Delirium After Cardiac Surgery and Cumulative Fluid Balance: A Case-Control Cohort Study

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 reaching 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 associated 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. Conclusion Delirium is associated with a cumulative fluid balance, but the extent through which this plays an etiologic role remains to be determined. 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 reaching the brain. Retrospective case-control (1:1) cohort study. University-affiliated tertiary cardiology center. Cardiac surgery intensive care unit (ICU) patients. None. 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 associated 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. Delirium is associated with a cumulative fluid balance, but the extent through which this plays an etiologic role remains to be determined.