The use of DSM-IV and ICD-10 criteria and diagnostic scales for delirium among cardiac surgery patients: results from the IPDACS study.

Diagnostic accuracy of different diagnostic systems in estimating the incidence of delirium among surgery patients has not been investigated to date. Therefore, the authors evaluated the frequency of delirium according to DSM-IV and ICD-10 criteria and the cutoff values of the Memorial Delirium Assessment Scale (MDAS) and Delirium Index in 563 patients undergoing cardiac surgery. DSM-IV criteria were found as more inclusive, while ICD-10 criteria were more restrictive in establishing a diagnosis of postoperative delirium. The cutoff scores of 10 on the MDAS and 7 on the Delirium Index were optimal to the presence or absence of delirium.

Incidence and predictors of delirium after cardiac surgery: Results from The IPDACS Study.

OBJECTIVE: Delirium after cardiac surgery is a serious complication that results in higher morbidity and mortality rates, and prolongs hospitalisation. However, the knowledge base regarding the issue of postoperative delirium is still limited. Therefore, in the current study, we evaluated the incidence and independent perioperative risk factors of delirium after cardiac surgery. METHODS: The IPDACS Study recruited 563 consecutive patients undergoing cardiac surgery with cardiopulmonary bypass. The subjects were preoperatively examined by psychiatrists using the Mini-Mental State Examination and the Mini International Neuropsychiatric Interview to assess psychiatric comorbidity. Additionally, other variables connected to the patients' medical condition and surgical and anaesthetic procedures were evaluated. A diagnosis of delirium following surgical intervention was based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. RESULTS: The incidence of postoperative delirium according to DSM-IV criteria was 16.3% (95% confidence interval: 13.5-19.6). Multivariate stepwise logistic regression analysis revealed that advanced age, preoperative cognitive impairment, an ongoing episode of major depression, anaemia, atrial fibrillation, prolonged intubation and postoperative hypoxia were independently associated with delirium after cardiac surgery. CONCLUSION: According to the current analysis, the aforementioned conditions independently predispose to delirium following cardiac surgery. Since some of these factors can be successfully treated and eliminated preoperatively and postoperatively, this study should be helpful in reducing the risk of delirium and in improving the medical care of patients undergoing cardiac surgery (Clinical Trials Identifier: NCT00784576).

Atrial fibrillation as a nonpsychiatric predictor of delirium after cardiac surgery: a pilot study.

BACKGROUND: Preoperative atrial fibrillation (AF) increases the risk of cardiac surgery and the occurrence of postoperative complications, including arrhythmias, low-output syndrome, delirium, and death. The aim was to evaluate its direct influence on prognosis of patients subjected to cardiac surgery. MATERIAL/METHODS: This is a pilot study of the CODACS trial (COnsciousness Disorders After Cardiac Surgery). Two hundred sixty patients admitted for open-heart surgery were prospectively included in the study. Preoperative AF was diagnosed on the basis of multiple electrocardiographic examinations and confirmed by 24-h Holter monitoring. Diagnosis of delirium following surgical intervention was based on DSM-IV criteria. RESULTS: Preoperative AF was diagnosed in 23 patients (8.8%): in 15 patients in the nondelirious group (7%) and 8 (27.0%) in the delirious group. Preoperative AF was an independent predictor of postoperative delirium (p<0.001), increasing its risk of occurrence over sevenfold (OR=7.2). AF also increased the risk of such postoperative complications as supraventricular arrhythmia (AF: 78.3% vs. non-AF: 22.8%, p<0.001), stroke (8.7% vs. 1.3%, p<0.001), and low-output syndrome (21.7% vs. 17.3%, p=0.033) and worsened prognosis, significantly increasing the risk of death (8.7% vs. 0.8%, p<0.001). CONCLUSIONS: Preoperative AF was an independent risk factor of postoperative delirium (OR=7.2). It was also associated with significantly worse postoperative outcome (supraventricular arrhythmia, stroke, low-output syndrome, and risk of death). These results and data from available studies suggest that preoperative AF should be considered as an important predictor of postoperative outcome. This problem should be the subject of future research to establish beneficial treatment options.

Clinical utility and use of DSM-IV and ICD-10 Criteria and The Memorial Delirium Assessment Scale in establishing a diagnosis of delirium after cardiac surgery.

Authors evaluated the sensitivity and specificity of DSM-IV and ICD-10 criteria and the cutoff value of the Memorial Delirium Assessment Scale (MDAS) in diagnosing postoperative delirium in 260 cardiac surgery patients. Incidence of delirium diagnosed on the basis of DSM-IV and ICD-10 criteria, and with the use of the MDAS was 11.5%, 9.2%, and 6.5%, respectively. The DSM-IV criteria for delirium were found to be more inclusive than those of ICD-10. The cutoff point of 10 of the MDAS was optimal in relation to the presence or absence of delirium after cardiac surgery.

Preoperative predictors of delirium after cardiac surgery: a preliminary study.

