In-hospital catatonia, delirium, and coma and mortality: Results from the delirium and catatonia prospective cohort investigation.

BACKGROUND: Catatonia, a form of acute brain dysfunction typically linked with severe affective and psychotic disorders, occurs in critical illness with delirium and coma. Delirium and coma are associated with mortality, though catatonia's relationship with mortality is unclear. We aim to describe whether catatonia, delirium, and coma are associated with mortality. METHODS: We enrolled a convenience cohort of critically ill adults (N = 378) at an academic medical center. We assessed catatonia, delirium, and coma using the Bush-Francis Catatonia Rating Scale, the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively. We tested the associations between previous day brain dysfunction state occurrence with in-hospital and one-year mortality using multivariable time-dependent risk models. Additionally, we tested the association between brain dysfunction duration and one-year mortality. RESULTS: Catatonia was not associated with death on the day after diagnosis during hospitalization, and neither previous catatonia occurrence nor duration was associated with one-year mortality. Delirium was not associated with death on any day following diagnosis during hospitalization, and neither previous delirium occurrence nor duration was associated with one-year mortality. The occurrence of coma was associated with death on any day after diagnosis during hospitalization (HR 2.30,CI 1.19-4.44,p = 0.014), as well as through one year following hospital discharge (HR 1.68,CI 1.09-2.59,p = 0.02). CONCLUSIONS: Coma, but neither catatonia nor delirium, was associated with future day in-hospital and one-year mortality. More research is needed to understand catatonia's clinical impact. Delirium results differ from existing literature likely due to cohort demographics and size. Coma results highlight the prognostic significance of suppressed arousal while critically ill.

Serious adverse events and 30-day hospital readmission rate following elective total knee arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Elective total knee arthroplasty (TKA) is a common surgery which has evolved rapidly. However, there are no recent large systematic reviews of serious adverse event (SAE) rate and 30-day readmission rate (30-dRR) or an indication of whether surgical methods have improved. METHODS: To obtain a pooled estimate of SAE rate and 30-dRR following TKA, we searched Medline, Web of Science, Cochrane Library, and Google Scholar databases. Data were extracted by two authors following PRISMA guidelines. Eligibility criteria were defined prior to a comprehensive search. Studies were eligible if they were published in 2007 or later, described sequelae of TKA with patient N > 1000, and the SAE or 30-dRR rate could be calculated. SAEs included return to operating room, death or coma, venous thromboembolism (VTE), deep infection or sepsis, myocardial infarction, heart failure or cardiac arrest, stroke or cerebrovascular accident, or pneumonia. RESULTS: Of 248 references reviewed, 28 are included, involving 10,153,503 patients; this includes 9,483,387 patients with primary TKA (pTKA), and 670,116 patients with revision TKA (rTKA). For pTKA, the SAE rate was 5.7% (95% CI 4.4-7.2%, I2 = 100%), and the 30-dRR was 4.8% (95% CI 4.3-5.4%, I2 = 100%). For rTKA, the SAE rate was 8.5% (95% CI 8.3-8.7%, I2 = 77%), while the 30-dRR was 7.2% (95% CI 6.4-8.0%, I2 = 81%). Odds of 30-dRR following pTKA were about half that of rTKA (OR 0.57, 95% CI 0.53-0.62%, p < 0.001, I2 = 45%). Of patients who received pTKA, the commonest SAEs were VTE (1.22%; 95% CI 0.83-1.70%) and genitourinary complications including renal insufficiency or renal failure (1.22%; 95% CI 0.83-1.67%). There has been significant improvement in SAE rate and 30-dRR since 2010 (χ2 test < 0.001). CONCLUSIONS: TKA procedures have a relatively low complication rate, and there has been a significant improvement in SAE rate and 30-dRR over the past decade.

Prevalence and risk factors for delirium in critically ill patients with COVID-19 (COVID-D): a multicentre cohort study.

