay, long-term cognitive impairment, and increased mortality. Therefore, early prediction of delirium after percutaneous coronary intervention (PCI) is necessary, but currently, there is still a lack of reliable and effective prediction models for such patients. Methods: All data used in this study were derived from the MIMIC-IV database. Multivariable Cox regression was employed to analyze the data, and the performance of the newly developed nomogram was evaluated based on the area under the receiver operating characteristic curve (AUC). The clinical value of the prediction model was tested using decision curve analysis (DCA). Results: A total of 313 PCI patients in the intensive care unit (ICU) were included in the analysis, comprising 219 in the training cohort and 94 in the testing cohort. Twenty variables were selected for model development. Multivariable Cox regression revealed that benzodiazepine use, vasoactive drug therapy, age, white blood cell count (WBC), and serum potassium were independent risk factors for predicting the occurrence of delirium after PCI. The AUC values for predicting delirium occurrence in the training and validation cohorts were 0.771 and 0.743, respectively. Conclusions: This study has identified several important demographic and laboratory parameters associated with the occurrence of delirium after PCI, and used them to establish a more accurate and convenient nomogram model to predict the occurrence of postoperative delirium in such patients. Full article

Background and Objectives: Postoperative delirium (POD) is a common complication in elderly patients undergoing major surgery, associated with systemic inflammation and potentially influenced by anesthetic techniques. This study investigated whether remimazolam-based total intravenous anesthesia (R-TIVA) reduces the level of systemic inflammatory biomarkers and the incidence of POD more compared to inhalational anesthesia (IA) or balanced anesthesia (BA) in patients aged ≥ 65 years undergoing major non-neurosurgical, non-cardiac surgery. Materials and Methods: This retrospective cohort study analyzed the medical records of 340 patients categorized by anesthesia type: R-TIVA (n = 111), IA (n = 117), or BA (n = 112). Propensity score matching (PSM) created POD (n = 104) and No POD (n = 106) cohorts. Systemic inflammatory biomarkers—the systemic immune–inflammation index (SII), the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP)—were measured pre- and postoperatively. POD was identified by clinical symptoms or the postoperative use of antipsychotics/sedatives. Results: The incidence of POD did not significantly differ among the R-TIVA, IA, and BA groups. However, the postoperative SII, NLR, PLR, and CRP levels were significantly lower in the R-TIVA group compared to those in the IA group (p < 0.05). Both the preoperative (r_pb = 0.72, p < 0.01) and postoperative (r_pb = 0.58, p < 0.01) NLRs were strongly correlated with POD. Higher NLR values predicted the incidence of POD, with odds ratios of 1.71 for preoperative and 1.32 for postoperative measurements. Conclusions: While R-TIVA did not significantly reduce the incidence of POD compared to that of IA or BA, it was associated with reduced levels of postoperative inflammatory biomarkers. The preoperative and postoperative NLRs emerged as strong predictors of POD, suggesting their potential utility in guiding prophylactic strategies for older surgical patients. These findings underscore the interplay between anesthesia type, systemic inflammation, and delirium risk. Full article

Background and Objectives: Postoperative delirium (POD) is a frequent and severe complication following cardiac surgery, particularly in high-risk patients undergoing coronary artery bypass grafting (CABG) and aortic valve replacement (AVR). Despite extensive research, predicting POD remains challenging due to the multifactorial and often non-linear nature of its risk factors. This study aimed to improve POD prediction using an interpretable machine learning approach and to explore the combined effects of clinical, biochemical, and perioperative variables. Materials and Methods: This study included 131 patients who underwent CABG or AVR. POD occurrence was assessed using standard diagnostic criteria. Clinical, biochemical, and perioperative variables were collected, including patient age, sedation type, and mechanical ventilation status. Machine learning analysis was performed using an XGBoost classifier, with model interpretation achieved through SHapley Additive exPlanations (SHAP). Univariate logistic regression was applied to identify significant predictors, while SHAP analysis revealed variable interactions. Results: POD occurred in 34.3% of patients (n = 45). Patients who developed POD were significantly older (67.7 ± 6.5 vs. 64.5 ± 8.7 years, p = 0.020). Sedation with mechanical ventilation and the type of sedative used were strongly associated with POD (both p < 0.001). Sedation during mechanical ventilation showed the strongest association (OR = 2520.0; 95% CI: 80.9–78,506.7; p < 0.00001). XGBoost classifier achieved excellent performance (AUC = 0.998, accuracy = 97.6%, F1 score = 0.976). SHAP analysis identified sedation, mechanical ventilation, and their interactions with fibrinogen, troponin I, leukocyte parameters, and lung infection as key predictors. Conclusions: This study demonstrates that an interpretable machine learning approach can enhance POD prediction, providing insights into the combined impact of multiple clinical, biochemical, and perioperative factors. Integration of such models into perioperative workflows may enable early identification of high-risk patients and support individualized preventive strategies. Full article

