Department of Surgery, University of California, San Francisco, San Francisco, CA.
University of Utah, School of Medicine, Salt Lake City, UT.
Ann Vasc Surg. 2022 Nov;87:254-262. doi: 10.1016/j.avsg.2022.06.001. Epub 2022 Jul 6.
Post-operative delirium (POD) is common yet often underdiagnosed following vascular surgery. Elderly patients with advanced peripheral artery disease may be at particular risk for POD yet understanding of the clinical predictors and impact of POD is incomplete. We sought to identify POD predictors and associated resource utilization after infrainguinal lower extremity bypass.
This single center retrospective analysis included all infrainguinal bypass cases performed for peripheral arterial disease from 2012-2020. The primary outcome was inpatient POD. Delirium sequelae were also evaluated. Key secondary outcomes were length of stay, nonhome discharge, readmission, 30-day amputation, post-operative myocardial infarction, mortality, and 2-year survival. Regression analysis was used to evaluate risk factors for delirium in addition to association with 2-year survival and amputation free survival.
Among 420 subjects undergoing infrainguinal lower extremity bypass, 105 (25%) developed POD. Individuals with POD were older and more likely to have non-elective surgery (P < 0.05). On multivariable analysis, independent predictors of POD were age 60-89 years old, chronic limb threatening ischemia, female sex, and nonelective procedure. Consultations for POD took place for 25 cases (24%); 13 (52%) were with pharmacists, and only 4 (16%) resulted in recommendations. The average length of stay for those with POD was higher (17 days vs. 9 days; P < 0.001). POD was associated with increased non-home discharge (61.8% vs. 22.1%; P < 0.001), 30-day major amputation (6.7% vs. 1.6%; P < 0.01), 30-day postoperative myocardial infarction (11.4% vs. 4.1%; P < 0.01), and 90-day mortality (7.6% vs. 2.9%; P = 0.03). Survival at 2 years was lower in those with delirium (89% vs. 75%; P < 0.001). In a Cox proportional hazards model, delirium was independently associated with decreased survival (HR = 2.0; 95% CI = 1.15-3.38; P = 0.014) and decreased major-amputation free survival (HR = 1.9; 95% CI = 1.18-2.96; P = 0.007).
POD is common following infrainguinal lower extremity bypass and is associated with other adverse post-operative outcomes and increased resource utilization, including increased hospital length of stay, nonhome discharge, and worse 2-year survival. Future studies should evaluate the role of routine multidisciplinary care for high-risk patients to improve perioperative outcomes for vulnerable older adults undergoing infrainguinal lower extremity bypass.
术后谵妄（POD）在血管手术后很常见，但常常诊断不足。患有晚期外周动脉疾病的老年患者可能特别容易发生 POD，但对 POD 的临床预测因素和影响的了解并不完整。我们旨在确定下肢旁路手术后 POD 的预测因素及相关资源利用情况。
本单中心回顾性分析纳入了 2012 年至 2020 年间因外周动脉疾病而行下肢旁路手术的所有病例。主要结局为住院期间发生 POD。还评估了谵妄后遗症。关键次要结局为住院时间、非家庭出院、再入院、30 天内截肢、术后心肌梗死、死亡率和 2 年生存率。回归分析用于评估除与 2 年生存率和无截肢生存率相关外，发生谵妄的危险因素。
在 420 例行下肢旁路手术的患者中，105 例（25%）发生 POD。发生 POD 的患者年龄较大，更有可能接受非择期手术（P<0.05）。多变量分析显示，60-89 岁、慢性肢体威胁性缺血、女性和非择期手术是 POD 的独立预测因素。有 25 例（24%）进行了谵妄咨询；13 例（52%）咨询了药剂师，仅 4 例（16%）提出了建议。发生 POD 的患者平均住院时间较长（17 天比 9 天；P<0.001）。POD 与非家庭出院率增加（61.8%比 22.1%；P<0.001）、30 天内主要截肢（6.7%比 1.6%；P<0.01）、30 天内术后心肌梗死（11.4%比 4.1%；P<0.01）和 90 天死亡率（7.6%比 2.9%；P=0.03）相关。发生谵妄的患者 2 年生存率较低（89%比 75%；P<0.001）。在 Cox 比例风险模型中，谵妄与生存率下降独立相关（HR=2.0；95%CI=1.15-3.38；P=0.014）和主要截肢无生存率下降独立相关（HR=1.9；95%CI=1.18-2.96；P=0.007）。
下肢旁路手术后 POD 很常见，与其他不良术后结局和增加的资源利用相关，包括住院时间延长、非家庭出院和 2 年生存率下降。未来的研究应评估对高危患者进行常规多学科护理的作用，以改善行下肢旁路手术的脆弱老年患者的围手术期结局。
