The association between intraoperative hypotension and postoperative delirium- a retrospective cohort analysis.

BACKGROUND: Intraoperative hypotension might contribute to the development of postoperative delirium through inadequate cerebral perfusion. However, evidence regarding the association between intraoperative hypotension and postoperative delirium is equivocal. We therefore tested the hypothesis that in patients>70 years having elective non-cardiac surgery, intraoperative hypotension is associated with postoperative delirium. METHODS: We conducted a retrospective cohort analysis of patients >70 years who underwent elective non-cardiac surgery in a single tertiary academic center between 2020 and 2021. Intraoperative hypotension was quantified as the area under a mean arterial pressure (MAP) threshold of 65 mmHg. Postoperative delirium was defined as a collapsed composite outcome including positive 4A's test during the initial 2 postoperative days, and/or delirium identification using the Chart-based Delirium Identification Instrument. The association between hypotension and postoperative delirium was assessed using multivariable logistic regression, adjusting for potential confounding variables. Several sensitivity analyses were performed using similar regression models. RESULTS: In total, 2352 patients were included (median age 76 years, 1112 (47%) women, 1166 (50%) ASA score≥3, and 698 (31%) having high-risk surgeries). The median [IQR] intraoperative AUC of MAP<65 mmHg was 28 [0,103] mmHg. min. The overall incidence of postoperative delirium was 14% (327/2352). After adjustment for potential confounding variables, hypotension was not associated with postoperative delirium. Compared to the 1st quartile of AUC of MAP<65 mmHg, patients in the 2nd, 3rd, and 4th quartiles did not have more postoperative delirium, with adjusted odds ratio (aOR) of 0.94 (95% confidence interval (CI) 0.64-1.36; P=0.73), 0.95 (0.66-1.36; P=0.78), and 0.95 (0.65-1.36; P=0.78), respectively. Intraoperative hypotension was also not associated with postoperative delirium in any of the sensitivity and sub-group analyses performed. CONCLUSIONS: To the extent of hypotension observed in our cohort, our results suggest that intraoperative hypotension is not associated with postoperative delirium in elderly patients having elective non-cardiac surgery.

Utility of NICaS Non-Invasive Hemodynamic Monitoring in Critically Ill Patients with COVID-19.

(1) Background: COVID-19 presented many challenges to effective treatments, such as managing cardiovascular insufficiency while mitigating risks to healthcare providers. This study utilized NICaS, a non-invasive hemodynamic monitor that provides advanced data via whole-body impedance analysis. We investigated the associated trends in hemodynamic parameters obtained by the NICaS device and their correlation with in-hospital all-cause mortality during COVID-19 hospitalization in the intensive care unit. (2) Methods: Data from 29 patients with COVID-19 admitted to the intensive care unit and monitored with NICaS between April 2020 and February 2021 were analyzed retrospectively. (3) Results: Decreasing cardiac output and cardiac power were significantly associated with death. Total peripheral resistance was significantly increasing in non-survivors as was total body water percentage. Those admitted with a heart rate above 90 beats per minute had a significantly reduced survival. (4) Conclusions: Non-invasive hemodynamic monitoring via the NICaS device is simple and effective in evaluating critically ill patients with COVID-19 and may help guide clinical management via remote monitoring. Controlling tachycardia may help ensure adequate oxygen supply-demand ratio. A hint toward a beneficiary effect of a restrictive fluid balance may be observed.

Preoperative cognitive impairment and postoperative delirium among Holocaust survivors who achieved longevity.

