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Journal of Cardiothoracic and Vascular Anesthesia 000 (2018) 19

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Journal of Cardiothoracic and Vascular Anesthesia


journal homepage: www.jcvaonline.com

Original Article
Delirium After Cardiac Surgery and Cumulative Fluid
Balance: A Case-Control Cohort Study
D1X XTanya Mailhot, D2X XRN, PhD{ , D3X XSylvie Cossette, D4X XRN, PhD*,
,1

D5X XJean Lambert, D6X XPhDy, D7X XWilliam Beaubien-Souligny, D8X XMDz,
D9X XAlexis Cournoyer, D10X XMDz, D1X XEileen O’Meara, D12X XMD, FRCPCz,
D13X XMarc-Andre Maheu-Cadotte, D14X XRN, BScz,
D15X XGuillaume Fontaine, D16X XRN, MSc*, D17X XJosee Bouchard, D18X XMDz,
D19X XYoan Lamarche, D20X XMD, MScz, D21X XAymen Benkreira, D2X XMDx,
D23X XAntoine Rochon, D24X XMD||, D25X XAndre Denault, D26X XMD, PhD||
*
Faculty of Nursing, Universite de Montr eal, Montreal Heart Institute Research Center, Montreal, Canada
y
School of Public Health, Department of Preventive Medicine, Montreal Heart Institute Research Center,
Montreal, Canada
z
Faculty of Medicine, Universite de Montreal, Montreal Heart Institute, Montreal, Canada
x
Faculty of Medicine, Universit e de Sherbrooke, Montreal Heart Institute Research Center, Montreal, Canada
||
Faculty of Medicine, Department of Anesthesiology, Universite de Montreal, Montreal Heart Institute,
Montreal, Canada
{
Faculty of Nursing, Faculty of Medicine, Universit e de Montr
eal, Montreal Heart Institute Research Center,
5000 B
elanger St, S-2490, Montreal, Quebec, H1T 1C8, Canada

Objective: To assess a novel hypothesis to explain delirium after cardiac surgery through the relationship between cumulative fluid balance and
delirium. This hypothesis involved an inflammatory process combined with a hypervolemic state, which could lead to venous congestion reach-
ing the brain.
Design: Retrospective case-control (1:1) cohort study.
Setting: University-affiliated tertiary cardiology center.
Participants: Cardiac surgery intensive care unit (ICU) patients.
Interventions: None.
Measurements and Main Results: Cumulative fluid balance was evaluated at 3 times: (1) upon arrival at the ICU after surgery, (2)
24 hours post-ICU arrival, and (3) 48 hours post-ICU arrival. A generalized estimated equation was used to model the association
between cumulative fluid balance and delirium occurrence 24 hours later. Covariates were selected based on the statistical differences
between cases and controls on delirium risk factors and clinical characteristics. The cohort included 346 patients, of which 39 (11%),
104 (30%), and 142 patients (41%) presented delirium at 24, 48, and 72 hours post-ICU arrival, respectively. The effect of time had an
odds ratio (OR) of 2.14, 95% confidence interval (CI) 1.603 to 2.851, and a p value < 0.001. The cumulative fluid balance was associ-
ated with delirium occurrence (OR 1.20, 95% CI: 1.066-1.355, p = .003). History of neurological disorder, having both hearing and
visual impairment, type of procedure, perioperative cerebral oximetry, mean pulmonary artery pressure pre-cardiopulmonary bypass
(CPB), and mean arterial pressure post-CPB also contributed to delirium in the model.

The team acknowledges the support of the Montreal Heart Institute Foundation (TD group), via a postdoctoral grant.
Date and number of IRB approval: #2017-2139; 2017-01-30.
1
Address reprint requests to.
E-mail address: t.mailhot@umontreal.ca (T. Mailhot).

https://doi.org/10.1053/j.jvca.2018.07.012
1053-0770/Ó 2018 Elsevier Inc. All rights reserved.
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Conclusion: Delirium is associated with a cumulative fluid balance, but the extent through which this plays an etiologic role remains to be
determined.
Ó 2018 Elsevier Inc. All rights reserved.