BACKGROUND: To date, 750 000 patients with COVID-19 worldwide have required mechanical ventilation and thus are at high risk of acute brain dysfunction (coma and delirium). We aimed to investigate the prevalence of delirium and coma, and risk factors for delirium in critically ill patients with COVID-19, to aid the development of strategies to mitigate delirium and associated sequelae. METHODS: This multicentre cohort study included 69 adult intensive care units (ICUs), across 14 countries. We included all patients (aged ≥18 years) admitted to participating ICUs with severe acute respiratory syndrome coronavirus 2 infection before April 28, 2020. Patients who were moribund or had life-support measures withdrawn within 24 h of ICU admission, prisoners, patients with pre-existing mental illness, neurodegenerative disorders, congenital or acquired brain damage, hepatic coma, drug overdose, suicide attempt, or those who were blind or deaf were excluded. We collected de-identified data from electronic health records on patient demographics, delirium and coma assessments, and management strategies for a 21-day period. Additional data on ventilator support, ICU length of stay, and vital status was collected for a 28-day period. The primary outcome was to determine the prevalence of delirium and coma and to investigate any associated risk factors associated with development of delirium the next day. We also investigated predictors of number of days alive without delirium or coma. These outcomes were investigated using multivariable regression. FINDINGS: Between Jan 20 and April 28, 2020, 4530 patients with COVID-19 were admitted to 69 ICUs, of whom 2088 patients were included in the study cohort. The median age of patients was 64 years (IQR 54 to 71) with a median Simplified Acute Physiology Score (SAPS) II of 40·0 (30·0 to 53·0). 1397 (66·9%) of 2088 patients were invasively mechanically ventilated on the day of ICU admission and 1827 (87·5%) were invasively mechanical ventilated at some point during hospitalisation. Infusion with sedatives while on mechanical ventilation was common: 1337 (64·0%) of 2088 patients were given benzodiazepines for a median of 7·0 days (4·0 to 12·0) and 1481 (70·9%) were given propofol for a median of 7·0 days (4·0 to 11·0). Median Richmond Agitation-Sedation Scale score while on invasive mechanical ventilation was -4 (-5 to -3). 1704 (81·6%) of 2088 patients were comatose for a median of 10·0 days (6·0 to 15·0) and 1147 (54·9%) were delirious for a median of 3·0 days (2·0 to 6·0). Mechanical ventilation, use of restraints, and benzodiazepine, opioid, and vasopressor infusions, and antipsychotics were each associated with a higher risk of delirium the next day (all p≤0·04), whereas family visitation (in person or virtual) was associated with a lower risk of delirium (p<0·0001). During the 21-day study period, patients were alive without delirium or coma for a median of 5·0 days (0·0 to 14·0). At baseline, older age, higher SAPS II scores, male sex, smoking or alcohol abuse, use of vasopressors on day 1, and invasive mechanical ventilation on day 1 were independently associated with fewer days alive and free of delirium and coma (all p<0·01). 601 (28·8%) of 2088 patients died within 28 days of admission, with most of those deaths occurring in the ICU. INTERPRETATION: Acute brain dysfunction was highly prevalent and prolonged in critically ill patients with COVID-19. Benzodiazepine use and lack of family visitation were identified as modifiable risk factors for delirium, and thus these data present an opportunity to reduce acute brain dysfunction in patients with COVID-19. FUNDING: None. TRANSLATIONS: For the French and Spanish translations of the abstract see Supplementary Materials section.

Impact of Videolaryngoscopy Expertise on First-Attempt Intubation Success in Critically Ill Patients.

OBJECTIVES: The use of a videolaryngoscope in the ICU on the first endotracheal intubation attempt and intubation-related complications is controversial. The objective of this study was to evaluate the first intubation attempt success rate in the ICU with the McGrath MAC videolaryngoscope (Medtronic, Minneapolis, MN) according to the operators' videolaryngoscope expertise and to describe its association with the occurrence of intubation-related complications. DESIGN: Observational study. SETTING: Medical ICU. SUBJECTS: Consecutive endotracheal intubations in critically ill patients. INTERVENTIONS: Systematic use of the videolaryngoscope. MEASUREMENTS AND MAIN OUTCOMES: We enrolled 202 consecutive endotracheal intubations. Overall first-attempt success rate was 126 of 202 (62%). Comorbidities, junior operator, cardiac arrest upon admission, and coma were associated with a lower first-attempt success rate. The first-attempt success rate was less than 50% in novice operators (1-5 previous experiences with videolaryngoscope, independently of airway expertise with direct laryngoscopies) and 87% in expert operators (> 15 previous experiences with videolaryngoscope). Multivariate analysis confirmed the association between specific skill training with videolaryngoscope and the first-attempt success rate. Severe hypoxemia and overall immediate intubation-related complications occurred more frequently in first-attempt failure intubations (24/76, 32%) than in first-attempt success intubations (14/126, 11%) (p < 0.001). CONCLUSIONS: We report for the first time in the critically ill that specific videolaryngoscopy skill training, assessed by the number of previous videolaryngoscopies performed, is an independent factor of first-attempt intubation success. Furthermore, we observed that specific skill training with the McGrath MAC videolaryngoscope was fast. Therefore, future trials evaluating videolaryngoscopy in ICUs should consider the specific skill training of operators in videolaryngoscopy.

