Prevalence and Risk Factors for Postoperative Delirium in a Cardiovascular Intensive Care Unit

Yu-Ling Chang, Yun-Fang Tsai, Pyng-Jing Lin, Min-Chi Chen and Chia-Yih Liu
Am J Crit Care 2008;17:567-575
2008 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

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AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright 2008 by AACN. All rights reserved.

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Delirium Assessment

RISK FACTORS FOR POSTOPERATIVE DELIRIUM IN A CARDIOVASCULAR INTENSIVE CARE UNIT

REVALENCE AND
By Yu-Ling Chang, RN, MS, Yun-Fang Tsai, RN, PhD, Pyng-Jing Lin, MD, Min-Chi Chen, PhD, and Chia-Yih Liu, MD
Background Delirium after cardiac surgery is a common complication in cardiovascular intensive care units. The prevalence of delirium and its likely risk factors have not previously been explored in a single sample of postoperative cardiac patients in an intensive care unit. Objective To compare a variety of characteristics in patients with and without delirium and to identify risk factors associated with delirium in patients hospitalized in an intensive care unit after cardiac surgery. Methods A retrospective chart review was used to collect data on 288 patients who had open heart surgery during the period 2004 to 2005 at Chang Gung Memorial Hospital in northern Taiwan. A researcher-designed checklist of 52 patient-related risk factors for delirium was used to collect preoperative, intraoperative, and postoperative data. All patients were assessed by psychiatrists, and delirium was diagnosed according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Data were analyzed via univariate analysis and multivariate logistic regression. Results The prevalence of postoperative delirium was 41.7%. Patients with and without delirium differed significantly on 29 variables. Four postoperative factors, hematocrit less than 30%, cardiogenic shock, hypoalbuminemia, and acute infection, were significant, independent predictors of postoperative delirium. Conclusions The results of this study can be used to develop a revised checklist of 29 preoperative, intraoperative, and postoperative risk factors for delirium, with special attention to the 4 predictive postoperative factors. Use of such a checklist may facilitate the ability to prevent or detect delirium early and provide suitable treatment. (American Journal of Critical Care. 2008;17:567-575)

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elirium after cardiac surgery is a common complication in cardiovascular intensive care units (ICUs); estimated incidence rates are approximately 30% to 73%.1-4 Delirium is defined as a disturbance of consciousness with inattention that is accompanied by changes in cognition or perceptual disturbance and has an acute onset and a fluctuating course.5-7 Common signs and symptoms of delirium are memory impairment, disorientation, irrelevant speech, hallucinations, and illusions or delusions.6,7 Delirium, sometimes known as acute confusion,5 has 3 clinical subtypes: hyperactive, hypoactive, and mixed.6,7 Delirium is distinct from dementia, which is characterized by memory impairment and cognitive disturbance that develop over a longer period and progressively worsen.6 Delirium results in a 20% to 30% increase in morbidity and mortality rates,8,9 a decrease in cognitive and functional abilities,10,11 prolonged hospital stays, higher rates of discharge to nursing homes, rehabilitation, and increased costs.12,13

Delirium remains unrecognized and misdiagnosed in 66% to 84% of patients.

The exact pathophysiological mechanisms involved in the development and progression of delirium are unknown.14 According to the criteria of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders7 and previous reports,2,15-30 delirium after cardiac surgery is related to factors that are present before surgery (predisposing or preoperative variables), during surgery (intraoperative variables), and after surgery (postoperative variables; see Figure). Predisposing factors, which reflect a patients baseline vulnerability, include age greater than 65 years, history of psychological disorder, and history of medical disease.9,15,18 Intraoperative factors include noxious stimuli or injuries related to the ICU and/or cardiac surgery factors.2,8,12,15-30 Postoperative factors include cardiogenic shock, atrial fibrillation, massive blood transfusions,16,17 hypoalbuminemia,6,12 low hematocrit,16,17,23 acute infection,15,27 and drugs.8,12,17,18,30 Delirium remains unrecognized and misdiagnosed in 66% to 84% of patients because of its short onset, fluctuating course, and manifestations similar to those

of depression and dementia.12,31,32 In addition, many health care providers do not understand the progression of delirium and do not recognize the outcomes of its complications (eg, high mortality rate).29,31 Knowing the risk factors for delirium would enable clinicians to avoid or detect delirium soon after onset and provide symptomatic relief, thus decreasing complications and even death. So far, no researchers have exhaustively examined likely risk factors for delirium in a single sample of patients. Therefore, the aims of this study were to compare a variety of characteristics in patients with and without delirium and to identify the risk factors associated with the development of delirium in patients hospitalized in an ICU after cardiac surgery.