D27X X
Key Words: delirium; cardiac surgery; fluid balance; critical care; cohort study; cardiology

DESPITE THE IMPLEMENTATION of preventive strate- ethics and scientific committee (#2017-2139).13,14 Reporting
gies based on best-practice guidelines, up to 37% of patients was done in accordance with the STrengthening the Reporting
undergoing cardiac surgery will suffer from delirium, a com- of OBservational studies in Epidemiology statement extension
plication that can prolong intensive care unit (ICU) stay, com- for case-control studies and the REporting of studies Con-
plicate recovery, and further the mortality risk.15 Delirium is ducted using Observational Routinely collected health Data
a disturbance of attention and consciousness as well as a cog- statement.21,22 Data was collected using an electronic medical
nitive impairment with fluctuation between a normal state and chart review.
phases of agitation or lethargy.6
Delirium pathophysiology is thought to involve disruption of Cohort Patient Selection: Eligibility Criteria and Selection of
neurotransmitter signaling and neuroinflammation.7 Although Cases and Controls
several different pathways are suggested to explain this disruption,
it remains unclear which mechanisms are involved.7 However, The cohort was selected from a screening log generated in a
what triggers these mechanisms and leads to delirium is known to previous prospective clinical trial of consecutive patients who
be a combination of factors of vulnerability and stressors related were scheduled for a surgical procedure between 2013 and
to the acute illness.8,9 In the context of cardiac surgery, factors of 2015 in a quaternary cardiac hospital (registered with Con-
vulnerability reflect the preoperative state of patients and include trolled Trials #ISRCTN95736036). The inclusion and exclu-
age, comorbidity, and low preoperative cerebral oximetry val- sion criteria for the 30 patients included in the clinical trial
ues.1012 Stressors related to acute illness that can trigger delirium have been presented previously.14 These 30 patients were
among vulnerable patients include complicated procedures and excluded from the present study, as requested by the ethics
red blood cell transfusions.1012 Although several factors are committee of the study hospital. Remaining patients were
known to lead to delirium, other mechanisms likely are involved sorted by presence or absence of delirium and then by date in
in the pathogenesis of post-cardiac surgery delirium.13,14 chronological order from more to less recent surgical dates.
After recent advances in the cardiohepatic, cardiorenal, and car- Included patients had to have undergone cardiac surgery and
diointestinal syndromes, a novel hypothesis is emerging to explain to have their medical chart available in an electronic scanned
delirium among cardiac surgery patients.1517 Acute cardiac dys- format in the study hospital database. Patients were divided
function during the perioperative period could result in a cardio- into cases (with delirium within 72 hours after ICU arrival)
cerebral syndrome in which venous congestion might lead to and controls (without delirium within 72 hours after ICU
cerebral dysfunction. Venous congestion could be promoted by arrival). Patients who underwent surgery in the context of a
the administration of large volumes of fluid, reflected by a cumula- congenital disease or who underwent transcatheter valve
tive fluid balance that is increasingly positive over time and an implantation were excluded because of their particular clinical
inflammatory state.15,18,19 Edema accompanying venous conges- profiles.23 The authors included the most recent patients satis-
tion compresses structures and can alter blood perfusion to the fying the criteria to reach the required calculated sample size.
brain along with its normal functioning.18 This phenomenon also
is observed in the cardiohepatic or cardiorenal syndromes, in
Variables and Data Collection
which the elevation of venous pressures is the main factor predict-
ing organ function impairment.16,17,20
A structured case report form was developed in Excel
In this study, the authors describe the association between
(Microsoft Corporation, Redmond, WA) and used to extract
cumulative fluid balance and delirium occurrence among car-
data. After extraction by trained research assistants, data was
diac surgery patients. The authors hypothesized that, apart
reviewed for errors and missing values, which were corrected.
from known delirium risk factors and while controlling for
The accuracy of data was verified for a random sample of 10%
clinical data, an increased cumulative fluid balance would be
of the cohort, which was reviewed by a third trained research
associated with higher risk of delirium.
assistant who was blinded to case or control allocation and
study hypothesis.24
The collected sociodemographic characteristics and preop-
Methods
erative clinical characteristics included age, sex, body mass
Study Design index, smoking, alcohol consumption, hearing and visual
impairment, recent memory loss (reported at admittance
This retrospective case-control (1:1) cohort study was assessment), functional status, left ventricular ejection frac-
approved by the Montreal Heart Institute Research Center tion, hemoglobin and creatinine levels, type of admission
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before cardiac surgery (urgent v not), preoperative critical flow was described using descriptive analyses. Normality of