Background/Objectives: Postoperative delirium has not been well explored in patients undergoing elective hip and knee arthroplasty. This study assessed the incidence of delirium in these patients in the postanesthetic care unit (PACU) and throughout their hospital admission. Predictors of postoperative delirium and impact of delirium on length of stay were also analyzed. Methods: This prospective observational study recruited patients (n = 978) with normal cognitive function presenting for elective primary hip or knee arthroplasty at a single tertiary academic center. Delirium was assessed using the Nursing Delirium Scoring Scale (NuDESC) in the PACU, and twice daily after that on postoperative days 1, 2 and 3, or until discharge, whichever came first. Results: In total, 26 (2.7%) patients developed delirium postoperatively. Unadjusted logistic regression analyses revealed that age; history of cardiovascular, central nervous system, hematologic, endocrinologic, psychiatric disease; postoperative opioid use; and ASA level were associated with an increased risk of delirium, with odds ratios (95% confidence interval) of 1.7 (1.35 to 2.11), 3.6 (1.09 to 12.25), 3.5 (1.53 to 8.03), 2.7 (1.09 to 6.45), 2.3 (1.04 to 4.97), 4.7 (2.10 to 10.70), 0.4 (0.17 to 0.89), and 2.37 (1.05 to 5.33), respectively. A Mann–Whitney U test showed no difference in PACU or hospital length of stay between patients who did and did not have delirium in the PACU (within the first hour). Conclusions: Age, ASA > 3, a history of cardiovascular disease, central nervous system disease, hematologic disease, endocrinologic disease, psychiatric disease and postoperative opioid use are individually associated with postoperative delirium. A future study with an even larger sample size is needed to further evaluate these factors in an adjusted analysis. Full article

Background/Objectives: Efficient postoperative recovery room care in pediatric patients is crucial for optimizing perioperative safety, patient outcome, and effective pain management. However, this area is frequently underemphasized, leading to higher complication rates compared to the operating room, which in turn increases healthcare costs. Improving pediatric recovery room care offers a significant opportunity to enhance the quality and safety of perioperative pediatric care. From an economic perspective, this is prudent; however, more importantly, every child has the right to the highest attainable standard of health, as outlined by the United Nations. Key aspects of recovery room care include ensuring adequate staffing and equipment, while also prioritizing the child’s privacy and parental presence, both of which are crucial for enhancing patient well-being. A +multimodal approach to postoperative pain management is essential for minimizing fear and stress, alongside strict adherence to established guidelines for the management of postoperative nausea, vomiting, and emergence delirium. Furthermore, addressing risk factors such as hypothermia and airway complications, as well as promoting early intake of clear fluids, plays a crucial role in optimizing pediatric recovery. Organizational strategies such as quality improvement initiatives, structured handovers, standardized care protocols with checklists, continuous staff training, and well-defined discharge criteria are further essential components to reduce translational gaps and to enhance postoperative pediatric safety. Conclusions: Improving pediatric postoperative anesthetic care is a multifaceted challenge for all healthcare providers that can significantly enhance care quality and safety while also reducing costs. Success in this area requires addressing both structural and medical factors. Full article

Background and Objectives: Postoperative delirium (PODil) is a cognitive condition characterized by sudden fluctuations in consciousness and orientation after surgery. PODil following total knee arthroplasty (TKA) is associated with prolonged hospital stays and increased morbidity. Therefore, prevention of PODil is particularly important. Life’s Simple 7 score, published by the American Heart Association, is a new measure of cardiovascular health (CVH). Better CVH is associated with a lower risk of cognitive impairment. Hence, this study aimed to determine whether Life’s Simple 7 score is associated with PODil following TKA. Materials and Methods: This retrospective study included 973 patients who underwent TKA between January 2015 and January 2020. Patients were divided into two groups (group I: delirium group, n = 60; group II: non-delirium group, n = 913). Demographic data, use of analgesics, surgical factors, underlying diseases, laboratory results, and Life’s Simple 7 score were evaluated. Results: Significant differences were observed between the two groups for Parkinson’s disease, intraoperative hypotension, preoperative duloxetine administration, and Life’s Simple 7 score. In the receiver operating characteristic (ROC) curve analysis, the optimal cut-off value for Life’s Simple 7 score was determined to be 8 at the maximal Youden index, with an area under the curve (AUC) of 0.82, a sensitivity of 0.92, and a specificity of 0.58. Conclusions: Lower Life’s Simple 7 score is an independent risk factor for the incidence of PODil after TKA. Given its ease of measurement, Life’s Simple 7 score may be a useful measure for predicting PODil and will aid in preoperative risk assessment and post-operative patient management. Full article