Methods
The study was approved by the institutional review board at Chang Gung Memorial Hospital. Design A retrospective chart review was used to collect data. The conceptual framework (see Figure) was modified from the multifactorial model of Inouye and Charpentier8 by adding other likely risk factors for delirium.6,16-30,32,33 All patients were systematically assessed by psychiatrists, and delirium was diagnosed according to criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.7 Sample and Setting The sample consisted of 288 consecutive adult patients who underwent open heart surgery during the period December 2004 to December 2005 and received postoperative care in the 14-bed cardiovascular ICU of Chang Gung Memorial Hospital, a 3300-bed medical center in northern Taiwan.

About the Authors

Yu-Ling Chang is a nurse practitioner in the Department of Cardiac Surgery, Pyng-Jing Lin is a professor in the Department of Cardiac Surgery, and Chia-Yih Liu is an associate professor, Department of Psychiatry, at Chang Gung Memorial Hospital, Tao-Yuan, Taiwan. Yun-Fang Tsai is a professor in the School of Nursing, Chang Gung University, Tao-Yuan, Taiwan, and associate director, Department of Nursing, Chang Gung Memorial Hospital, Kee-Long, Taiwan. Min-Chi Chen is an associate professor, School of Medicine, Chang Gung University. Corresponding author: Yun-Fang Tsai, RN, PhD, School of Nursing, Chang Gung University, 259, Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan, Taiwan, 333 (e-mail: yftsai @mail.cgu.edu.tw).

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Predisposing factors (preoperative variables) Age, sex, educational background, marriage, body mass index, living condition, ethnic group9,15 History of smoking (minimum 20 cigarettes per day within 1 month)12,18 History of psychological disorders (depression, schizophrenia, acute delirium, drug addiction)2,9,12,19 Alcohol and sedative-hypnotic withdrawal (within past month)12 History of medical disease: hypertension, diabetes mellitus, stroke, peripheral vascular disease, pulmonary disease, renal disease12,16 Left ventricular ejection fraction <30%, atrial brillation12 Score 8 on Glasgow Coma Scale, cardiogenic shock9,12 Emergency cardiac surgery, waiting time for surgery9,12,22

Aggravating factors (intraoperative variables) Type of surgery16 Total cardiopulmonary bypass time, circulatory arrest time16-18,23,26 Ischemic time16,17 Intraoperative blood transfusion >1 L16,17 Hypothermia during surgery16,17 Anesthesia19

Delirium

Precipitating factors (postoperative variables) Left ventricular ejection fraction 30%, atrial brillation12,16,23 Cardiogenic shock after surgery12,16,23 Red blood cell transfusion >1 L, blood loss >1 L12,16 Hypoalbuminemia: serum albumin <3.0 g/dL6,12 Acute infection (based on systemic inammatory response syndrome)15,27 Hematocrit <30%15-17 Hypoxemia: arterial oxygen saturation <90%26 Serum creatinine >2 mg/dL, total bilirubin >2 mg/dL, low or high levels of sodium, potassium, sugar12,26,28,a Hypocarbia or hypercarbia: PaCO2 <25 or 45 mm Hg12,26 Dehydration: urea nitrogen to creatinine ratio 1812,26,28 Unexpected repeat surgery16,23 Medications: psychoactive drugs, analgesics, hypohypnotics, anticholinergics, corticosteroids, high dose of inotropic drug6,12,17,18,30

Figure Multiple-factor framework for delirium after cardiac surgery.

a

To convert milligrams per deciliter to micromoles per liter, for creatinine, multiply by 88.4; for total bilirubin, multiply by 17.104.