10 Years of Implementation of the "Glasgow 7" Quality Guarantee Program in the Mendoza Central Hospital: Epidemiology and Evolution of Neurocrytic Patients.

INTRODUCTION: In 2003, the Glasgow 7 Quality Guarantee Program was put into effect in Argentina with the objective of standardizing the donation and transplant process throughout the country, establishing the observation and registration of all neurocritical patients with a score on the Glasgow Coma Scale of 7 of 15 or less admitted to critical beds of selected establishments. MATERIALS AND METHODS: The following study is retrospective, observational, and cohort-based. It was developed in the Central Hospital of Mendoza, in the critical units, including guard, coronary, cardiovascular surgery recovery, and intensive care therapy. The inclusion criteria were admission to the institution with a score on the Glasgow Coma Scale of 7 or less with a structural cause of coma. Data collection was carried out in the national online database SINTRA. RESULTS: From January 1, 2008, to December 31, 2018, 1757 patients were enrolled at the Central Hospital of Mendoza, Argentina with Glasgow scores of 7 or less. The most frequent cause of coma was brain trauma (934 patients; 53%), followed by stroke (614 patients; 35%). Of those who scored 3 of 15 in the GCS upon admission, 65% progressed to brain death, whereas 72% of those who scored 7 were discharged. Of all these patients, 270 became donors, accounting for 43% of all brain deaths, whereas 187 had refused to become organ donors (30.6%). Of the total real donors, 55% were multiorganic (150 donors).

Biomarkers of Delirium Duration and Delirium Severity in the ICU.

OBJECTIVES: Both delirium duration and delirium severity are associated with adverse patient outcomes. Serum biomarkers associated with delirium duration and delirium severity in ICU patients have not been reliably identified. We conducted our study to identify peripheral biomarkers representing systemic inflammation, impaired neuroprotection, and astrocyte activation associated with delirium duration, delirium severity, and in-hospital mortality. DESIGN: Observational study. SETTING: Three Indianapolis hospitals. PATIENTS: Three-hundred twenty-one critically ill delirious patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed the associations between biomarkers collected at delirium onset and delirium-/coma-free days assessed through Richmond Agitation-Sedation Scale/Confusion Assessment Method for the ICU, delirium severity assessed through Confusion Assessment Method for the ICU-7, and in-hospital mortality. After adjusting for age, gender, Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity score, sepsis diagnosis and study intervention group, interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100ß levels in quartile 4 were negatively associated with delirium-/coma-free days by 1 week and 30 days post enrollment. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium-/coma-free days at both time points. Interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100ß levels in quartile 4 were also associated with delirium severity by 1 week. At hospital discharge, interleukin-6, -8, and -10 retained the association but tumor necrosis factor-α, C-reactive protein, and S-100ß lost their associations with delirium severity. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium severity at both time points. Interleukin-8 and S-100ß levels in quartile 4 were also associated with higher in-hospital mortality. Interleukin-6 and -10, tumor necrosis factor-α, and insulin-like growth factor-1 were not found to be associated with in-hospital mortality. CONCLUSIONS: Biomarkers of systemic inflammation and those for astrocyte and glial activation were associated with longer delirium duration, higher delirium severity, and in-hospital mortality. Utility of these biomarkers early in delirium onset to identify patients at a higher risk of severe and prolonged delirium, and delirium related complications during hospitalization needs to be explored in future studies.