care, preoperative cerebral oximetry, and comorbidities (Euro- data was assessed with the Kolmogorov-Smirnov and Shapiro-
pean System for Cardiac Operative Risk Evaluation, chronic Wilk tests. Kappa coefficients were calculated for the main
obstructive pulmonary disease, diabetes, renal disorder, his- outcome variables extracted to assess data validity.
tory of psychiatric or neurological disorder, myocardial infarc-
tion in the last 4 weeks, and New York Heart Association Hypothesis Testing
functional classification).
The cohort’s perioperative clinical characteristics were Covariates were selected based on statistically significant
described using the following variables: type of procedure differences between the cases and the controls.
(isolated coronary artery bypass graft, isolated valve proce- The authors used a generalized estimated equation (GEE) to
dure, combined procedures, or more), length of procedure and assess the relationship between cumulative fluid balance and
length of cardiopulmonary bypass (CPB), premedication with delirium to account for the correlations over time while con-
benzodiazepines, use of ketamine, lowest cerebral oximetry trolling for covariates. The authors used cumulative fluid bal-
value, and hemodynamic state before and after CPB (maxi- ance at ICU arrival, 24 hours and 48 hours post-ICU arrival,
mum mean pulmonary artery pressure [PAP], lowest mean and delirium 24 hours later, that is, at 24, 48, and 72 hours
arterial pressure [MAP], maximum cardiac output, and maxi- post-ICU arrival. In addition to covariates, the interaction
mum central venous pressure [CVP]). between fluid balance and time also was entered in the equa-
To reflect the severity of hemodynamic instability, clinical tion to assess differences in effects through time.
characteristics, such as the maximum number of vasopressors Sensitivity analyses were performed to assess the relation-
and inotropes received simultaneously at ICU arrival and at ship between cumulative fluid balance and delirium 24 hours
24 hours, maximum PAP and CVP, and laboratory test results later at each time, for a total of 3 logistic regressions. Cumula-
(Supplementary Materials 1 and 2), also were extracted. tive fluid balance variables were transformed in liters (L) and
then stratified into the following 4 categories: (1) ˂1 L, (2)
between 1 L and 2 L, (3) between 2 L and 3L, and (4) ˃3 L.
Hypothesis Testing Variables and Data Collection
Proportions of patients with delirium were presented for each
category.
Cumulative fluid balances were collected using the input of
All statistical analyses were performed using SPSS, version
fluids from the following types: crystalloids, colloids, red
24.0 (SPSS Inc., Chicago, IL). The significance level was set
blood cell, or other blood products (plasma, platelets, etc.)
minus the output of fluids from urine, bleeding, nasogastric at 0.05 for all tests.
tube, and drains. Cumulative fluid balances were calculated at
3 times: (1) between the beginning of surgery and ICU arrival, Results
(2) between the beginning of surgery and 24 hours post-ICU
arrival, and (3) between the beginning of surgery and 48 hours The authors screened 187 patients before reaching the 173
post-ICU arrival. cases and 190 patients before reaching the 173 controls. Rea-
Delirium was defined as a diagnosis of delirium or a men- sons for exclusion are presented in Figure 1.
tion of acute confusion or encephalopathy in the electronic
medical chart at 24, 48, and 72 hours post-ICU arrival.24 For Description of the Cohort
the classification of cases versus controls, patients were con-
sidered as “cases” if delirium occurred at any of the 3 times. As shown in Table 1, patients with delirium were older; had
more often both hearing and visual impairment, recent mem-
Statistical Analyses ory loss, poorer functional status, lower preoperative hemoglo-
bin, higher creatinine levels, and lower cerebral oximetry
Sample Size Calculation and Power values; and had more often a history of neurological disorder.
A sample size of 346 patients (1:1 allocation) granted this Although most of the cohort underwent isolated coronary
study a 90% statistical power to detect an effect size of 0.35 artery bypass graft surgery, cases underwent combined proce-
for the effect of cumulative fluid balance on delirium occur- dures more often than controls, but the length of the procedure
rence using bilateral comparisons of means and a significance was similar in both groups (Table 1). Cases had higher PAP
threshold of 0.05. and lower cardiac output both before and after CPB, and
showed lower MAP after CPB. On ICU arrival, the clinical
state of cases was more severe than controls, as shown by
Descriptive Results and Group Comparisons for Clinical
cases receiving more vasopressors or inotropes than controls.
Variables
Mean scores of cumulative fluid balance 24 hours preceding
Continuous variables are presented as mean § standard delirium occurrence are presented in Figure 2, A and are higher
deviation or median and interquartile range and compared for those with delirium occurrence. Of all types of fluids, means
using the t test or the Mann-Whitney U test, as appropriate. of crystalloids and red blood cells were higher for patients with
Categorical variables are presented as proportions and com- delirium (Supplementary Material 3). Finally, as shown in
pared using the chi-squared (x2) test. The study participants Figure 2, B, at 24 hours and 48 hours post-ICU arrival, larger
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Fig. 1. CONSORT flowchart. The flow diagram is presented.

