Patients and Methods: A total of 171 patients who had undergone off-pump CABG without any history of psychiatric disorders were enrolled. Samples were selected according to a purposive sampling method. The Mini-Mental State Examination (MMSE) questionnaire was given to each patients to assess the incidence of cognitive disorder during the first 24 hours of surgery in ICU. To compare creatinine, erythrocytes sedimentation rate, extubation time, and patients’ age between those with and those without postoperative cognitive disorder, independent-samplest test was employed. To compare two groups in terms of any history of diseases such as diabetes, hypertension, and hyperlipidemia, and qualitative C-reactive protein (CRP), Chi square test was used.



Results: Results showed that 75% of patients had postoperative cognitive disorder. There was a significant association between the history of hypertension, CRP, and preoperative creatinine levels in both cognitive disorder and control groups.



Background: Cognitive disorder, which is a common problem for the hospitalized patients, is a fluctuating cognitive destruction that leads to the loss of consciousness. It is usually accompanied by increased mortality, prolonged hospital stay, and decreased rehabilitation. Objectives: The purpose of this study was to determine the risk factors associated with cognitive disorder after coronary artery bypasses graft surgery (CABG).



Conclusions: Given the significant prevalence of postoperative cognitive disorder and significant association between the history of hypertension, CRP, and preoperative creatinine and cognitive disorder, the detection of patient’s clinical symptoms may improve diagnosis, treatment, and even prevention of cognitive disorder. © 2014, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM); Published by Kowsar

Fathi, M.

Harati, H.

Izanloo, A.

Joudi, M.

Rahdari, A.

Soltani, G.