Background: Advancements in surgical care have made it possible to offer cardiac surgery to an older and frailer patient cohort. Frailty has been recognised as a prognostic indicator that impacts post-operative recovery and patient outcomes. The aim of this study is to identify frailty assessment tools, evaluate the impact of frailty on post-operative outcomes, and explore strategies to optimise care for frail patients undergoing cardiac surgery. Methods: A comprehensive literature search was performed across PubMed, MEDLINE, and SCOPUS to identify articles reporting post-operative outcomes related to frail patients undergoing cardiac surgery. Results: Measurement tools such as gait speed, the Clinical Frailty Scale, Fried frailty phenotype, deficit accumulation frailty index and the Short Physical Performance Battery can be used to assess frailty. Frailty has been reported to increase the risk of post-operative morbidity and mortality. Multiple studies have also reported the association between frailty and an increased length of intensive care unit and hospital stays, as well as an increased risk of post-operative delirium. It is important to perform a comprehensive frailty assessment and implement perioperative optimisation strategies to improve outcomes in this patient population. Pre-operative strategies that can be considered include adequate nutritional support, cardiac prehabilitation, and assessing patients using a multidisciplinary team approach with geriatric involvement. Post-operatively, interventions such as early recognition and treatment of post-operative delirium, nutrition optimisation, early planning for cardiac rehabilitation, and occupational therapy can support patients’ recovery and reintegration into daily activities. Conclusions: The early identification of frail patients during the perioperative period is essential for risk stratification and tailored management strategies to minimise the impact of frailty on outcomes following cardiac surgery. Full article

Background/Objectives: Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are prevalent neurological complications following cardiac surgery, significantly affecting patient recovery and long-term outcomes, including increased risk of persistent cognitive impairment, functional decline, and mortality. Understanding the underlying mechanisms and risk factors for POD/POCD is crucial for improving perioperative management. This study aimed to investigate the relationship between postoperative systemic inflammation, assessed through inflammatory markers, and the occurrence of POD and POCD in patients undergoing cardiac surgery. Methods: We prospectively enrolled 88 patients aged 18–79 years undergoing open-heart surgery. Patients with preoperative cognitive impairment or high surgical risk (based on EuroSCORE and SOFA scores) were excluded to focus on the impact of inflammation in a relatively unselected cohort. Postoperative inflammatory responses (CRP, NLR, IL-6, IL-17A, SII, and SIRI) were measured, and patients were assessed for POD (CAM-ICU) and POCD (neuropsychological testing) during hospitalization and at 3 months follow-up. Statistical comparisons were performed between patients who developed POD/POCD and those who did not. Results: Postoperative inflammation was confirmed across the cohort, with significant increases in CRP, NLR, IL-6, SII, and SIRI. While correlational analyses between changes in individual inflammatory markers and POD/POCD were not statistically significant in the entire cohort, patients who developed POD/POCD exhibited significantly higher levels of IL-6 and NLR at 48 h postoperatively (p < 0.05). Established clinical risk factors significantly associated with POD/POCD included older age, prolonged cardiopulmonary bypass (CPB) duration, extended mechanical ventilation, vasopressor support duration, blood transfusion, renal dysfunction, and elevated postoperative creatine kinase (CK) and lactate dehydrogenase (LDH) (p < 0.05). Ejection fraction (EF) < 45% and atrial fibrillation (AF) were also more prevalent in the POD/POCD group. Conclusions: Our findings emphasize the significant role of the postoperative inflammatory response, particularly IL-6 and NLR, in conjunction with established clinical risk factors, in the development of POD and POCD after cardiac surgery. Postoperative IL-6 and NLR levels, readily measurable and cost-effective markers, may contribute to identifying patients at higher risk. Comprehensive perioperative management strategies targeting inflammation, modifiable clinical risk factors, and organ function are crucial for mitigating POD and POCD and improving cognitive outcomes in this vulnerable population. Full article