fluid balances are associated with a higher proportion of patients statistically significant. A medical history of neurological dis-
among those with delirium at 48 hours and 72 hours. order (OR 2.34; 95% CI, 1.278-4.291; p = 0.006), having
both hearing and visual impairment (OR 2.77; 95% CI,
Hypothesis Testing Results 1.583-4.847; p < .001), more complicated type of procedure
(OR 1.47; 95% CI, 1.103-1.959; p =.009), and increased
In the GEE model (Table 2), results were in line with the mean PAP pre-CPB (OR 1.05; 95% CI, 1.014-1.080;
hypothesis while controlling for time, interaction between p = .005) increased the risk of delirium in the statistical
time and cumulative fluid balance, age, having both hearing model. In addition, increased perioperative cerebral oximetry
and visual impairment, body mass index, recent memory value (OR .93; 95% CI, 0.888-0.965; p < .001) and increased
loss, functional status, preoperative hemoglobin and creati- mean MAP post-CPB (OR .97; 95% CI, 0.942-0.997;
nine levels, preoperative cerebral oximetry value, history of p = .029) decreased the risk of delirium.
neurological disorder, type of procedure, use of ketamine,
perioperative cerebral oximetry, pre-CPB PAP, post-CPB Sensitivity Analyses
PAP, post-CPB MAP, pre-CPB cardiac output, post-CPB car-
diac output, and maximum number of vasopressors and ino- In the 3 logistic regressions (1 per time point), the authors
tropes received simultaneously at ICU arrival and at controlled for the same covariates as in the GEE model. As
24 hours. Each increase of 1 L of cumulative fluid balance shown in Table 3, for logistic regression #1 between fluid bal-
was related to increased odds of delirium (odds ratio [OR] ance at ICU arrival and delirium at 24 hours, only the cumula-
1.20; 95% confidence interval (CI), 1.066-1.355; p = .003). tive fluid balance between 1 L and 1.9 L was related to
Delirium occurrence increased over time (n = 39 delirium at delirium (OR 4.18; 95% CI, 1.529-.430; p = .005), whereas the
24 hours; n = 104 delirium at 48 hours; n = 142 patients at categories of larger cumulative fluid balance were not. For
72 hours post-ICU arrival), resulting in a significant effect of logistic regression #2 between fluid balance 24 hours post-
time (OR 2.14; 95% CI, 1.603-2.851; p < 0.001). The inter- ICU arrival and delirium at 48 hours, each category was
action between time and the cumulative fluid balance was not related to delirium, with a higher OR associated with the fluid
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Table 1
Sociodemographic and Clinical Data (n = 346)