Preoperative risk factors of postoperative delirium were evaluated in 260 patients admitted for open heart surgery. The incidence of delirium was 11.5%. Independent predictors included cognitive impairment, atrial fibrillation, a history of peripheral vascular disease major depression and advanced age. Aforementioned factors might be helpful in predicting delirium following cardiac surgery.

L-arginine improves hemodynamic function and coronary flow in an experimental model of ischemia-reperfusion injury.

BACKGROUND: Ischemia and reperfusion injury decrease the release of nitric oxide by vessels endothelial cells, which influences postischaemic coronary flow and return of left ventricle haemodynamic function. The study was conducted to answer the question how addition of L-arginine in cardioplegic and reperfusion fluids influences nitric oxide release, inducing the coronary flow and postischaemic haemodynamic heart function. MATERIALS AND METHODS: The research was conducted on 56 rats, divided randomly into seven groups: control (C) and six experimental groups (E), where L-arginine was administrated in increasing doses of 0.3, 3.0 and 30.0 mM/L to cardioplegic (E1, E2 and E3 group) or reperfusion solution (E4, E5 and E6 group). To simulate a course of cardiac surgery the following stages of experiment were carried out: initial perfusion on the nonworking and working heart, cardioplegia, cold cardioplegic arrest and reperfusion of the non-working and working heart. RESULTS: Level of nitric oxide during cardioplegic perfusion decreased in all groups. During reperfusion on non-working and working heart model we noticed the significant increase of nitric oxide for all groups. Along with nitric oxide increase, coronary flow increases, whereas with the decrease of level of nitric oxide, the coronary flow also diminished. During cardioplegic perfusion coronary flow constantly decreased in all groups and during reperfusion we observed the new increase of coronary flow. In groups E1, E2 and E3 the increase of coronary flow was significant. CONCLUSIONS: Obtained data suggest that administration of L-arginine in the preischaemic and in the initial phase of reperfusion stimulates increase in nitric oxide release what is positively correlated with the increase of coronary flow.

[Evaluation of surgical treatment of mitral valve defect in patients with chronic renal failure]. / Ocena wyników leczenia operacyjnego wady zastawki mitralnej u chorych z przewlekla niewydolnoscia nerek.

UNLABELLED: Renal failure of patients qualified for open-heart surgical treatment seems to be very important problem since years. The operation with extracorporeal circulation is large burden for kidneys and there is huge risk of intensifying of existing failure. The aim of the study was the evaluation of renal parameters, complications occurrence and mortality of patients with chronic renal failure (ChRF) (grade II--mild ChRF) subjected to mitral valve replacement. MATERIALS AND METHODS: To retro- and prospective analysis were subjected 34 patients with severe mitral valve defect, subjected to operation between 1998 and 2002 in Department of Cardiac Surgery in Lodz. All patients included to study had increased level of creatinine--1, 5-3, 0 mg/dl (at least in three measurements). All examined patients were subjected to artificial mitral valve replacement and 13 patients to simultaneous tricuspid valve plastic surgery. Postoperative evaluation of clinical condition and renal parameters was performed twice: early (till 30 day after operation) and long-term (after meanly 14 months). RESULTS: In seven patients, in early postoperative period, it was necessary to implement extracorporeal dialysis with artificial kidney dialysis machine. Among these patients we ascertained three deaths (intrahospital mortality was 8.8%). During long-term observation we noted two cases of infective endocarditis requiring reoperation and re-implantation of mitral valve. During this time of observation only one death was noted (post-hospital mortality was 3.2%). CONCLUSIONS: Dysfunction of kidneys, even in mild degree, causes significant increase of risk of early death (about 2.5 times). In most research population in long-term observation we ascertained the large improvement of kidney functions (significant decrease of creatinine level; p < 0.001). Concomitant tricuspid valve regurgitation, requiring plastic surgery is an additional factor incriminating long-term results of surgical treatment.

[Aortic valve replacement in patients with heart failure]. / Wymiana zastawki aortalnej u chorych z niewydolnoscia miesnia serca.

UNLABELLED: Severe aortic regurgitation and stenosis are urgent indication for aortic valve replacement in patients with left ventricular dysfunction, however the effect of cardiac surgery may differ in both groups. The aim of the study was to evaluate the early changes of haemodynamic parameters of heart: ejection fraction, endsystolic and enddiastolic left ventricle diameters, endsystolic and enddiastolic left ventricular wall thickness and left atrium diameter, depending on ejection fraction value (EF), in patients undergoing aortic valve replacement due to isolated aortic stenosis or regurgitation. MATERIALS AND METHODS: 250 patients engaged to the study were subjected to the mechanical aortic valve replacement in Cardiac Surgery Department in Lodz. All patients were divided into two groups--patients operated due to aortic regurgitation and aortic stenosis. Then each group, depending on EF volume before operation, was divided into two subgroups (A - EF between 35 and 50%; B - EF below 35%). RESULTS: Comparing the pre- and early postoperative period, ejection fraction rose markedly in both subgroups of patients with aortic stenosis and the highest increase was ascertained in subgroups A. Analyzing endsystolic and enddiastolic left ventricle diameters we observed the reduction of left ventricle diameters in all groups. Evaluating endsystolic left ventricular wall thickness we observed the increase of wall thickness in both subgroups B. Analogically enddiastolic left ventricular wall thickness increased in all analyzing groups, whereas in groups with lowest fraction the rise was essential. CONCLUSIONS: Aortic valve replacement both due to aortic stenosis and regurgitation is associated with improved haemodynamic status in early postoperative period.

