Background Post-operative delirium (POD) is a specific condition with a high incidence during the postoperative period in patients who underwent cardiovascular surgery. Factors affecting POD, in heart-operated patients, are not well established and instruments for detecting or preventing POD have not yet been identified. This study aims to evaluate if the alteration in pupillary function during open heart surgery, assessed with automated pupillometry, could be predictive of POD. Methods This prospective, monocentric, observational cohort study was conducted at the University Hospital of Verona. Patients who underwent elective open-heart surgery with extracorporeal circulation (CPB) admitted to the Cardio-Intensive Care Unit (ICU) were eligible for the study. Included patients were assessed with an automated pupillometer (Npi-200) ® every 30 minutes from the beginning of surgery until awakening (i.e., Richmond Agitation sedation scale>-3). The CAM-ICU scale, as the primary outcome, was used by medical staff to assess the presence of POD within the first 5 postoperative days. The Ethics Committee of Verona approved this study. Results In this preliminary analysis, we enrolled 45 patients from March 2023 to October 2023 of whom the majority was male (77%) and POD was diagnosed in 30 (15%) of them all. Patients were more likely to develop POD when undergoing valve replacement surgery, and when a longer CPB (118 min vs. 142 min, p=0.12) and aortic cross-clamp (73 min vs 85 min, p=0.10) were observed. NPi was slightly higher in patients with POD compared to others (0.12 (IQR, [-0.21-0.46], p=0.48), but the difference was not significant. Otherwise, the maximum velocity of constriction was well correlated to delirium in the backward stepwise model (OR 0.046, 95% CI 0.003-0.705,p=0.003). rSO2 was found not to be relevant for delirium prediction in our cluster. In a multivariate model comprehensive of variation of NPi combined with other predictors such as age, CBP duration, mechanical ventilation duration, postoperative sodium was found to be predictive for POD (AUC 0.678). Conclusion Automated pupillary monitoring during cardiovascular surgery may be useful in stratification of the risk for delirium in postoperative care. In a multivariate model, NPi combined with other specific cardiovascular prognostic factors is predictive for POD.
Introduzione Il delirio post-operatorio (POD) a seguito di chirurgia cardiaca ha un’incidenza molto elevata tra la I e IV giornata postoperatoria. Ad oggi, non è stata identificata una chiara causa scatenante di POD nel paziente cardiochirurgico né sono stati identificati strumenti in grado di predire il rischio di delirio nei pazienti operati per problematiche cardiochirurgiche. Pertanto, il nostro intento è quello di valutare se alterazioni pupillari, misurate con il pupillometro automatico, durante l’intervento cardiochirurgico siano predittive per POD nel primo periodo post-operatorio. Materiali e metodi Abbiamo condotto uno studio prospettico sperimentale monocentrico presso l’ospedale universitario di Verona. Sono stati reclutati pazienti consecutivi sottoposti a chirurgia cardiaca e ricoverati presso la terapia intensiva cardio-toraco-vascolare. Sono stati inclusi nello studio pazienti adulti sottoposti a chirurgia cardiaca elettiva standard e con tecnica mini-invasiva che comprende l’utilizzo della circolazione extracorporea (CPB). I pazienti arruolati vengono sottoposti a monitoraggio con il pupillometro NPi-200 ® durante l’intervento cardio-chirurgico e fino alla ripresa di coscienza in terapia intensiva(i.e., Richmond Agitation sedation scale>-3). Abbiamo utilizzato la scala CAM-ICU (confusion assessment method-intensive care) nelle prime cinque giornate post-operatorie al fine di valutare la presenza di POD. Il comitato etico di Verona ha approvato lo studio. Risultati I risultati preliminari del nostro studio sono stati effettuati sui pazienti arruolati da marzo 2023 ad ottobre 2023. Abbiamo incluso nell’analisi 45 pazienti di cui la maggioranza è maschile (35,77%) e nella quale abbiamo osservato un’incidenza di delirio pari al 30%(15/45). Nei pazienti che sviluppano POD si sono osservati tempi di assistenza circolatoria (118 min vs. 142 min, p=0.12), e di clampaggio aortico (73 min vs 85 min, p=0.10) prolungati. L’NPi nelle persone che sviluppano delirio, è maggiore di 0.12 (IQR, [-0.21-0.46], p=0.48) rispetto ai pazienti che non lo sviluppano, tuttavia la differenza non è significativa. La variazione di velocità costrizione massima, dal baseline al tempo di CPB, è correlata con delirio (OR 0.046, 95% CI 0.003-0.705,p=0.003). La rSO2 non si è dimostrata efficace nel predire delirio. All’interno di un modello multivariato la variazione di NPi intraoperatoria combinato con altre variabili (durata CPB, età, tempo ventilazione meccanica, sodiemia postoperatoria) ha dimostrato di esser predittivo per POD ( AUC 0.678). Conclusioni L’analisi della variazione pupillare tramite pupillometro automatico durante intervento cardiochirurgico può esser utile nel predire il rischio di delirio postoperatorio. All’interno di un’analisi multivariata l’NPi, insieme ad altre variabili specifiche del paziente, ha dimostrato di esser predittivo per POD.
Il ruolo della pupillometria quantitativa nel predire il delirio postoperatorio in pazienti adulti sottoposti ad intervento cardiochirurgico
Romagnosi, Federico
2024
Abstract
Background Post-operative delirium (POD) is a specific condition with a high incidence during the postoperative period in patients who underwent cardiovascular surgery. Factors affecting POD, in heart-operated patients, are not well established and instruments for detecting or preventing POD have not yet been identified. This study aims to evaluate if the alteration in pupillary function during open heart surgery, assessed with automated pupillometry, could be predictive of POD. Methods This prospective, monocentric, observational cohort study was conducted at the University Hospital of Verona. Patients who underwent elective open-heart surgery with extracorporeal circulation (CPB) admitted to the Cardio-Intensive Care Unit (ICU) were eligible for the study. Included patients were assessed with an automated pupillometer (Npi-200) ® every 30 minutes from the beginning of surgery until awakening (i.e., Richmond Agitation sedation scale>-3). The CAM-ICU scale, as the primary outcome, was used by medical staff to assess the presence of POD within the first 5 postoperative days. The Ethics Committee of Verona approved this study. Results In this preliminary analysis, we enrolled 45 patients from March 2023 to October 2023 of whom the majority was male (77%) and POD was diagnosed in 30 (15%) of them all. Patients were more likely to develop POD when undergoing valve replacement surgery, and when a longer CPB (118 min vs. 142 min, p=0.12) and aortic cross-clamp (73 min vs 85 min, p=0.10) were observed. NPi was slightly higher in patients with POD compared to others (0.12 (IQR, [-0.21-0.46], p=0.48), but the difference was not significant. Otherwise, the maximum velocity of constriction was well correlated to delirium in the backward stepwise model (OR 0.046, 95% CI 0.003-0.705,p=0.003). rSO2 was found not to be relevant for delirium prediction in our cluster. In a multivariate model comprehensive of variation of NPi combined with other predictors such as age, CBP duration, mechanical ventilation duration, postoperative sodium was found to be predictive for POD (AUC 0.678). Conclusion Automated pupillary monitoring during cardiovascular surgery may be useful in stratification of the risk for delirium in postoperative care. In a multivariate model, NPi combined with other specific cardiovascular prognostic factors is predictive for POD.File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.14242/115628
URN:NBN:IT:UNIVR-115628