Diagnostic Value of Cholinesterase Activity for the Development of Postoperative Delirium after Cardiac Surgery
Background Depression of cholinesterase (CHE) activity has been reported to lead to an amplified neuroinflammatory response, which clinically manifests as postoperative delirium (PD). This observational study investigates the association between CHE activity and the development of PD following elective cardiac surgery.
Methods Patients with preexisting neurologic deficits or carotid artery disease as well as patients undergoing reoperations or procedures under circulatory arrest have been excluded from this study. The Mini-Mental State Examination, the Confusion Assessment Method for the Intensive Care Unit, and the Intensive Care Delirium Screening Checklist were performed at regular intervals. CHE activity was estimated pre- and postoperatively until postoperative day (POD) 5 and at discharge.
Results A total of 107 patients were included. PD was diagnosed in 34 (31.8%) patients, who have been compared with those without PD. Time on ventilator, length of ICU, and hospital stay were longer in patients with PD (p = 0.001, p < 0.001, and p = 0.004, respectively). MMSE scores were lower in patients with PD (p < 0.001; p = 0.015). CHE activity on POD 1 to 4 as well as at discharge were lower in the delirium group (p = 0.041; p = 0.029; p = 0.015; p = 0.035; p = 0.028, respectively). A perioperative drop of CHE activity of more than 50% and a postoperative CHE activity below 4,800 U/L (on POD 0) were independently associated with an increased risk of development of PD (p = 0.038; p = 0.008, respectively).
Conclusion In addition to the established functional tests, routine estimation of CHE activity may serve as an additional diagnostic tool allowing for the timely diagnosis and treatment of PD in cardiac surgery patients.
Received: 21 May 2020
Accepted: 17 August 2020
20 November 2020 (online)
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- 1 Engel GL, Romano J. Delirium, a syndrome of cerebral insufficiency. 1959. J Neuropsychiatry Clin Neurosci 2004; 16 (04) 526-538
- 2 John M, Ely EW, Halfkann D. et al. Acetylcholinesterase and butyrylcholinesterase in cardiosurgical patients with postoperative delirium. J Intensive Care 2017; 5: 29
- 3 Rudolph JL, Jones RN, Grande LJ. et al. Impaired executive function is associated with delirium after coronary artery bypass graft surgery. J Am Geriatr Soc 2006; 54 (06) 937-941
- 4 Norkiene I, Ringaitiene D, Misiuriene I. et al. Incidence and precipitating factors of delirium after coronary artery bypass grafting. Scand Cardiovasc J 2007; 41 (03) 180-185
- 5 Pavlov VA, Wang H, Czura CJ, Friedman SG, Tracey KJ. The cholinergic anti-inflammatory pathway: a missing link in neuroimmunomodulation. Mol Med 2003; 9 (5-8): 125-134
- 6 Nashef SAM, Roques F, Sharples LD. et al. EuroSCORE II. Eur J Cardiothorac Surg 2012; 41 (04) 734-744 , discussion 744–745
- 7 Lozano-ortega G, Johnston KM, Cheung A. et al. A review of published anticholinergic scales and measures and their applicability in database analyses. Arch Gerontol Geriatr 2019
- 8 Kiesel EK, Hopf YM, Drey M. An anticholinergic burden score for German prescribers: score development. BMC Geriatr 2018; 18 (01) 239
- 9 Mueller A, Spies CD, Eckardt R. et al. Anticholinergic burden of long-term medication is an independent risk factor for the development of postoperative delirium: a clinical trial. J Clin Anesth 2020; 61: 109632
- 10 Pangman VC, Sloan J, Guse L. An examination of psychometric properties of the Mini-Mental State Examination and the standardized Mini-Mental State Examination: implications for clinical practice. Appl Nurs Res 2000; 13 (04) 209-213
- 11 Radtke FM, Franck M, Oppermann S. et al. Die Intensive Care Delirium Screening Checklist (ICDSC)--Richtlinienkonforme Ubersetzung und Validierung einer intensivmedizinischen Delirium-Checkliste. Anasthesiol Intensivmed Notfallmed Schmerzther 2009; 44 (02) 80-86
- 12 Gusmao-Flores D, Salluh JI, Chalhub RÁ, Quarantini LC. The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies. Crit Care 2012; 16 (04) R115
- 13 Arrowsmith JE, Grocott HP, Reves JG, Newman MF. Central nervous system complications of cardiac surgery. Br J Anaesth 2000; 84 (03) 378-393
- 14 Levy B, Bastien O, Karim B. et al. Experts' recommendations for the management of adult patients with cardiogenic shock. Ann Intensive Care 2015; 5 (01) 52
- 15 Müller A, Olbert M, Heymann A. et al. Relevance of peripheral cholinesterase activity on postoperative delirium in adult surgical patients (CESARO): a prospective observational cohort study. Eur J Anaesthesiol 2019; 36 (02) 114-122
- 16 Tremblay P, Gold S. Prevention of post-operative delirium in the elderly using pharmacological agents. Can Geriatr J 2016; 19 (03) 113-126
- 17 Gamberini M, Bolliger D, Lurati Buse GA. et al. Rivastigmine for the prevention of postoperative delirium in elderly patients undergoing elective cardiac surgery--a randomized controlled trial. Crit Care Med 2009; 37 (05) 1762-1768
- 18 Robinson TN, Eiseman B. Postoperative delirium in the elderly: diagnosis and management. Clin Interv Aging 2008; 3 (02) 351-355
- 19 Bronicki RA, Hall M. Cardiopulmonary bypass-induced inflammatory response: pathophysiology and treatment. Pediatr Crit Care Med 2016; 17 (08) (Suppl. 01) S272-S278
- 20 Lin Y, Chen J, Wang Z. Meta-Analysis of Factors Which Influence Delirium Following Cardiac Surgery. Anasthesiol Intensive Med 2012; 27 (04) 481-492
- 21 Cerejeira J, Batista P, Nogueira V, Firmino H, Vaz-Serra A, Mukaetova-Ladinska EB. Low preoperative plasma cholinesterase activity as a risk marker of postoperative delirium in elderly patients. Age Ageing 2011; 40 (05) 621-626
- 22 Cerejeira J, Firmino H, Vaz-Serra A, Mukaetova-Ladinska EB. The neuroinflammatory hypothesis of delirium. Acta Neuropathol 2010; 119 (06) 737-754
- 23 Pasina L, Colzani L, Cortesi L. et al. Relation between delirium and anticholinergic drug burden in a cohort of hospitalized older patients: an observational study. Drugs Aging 2019; 36 (01) 85-91
- 24 Deiner S, Silverstein JH. Postoperative delirium and cognitive dysfunction. Br J Anaesth 2009; 103 (01) (Suppl. 01) i41-i46