English

Golestan University of Medical Sciences Repository

Anesth Pain Med. 2014 October; 4(4): e18514. DOI: 10.5812/aapm.18514Published online 2014 September 9. Research ArticleIncidence and Predisposing Factors of Cognitive Disorders Following off-Pump Coronary Artery Bypasses Graft SurgeryMarjan Joudi 1; Mehdi Fathi 2,*; Hadi Harati 3; Mitra Joudi 4; Azra Izanloo 5; Ali Rahdari 2; Ghasem Soltani 21Surgical Oncology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran2Department of Anesthesiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran3Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran4Department of Psychiatry, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Iran5Department of Radiologic Technology, Faculty of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran*Corresponding author: Mehdi Fathi, Department of Anesthesiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Tel: +98-5138525209, E-mail: Man-dala_110@yahoo.com Received: February 23, 2014; Revised: March 30, 2014; Accepted: April 23, 2014Background: Cognitive disorder, which is a common problem for the hospitalized patients, is a fluctuating cognitive destruction that leads to the loss of consciousness. It is usually accompanied by increased mortality, prolonged hospital stay, and decreased rehabilitation.Objectives: The purpose of this study was to determine the risk factors associated with cognitive disorder after coronary artery bypasses graft surgery (CABG).Patients and Methods: A total of 171 patients who had undergone off-pump CABG without any history of psychiatric disorders were enrolled. Samples were selected according to a purposive sampling method. The Mini-Mental State Examination (MMSE) questionnaire was given to each patients to assess the incidence of cognitive disorder during the first 24 hours of surgery in ICU. To compare creatinine, erythrocytes sedimentation rate, extubation time, and patients’ age between those with and those without postoperative cognitive disorder, independent-samplest test was employed. To compare two groups in terms of any history of diseases such as diabetes, hypertension, and hyperlipidemia, and qualitative C-reactive protein (CRP), Chi square test was used.Results: Results showed that 75% of patients had postoperative cognitive disorder. There was a significant association between the history of hypertension, CRP, and preoperative creatinine levels in both cognitive disorder and control groups.Conclusions: Given the significant prevalence of postoperative cognitive disorder and significant association between the history of hypertension, CRP, and preoperative creatinine and cognitive disorder, the detection of patient’s clinical symptoms may improve diagnosis, treatment, and even prevention of cognitive disorder.Keywords:Off-Pump Coronary Artery Bypass; Cognitive Disorder; Delirium; Risk FactorsCopyright © 2014, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM); Published by Kowsar. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.1. BackgroundCognitive disorder is a fluctuating cognitive damage as well as a consciousness disorder, which is a common acute problem among hospitalized patients. In another definition, cognitive disorder is a type of cognitive and consciousness dysfunction that is spread in a short time and is characterized by features such as changed level of consciousness, reduced concentration and memory, impaired orientation, rapid incidence for several hours to several days, short period, and notable fluctuations (mostly at night) (1). The incidence of cognitive disor-der in hospitalized patients is associated with increased mortality (2-4), prolonged hospital stay (5, 6), increased hospitalization (7), impaired rehabilitation of patient, in-creased nursing measures (8), prolonged intubation (9), higher risk of falls (2), impaired cognitive function (5), increased risk of dementia (6), inability to return to work (3), poor quality of life (10), and long-term care (11). The incidence of cognitive disorder is an indicator of poor prognosis; the rate of mortality in patients with an attack of cognitive disorder is 23% to 33% and their an-nual mortality rate is 50%. The mortality rate of patients who develop cognitive disorder during hospitalization is 20% to 75% and 15% and 25% of them would pass away within one and six months, respectively (12). The inci-dence of cognitive disorder varies in different wards. The highest rate of cognitive disorder is seen following thoracotomy and cardiac surgeries, which may even reach 90% (4).The hypotheses about causes of cognitive disorder in-clude metabolic encephalopathy, drug toxicity, hypo-glycemia, preoperative hypoxemia, visual and hearing impairment, and the type and duration of anesthesia (6, 9). The main postoperative causes include surgical stress, postoperative pain, insomnia, pain control medications, electrolyte disturbances, fever, and bleeding (13).The risk of cognitive disorder might increase in major Joudi M et al.Anesth Pain Med. 2014;4(4):e185142operations such as heart surgery due to the complex surgical procedure, the use of anesthetics and relaxants during and after surgery, and postoperative complica-tions (14). The postoperative pain may also lead to sleep disturbance, increased metabolism, myocardial isch-emia, anxiety, and cognitive disorder (5). Thus, it is clear that the prevalence and risk factors associated with cog-nitive disorder in patients undergoing cardiac surgery, who are held in ICU, is necessary. Identifying the cogni-tive disorder risk factors may help early diagnose and reduce complications.2. ObjectivesThis study aimed to assess the incidence and risk factors of cognitive disorder in patients after open-heart surgery, ie, off-pump coronary artery bypass graft surgery (CABG). 