Data Collection A researcher-designed checklist of 52 patientrelated risk factors for delirium was used to collect preoperative, intraoperative, and postoperative data. The checklist was based on the results of empirical1618,23-26,29,33 and clinical19-22,32 studies. A review of the checklist by 3 cardiovascular surgeons, 1 psychiatrist, and 1 cardiovascular nursing specialist provided a content validity index of 0.95.34 The checklist was tested by a cardiovascular nurse practitioner (Y.-L.C.) and an experienced cardiovascular nursing specialist on 20 patients after cardiotomy; the interrater reliability was 0.92. A principal investigator (Y.-L.C.) reviewed the charts of all patients who had open-heart surgery in

2005. Data were collected from the charts for 6 days, starting from the day of surgery (day 1). Data Analysis Continuous variables were analyzed by using descriptive statistics (mean, standard deviation); categorical data were analyzed as proportions (number, percentage). Continuous variables were compared between patients with and without delirium by using a t test or the Mann-Whitney test. The t test was used if the data were normally distributed in both groups; the Mann-Whitney test, if normality was violated. Categorical variables were compared by using 2 tests or the Fisher exact test. When sample sizes in each category were large enough, the 2

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Delirium results in 20% to 30% increased morbidity and mortality rates.

test was used; otherwise, the Fisher exact test was used. The criteria of large samples were examined by using SPSS software (SPSS Inc, Chicago, Illinois). All P values were 2-tailed. Variables with significantly different prevalences between groups (P < .05) were analyzed by using stepwise logistic regression to develop 3 separate predictive models for (1) preoperative, predisposing factors, (2) intraoperative factors, and (3) postoperative factors. The P values for entry and removal were .05 and .01, respectively. These regression models were assessed for overall fit by using the Hosmer-Lemeshow goodness-of-fit test. All statistical analyses were performed with SPSS for Windows, version 12.0.

Results
In the 288 cases reviewed, 67% of the patients were men, and their mean age was 56.6 years (SD, 14.4; range, 20-84). The most common surgical procedures were coronary artery bypass grafting (41.7%), valvular surgery (valvular repair or replacement, 36.1%), and aortic surgery (11.5%). The prevalence of postoperative delirium was 41.7%. The first episode of delirium usually occurred on the second (40.0%) or third (21.6%) day after surgery and in the ICU (95.8%). Among patients with delirium, 59% received mechanical ventilation. Of those who experienced delirium, 71.7% had signs and symptoms that subsided within 24 hours after transfer to the regular unit. Of the 52 risk factors surveyed on the checklist, univariate analysis (independent t test, Mann-Whitney test, or 2 analysis) indicated that 29 were more prevalent in the patients who had delirium (Table 1). Predisposing (preoperative) factors more prevalent in delirium were older age, less education, single marital status, history of psychological disorder, diabetes mellitus, history of stroke, history of renal disease, left ventricular ejection fraction of 30% or less, atrial fibrillation, emergency cardiac surgery, and cardiogenic shock. Intraoperative factors more prevalent in delirium were complex surgical procedures, circulatory arrest that lasted 30 minutes or longer, blood transfusion volume greater than 1 L during surgery, and body temperature less than 25C. Postoperative precipitating factors more prevalent in patients with delirium were left ventricular ejection fraction of 30% or less, atrial fibrillation, blood transfusion

volume greater than 1 L, blood loss volume greater than 1 L, cardiogenic shock, unanticipated reoperation, hypoalbuminemia (serum albumin level <3.0 g/dL), acute infection, dehydration, hematocrit less than 30%, renal insufficiency (creatinine level >2 mg/dL; to convert to micromoles per liter, multiply by 88.4), hepatic dysfunction (total bilirubin >2 mg/dL; to convert to micromoles per liter, multiply by 17.104), hypercarbia (PaCO2 45 mm Hg), and treatment with anticholinergic agents (Table 1). Variables that univariate analysis (t test or 2 analysis) indicated to be significantly more prevalent in patients with delirium than in patients without delirium were analyzed by stepwise logistic regression. The independent risk factors predictive of postoperative delirium (Table 2) were postoperative hypoalbuminemia (odds ratio, 2.4), postoperative hematocrit less than 30% (odds ratio, 2.16), postoperative cardiogenic shock (odds ratio, 2.75), and postoperative acute infection (odds ratio, 6.9). In other words, patients with postoperative hypoalbuminemia, acute infection, low hematocrit, or cardiogenic shock were 2.4, 6.9, 2.16, or 2.75 times, respectively, more likely to have postoperative delirium than were patients without these conditions.