BACKGROUND: Holocaust survivors (HS) experience higher rates of physiological and psychological morbidities, increasing their vulnerability to perioperative complications. Limited information exists regarding their perioperative neurocognitive disorders. This study aimed to assess the rates of preoperative cognitive impairment, postoperative delirium, and other complications among HS aged 75+ undergoing elective surgery. METHODS: This is a single-center retrospective cohort study that analyzed prospectively collected data. All surgical patients born before 1945 who underwent elective noncardiac surgery at a tertiary hospital in Israel during 2020-2021 were included. The HS group was identified through the hospital's information system. Preoperative cognitive impairment was assessed using the Mini-Cog test. Postoperative delirium was defined as a combined outcome, which included a positive 4A's-Test (4AT) result during the postanesthesia care unit stay up to the second postoperative day, a positive 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) test administered by the geriatric team, and identification through the medical records using the Chart-based Delirium Identification Instrument (CHART-DEL). We used multivariable regression to assess the risk factors for postoperative delirium. RESULTS: Out of 1332 eligible patients, 422 (32%) were HS, while the others served as controls. Both groups had a similar rate of preoperative cognitive impairment (24%, p = 0.89) and postoperative delirium (16%, p = 0.95). HS exhibited a higher risk of the composite adverse events (24% vs. 20%, p = 0.05, aOR [95% CI] 1.3 [1.0-1.7]), driven mainly by falls during hospitalization (4% vs. 2%, p = 0.03, aOR 2.1 [1.1-4.1]). HS patients were more likely to be childless (33% vs. 11%, p = 0.001) and had higher rates of chronic antidepressant and benzodiazepine use. CONCLUSIONS: HS achieving longevity do not face increased risks of preoperative cognitive impairment and postoperative delirium. However, special care is still warranted due to their elevated rate of other complications during hospitalization.

The Prevalence of Post-traumatic Stress Disorder as Part of Post-ICU Syndrome among Israeli ICU Survivors.

BACKGROUND: Survivors of critical illness are at increased risk of long-term impairments, referred to as post-intensive care unit (ICU) syndrome (PICS). Post-traumatic stress disorder (PTSD) is common among ICU survivors with reported rates of up to 27%. The prevalence of PTSD among Israeli ICU survivors has not been reported to date. OBJECTIVES: To evaluate the prevalence of new onset PTSD diagnosed in a post-ICU clinic at a tertiary center in Israel. METHODS: We conducted a retrospective, single center, cohort study. Data were collected from medical records of all patients who visited the Tel Aviv Sourasky Medical Center post-ICU clinic between October 2017 and June 2020. New onset PTSD was defined as PTSD diagnosed by a certified board psychiatrist during the post-ICU clinic visit. Data were analyzed using descriptive statistics. RESULTS: Overall, 39 patients (mean age 51 ± 17 years, 15/39 females [38%]) attended the post-ICU clinic during the study period. They were evaluated 82 ± 57 days after hospital discharge. After excluding 7 patients due to missing proper psychiatric analysis, 32 patients remained eligible for the primary analysis. New PTSD was diagnosed in one patient (3%). CONCLUSIONS: We found lower incidence of PTSD in our cohort when compared to existing literature. Possible explanations include different diagnostic tools and low risk factors rate. Unique national, cultural, and/or religious perspectives might have contributed to the observed low PTSD rate. Further research in larger study populations is required to establish the prevalence of PTSD among Israeli ICU survivors.

The association between midazolam premedication and postoperative delirium - a retrospective cohort study.