Preoperative STOP-BANG Scores and Postoperative Delirium and Coma in Thoracic Surgery Patients.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with higher rates of postoperative delirium. The relationship between preoperative OSA risk and postoperative delirium and coma in thoracic surgery patients hospitalized in the intensive care unit (ICU) is not well understood. This study tests the hypothesis that thoracic surgery patients hospitalized in ICU with a higher preoperative risk for OSA are more likely to develop postoperative delirium and coma, resulting in longer hospital stays. METHODS: Preoperative OSA risk was measured using the STOP-BANG questionnaire. STOP-BANG scores of greater than or equal to 3 were defined as intermediate-high risk for OSA; 128 patients who underwent major thoracic surgery completed the STOP-BANG questionnaire preoperatively. The Richmond Agitation and Sedation Scale was used to assess level of consciousness. The Confusion Assessment Method for the ICU was used to assess for delirium. Linear regression was used to assess the relationship between risk of OSA and outcome measures. Results were adjusted for age, sex, body mass index, Charlson Comorbidity Index, instrumental activities of daily living, and surgery type. RESULTS: A total of 96 of 128 patients (76%) were in the intermediate-high-risk OSA group. Adjusted analyses showed that the intermediate-high-risk OSA group had a longer duration of postoperative ICU delirium and coma compared with the low-risk OSA group (1.4 ± 1.3 days versus 0.9 ± 1.4 days; P = 0.04). Total number of hospital days was not significantly different. CONCLUSIONS: Higher preoperative risk for OSA in thoracic surgery patients was associated with a longer duration of postoperative delirium and coma.

Predictors of Stroke and Coma After Neurosurgery: An ACS-NSQIP Analysis.

OBJECTIVE: The American College of Surgeons National Surgical Quality Improvement Program database aims to reduce 30-day postoperative complications. Reduction of postoperative stroke and coma can decrease length and cost of hospitalization, improve patient functional status, and decrease morbidity and mortality. METHODS: We performed a search of the American College of Surgeons National Surgical Quality Improvement Program database for all patients from 2006 to 2013 undergoing an operation with a surgeon whose primary specialty was neurologic surgery. RESULTS: Of 94,546 neurosurgical patients reported, there were 687 (0.73%) cases of postoperative stroke and coma. The annual rate of coma longer than 24 hours decreased from 0.90% in 2006 to 0.002% in 2013 (P < 0.001), and the annual rate of stroke decreased from 1.2% in 2006 to 0.5% in 2013 (P = 0.013). Multivariate analysis showed that inpatient status (P = 0.001; odds ratio [OR], 30.3), age (P = 0.005; OR, 1.012), history of diabetes (P = 0.017; OR, 1.515), ventilator dependence (P < 0.001; OR, 4.379), impaired sensorium (P < 0.001; OR, 2.314), history of coma longer than 24 hours (P < 0.001; OR, 2.655), hemiparesis (P = 0.022; OR, 1.492), cerebrovascular accident/stroke with neurologic deficit (P < 0.001; OR, 2.091), cerebrovascular accident/stroke without neurologic deficit (P = 0.001; OR, 2.44), and tumor involving central nervous system (P < 0.001; OR, 2.928) are significant risk factors for developing postneurosurgical stroke and coma. CONCLUSIONS: The rate of postneurosurgical stroke decreased from 1.2% in 2006 to 0.5% in 2013 and the rate of postneurosurgical coma greater than 24 hours decreased from 0.9% in 2006 to 0.002% in 2013. Ten risk factors for developing postneurosurgical stroke and coma were identified using multivariable analysis. These risk factors should be assessed preoperatively and incorporated into clinical decision making so that individuals who are at higher risk for the development of stroke and coma can be appropriately monitored during the postoperative period.

Prognosis of patients in coma after acute subdural hematoma due to ruptured intracranial aneurysm.

Acute subdural hematomas (aSDH) secondary to intracranial aneurysm rupture are rare. Most patients present with coma and their functional prognosis has been classically considered to be very poor. Previous studies mixed good-grade and poor-grade patients and reported variable outcomes. We reviewed our experience by focusing on patients in coma only and hypothesized that aSDH might worsen initial mortality but not long-term functional outcome. Between 2005 and 2013, 440 subarachnoid hemorrhage (SAH) patients were admitted to our center. Nineteen (4.3%) were found to have an associated aSDH and 13 (2.9%) of these presented with coma. Their prospectively collected clinical and outcome data were reviewed and compared with that of 104 SAH patients without aSDH who presented with coma during the same period. Median aSDH thickness was 10mm. Four patients presented with an associated aneurysmal cortical laceration and only one had good recovery. Overall, we observed good long-term outcomes in both SAH patients in coma with aSDH and those without aSDH (38.5% versus 26.4%). Associated aSDH does not appear to indicate a poorer long-term functional prognosis in SAH patients presenting with coma. Anisocoria and brain herniation are observed in patients with aSDH thicknesses that are smaller than those observed in trauma patients. Despite a high initial mortality, early surgery to remove the aSDH results in a good outcome in over 60% of survivors. Aneurysmal cortical laceration appears to be an independent entity which shows a poorer prognosis than other types of aneurysmal aSDH.

