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The Effect of Impaired Cerebral Autoregulation on Postoperative Delirium in Neonates and Infants After Corrective
Yordan H Georgiev1, Marcel Methner1, Maximilian Iller1
1Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, 72076 Tübingen, Germany.
Insights
Impaired cerebral autoregulation does not solely explain postoperative pediatric delirium in children with congenital heart disease. Other factors like ventilation duration and medication use are more significant. Further research is needed.
Area of Science:
- Pediatric critical care medicine
- Neuroscience
- Cardiology
Background:
- Postoperative pediatric delirium (PD) in children with congenital heart disease (CHD) is multifactorial.
- Disturbed cerebral autoregulation in CHD patients can lead to altered brain perfusion and neurological issues.
- The link between postoperative cerebral autoregulation and PD onset in pediatric CHD patients requires investigation.
Purpose of the Study:
- To investigate the association between disturbed postoperative cerebral autoregulation and the onset of PD in neonates and infants undergoing corrective surgery for CHD.
- To determine if impaired cerebral autoregulation is a primary driver of PD in this vulnerable population.
Main Methods:
- Prospective observational study involving neonates and infants undergoing CHD surgery with cardiopulmonary bypass.
- Measurement of cerebral regional oxygen saturation (rSO2) and mean arterial pressure (MAP) postoperatively.
- Calculation of cerebral oximetry index (COx) to assess autoregulation; delirium assessed using the Sophia Observation of Withdrawal-Pediatric Delirium (SOS-PD) score.
Main Results:
- 55% of 49 CHD patients developed postoperative PD.
- No significant difference in impaired cerebral autoregulation duration between delirious and non-delirious groups (p=0.416).
- MAP outside autoregulation limits did not correlate with PD onset (p=0.145, p=0.904).
- Delirious patients had longer ventilation, PICU stay, and higher opioid/benzodiazepine use.
Conclusions:
- Impaired cerebral autoregulation alone does not fully explain PD in pediatric CHD patients post-surgery.
- Hemodynamic management is crucial to mitigate cerebral perfusion issues.
- Larger studies are necessary to confirm these findings and explore other contributing factors to PD.
Background:
The risk factors for developing postoperative pediatric delirium (PD) are multifactorial and include underlying conditions, cyanosis, surgery, intensive care stay, analgesia used for sedation, and withdrawal symptoms. Disturbed cerebral autoregulation in children with congenital heart disease (CHD) can lead to hyper- and hypoperfusion states of the central nervous system and is potentially associated with poor neurological outcomes. Our study aimed to investigate whether disturbed cerebral autoregulation postoperatively is associated with the onset of PD in children with CHD.
Methods:
We conducted a prospective observational study in neonates and infants undergoing corrective surgery for CHD via cardiopulmonary bypass (CPB). Cerebral regional oxygen saturation (rSO2) and mean arterial pressure (MAP) were measured within the first 24 hours after surgery in the pediatric intensive care unit (PICU). The cerebral oximetry index (COx) was calculated from these parameters using ICM+ software. A COx ≥0.4 was considered indicative of impaired autoregulation. Delirium symptoms were assessed using the Sophia Observation of Withdrawal-Pediatric Delirium (SOS-PD) score.
Results:
Cerebral autoregulation was evaluated postoperatively at the bedside of 49 neonates and infants (22 males, 44.9%, vs. 27 females, 55.1%) between January 2019 and April 2023. The median age of the patients was 134 days (interquartile range (IQR): 49.5-184 days), the median weight was 5.1 kg (IQR: 4.0-6.3 kg), and the monitoring duration was 23.0 hours (IQR: 20-24.5 hours). In total, 27/49 (55%) patients developed postoperative PD during their stay in the PICU. There was no statistically significant difference in the duration of globally impaired autoregulation between the delirious and non-delirious groups (14.5% vs. 13.9%, p = 0.416). No evidence was found supporting the effect of MAP outside the lower and upper limits of autoregulation for the onset of postoperative delirium (p = 0.145 and p = 0.904, respectively). Prolonged mechanical ventilation, longer PICU stay, and higher use of opioids and benzodiazepines were observed in the delirious group.
Conclusion:
Our findings suggest that impairment of cerebral autoregulation cannot solely explain the higher rate of PD in children undergoing congenital cardiac surgery. Rigorous hemodynamic management may potentially minimize the impact of cerebral hypo- or hyperperfusion states during the postoperative period, preventing their harmful effects. Additional studies with a larger sample size are needed to confirm the hypothesis and current findings.
