Enhanced Recovery After Cardiac Surgery and Postoperative Delirium: Comment

We read with great interest the Jelly et al. article reporting the association between enhanced recovery after cardiac surgery (ERACS)-guided analgesics and postoperative delirium (POD).1Jelly CA, Clifton JC, Billings FT, et al. The association between Enhanced Recovery After Cardiac Surgery (ERACS) guided analgesics and postoperative delirium [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2022.12.023. Accessed January 24, 2023.Google Scholar Evaluating the impact of multimodal analgesia on POD after cardiac surgery is important to ERACS.2Magoon R, Jose J. Multimodal analgesia in paving the way for enhanced recovery after cardiac surgery [e-pub ahead of print]. Braz J Cardiovasc Surg. doi: 10.21470/1678-9741-2022-0058. Accessed January 24, 2023.Google Scholar, 3Choudhury A Magoon R Sahoo S et al.Opioid free cardiac surgery: Opportunities and obstacles.J Cardiothorac Vasc Anesth. 2020; 34: 567-568Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 4Magoon R, Mahajan S, Jose J. DEX, delirium and dilemma [e-pub ahead of print]. Braz J Cardiovasc Surg. doi: 10.21470/1678-9741-2022-0002. Accessed January 24, 2023.Google Scholar We congratulate the authors on their work, but feel that some additional limitations should be mentioned. First, documentation of preoperative cognitive status (eg, Mini-Mental State Examination) and a history of depression are essential aspects of postoperative delirium research, but this information was not included in the study.1Jelly CA, Clifton JC, Billings FT, et al. The association between Enhanced Recovery After Cardiac Surgery (ERACS) guided analgesics and postoperative delirium [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2022.12.023. Accessed January 24, 2023.Google Scholar,4Magoon R, Mahajan S, Jose J. DEX, delirium and dilemma [e-pub ahead of print]. Braz J Cardiovasc Surg. doi: 10.21470/1678-9741-2022-0002. Accessed January 24, 2023.Google Scholar, 5Guenther U Theuerkauf N Frommann I et al.Predisposing and precipitating factors of delirium after cardiac surgery: A prospective observational cohort study.Ann Surg. 2013; 257: 1160-1167Crossref PubMed Scopus (81) Google Scholar, 6Chen H Mo L Hu H et al.Risk factors of postoperative delirium after cardiac surgery: A meta-analysis.J Cardiothorac Surg. 2021; 16: 113Crossref PubMed Scopus (41) Google Scholar Second, the authors did not clarify whether cardiopulmonary bypass (CPB) was used for all coronary artery bypass grafting surgeries, or whether a fraction were performed off-pump. The use of CPB cannot be overemphasized when POD is studied,1Jelly CA, Clifton JC, Billings FT, et al. The association between Enhanced Recovery After Cardiac Surgery (ERACS) guided analgesics and postoperative delirium [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2022.12.023. Accessed January 24, 2023.Google Scholar,7O'Neal JB Billings 4th, FT Liu X et al.Risk factors for delirium after cardiac surgery: A historical cohort study outlining the influence of cardiopulmonary bypass.Can J Anaesth. 2017; 64: 1129-1137Crossref PubMed Scopus (34) Google Scholar as Guenther et al. previously highlighted the association between the duration of CPB and POD.5Guenther U Theuerkauf N Frommann I et al.Predisposing and precipitating factors of delirium after cardiac surgery: A prospective observational cohort study.Ann Surg. 2013; 257: 1160-1167Crossref PubMed Scopus (81) Google Scholar Third, the recent meta-analysis by Chen et al. identified preoperative carotid artery stenosis and New York Heart Association functional status III and IV as independent predictors of POD (odds ratio; 95%CI, I2: 1.72; 1.37-2.16; 0% and 1.89; 1.51-2.37; 23%, respectively).6Chen H Mo L Hu H et al.Risk factors of postoperative delirium after cardiac surgery: A meta-analysis.J Cardiothorac Surg. 2021; 16: 113Crossref PubMed Scopus (41) Google Scholar Indeed, extracardiac arteriopathy and the New York Heart Association status are relevant to the computation of the European System for Cardiac Operative Risk Evaluation II and should have been considered in the current work.1Jelly CA, Clifton JC, Billings FT, et al. The association between Enhanced Recovery After Cardiac Surgery (ERACS) guided analgesics and postoperative delirium [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2022.12.023. Accessed January 24, 2023.Google Scholar,8Ranjan R Adhikary D Mandal S et al.Performance of EuroSCORE II and logistic EuroSCORE in Bangladeshi population undergoing off-pump coronary artery bypass surgery: A prospective cohort study.JRSM Cardiovasc Dis. 2019; 82048004019862125PubMed Google Scholar None. The Association Between Enhanced Recovery After Cardiac Surgery–Guided Analgesics and Postoperative DeliriumJournal of Cardiothoracic and Vascular AnesthesiaVol. 37Issue 5PreviewDelirium is a common postoperative complication associated with death and long-term cognitive impairment. The authors studied the association between opioid-sparing anesthetics, incorporating Enhanced Recovery After Cardiac Surgery (ERACS)-guided analgesics and postoperative delirium. Full-Text PDF