Preoperative Delirium Associated With Increased Complications In Veterans Undergoing Lower Extremity Bypass
James M. Dittman, BS1, Sally Boyd, MD2, Kedar S. Lavingia, MD3, Michael F. Amendola, MD MEHP FACS FSVS3.
1Virginia Commonwealth University School of Medicine, Richmond, VA, USA, 2VCUHealth, Richmond, VA, USA, 3Central Virginia VA Health Care System, Richmond, VA, USA.
OBJECTIVES: As vascular patients tend to be older than other surgical populations, they are at higher risk of developing altered mental status. While preoperative delirium has been associated with increased adverse outcomes following elective orthopedic procedures, it has not been investigated whether altered mental status correlates with outcomes in vascular procedures. We set forth to determine whether preoperative delirium independently influences outcomes for lower extremity bypass (LEB) revascularization in veterans utilizing the Veteran Affairs Surgical Quality Improvement Program (VASQIP) database. METHODS: All 1999-2018 VASQIP entries concerning infrainguinal LEB were compiled following IRB approval. Risk Analysis Index (RAI) frailty scores were calculated for each patient. Entries were divided based on presence of delirium (PD) versus absence of delirium (AD) prior to surgery. Aggregate demographics, preoperative factors, and 30-day outcomes were compared between cohorts using unpaired t-test* and chi squared test**. A multivariate binary logistic regression† model was applied to generate adjusted odds-ratios for adverse outcomes using patient age, smoking status, preoperative delirium, ascites, diabetes, dialysis-dependance, prior MI, PVD, CHF, COPD, TIA/CVA, and sepsis as covariates. RESULTS: During the study period, 22,958 LEB VASQIP entries (99% male) were recorded including 203 (0.9%) with preoperative delirium. Compared to AD patients, PD patients were on average older (70.1±9.2 vs 65.4±9.1 years; p<0.0001*) with higher RAI frailty scores (37.0±8.2 vs 24.9±6.7; p<0.0001*) and postoperative length of stay (21±33 vs 9±12 days; p<0.0001*). Incidence of adverse outcomes were not uniformly elevated in the PD cohort (Table). Preoperative delirium was associated with significantly higher covariate-adjusted odds for any complication (2.842; CI:1.764-4.578; p<0.001†) and failure to wean from a ventilator following surgery (6.075; CI:2.498-14.776; p<0.001†), and was not significantly associated with postoperative death, return to operating room, reintubation, impaired consciousness, or CVA incidence within 30 days. CONCLUSIONS: Analysis of a large national cohort of veterans undergoing lower extremity bypass suggests that preoperative delirium relates significantly to increased postoperative complications within 30 days. Further investigation of the impact of preoperative delirium on short and long term outcomes for vascular procedures in general and veteran cohorts would assist vascular surgeons conducting preoperative risk assessments for lower extremity revascularization.
| Postoperative Outcome | PD; n=203 | AD; n=22,755 | p-value** |
| Any Complication | 79 (39%) | 5,032 (22%) | <0.0001 |
| Failure to Wean from Ventilator within 48 Hrs | 14 (7%) | 2,563 (11%) | <0.0001 |
| Reintubation | 13 (6%) | 390 (2%) | <0.0001 |
| Return to OR | 93 (46%) | 5,669 (25%) | <0.0001 |
| Cerebrovascular Accident | 2 (1%) | 71 (0.3%) | 0.3 |
| Coma lasting >24 Hrs | 1 (0.5%) | 18 (0.1%) | 0.4 |
| Death | 16 (8%) | 322 (1%) | <0.0001 |
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