STUDY OBJECTIVE: To evaluate the association between midazolam premedication and postoperative delirium in a large retrospective cohort of patients ≥70 years. DESIGN: Retrospective cohort study. SETTING: A single tertiary academic medical center. PATIENTS: Patients ≥70 years having elective non-cardiac surgery under general anesthesia from 2020 to 2021. INTERVENTIONS: Midazolam premedication, defined as intravenous midazolam administration prior to induction of general anesthesia. MEASUREMENTS: The primary outcome, postoperative delirium, was a collapsed composite outcome including at least one of the following: a positive 4A's test during post-anesthesia care unit stay and/or the initial 2 postoperative days; physician or nursing records reporting new-onset confusion as captured by the CHART-DEL instrument; or a positive 3D-CAM test. The association between midazolam premedication and postoperative delirium was assessed using multivariable logistic regression, adjusting for potential confounding variables. As secondary analysis, we investigated the association between midazolam premedication and a composite of other postoperative complications. Several sensitivity analyses were performed using similar regression models. MAIN RESULTS: In total, 1973 patients were analyzed (median age 75 years, 47% women, 50% ASA score ≥ 3, 32% high risk surgery). The overall incidence of postoperative delirium was 15.3% (302/1973). Midazolam premedication was administered to 782 (40%) patients (median [IQR] dose 2 [1,2] mg). After adjustment for potential confounding variables, midazolam premedication was not associated with increased odds of postoperative delirium, with adjusted odds ratio of 1.09 (95% confidence interval 0.82-1.45; P = 0.538). Midazolam premedication was also not associated with the composite of other postoperative complications. Furthermore, no association was found between midazolam premedication and postoperative delirium in any of the sensitivity analyses preformed. CONCLUSIONS: Our results suggest that low doses of midazolam can be safely used to pre-medicate elective surgical patients 70 years or older before non-cardiac surgery, without significant effect on the risk of developing postoperative delirium.

Assessment of Intra-Abdominal Pressure with a Novel Continuous Bladder Pressure Monitor-A Clinical Validation Study.

INTRODUCTION: Intra-abdominal hypertension and the resulting abdominal compartment syndrome are serious complications of severely ill patients. Diagnosis requires an intra-abdominal pressure (IAP) measurement, which is currently cumbersome and underused. We aimed to test the accuracy of a novel continuous IAP monitor. METHODS: Adults having laparoscopic surgery and requiring urinary catheter intra-operatively were recruited to this single-arm validation study. IAP measurements using the novel monitor and a gold-standard foley manometer were compared. After anesthesia induction, a pneumoperitoneum was induced through a laparoscopic insufflator, and five randomly pre-defined pressures (between 5 and 25 mmHg) were achieved and simultaneously measured via both methods in each participant. Measurements were compared using Bland-Altman analysis. RESULTS: In total, 29 participants completed the study and provided 144 distinct pairs of pressure measurements that were analyzed. A positive correlation between the two methods was found (R2 = 0.93). There was good agreement between the methods, with a mean bias (95% CI) of -0.4 (-0.6, -0.1) mmHg and a standard deviation of 1.3 mmHg, which was statistically significant but of no clinical importance. The limits of agreement (where 95% of the differences are expected to fall) were -2.9 and 2.2 mmHg. The proportional error was statistically insignificant (p = 0.85), suggesting a constant agreement between the methods across the range of values tested. The percentage error was 10.7%. CONCLUSIONS: Continuous IAP measurements using the novel monitor performed well in the clinical setup of controlled intra-abdominal hypertension across the evaluated range of pressures. Further studies should expand the range to more pathological values.

Neurosurgical aspects of Noonan syndrome.

PURPOSE: Noonan syndrome (NS) is a rare neurodevelopmental syndrome characterized by dysmorphic features, congenital heart defects, neurodevelopmental delay, and bleeding diathesis. Though rare, several neurosurgical manifestations have been associated with NS, such as Chiari malformation (CM-I), syringomyelia, brain tumors, moyamoya, and craniosynostosis. We describe our experience in treating children with NS and various neurosurgical conditions, and review the current literature on neurosurgical aspects of NS. METHODS: Data were retrospectively collected from the medical records of children with NS who were operated at a tertiary pediatric neurosurgery department, between 2014 and 2021. Inclusion criteria were clinical or genetic diagnosis of NS, age < 18 years at treatment, and need for a neurosurgical intervention of any kind. RESULTS: Five cases fulfilled the inclusion criteria. Two had tumors, one underwent surgical resection. Three had CM-I, syringomyelia, and hydrocephalus, of whom one also had craniosynostosis. Comorbidities included pulmonary stenosis in two patients and hypertrophic cardiomyopathy in one. Three patients had bleeding diathesis, two of them with abnormal coagulation tests. Four patients were treated preoperatively with tranexamic acid, and two with Von Willebrand factor or platelets (1 each). One patient with a clinical bleeding predisposition developed hematomyelia following a syringe-subarachnoid shunt revision. CONCLUSIONS: NS is associated with a spectrum of central nervous system abnormalities, some of which with known etiology, while in others a pathophysiological mechanism has been suggested in the literature. When operating on a child with NS, a meticulous anesthetic, hematologic, and cardiac evaluation should be conducted. Neurosurgical interventions should then be planned accordingly.