3. Materials and MethodsThis descriptive study was performed on 171 patients undergoing elective CABG in Heart Center of Imam Reza Hospital, Mashhad, during eight months. The samples size was calculated using 329 North 1000 East, Kaysville, Utah 84037, USA NCSS and PASS statistical software with minimum 80% (the 1-β for the multiple logistic regres-sion test) for the multiple logistic regression test, the sig-nificance level of 5% (the α for multiple logistic regression test), The coefficient of determination of 80%, odds ratio of 2.91 and 0.28 and 0.531 probability of cognitive disor-der incidence (15). The sample size estimated 170 patients Then the samples were selected according to a purposive sampling method. For all patients, echocardiography and Doppler sonography of carotid arteries was per-formed before surgery. The night before the surgery, a psychologist visited the patients and conducted a clinical interview with Millon test to evaluate the patients in terms of the history of cognitive disorder as well as mood and psychiatric disor-ders. Furthermore, the selected patients were examined for any sign of psychological disorder. Patients' ASA class was at least III and even IV. Exclusion criteria were emergency operations, repeated opera-tions, carotid stenosis > 40%, preoperative creatinine > 2 mg/dL, history of cognitive disorders, and late extuba-tion (> 8 hours).Anesthesia was induced by 0.1 -mg/kg midazolam, 10 -μg/kg fentanyl, 1 -mg/kg propofol, and 0.5 -mg/kg atra-curium. During the operation, anesthesia was main-tained by 5 -mg/h midazolam, 20 -mg/h atracurium, and 50 -μg/kg/min propofol. After transferring patients to ICU and acquiring wining and extubation condition (4 to 8 hours after operation), they were extubated and the cognitive disorder score of patient during the first 24 hours of stay in ICU (calculated after extubation) was assessed and recorded according to Mini-Mental State Examination (MMSE). The data on the history of patients as well as other col-lected data were entered into SPSS version 21 (SPSS Inc., Chicago, IL. USA). To compare creatinine, erythrocyte sedimentation rate (ESR), extubation time, and patients’ age between two groups of patients with and without postoperative cognitive disorder, independent-samples t test was used and to compare two groups in terms of any history of diseases such as diabetes, hypertension (HTN), and hyperlipidemia, Chi square test was used. 4. ResultsAmong 171 patients with mean age of 64.04 ± 9.84 years, 75% had postoperative cognitive disorder with mean age of 64.26 ± 9.04 years. As shown in Table 1, only the preop-erative creatinine was significantly different between pa-tients with and without cognitive disorder symptoms (P = 0.02) while other factors such as ejection fraction (EF), ESR, age, and even extubation duration were not signifi-cantly different.As shown in Table 2, the patients with and without post-operative cognitive disorder were significantly different regarding the history of HTN and C-reactive protein while two groups were not significantly different regarding the history of stroke, diabetes, and hyperlipidemia.Table 1. Comparing Age, Extubation Duration, Ejection Fraction, and Erythrocyte Sedimentation Rate Between Participants a,b,cGroup Without Cognitive Disorder (n = 42)Group With Cognitive Disorder (n = 129)Total (n = 171) P valueAge, y 63.97± 10.14 64.26± 9.04 64.04 ± 9.84 0.868Cr, mg/dL 1.11± 0.33 1.22± 0.35 1.13 ± 0.34 0.029ExtubationDura-tion, h4.95± 2.48 5.42± 2.39 5.16 ± 2.43 0.236Preoperative EF, % 48.01± 11.33 47.43± 8.91 47.87 ± 10.76 0.468ESR, h - - 44.69 ± 11.95 0.354a Abbreviations: EF, ejection fraction; and ESR, erythrocyte sedimentation rate.b  Data are presented as mean ± SD.c  Results of independent-samples t test.Joudi M et al.3Anesth Pain Med. 2014;4(4):e18514Table 2. Comparing the History of Stroke, Hypertension, Diabetes, Dyslipidemia, and Positive Results for CRP Between Participants a,bWithout Cognitive Disorder (n = 42) With Postoperative Cognitive Disorder (n = 129) P ValueCVA 2.3 7.1 0.171DM 29.5 35.7 0.44HTN 83.7 61.9 0.003HLP 49.6 40.5 0.3CRP+ 32 80 0.045a  Abbreviations: CVA, cerebrovascular accident; DM, diabetes mellitus; HTN, hypertension; HLP, hyperlipidemia; and CRP, C-reactive protein.b  Chi square was used to compare groups. Data are presented as frequencies.5. DiscussionThe results of this study revealed that 75% of the patients had cognitive disorder after off-pump CABG whereas the incidence of this syndrome after open-heart surgery had been reported to be 20% to 45%in other studies (16-18). In the study of Ganavati et al. in Iran, this rate was reported to be 47% (19). This difference could be due to a variety of reasons such as the sample size of the study, or the use of various diag-nostic criteria to identify cognitive disorder. Moreover, this study was conducted on an aging population and since most studies introduce age as a risk factor that is associat-ed with postoperative cognitive complications, older age may increase cognitive disorders (20-22). In the study un-dertaken by Miyazaki et al. high level of serum creatinine was found to be a predisposing factor for cognitive disor-der (23); a finding that was confirmed by the present study. In numerous studies including Miyazaki et al. (23) and Koster et al. (15), it was suggested that a history of stroke and HTN can be a predisposing factor for severe disorders such as cognitive disorder, whereas the present study sug-gested that two groups were not significantly different in terms of the history of stroke. In addition, HTN in those without cognitive disorder was more frequent than in those with postoperative cognitive disorder, which could be due to the small sample size. A study in China showed that diabetes could be consid-ered as a risk factor for cognitive disorder (18). Consistent with this finding, a history of diabetes in our patients with postoperative cognitive disorder was more com-mon than in patients without this complication. Overall, given the results of this study and the high in-cidence of cognitive disorder after open-heart surgery, especially among the elderly, the preoperative assess-ment of cognitive function of the patients is of utmost importance. Furthermore, the complications of cogni-tive disorder can be controlled in nonemergency surger-ies by psychiatric consulting and identifying associated risk factors. Obviously, it requires studies to investigate the effect of these interventions on postoperative cogni-tive state of patients.AcknowledgementsWe would like to thank the Anesthesiology Department of teaching hospitals of Mashhad University of Medical SciencesAuthors’ ContributionsMehdi Fathi and Ghasem Soltani, designing the project and performing the study; Mehdi Fathi and Azra Izanloo, analysis and interpretation of data and writing the man-uscript; and Marjan Joudi, acquisition of data and super-vision of the study.References1.       Trzepacz PT, Sclabassi RJ, Van Thiel DH. Delirium: a subcortical phenomenon? J Neuropsychiatry Clin Neurosci. 1989;1(3):283–90.2.       George C, Nair JS, Ebenezer JA, Gangadharan A, Christudas A, Gnanaseelan LK, et al. Validation of the Intensive Care Delirium Screening Checklist in nonintubated intensive care unit pa-tients in a resource-poor medical intensive care setting in South India. J Crit Care. 2011;26(2):138–43.3.       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Incidence and predisposing factors of cognitive disorders following off-pump coronary artery bypasses graft surgery

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Incidence and predisposing factors of cognitive disorders following off-pump coronary artery bypasses graft surgery

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