Admission Hyperglycemia and Clinical Outcome in Cerebral Venous Thrombosis.

BACKGROUND AND PURPOSE: Admission hyperglycemia is associated with poor clinical outcome in ischemic and hemorrhagic stroke. Admission hyperglycemia has not been investigated in patients with cerebral venous thrombosis. METHODS: Consecutive adult patients with cerebral venous thrombosis were included at the Academic Medical Center, The Netherlands (2000-2014) and the Helsinki University Central Hospital, Finland (1998-2014). We excluded patients with known diabetes mellitus and patients without known admission blood glucose. We defined admission hyperglycemia as blood glucose ≥7.8 mmol/L (141 mg/dL) and severe hyperglycemia as blood glucose ≥11.1 mmol/L (200 mg/dL). We used logistic regression analysis to determine if admission hyperglycemia was associated with modified Rankin Scale (mRS) score of 3 to 6 or mortality at last follow-up. We adjusted for: age, sex, coma, malignancy, infection, intracerebral hemorrhage, deep cerebral venous thrombosis, and location of recruitment. RESULTS: Of 380 patients with cerebral venous thrombosis, 308 were eligible. Of these, 66 (21.4%) had admission hyperglycemia with 8 (2.6%) having severe admission hyperglycemia. Coma (31.3% versus 5.0%, P<0.001) and intracerebral hemorrhage (53.0% versus 32.6%, P=0.002) at presentation were more common among patients with admission hyperglycemia than normoglycemic patients. Patients with admission hyperglycemia had a higher risk of mRS score of 3 to 6 (adjusted odds ratio, 3.10; 95% confidence interval, 1.35-7.12) and mortality (adjusted odds ratio, 4.13; 95% confidence interval, 1.41-12.09). Severe hyperglycemia was even more strongly associated with mRS score of 3 to 6 (adjusted odds ratio, 11.59; 95% confidence interval, 1.74-77.30) and mortality (adjusted odds ratio, 33.36; 95% confidence interval, 3.87-287.28) compared with normoglycemic patients. CONCLUSIONS: Admission hyperglycemia is a strong predictor of poor clinical outcome in patients with cerebral venous thrombosis.

Chronic subdural haematoma associated with disturbance of consciousness: significance of acute-on-chronic subdural haematoma.

OBJECTIVE: Detailed features of chronic subdural haematoma (cSDH) associated with disturbance of consciousness and acute-on-chronic subdural haematoma (a/cSDH), in which acute subdural haematoma overlaps cSDH, remain poorly understood. The object of this study was to clarify both characteristics of cSDH associated with disturbance of consciousness and the significance of a/cSDH. METHODS: Clinical factors and computed tomography (CT) findings were retrospectively investigated in 349 consecutive patients admitted between 2006 and 2013 and diagnosed with cSDH. RESULTS: Glasgow Coma Scale (GCS) was ≤ 8 in 21 patients (6.0%) and 9-14 in 29 patients excluding aphasia and/or dementia (8.3%). Multiple logistic regression analysis indicated that a/cSDH, female sex and haemodialysis were significantly related to severe disturbance of consciousness (GCS ≤ 8). Predictors for a/cSDH observed in 29 patients (8.3%) were trauma history within 7 days before admission, high prothrombin time-international rate, and use of anticoagulants and/or antiplatelets. Unfavourable outcomes were observed in 29 of 299 patients (9.7%) without consciousness disturbance, compared to 27 of 50 patients (54%) with consciousness disturbance. Predictors of unfavourable outcome were consciousness disturbance, increase in age, malignancy, trauma history within 7 days and haemodialysis. DISCUSSION: Disturbance of consciousness associated with cSDH, often caused by either a/cSDH or concomitant disease, frequently resulted in unfavourable outcomes. As a result, in cSDH patients associated with disturbance of consciousness, underlying conditions, especially a/cSDH, which is often caused by haemostatic abnormality, should be clarified and managed.

