CC BY-NC-ND 4.0 · Thorac Cardiovasc Surg 2022; 70(07): 549-557
DOI: 10.1055/s-0040-1715891
Original Cardiovascular

Mannitol Is Associated with Less Postoperative Delirium after Aortic Valve Surgery in Patients Treated with Bretschneider Cardioplegia

Marwan Hamiko
1   Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
,
Efstratios I. Charitos
1   Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
,
Markus Velten
2   Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
,
Tobias Hilbert
2   Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
,
Christian Putensen
2   Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
,
Hendrik Treede
1   Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
,
1   Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
› Institutsangaben
Source of Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Abstract

Background Heart surgery with extracorporeal circulation (ECC) often leads to postoperative delirium (POD). This is associated with increased morbidity resulting in longer hospital stay and associated costs. The purpose of our study was to analyze the effect of intraoperative mannitol application on POD in patients undergoing elective aortic valve replacement (AVR).

Materials and Methods In our retrospective single-center study, 259 patients underwent elective AVR, using Bretschneider cardioplegic solution for cardiac arrest, between 2014 and 2017. Patients were divided in mannitol (n = 188) and nonmannitol (n = 71) groups. POD was assessed using the confusion assessment method for the intensive care unit (ICU). Statistical significance was assumed at p < 0.05.

Results Baseline patient characteristics did not differ between the groups. Incidence of POD was significantly higher in the nonmannitol group (33.8 vs. 13.8%; p = 0.001). These patients required longer ventilation time (24.1 vs. 17.1 hours; p = 0.021), higher reintubation rate (11.3 vs. 2.7%; p = 0.009), ICU readmission (12.7 vs. 4.8%; p = 0.026), prolonged ICU (112 vs. 70 hours; p = 0.040), and hospital stay (17.8 vs. 12.6 days; p < 0.001), leading to higher expenses (19,349 € vs. 16,606 €, p < 0.001). A 30-day mortality was not affected, but nonmannitol group showed higher Simplified Acute Physiology Score II score (32.2 vs. 28.7; p < 0.001). Mannitol substitution was independently associated with lower incidence of POD (odds ratio: 0.40; 95% confidence interval: 0.18–0.89; p = 0.02).

Conclusion Treatment with mannitol during ECC was associated with decreased incidence of POD. This was accompanied by shorter ventilation time, ICU and hospital stay, and lower treatment expenses.

Both authors contributed equally to this work.


