Abstract
Background
Venous congestion might lead to congestive encephalopathy after cardiac surgery. However,
objective signs of congestion have yet to be associated with delirium. Portal vein
flow pulsatility is a congestion marker that may identify a subgroup of patients at
risk.
Methods
We performed a retrospective study and a prospective study in patients undergoing
cardiac surgery. Adult patients who underwent portal vein Doppler imaging by the attending
physician during usual care in the intensive care unit were included in the retrospective
cohort. For the prospective cohort, patients had a cognitive and echocardiographic
evaluation the day before surgery and daily for 3 days after surgery. Delirium was
independently assessed by the nursing staff in the prospective cohort.
Results
A total of 237 patients in the retrospective cohort and 145 patients in the prospective
cohort were included, for whom 1074 portal Doppler evaluations were performed. An
association was found between delirium and portal vein pulsatility in the retrospective
cohort (odds ratio [OR], 2.69; confidence interval [CI], 1.47-4.90; P = 0.001). In the prospective cohort, significant associations were found between
the presence of portal vein pulsatility and the development of cognitive dysfunction
and asterixis assessed by the investigators (OR, 2.10; CI, 1.25-3.53; P = 0.005 and OR, 2.23; CI, 1.13; 4.41; P = 0.02, and delirium detected by the nursing staff (hazard ratio, 2.63; CI, 1.13-6.11;
P = 0.025). Higher N-terminal pro-beta natriuretic peptide measurements (OR, 4.03; CI,
1.78-9.15; P = 0.001) and cerebral desaturations (OR, 2.54; CI, 1.12-5.76; P = 0.03) were associated with cognitive dysfunction.
Conclusion
These data present an association among hepatic congestion, delirium, and encephalopathy
in patients undergoing cardiac surgery. Further studies should explore whether those
neurological complications may have a congestive origin in some patients.
Résumé
Contexte
La congestion veineuse peut entraîner une encéphalopathie congestive après une chirurgie
cardiaque. Toutefois, aucune association n’a été établie jusqu’à présent entre les
signes objectifs de la congestion et le délire. La pulsatilité du flux de la veine
porte est un marqueur de la congestion qui pourrait permettre de distinguer un sous-groupe
de patients à risque.
Méthodologie
Nous avons effectué une étude rétrospective et une étude prospective portant sur des
patients subissant une chirurgie cardiaque. Des patients adultes qui se sont prêtés
à un examen de la veine porte par imagerie Doppler, réalisé par le médecin dans le
cadre des soins standard dispensés à l’unité des soins intensifs, ont été inclus dans
la cohorte rétrospective. Pour la cohorte prospective, les patients avaient fait l’objet
d’une évaluation cognitive et échocardiographique la veille de l’intervention chirurgicale
et quotidiennement pendant les 3 jours suivant la chirurgie. Dans la cohorte prospective,
le délire était évalué de façon indépendante par le personnel infirmier.
Résultats
Au total, 237 patients ont été inclus dans la cohorte rétrospective et 145 patients
dans la cohorte prospective, chez lesquels 1074 examens Doppler de la veine porte
avaient été effectués. Une association a été observée entre le délire et la pulsatilité
de la veine porte dans la cohorte rétrospective (rapport de cotes [RC] : 2,69; intervalle
de confiance [IC] : de 1,47 à 4,90; p = 0,001). Dans la cohorte prospective, les chercheurs ont observé des associations
significatives entre la présence d’une pulsatilité de la veine porte et l’apparition
d’une dysfonction cognitive et d’un astérixis (RC : 2,10; IC : de 1,25 à 3,53; p = 0,005 et RC : 2,23; IC : de 1,13 à 4.41; p = 0,02) ainsi que le délire détecté par le personnel infirmier (RC : 2,63; IC : de
1,13 à 6,11; p = 0,025). Des valeurs élevées du fragment propeptide natriurétique de type B N-terminal
(RC : 4,03; IC : de 1,78 à 9,15; p = 0,001) et la désaturation cérébrale (RC : 2,54; IC : de 1,12 à 5,76; p = 0,03) étaient associées à une dysfonction cognitive.
Conclusions
Ces données montrent l’association existant entre la congestion hépatique, le délire
et l’encéphalopathie chez des patients subissant une chirurgie cardiaque. Des études
additionnelles devraient être menées dans le but de voir si ces complications neurologiques
pourraient avoir une origine congestive chez certains patients.
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Article info
Publication history
Published online: April 15, 2019
Accepted:
April 2,
2019
Received:
January 29,
2019
Footnotes
See editorial by Randhawa et al., pages 1088–1090 of this issue.
See page 1141 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Portal Vein Pulsatility After Cardiac Surgery—Who Cares?Canadian Journal of CardiologyVol. 35Issue 9
- PreviewDelirium is a clinical syndrome defined by transient neurological disturbances in attention, cognition, and consciousness.1 Postoperative delirium affects more than 25% to 50% of patients undergoing cardiac surgery, is often multifactorial, and has been associated with increased morbidity and mortality.1-3 Studies report prolonged lengths of hospital stay, as well as an increased risk of cognitive and functional decline requiring rehabilitation or long-term facility care due to delirium.1-3 Common causes of delirium in the postsurgical setting include need for circulatory arrest, duration of surgery or cardiopulmonary bypass time, chronic illness, sleep deprivation, fever, infection, metabolic imbalance, organ dysfunction, drugs, and toxins.
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