Cases N = 173 Controls N = 173 p Values

Sociodemographic and preoperative clinical characteristics


Age, y, median (IQR) 74 (68-74) 69 (61-75) <0.001
Sex, male, n (%) 127 (73.4) 132 (76.3) .54
Body mass index, kg/m2, median (IQR) 27.28 (24.46-31.51) 29.07 (25.22-32.46) .037
Smoking, yes, n (%) 25 (15.3) 15 (8.9) .07
Alcohol consumption, daily consumption, self-reported in nursing 18 (10.4) 12 (6.9) .20
initial assessment chart, n (%)
Hearing and visual impairment, needs hearing and visual aids, n (%) 44 (30.8)a 24 (14.8)b <0.001
Recent memory loss, self-reported in nursing initial assessment chart, n (%) 39 (26.2)c 14 (8.4)d <0.001
Functional status, needs help with activities of daily living, self-reported in 42 (28.0)e 20 (12.4)f <0.001
nursing initial assessment chart, n (%)
Left ventricular ejection fraction, %, median (IQR) 55 (45-60) 55 (50-60) .63
Hemoglobin level, median (IQR) 117 (101-137) 135 (119-145) <0.001
Creatinin level, median (IQR) 107 (89-132) 82 (69-104) <0.001
Type of admission, urgent yes, n (%) 27 (15.9)g 20 (11.7)g .26
Preoperative critical care, yes, n (%) 41 (23.7) 40 (23.1) .73
Preoperative cerebral oximetry value, %, median (IQR) 66 (60-70) 69 (64-73) .001
Comorbidities, yes, n (%)
EuroSCORE, median (IQR) 3.49 (1.96-5.38) 2.20 (0.84-3.43) <0.001
Chronic obstructive pulmonary disease 30 (22.4) 35 (20.2) .89
Diabetes 64 (39.0)h 57 (33.7) .32
Renal disorder 39 (22.0)i 28 (16.2) .10
History of psychiatric disorder 16 (9.2) 14 (8.3) .64
History of neurological disorder 44 (26.8) 20 (11.9) <0.001
Myocardial infarction in the last 4 wk 19 (11) 26 (15.2) .254
NYHA functional classification 3 8 (4.6) 15 (8.7) .13
Perioperative clinical characteristics
Type of procedure, yes, n (%)
Isolated CABG procedure 64 (37.0) 102 (59.0) <0.001
Isolated valve procedure 45 (26.0) 49 (28.3)
Combined procedures or more 64 (37.0) 22 (13.0)
Length of procedure, hh:mm, median (IQR) 2:50 (2:19-3:20) 2:49 (2:13-3:35) .74
Length of CPB, hh:mm, median (IQR) 1:23 (1:04-1:48) 1:12 (0:54-1:36) .18
Premedication with benzodiazepines, yes, n (%) 111 (66.0) 108 (65.5) .85
Use of ketamine, mg, median (IQR) 22.5 (0-48.17) 0 (0-32.9) .002
Lowest cerebral oximetry value, %, median (IQR) 58 (52-63) 63 (58-67) <0.001
Hemodynamic state before and after CPB
Maximum PAP, median (IQR)
Pre-CPB 25 (21-29) 23 (19-26) .005
Post-CPB 26 (23-32) 24 (21-28) <0.001
Lowest MAP, median (IQR)
Pre-CPB 70 (65-80) 75 (65-80) .29
Post-CPB 65 (60-70) 70 (65-75) <0.001
Maximum cardiac output, median (IQR)
Pre-CPB 3.39 (2.95-4.03) 3.66 (3.09-4.38) .044
Post-CPB 3.62 (3.07-4.33) 3.95 (3.32-4.64) .017
Maximum CVP, median (IQR)
Pre-CPB 15 (11-20) 15 (11-18) .28
Post-CPB 16 (12-22) 16 (12-21) .85
Postoperative clinical characteristics
Maximum number of vasopressor and inotropes received
simultaneously, yes, n (%)
At ICU arrival, 3 or more 21 (12.1) 11 (6.3) <0.001
At 24 hours, 3 or more 20 (11.5) 7 (4.0) <0.001