Temporal trends in critical events complicating HIV infection: 1999-2010 multicentre cohort study in France.

PURPOSE: Multicentre data are limited to appraise the management and prognosis of critically ill human immunodeficiency virus (HIV)-infected patients. We sought to describe temporal trends in demographic and clinical characteristics, indications for intensive care and outcome in this patient population. METHODS: We conducted a cohort study of unselected HIV-infected patients admitted between 1999 and 2010 to 34 French ICUs contributing to the CUB-Réa prospective database. RESULTS: We included 6,373 consecutive patients. Over the 12-year period, increases occurred in median age (39 years in 1999-2001; 47 years in 2008-2010, p < 0.0001) and prevalence of comorbidities (notably malignancies, from 6.7 to 16.4%, p < 0.0001). Admissions for respiratory failure (39.8% overall), shock (8.1%) and coma (22.7%) decreased (p < 0.0001), while those for sepsis (19.3%) remained stable. The main final diagnoses were bacterial sepsis (24.6%) and non-bacterial acquired immune deficiency syndrome (AIDS)-defining diseases (steady decline from 26.0 to 17.5%, p < 0.0001). Patients increasingly received mechanical ventilation (from 42.9 to 54.0%) and renal replacement therapy (from 9.6 to 16.8%) (p < 0.0001), whereas vasopressor use remained stable (27.4%). ICU readmissions increased after 2004 (p < 0.0001). ICU and hospital mortality (17.6 and 26.9%, respectively) dropped markedly in the most severely ill patients requiring multiple life-sustaining therapies. Malignancies and chronic liver disease were heavily associated with hospital mortality by multivariate analysis, while the most common AIDS-defining complications (Pneumocystis jirovecii pneumonia, cerebral toxoplasmosis and tuberculosis) had no independent impact. CONCLUSIONS: Progressive ageing, increasing prevalence of comorbidities (mainly malignancies), a steady decline in AIDS-related illnesses and improved benefits from life-sustaining therapies were the main temporal trends in HIV-infected patients requiring ICU admission.

Morbidity and mortality after massive transfusion in patients undergoing non-cardiac surgery.

BACKGROUND: Massive transfusion is associated with high morbidity and mortality, yet existing reports of massive transfusion are limited. Our primary aim was to determine the incidence of complications and 30-day mortality among patients who received massive transfusions and to explore risk factors associated with 30-day mortality. METHODS: We evaluated 971,455 patients from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. We assessed the associations between 30-day mortality and baseline, intraoperative, and postoperative factors among 5,143 patients who received massive transfusions and for whom complete data were available. RESULTS: The crude 30-day postoperative mortality of the non-transfused, low transfusion (1-4 units), and massive transfusion (≥ 5 units) patients in the NSQIP was 1.2%, 8.9%, and 21.5%, respectively. Of the 5,143 massive transfusion patients with non-missing covariable data, 17% (95% confidence interval [CI] 16% to 18%) died within 30 days of surgery, while 54% (95% CI 53% to 56%) had at least one non-fatal major complication. The following baseline and intraoperative variables were independently associated with 30-day mortality after adjusting for multiple testing: age, American Society of Anesthesiologists (ASA) physical status, emergency case, surgical types, coma > 24 hr before surgery, systemic sepsis, preoperative international normalized ratio of prothrombin time, the number of intraoperative transfusions, and requirement of postoperative transfusion. CONCLUSION: Massive transfusion is associated with substantial risk for respiratory and infectious complications and for mortality. Patients who died within 30 days of a massive perioperative transfusion were generally older, more likely to have vascular surgical procedure and abnormal international normalized ratio of prothrombin time, higher ASA physical status, preoperative coma and sepsis, and higher postoperative bleeding requiring transfusion, and they were likely given more intraoperative red cell units.

Long-lasting functional disabilities in patients who recover from coma after cardiac operations.