Postoperative coagulopathy among otherwise healthy pediatric patients undergoing open craniosynostosis repair: a retrospective study.

Significant blood loss and resultant transfusion may lead to coagulopathy. The need for routine transfusion of non-RBC blood products in healthy pediatric patients suffering significant, yet controlled, intra-operative blood loss is controversial. Open craniosynostosis surgery is often associated with significant intra-operative blood loss and transfusion, and routinely preformed on otherwise healthy pediatric patients. Therefore, we found it as a useful model for our study, which aimed to assess the need for routine transfusion of non-RBC blood products in healthy pediatric patients suffering significant intra-operative blood loss. We conducted a retrospective cohort study of otherwise healthy pediatric patients, undergoing open craniosynostosis surgery and transfused solely with packed red blood cells (pRBCs) in a single large-volume tertiary surgical center, between January 2010 and December 2021. Among 457 eligible patients, 34 (7.4%) developed significant postoperative coagulopathy. Median [IQR] intra-operative pRBC transfusion volume was 17.4 ml kg-1 [13.3, 23.1]. Patients who developed coagulopathy did not have higher postoperative pRBC transfusion rate (8.8% vs 3.8%, P = 0.16) or volume (median [IQR], 0 [0, 0] vs 0 [0, 0] ml, P = 0.15), nor higher hospital LOS (5 [4, 5] vs 5 [4, 5] days, P = 0.66). ICU LOS was 0.8 [0.7, 1] vs 0.7 [0.6, 0.8] days (P = 0.02), a difference of no clinical significance.  Conclusions: The incidence of significant coagulopathy after craniosynostosis surgery was low, and not associated with clinically important complications. In otherwise healthy pediatric patients, even significant intra-operative blood loss can be safely managed solely with intravenous fluids and pRBC transfusion. What is Known: • Significant intra-operative blood loss and resultant transfusion may lead to postoperative coagulopathy. • There are potential deleterious effects from both coagulopathy and administration of blood products. What is New: • Open craniosynostosis corrective surgery is a useful model for studying coagulopathy after significant intra-operative blood loss and transfusion in otherwise healthy children. • Under certain conditions, in otherwise healthy pediatric patients, even significant intra-operative blood loss can be safely treated with intravenous fluids and pRBC transfusion alone, with no clinically significant postoperative coagulopathy or its complications.

Percutaneous cholecystostomy in the management of high-risk patients presenting with acute cholecystitis: Timing and outcome at a single institution.

BACKGROUND: Cholecystectomy is the standard of care in acute cholecystitis (AC). Percutaneous cholecystostomy (PC) is an effective alternative for high-risk surgical cases. METHODS: A retrospective analysis is presented of AC patients treated with PC drainage at a single tertiary institution over a 21 month period, assessing outcome and complications. RESULTS: Of 119 patients, 103 had clinical improvement after PC insertion. There were 7 peri-procedural deaths (5.9%), all in elderly high-risk cases. Overall, 56/103 cases (54%) were definitively managed with PC drainage with 41 patients (40%) undergoing an elective cholecystectomy (75% performed laparoscopically). The timing of PC insertion did not affect AC resolution or drain-related complications, although more patients underwent an elective cholecystectomy if PC placement was delayed (>24 h after admission). CONCLUSIONS: In AC, drainage by a PC catheter is a safe and effective procedure. It may be used either as a bridge to elective cholecystectomy or in selected cases as definitive therapy.