NOTE. Categorial variables are expressed as n (%) and continuous variables as median (interquartile range). The European System for Cardiac Operative Risk
Evaluation (EuroSCORE) onlinecalculator was used (http://www.euroscore.org/calc.html). Comparison between cases and controls was performed with chi-square
test for categorial variables and Mann-Whitney or t tests for continuous vairables as appropriate. Bold p values indicate p < 0.05.
Abbreviations: CABG, coronary artery bypass graft; CPB, cardiopulmonary bypass; CVP, central venous pressure; ICU, intensive care unit; IQR, interquartile
range; MAP, mean arterial pressure; NYHA, New York Heart Association; PAP, pulmonary artery pressure.
a
n = 143; b n = 162; c n = 149; d n = 167; e n = 150; f n = 161; g n = 170; h n = 164; i n = 163.
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balance between 2 L and 3 L (OR 11.02; 95% CI, 2.037- both hearing and visual impairment, undergoing a more compli-
59.641; p = .005). As for logistic regression #3 between fluid cated type of procedure, and increased mean PAP pre-CPB
balance 48 hours post-ICU arrival and delirium at 72 hours, increased the risk of delirium, whereas increased perioperative
only fluid balance larger than 3 L was related to delirium (OR cerebral oximetry value and increased mean MAP post-CPB
5.45; 95% CI, 2.147-13.854; p < .001). decreased the risk of delirium. Although the interaction between
time and the cumulative fluid balance was not statistically sig-
Discussion nificant in the GEE model, results from the logistic regressions
performed for each time suggest the effect of fluid balance
The authors observed patients who presented delirium after might be different at ICU arrival than at 24 hours and 48 hours
cardiac surgery had higher cumulative fluid balance in compari- post-ICU arrival. In the first logistic regression, the authors
son to the patients who did not. In the robust GEE model, the observed the relationship between fluid balance and delirium
authors found the cumulative fluid balance to be related to delir- was not linear. This suggests other factors may be involved in
ium diagnosed 24 hours later while controlling for time, interac- delirium onset at 24 hours post-cardiac surgery.
tion between time, and cumulative fluid balance, in addition to The clinical variables offer some possible explanations
several covariates selected based on statistically significant dif- about why patients who developed delirium received more flu-
ferences between the cases and the controls. The authors also ids than controls. The higher maximum number of vasopres-
observed that a medical history of neurological disorder, having sors and inotropes suggests a more severe clinical state,

Fig. 2. Descriptive data on cumulative fluid balance. (A) Cumulative fluid balance 24 hours preceding each delirium time are presented as mean § standard devia-
tion. The black line represents cases who presented delirium, while the gray line reprensents controls who did not present delirium. (B) The categorized cumulative
fluid balances are presented as frequency and percentage among patients with delirium for each category.
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Table 2
Result of GEE for Primary Outcome (n = 346)

Parameters B § SE p Value OR 95% CI

Intercept ¡2.04 § 1.59 .07


History of neurological disorder .85 § .31 .006 2.342 (1.278-4.291)
Hearing and visual impairment 1.019 § .29 <.001 2.770 (1.583-4.847)
Type of procedure .385 § .15 .009 1.470 (1.103-1.959)
Perioperative cerebral oximetry value ¡.08 § .02 <.001 0.926 (0.888-0.965)
Mean PAP pre-CPB .046 § .02 .005 1.047 (1.014-1.080)
Mean MAP post-CPB ¡.032 § .01 .029 0.969 (0.942-0.997)
Cumulative fluid balance* .184 § .06 .003 1.202 (1.066-1.355)
Time .760 § .15 <.001 2.138 (1.603-2.851)

NOTE. Variables entered in the model as covariates: time, interaction between time and fluid balance, age, having both hearing and visual impairment, BMI, recent
memory loss, functional status, preoperative hemoglobin and creatinine levels, preoperative cerebral oximetry value, history of neurological disorder, type of
procedure, use of ketamine, perioperative cerebral oximetry, pre-CPB PAP, post-CPB PAP, post-CPB MAP, pre-CPB cardiac output, post-CPB cardiac output,
dosage of noradrenaline at ICU arrival and maximum number of vasopressor and inotropes received simultaneously at ICU arrival and 24 hours.
Abbreviations: CI, confidence interval; CPB, cardiopulmonary bypass; GEE, generalized estimated equation; MAP, mean arterial pressure; OR, odds ratio; PAP,
pulmonary artery pressure.
*In-out fluid balance used here is end of surgery, 24 hours, and 48 hours, while delirium is 24, 48, and 72 hours.

whereas lower hemoglobin levels may explain why cases This study is the largest to date to assess the relationship
received more red blood cells, in turn increasing cumulative between delirium and cumulative fluid balance. A limited num-
fluid balance. Although CVP was statistically higher among ber of small studies have reported an association between varia-
cases compared to controls at 72 hours post-ICU arrival, CVP bles related to cumulative fluid balance and delirium, and the
did not differ between cases and controls at other times; limita- current observations are in line with previous results. In a small
tions associated with the measuring technique of CVP in usual observational study, the occurrence of delirium was explained,
care, in addition to that the authors retained only maximum in part, by acute renal failure, and delirium severity was related
values, may explain this lack of difference.25 to the positive cumulative fluid balance of 2 L of more 24 hours