BACKGROUND: Uncertainty regarding the long-term functional outcome of patients who awaken from coma after cardiac operations is difficult for families and physicians and may delay rehabilitation. We studied the long-term functional status of these patients to determine if duration of coma predicted outcome. METHODS: We followed 71 patients who underwent cardiac operations; recovered their ability to respond to verbal commands after coma associated with postoperative stroke, encephalopathy, and/or seizures; and were discharged from the hospital. The Glasgow Outcome Scale Extended (GOSE) was used to assess functional disability 2 to 4 years after discharge. Outcomes were classified as favorable (GOSE scores 7 and 8) and unfavorable (GOSE scores 1-6). RESULTS: Of 71 patients identified, 39 were interviewed, 15 died, 1 refused to be interviewed, and 16 were lost to follow-up. Of the 54 patients with completed GOSE evaluations, only 15 (28%) had favorable outcomes. Among patients with unfavorable outcomes, 15 (28%) died, 14 (26%) survived with moderate disabilities, and 10 (18%) had severe disabilities. Factors associated with unfavorable outcomes were increases in duration of coma (p = 0.007), time in intensive care (p = 0.006), length of hospitalization (p = 0.004), and postoperative serum creatine kinase levels (p = 0.006). Only duration of coma was an independent predictor of unfavorable outcome (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.008-1.537; p = 0.042). Patients with durations of coma greater than 4 days were more likely to have unfavorable outcomes (OR, 5.1; 95% CI, 1.3-21.3; p = 0.02). CONCLUSIONS: Two thirds of comatose patients who survived to discharge after cardiac operations had unfavorable long-term functional outcomes. A longer duration of unconsciousness is a predictor of unfavorable outcome.

Incidence, predictors and outcomes of postoperative coma: an observational study of 858,606 patients.

CONTEXT: Coma is a state of profound unresponsiveness that can occur as a serious perioperative complication. The study of risk factors for, and sequelae of, postoperative coma has been limited due to the rarity of the event. OBJECTIVE: To determine the incidence, risk factors and impact of postoperative coma in a large patient population. DESIGN: Observational study using a prospectively gathered national dataset. PATIENTS: Data from 858 606 patients were analysed. MAIN OUTCOME MEASURES: The incidence of postoperative coma of more than 24-h duration was identified. Logistic regression was used to identify independent predictors and develop a risk model of postoperative coma in derivation and validation cohorts; 30-day mortality was also analysed. RESULTS: The incidence of postoperative coma was 0.06%. Multivariate analysis revealed the following independent predictors: liver disease, systemic sepsis, age at least 63 years, renal disease, emergency operation, cardiac disease, hypertension, prior neurological disease, diabetes mellitus and BMI 25 to 29.99 kg m (protective). These predictors were incorporated into a risk index classification; odds ratios for postoperative coma increased from 2.5 with one risk factor to 18.4 with three. Coma was associated with 74.2% all-cause mortality; coma associated with cardiac arrest had a 1.9-fold higher mortality. CONCLUSION: This is the largest study of postoperative coma ever reported and will be useful for determining risk of coma of more than 24 h duration when evaluating an unresponsive patient following surgery. Data on prognosis will aid medical and ethical decision-making for the comatose surgical patient.

Delirium in the cardiovascular ICU: exploring modifiable risk factors.

OBJECTIVE: Delirium, an acute organ dysfunction, is common among critically ill patients leading to significant morbidity and mortality; its epidemiology in a mixed cardiology and cardiac surgery ICU is not well established. We sought to determine the prevalence and risk factors for delirium among cardiac surgery ICU patients. DESIGN: Prospective observational study. SETTING: Twenty-seven-bed medical-surgical cardiac surgery ICU. PATIENTS: Two hundred consecutive patients with an expected cardiac surgery ICU length of stay >24 hrs. INTERVENTIONS: None. MEASUREMENTS: Baseline demographic data and daily assessments for delirium using the validated and reliable Confusion Assessment Method for the ICU were recorded, and quantitative tracking of delirium risk factors were conducted. Separate analyses studied the role of admission risk factors for occurrence of delirium during the cardiac surgery ICU stay and identified daily occurring risk factors for the development of delirium on a subsequent cardiac surgery ICU day. MAIN RESULTS: Prevalence of delirium was 26%, similar among cardiology and cardiac surgical patients. Nearly all (92%) exhibited the hypoactive subtype of delirium. Benzodiazepine use at admission was independently predictive of a three-fold increased risk of delirium (odds ratio 3.1 [1, 9.4], p = 0.04) during the cardiac surgery ICU stay. Of the daily occurring risk factors, patients who received benzodiazepines (2.6 [1.2, 5.7], p = 0.02) or had restraints or devices that precluded mobilization (2.9 [1.3, 6.5], p < 0.01) were more likely to have delirium the following day. Hemodynamic status was not associated with delirium. CONCLUSIONS: Delirium occurred in one in four patients in the cardiac surgery ICU and was predominately hypoactive in subtype. Chemical restraints via use of benzodiazepines or the use of physical restraints/restraining devices predisposed patients to a greater risk of delirium, pointing to areas of quality improvement that would be new to the vast majority of cardiac surgery ICUs.