Blood serum levels of IL-2, IL-6, IL-8, TNF-alpha and IL-1beta in patients on maintenance hemodialysis.

Cytokines are essential mediators of immune response and inflammatory reactions. Patients with chronic renal failure (CRF) commonly present with abnormalities of immune function related with impaired kidney function and the accumulation of uremic toxins in addition to bioincompatibility of dialyzer membranes. During a hemodialysis (HD) session, cytokines are released mainly by monocytes activated by endotoxin-type compounds in dialyzer fluid, complement factors and direct contact with dialyzer membrane. The study included 15 CRF patients, aged 36.4 +/- 2.9 years, on regular HD maintenance therapy for mean 68 +/- 10 months and 15 healthy controls. It was designed to assess serum levels of a panel of inflammatory cytokines: IL-1beta, IL-2, IL-6, IL-8 and TNF-alpha in CRF patients on regular maintenance HD before, 20, 60 and 240 minutes of a single HD session in parallel with C-reactive protein (CRP) as an additional parameter. CRP concentration was increased in HD patients when compared with healthy controls. The concentrations of IL-1, IL-6, IL-8 and TNF-alpha were increased, whereas the serum level of IL-2 was not altered during a single HD session.

Risk factors of atrial fibrillation following coronary artery bypass grafting: a preliminary report.

BACKGROUND: To evaluate the risks factors of atrial fibrillation (AF) following coronary artery bypass grafting (CABG). METHODS AND RESULTS: Twelve hundred patients subjected to CABG were included. Postoperative AF developed in 278 patients (23.2%). Statistical analysis identified 5 independent predictors of AF: advanced age, history of supraventricular arrhythmias, preoperative heart failure, operation with standard CABG technique and repeated revascularization. CONCLUSIONS: Postoperative AF caused a significant increase in mortality and hospitalization length. There were 4 independent risk factors of postoperative AF. Administration of beta-blockers and the OPCAB (off-pump CABG) operating technique were identified as protective factors.

[Prevention and treatment of atrial fibrillation following cardiac surgery]. / Zapobieganie i leczenie migotania przedsionków po operacjach serca.

Atrial fibrillation is the most common complications after cardiac surgery, occurring in 20-60% of patients depending on definition and diagnostic methods. Usually appears between 2 and 4 day after operation and often turns back during first 30 days in postoperative time. Treatment of this complication is often protracted, requiring increased monitoring and hospital resources, and extending hospital length of stay Clinical consequences can be significant and include hemodynamic instability and stroke. Recently we can see the increase of atrial fibrillation's frequency occurrence. It is related both with enlargement of patients qualified to cardiac operations and with more and more severe conditions of patients subjected to surgery. Despite of existence unique guidelines there are still many doubts, regarding to choice of antiarrhythmic agent, optimal time of therapy initiation or performing invasive treatment. Atrial fibrillation influences the worsening of patient's postoperative condition (e.g. significantly increasing postoperative mortality) and considerably increases the costs of hospitalization. Therefore competent prevention and suitable treatment of postoperative atrial fibrillation is one of the most important tasks for cardiac surgeons or clinicians who manage the patients after cardiosurgical operations.

[The role of inflammation in the pathogenesis of atherosclerosis]. / Rola zapalenia w patogenezie miazdzycy.

Inflammation plays an important role in the initiation and progression of coronary artery disease and the precipitation of acute coronary events. However, the inflammatory triggers are still poorly understood. Histologically, unstable atherosclerotic plaque contains activated macrophages and T lymphocytes, adhesion molecules, chemokines and cytokines, matrix-degrading enzymes and prothrombotic factors. Circulating inflammatory markers such as C-reactive protein (CRP), fibrinogen, and interleukins (especially IL-6) are increased in high-risk groups of patients and predict future risk.

[The role of infection in the pathogenesis of atherosclerosis]. / Rola zakazeniaw patogenezie miazdzycy.

Experimental models and human studies have supported a role of infection in the initiation of atherosclerosis. There are many known microorganisms who can play an important role in atherosclerosis, but especially two of them--Chlamydia pneumoniae and Cytomegalovirus are suspected to stimulate the process of atheromatosis. Until antibiotics or vaccines are useful in artery diseases prevention, therapies with proven vascular anti-inflammatory effects (diet, exercise, smoking cessation, aspirin, statins) should be optimized.