Table 3
Logistic Regression Models (n = 346)

Parameters B § SE p Value OR 95% CI

Logistic regression #1: cumulative fluid balance at ICU arrival and delirium at 24 h
(INDICATOR) Cumulative fluid balance ˂ 1 L .018
Cumulative fluid balance between 1 L and 1.9 L 1.431 § .513 .005 4.18 1.529-11.430
Cumulative fluid balance between 2 L and 3 L ¡0.016 § .855 .985 0.984 .184-5.260
Cumulative fluid balance ˃3L ¡0.052 § 0.869 .952 0.949 0.173-5.211
Hearing and visual impairment 1.433 § .470 .002 4.19 1.668-10.53
Logistic regression #2: cumulative fluid balance 24 h post-ICU arrival and delirium at 48 h
(INDICATOR) Cumulative fluid balance ˂ 1 L .050
Cumulative fluid balance between 1 L and 1.9 L 2.010 § .856 .019 7.462 1.393-39.980
Cumulative fluid balance between 2 L and 3 L 2.400 § .861 .005 11.023 2.037-59.641
Cumulative fluid balance ˃3 L 2.023 § .806 .012 7.559 1.557-36.701
Recent memory loss 1.852 § .432 .000 6.375 2.733-14.873
Functional status 1.104 § .404 .006 3.017 1.366-6.665
History of neurological disorder 0.858 § 0.426 .044 2.359 1.024-5.431
Lowest perioperative cerebral oximetry value ¡0.044 § 0.020 .027 0.957 0.920-0.995
Logistic regression #3: cumulative fluid balance 48 h post-ICU arrival and delirium at 72 h
(INDICATOR) Cumulative fluid balance ˂ 1 L .001
Cumulative fluid balance between 1 L and 1.9 L 0.645 § 0.551 .242 1.906 0.647-5.615
Cumulative fluid balance between 2 L and 3 L 0.653 § 0.576 .257 1.921 0.621-5.943
Cumulative fluid balance ˃3 L 1.696 § .476 .000 5.454 2.147-13.854
Preoperative hemoglobin level ¡0.023 § 0.008 .006 0.977 0.961-.0993
Type of procedure 0.454 § 0.163 .005 1.575 1.145-2.167
Maximum PAP pre-CPB 0.054 § 0.024 .021 1.056 1.008-1.106

NOTE. Variables entered in the model as covariates: age, having both hearing and visual impairment, BMI, recent memory loss, functional status, preoperative
hemoglobin and creatinine levels, preoperative cerebral oximetry value, history of neurological disorder, type of procedure, use of ketamine, perioperative cerebral
oximetry, pre-CPB PAP, post-CPB PAP, post-CPB MAP, pre-CPB cardiac output, post-CPB cardiac output, dosage of noradrenaline at ICU arrival, and maximum
number of vasopressors and inotropes received simultaneously at ICU arrival and 24 hours.
Abbreviations: CI, confidence interval; CPB, cardiopulmonary bypass; ICU, intensive care unit; MAP, mean arterial pressure; OR, odds ratio; PAP, pulmonary
artery pressure.
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before delirium, suggestive of venous congestion.13 Acute kid- congestion, reflected by cumulative fluid balance, seems to con-
ney injury has resulted in fluid overload and related to outcomes tribute to delirium, future studies on delirium incidence could
after cardiac surgery.26 Acute renal failure, which can result compare liberal and restrictive interventions or echo-guided and
from venous congestion reaching the kidneys, also was identi- personalized management for fluid resuscitation.
fied as a risk factor for delirium in acute care patients.27 More-
over, in acute heart failure after general surgery, the volume of Supplementary materials
crystalloids and colloids administered in the immediate postop-
erative period was related to delirium.28 This phenomenon also Supplementary material associated with this article can be
has been reported in a recent study in which delirium was asso- found, in the online version, at doi:10.1053/j.jvca.2018.07.012.
ciated with the inability to manage increased volumes of fluids,
reflected by an acutely failing heart.29 In that study, brain natri-
uretic peptide or BNP was an independent predictor of delirium. References
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