Predictors of duration of unconsciousness in patients with coma after cardiac surgery.

OBJECTIVES: To describe clinical and brain imaging characteristics of patients who recovered and did not recover consciousness from a coma after cardiac surgery and to investigate predictors of the duration of unconsciousness in those patients who ultimately recovered consciousness. DESIGN: A retrospective analysis from a cohort of patients who developed coma after cardiac surgery. SETTING: A single university hospital. PARTICIPANTS: One hundred twelve patients with postoperative stroke, encephalopathy, and/or seizures who remained in coma longer than 24 hours after cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors analyzed the patients' perioperative and intraoperative characteristics, laboratory values, noncontrast head computed tomography (CT) scans, and outcomes. Patients who did not recover consciousness (n = 16) were more likely to have been classified preoperatively as New York Heart Association class III/IV (p = 0.037). In patients who recovered consciousness (n = 96), only increased preoperative serum creatinine was an independent predictor of a longer duration of unconsciousness (p = 0.011). In patients who eventually recovered consciousness and had no acute findings on brain imaging, preoperative creatinine (p = 0.014), the lowest postoperative hemoglobin (p = 0.039), and surgical emergency (p = 0.045) were independent predictors of the duration of unconsciousness (p = 0.002). In patients who regained consciousness but had acute findings on brain imaging, cardiogenic shock (p = 0.012) and the insertion of an intra-aortic balloon pump before or during surgery (p = 0.025) predicted longer durations of unconsciousness (p < 0.001). CONCLUSIONS: In patients who ultimately recovered consciousness after being in a coma for at least 24 hours after cardiac surgery and have no abnormality on a brain CT scan, elevated preoperative serum creatinine, urgent cardiac surgery, and lower postoperative hemoglobin were correlated with an increased duration of unconsciousness.

Central neurological complications in critically ill patients with malignancies.

OBJECTIVE: To determine outcomes in critically ill patients hospitalized in the ICU for central neurological complications of cancer. DESIGN AND SETTING: A 7-year retrospective study. SUBJECT AND INTERVENTION: Observational study in 100 critically ill cancer patients with central neurological complications managed using standardized diagnostic and therapeutic strategies. MEASUREMENTS AND RESULTS: There were 52 men and 48 women, aged 55 years (IQR, 40-65). Presenting manifestations were coma (56%), epilepsy (48%), focal signs (35%), encephalopathy (31%), and meningitis (7%). Cerebral imaging was abnormal in 61 patients, lumbar puncture in 17, and electroencephalography in 6. Neurosurgical biopsy was performed on four patients. The main etiologies included drug toxicity in 28, malignant brain infiltration in 21 patients, and cerebrovascular disease in 20. Mechanical ventilation was needed for 60 patients. Anticancer chemotherapy was administered during the ICU stay in 15 patients. ICU and hospital mortalities were 28 and 45%, respectively. By multivariate analysis, independent positive predictors of hospital mortality were poor performance status [odds ratio (OR) 2.94, 95% CI, 1.01-8.55, P = 0.047), focal signs at presentation (OR 3.52, 95% CI, 1.14-10.88, P = 0.029), abnormal lumbar puncture (OR 5.49, 95% CI 1.09-27.66, P = 0.038), and need for vasoactive drugs (OR 6.47, 95% CI 1.32-31.66, P = 0.021), whereas remission of the malignancy (OR 0.20, 95% CI 0.04-0.88, P = 0.033) and GCS score at admission (OR 0.81/point, 95% CI, 0.70-0.95, P = 0.009) were negative predictors of hospital mortality. CONCLUSION: In cancer patients, central neurological events are mainly related to malignant brain infiltration and drug-related toxicity. Despite advanced severity, a standardized intensive management strategy yields a 55% hospital survival rate.