Supplementary Material



Publikationsverlauf

Eingereicht: 23. Mai 2020

Angenommen: 21. Juli 2020

Artikel online veröffentlicht:
04. September 2020

© 2020. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Lin Y, Chen J, Wang Z. Meta-analysis of factors which influence delirium following cardiac surgery. J Card Surg 2012; 27 (04) 481-492
  • 2 Rudolph JL, Jones RN, Levkoff SE. et al. Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Circulation 2009; 119 (02) 229-236
  • 3 Burkhart CS, Dell-Kuster S, Gamberini M. et al. Modifiable and nonmodifiable risk factors for postoperative delirium after cardiac surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2010; 24 (04) 555-559
  • 4 Lat I, McMillian W, Taylor S. et al. The impact of delirium on clinical outcomes in mechanically ventilated surgical and trauma patients. Crit Care Med 2009; 37 (06) 1898-1905
  • 5 Ely EW, Shintani A, Truman B. et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291 (14) 1753-1762
  • 6 Rudolph JL, Inouye SK, Jones RN. et al. Delirium: an independent predictor of functional decline after cardiac surgery. J Am Geriatr Soc 2010; 58 (04) 643-649
  • 7 Milbrandt EB, Deppen S, Harrison PL. et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2004; 32 (04) 955-962
  • 8 Zaubler TS, Murphy K, Rizzuto L. et al. Quality improvement and cost savings with multicomponent delirium interventions: replication of the Hospital Elder Life Program in a community hospital. Psychosomatics 2013; 54 (03) 219-226
  • 9 O'Neal JB, Billings IV FT, Liu X. et al. Risk factors for delirium after cardiac surgery: a historical cohort study outlining the influence of cardiopulmonary bypass. Can J Anaesth 2017; 64 (11) 1129-1137
  • 10 Scott TR, Kronsten VT, Hughes RD, Shawcross DL. Pathophysiology of cerebral oedema in acute liver failure. World J Gastroenterol 2013; 19 (48) 9240-9255
  • 11 Sirs JA, Glenville B, Stanbridge RL. et al. The influence of vascular pressure and different primes on the fluid balance of, and oxygen supply to, the patient during CABG. Perfusion 1995; 10 (01) 33-44
  • 12 Russell JA, Navickis RJ, Wilkes MM. Albumin versus crystalloid for pump priming in cardiac surgery: meta-analysis of controlled trials. J Cardiothorac Vasc Anesth 2004; 18 (04) 429-437
  • 13 Himpe D. Colloids versus crystalloids as priming solutions for cardiopulmonary bypass: a meta-analysis of prospective, randomised clinical trials. Acta Anaesthesiol Belg 2003; 54 (03) 207-215
  • 14 Weiler P, Hamiko M, Mellert F. et al. Impact of crystalloid or albumin priming of the heart-lung machine on inhospital outcome after coronary artery bypass surgery. Thorac Cardiovasc Surg 2019; 67 (06) 475-483
  • 15 Svendsen OS, Farstad M, Mongstad A, Haaverstad R, Husby P, Kvalheim VL. Is the use of hydroxyethyl starch as priming solution during cardiac surgery advisable? A randomized, single-center trial. Perfusion 2018; 33 (06) 483-489
  • 16 Frenette AJ, Bouchard J, Bernier P. et al. Albumin administration is associated with acute kidney injury in cardiac surgery: a propensity score analysis. Crit Care 2014; 18 (06) 602
  • 17 Lee EH, Kim WJ, Kim JY. et al. Effect of exogenous albumin on the incidence of postoperative acute kidney injury in patients undergoing off-pump coronary artery bypass surgery with a preoperative albumin level of less than 4.0 g/dl. Anesthesiology 2016; 124 (05) 1001-1011
  • 18 Jung DM, Ahn HJ, Yang M. et al. Hydroxyethyl starch is associated with early postoperative delirium in patients undergoing esophagectomy. J Thorac Cardiovasc Surg 2018; 155 (03) 1333-1343
  • 19 Nau R. Osmotherapy for elevated intracranial pressure: a critical reappraisal. Clin Pharmacokinet 2000; 38 (01) 23-40
  • 20 Poullis M. Mannitol and cardiac surgery. Thorac Cardiovasc Surg 1999; 47 (01) 58-62
  • 21 Ljunggren M, Sköld A, Dardashti A, Hyllén S. The use of mannitol in cardiopulmonary bypass prime solution-prospective randomized double-blind clinical trial. Acta Anaesthesiol Scand 2019; 63 (10) 1298-1305
  • 22 Ziegeler S, Raddatz A, Schneider SO. et al. Effects of haemofiltration and mannitol treatment on cardiopulmonary-bypass induced immunosuppression. Scand J Immunol 2009; 69 (03) 234-241
  • 23 Regier DA, Kuhl EA, Kupfer DJ. The DSM-5: classification and criteria changes. World Psychiatry 2013; 12 (02) 92-98
  • 24 Guenther U, Popp J, Koecher L. et al. Validity and reliability of the CAM-ICU flowsheet to diagnose delirium in surgical ICU patients. J Crit Care 2010; 25 (01) 144-151
  • 25 Pisani MA, Kong SY, Kasl SV, Murphy TE, Araujo KL, Van Ness PH. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 2009; 180 (11) 1092-1097
  • 26 Thomason JW, Shintani A, Peterson JF, Pun BT, Jackson JC, Ely EW. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Crit Care 2005; 9 (04) R375-R381
  • 27 Ha A, Krasnow RE, Mossanen M. et al. A contemporary population-based analysis of the incidence, cost, and outcomes of postoperative delirium following major urologic cancer surgeries. Urol Oncol 2018; 36 (07) 341.e15-341.e22
  • 28 Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 1993; 270 (24) 2957-2963
  • 29 Miranda DR, de Rijk A, Schaufeli W. Simplified Therapeutic Intervention Scoring System: the TISS-28 items--results from a multicenter study. Crit Care Med 1996; 24 (01) 64-73
  • 30 Yang FM, Marcantonio ER, Inouye SK. et al. Phenomenological subtypes of delirium in older persons: patterns, prevalence, and prognosis. Psychosomatics 2009; 50 (03) 248-254
  • 31 Eden BM, Foreman MD. Problems associated with underrecognition of delirium in critical care: a case study. Heart Lung 1996; 25 (05) 388-400
  • 32 Kazmierski J, Kowman M, Banach M. et al; IPDACS Study. Incidence and predictors of delirium after cardiac surgery: results from The IPDACS Study. J Psychosom Res 2010; 69 (02) 179-185
  • 33 Guenther U, Theuerkauf N, Frommann I. et al. Predisposing and precipitating factors of delirium after cardiac surgery: a prospective observational cohort study. Ann Surg 2013; 257 (06) 1160-1167
  • 34 Bakker RC, Osse RJ, Tulen JH, Kappetein AP, Bogers AJ. Preoperative and operative predictors of delirium after cardiac surgery in elderly patients. Eur J Cardiothorac Surg 2012; 41 (03) 544-549
  • 35 van der Mast RC, van den Broek WW, Fekkes D, Pepplinkhuizen L, Habbema JD. Incidence of and preoperative predictors for delirium after cardiac surgery. J Psychosom Res 1999; 46 (05) 479-483
  • 36 Smith MN, Best D, Sheppard SV, Smith DC. The effect of mannitol on renal function after cardiopulmonary bypass in patients with established renal dysfunction. Anaesthesia 2008; 63 (07) 701-704
  • 37 Yallop KG, Sheppard SV, Smith DC. The effect of mannitol on renal function following cardio-pulmonary bypass in patients with normal pre-operative creatinine. Anaesthesia 2008; 63 (06) 576-582
  • 38 Haydock MD, Kruger C, Willcox T, Haydock DA. Does removing Mannitol and Voluven from the priming fluid of the cardiopulmonary bypass circuit have clinical effects?. J Extra Corpor Technol 2014; 46 (01) 77-83
  • 39 Aldemir M, Ozen S, Kara IH, Sir A, Baç B. Predisposing factors for delirium in the surgical intensive care unit. Crit Care 2001; 5 (05) 265-270
  • 40 Wan S, LeClerc JL, Vincent JL. Inflammatory response to cardiopulmonary bypass: mechanisms involved and possible therapeutic strategies. Chest 1997; 112 (03) 676-692
  • 41 Rudolph JL, Ramlawi B, Kuchel GA. et al. Chemokines are associated with delirium after cardiac surgery. J Gerontol A Biol Sci Med Sci 2008; 63 (02) 184-189
  • 42 Cerejeira J, Firmino H, Vaz-Serra A, Mukaetova-Ladinska EB. The neuroinflammatory hypothesis of delirium. Acta Neuropathol 2010; 119 (06) 737-754
  • 43 Ferreira R, Burgos M, Llesuy S. et al. Reduction of reperfusion injury with mannitol cardioplegia. Ann Thorac Surg 1989; 48 (01) 77-83 , discussion 83–84