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Canadian Journal of Cardiology

Portal Hypertension Is Associated With Congestive Encephalopathy and Delirium After Cardiac Surgery

Published:April 15, 2019DOI:https://doi.org/10.1016/j.cjca.2019.04.006

      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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      References

        • Tucker L.A.
        Post-pump delirium.
        Intensive Crit Care Nurs. 1993; 9: 269-273
        • Deiner S.
        • Luo X.
        • Lin H.M.
        • et al.
        Intraoperative infusion of dexmedetomidine for prevention of postoperative delirium and cognitive dysfunction in elderly patients undergoing major elective noncardiac surgery: a randomized clinical trial.
        JAMA Surg. 2017; 152e171505
        • Prowle J.R.
        • Echeverri J.E.
        • Ligabo E.V.
        • Ronco C.
        • Bellomo R.
        Fluid balance and acute kidney injury.
        Nat Rev Nephrol. 2010; 6: 107-115
        • Nguyen D.N.
        • Huyghens L.
        • Parra J.
        • et al.
        Hypotension and a positive fluid balance are associated with delirium in patients with shock.
        PloS One. 2018; 13e0200495
        • Figg K.K.
        • Nemergut E.C.
        Error in central venous pressure measurement.
        Anesth Analg. 2009; 108: 1209-1211
        • Duerinckx A.J.
        • Grant E.G.
        • Perrella R.R.
        • Szeto A.
        • Tessler F.N.
        The pulsatile portal vein in cases of congestive heart failure: correlation of duplex Doppler findings with right atrial pressures.
        Radiology. 1990; 176: 655-658
        • Styczynski G.
        • Milewska A.
        • Marczewska M.
        • et al.
        Echocardiographic correlates of abnormal liver tests in patients with exacerbation of chronic heart failure.
        J Am Soc Echocardiogr. 2016; 29: 132-139
        • Ikeda Y.
        • Ishii S.
        • Yazaki M.
        • et al.
        Portal congestion and intestinal edema in hospitalized patients with heart failure.
        Heart Vessels. 2018; 33: 740-751
        • Beaubien-Souligny W.
        • Eljaiek R.
        • Fortier A.
        • et al.
        The association between pulsatile portal flow and acute kidney injury after cardiac surgery: a retrospective cohort study.
        J Cardiothorac Vasc Anesth. 2018; 32: 1780-1787
        • Eljaiek R.
        • Cavayas Y.A.
        • Rodrigue E.
        • et al.
        High postoperative portal venous flow pulsatility indicates right ventricular dysfunction and predicts complications in cardiac surgery patients.
        Br J Anaesth. 2019; 122: 206-214
        • Cruces P.
        • Salas C.
        • Lillo P.
        • et al.
        The renal compartment: a hydraulic view.
        Intensive Care Med Exp. 2014; 2: 26
        • Beaubien-Souligny W.
        • Benkreira A.
        • Robillard P.
        • et al.
        Alterations in portal vein flow and intrarenal venous flow are associated with acute kidney injury after cardiac surgery: a prospective observational cohort study.
        J Am Heart Assoc. 2018; 7e009961
        • Denault A.Y.
        • Beaubien-Souligny W.
        • Elmi-Sarabi M.
        • et al.
        Clinical significance of portal hypertension diagnosed with bedside ultrasound after cardiac surgery.
        Anesth Analg. 2017; 124: 1109-1115
        • Nashef S.A.
        • Roques F.
        • Sharples L.D.
        • et al.
        EuroSCORE II.
        Eur J Cardiothorac Surg. 2012; 41 (discussion 744-5): 734-744
        • McCusker J.
        • Cole M.G.
        • Dendukuri N.
        • Belzile E.
        The delirium index, a measure of the severity of delirium: new findings on reliability, validity, and responsiveness.
        J Am Geriatr Soc. 2004; 52: 1744-1749
        • Pal G.
        • Lin M.M.
        • Laureno R.
        Asterixis: a study of 103 patients.
        Metab Brain Dis. 2014; 29: 813-824
        • Bergeron N.
        • Dubois M.J.
        • Dumont M.
        • Dial S.
        • Skrobik Y.
        Intensive Care Delirium Screening Checklist: evaluation of a new screening tool.
        Intensive Care Med. 2001; 27: 859-864
        • Green D.W.
        A retrospective study of changes in cerebral oxygenation using a cerebral oximeter in older patients undergoing prolonged major abdominal surgery.
        Eur J Anaesthesiol. 2007; 24: 230-234
        • Rigamonti A.
        • Scandroglio M.
        • Minicucci F.
        • et al.
        A clinical evaluation of near-infrared cerebral oximetry in the awake patient to monitor cerebral perfusion during carotid endarterectomy.
        J Clin Anesth. 2005; 17: 426-430
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Mailhot T.
        • Cossette S.
        • Lambert J.
        • Cournoyer A.
        • Denault A.Y.
        Cerebral oximetry as a biomarker of postoperative delirium in cardiac surgery patients.
        J Crit Care. 2016; 34: 17-23
        • de Tournay-Jette E.
        • Dupuis G.
        • Bherer L.
        • et al.
        The relationship between cerebral oxygen saturation changes and postoperative cognitive dysfunction in elderly patients after coronary artery bypass graft surgery.
        J Cardiothorac Vasc Anesth. 2011; 25: 95-104
        • Brown J.R.
        • Kramer R.S.
        • Coca S.G.
        • Parikh C.R.
        Duration of acute kidney injury impacts long-term survival after cardiac surgery.
        Ann Thorac Surg. 2010; 90: 1142-1148
        • Scheuermann K.
        • Thiel C.
        • Thiel K.
        • et al.
        Correlation of the intracranial pressure to the central venous pressure in the late phase of acute liver failure in a porcine model.
        Acta Neurochirurgica Supplement. 2012; 114: 387-391
        • Ameloot K.
        • Genbrugge C.
        • Meex I.
        • et al.
        Is venous congestion associated with reduced cerebral oxygenation and worse neurological outcome after cardiac arrest?.
        Crit Care. 2016; 20: 146
        • Dabrowski W.
        • Kotlinska E.
        • Rzecki Z.
        • et al.
        Raised jugular venous pressure intensifies release of brain injury biomarkers in patients undergoing cardiac surgery.
        J Cardiothorac Vasc Anesth. 2012; 26: 999-1006
        • Numan T.
        • van den Boogaard M.
        • Kamper A.M.
        • et al.
        Recognition of delirium in postoperative elderly patients: a multicenter study.
        J Am Geriatr Soc. 2017; 65: 1932-1938
        • Rasulo F.A.
        • Bertuetti R.
        • Robba C.
        • et al.
        The accuracy of transcranial Doppler in excluding intracranial hypertension following acute brain injury: a multicenter prospective pilot study.
        Crit Care. 2017; 21: 44
        • Dubourg J.
        • Javouhey E.
        • Geeraerts T.
        • Messerer M.
        • Kassai B.
        Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis.
        Intensive Care Med. 2011; 37: 1059-1068

      Linked Article

      • Portal Vein Pulsatility After Cardiac Surgery—Who Cares?
        Canadian Journal of CardiologyVol. 35Issue 9
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          Delirium 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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