Improved perioperative neurological monitoring of coronary artery bypass graft patients reduces the incidence of postoperative delirium: the Haga Brain Care Strategy.
OBJECTIVE
Postoperative delirium is a major cause of morbidity and mortality after cardiovascular surgery. Risk factors for postoperative delirium include poor cerebral haemodynamics and perioperative cerebral desaturations. Our aim was to reduce the postoperative delirium rate by using a new prevention strategy called the Haga Brain Care Strategy. This study evaluates the efficacy of the implementation of the Haga Brain Care Strategy to reduce the postoperative delirium rate after elective coronary artery bypass graft (CABG) procedures. The primary endpoint was the postoperative delirium rate, and the secondary endpoint was the length of stay in the intensive care unit.


METHODS
The Haga Brain Care Strategy consisted of the conventional screening protocol for delirium with the addition of preoperative transcranial Doppler examinations, perioperative cerebral oximetry, modified Rankin score, delirium risk score and (if indicated) duplex examination of the carotid arteries. In case of poor preoperative haemodynamics, the cerebral blood flow was optionally optimized by angioplasty or the patient was operated on under mild hypothermic conditions. Perioperative cerebral desaturations >20% outside the normal range resulted in intervention to restore cerebral oxygenation. Cerebral oximetry was discontinued when patients regained consciousness. Patients undergoing elective CABG procedures in 2010 were compared with patients scheduled for coronary bypass graft procedures in 2009 who had not been exposed to additional Haga Brain Care Strategy assessment.


RESULTS
A total of 233 and 409 patients were included in 2009 and 2010, respectively. The number of patients subjected in 2010 to transcranial Doppler examinations, cerebral oximetry or both (Haga Brain Care Strategy) were 262 (64.1%), 201 (49.1%) and 139 (34.0%), respectively. The overall rate of postoperative delirium decreased from 31 (13.3%) in 2009 to 30 (7.3%) in 2010 (P = 0.019). A binary logistic regression model showed that the Haga Brain Care Strategy was an independent predictor of a reduced risk of developing a postoperative delirium (odd ratio = 0.37, P = 0.021).


CONCLUSIONS
With the implementation of the Haga Brain Care Strategy in 2010, a reduction of the incidence of postoperative delirium in patients undergoing elective CABG procedures was observed. In addition, the length of stay in the intensive care unit showed an overall tendency to decline. The limited number of observations and the current study design do not allow a full evaluation of the Haga Brain Care Strategy but the data support the idea that a sophisticated preoperative assessment of cerebral haemodynamics and perioperative monitoring of cerebral oximetry reduce the incidence of the postoperative delirium in CABG surgery.
Department of Neurology and Clinical Neurophysiology,  Haga Teaching Hospitals, The Hague,  Netherlands.
Wijnand A C
WA
Palmbergen
Agnes
A
van Sonderen
Ali M
AM
Keyhan-Falsafi
Ruud W M
RW
Keunen
Ron
R
Wolterbeek
D000368:Aged; D000369:Aged, 80 and over; D002339:Carotid Arteries / Q000000981:diagnostic imaging / Q000503:physiopathology; D002560:Cerebrovascular Circulation; D016009:Chi-Square Distribution; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D003693:Delirium / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology / Q000517:prevention & control*; D004185:Disability Evaluation; D017558:Elective Surgical Procedures; D005260:Female; D006439:Hemodynamics; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D016017:Odds Ratio; D010092:Oximetry; D059035:Perioperative Period; D011237:Predictive Value of Tests; D015397:Program Evaluation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D017585:Ultrasonography, Doppler, Transcranial