Discussion
We examined 52 likely preoperative, intraoperative, and postoperative risk factors for delirium in a single sample of patients after open heart surgery in Taiwan. The 41.7% prevalence of postoperative delirium was similar to the range of previous findings (30%-73%) among open heart surgical patients in ICUs.1-4 Factors more prevalent in patients with delirium than in patients without were older age, low educational level, single marital status, a history of psychological disorder, diabetes mellitus, a history of stroke or renal disease, depressed left ventricular function, preoperative atrial fibrillation or cardiogenic shock, and emergency cardiac surgery. These results for predisposing factors are consistent with those of previous studies.9,16,19,33 For example, predisposition to delirium in elderly patients has been related to decreased cerebral neuronal density, blood flow, metabolism, and levels of neurotransmitters.9,18 Our finding of a higher prevalence of single patients with postoperative delirium has not been previously reported. Single patients often receive less support than do married ones, possibly resulting in more depression and anxiety, which have been linked to postoperative delirium in the elderly.9 Diabetes mellitus may have been more prevalent among patients with postoperative delirium because diabetes has been associated with atherosclerosis.16 The endo-

The first episode of delirium usually occurred on the second or third day after surgery.

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Table 1 Prevalence of risk factors in cardiac patients with postoperative delirium (univariate analysis)a
Prevalence Variable Preoperative variables Age, y Mean (SD) 20-55 56-84 Educational background Illiterate and primary school Junior high school and above Marital status Married Single Divorced History of psychological disorder (depression, acute psychosis, prolonged drug abuse) No Yes Diabetes mellitus No Yes History of stroke No Yes History of renal disease No Yes Left ventricular ejection fraction 30% No Yes Atrial brillation No Yes Emergency cardiac surgery No Yes Cardiogenic shock No Yes Intraoperative variables Type of surgery Coronary artery bypass Valve Coronary artery bypass + valve Congenital repair Aortic Other Duration of circulatory arrest, min 0 <30 30 Blood transfusion (packed red blood cells) >1 L No Yes 50 (41.7) 45 (37.5) 5 (4.2) 0 (0) 20 (16.7) 0 (0) 102 (85.0) 2 (1.7) 16 (13.3) 101 (84.2) 19 (15.8) 70 (41.7) 59 (35.1) 8 (4.8) 14 (8.3) 13 (7.7) 4 (2.4) 161 (95.8) 0 7 (4.2) 157 (93.5) 11 (6.5) X25 = 10.1 <.001 Patients with delirium (n = 120) Patients without delirium (n = 168) X2 or t P

59.3 (12.3) 45 (37.5) 75 (62.5) 74 (61.7) 46 (38.3) 105 (87.5) 4 (3.3) 11 (9.2)

54.7 (14.9) 82 (48.8) 86 (51.2) 81 (48.2) 87 (51.8) 138 (82.1) 24 (14.3) 6 (3.6)

t286 = 2.67 X21 = 3.63 X21 = 5.10

<.001 .05 .02

X22 = 12.59

<.001

109 (90.8) 11 (9.2) 82 (68.3) 38 (31.7) 100 (83.3) 20 (16.7) 97 (80.8) 23 (19.2) 100 (83.3) 20 (16.7) 59 (49.2) 61 (50.8) 97 (80.8) 23 (19.2) 96 (80.0) 24 (20.0)

165 (98.2) 3 (1.8) 133 (79.2) 35 (20.8) 156 (92.9) 12 (7.1) 158 (94.0) 10 (6.0) 159 (94.6) 9 (5.4) 107 (63.7) 61 (36.3) 160 (95.2) 8 (4.8) 162 (96.0) 6 (4.0)

X21 = 8.25

<.001

X21 = 4.34

.03

X21 = 6.43

.01

X21 = 12.04

<.001

X21 = 9.89

<.001

X21 = 6.05

.01

X21 = 15.12

<.001

X21 = 20.25

<.001

X22 = 11.07

<.001

X21 = 6.49

<.001

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Table 1 continued
Prevalence Variable Body temperature <25C No Yes Postoperative variables Left ventricular ejection fraction 30% No Yes Atrial brillation No Yes Blood transfusion >1 L No Yes Blood loss >1 L No Yes Cardiogenic shock No Yes Unanticipated reoperation No Yes Hypoalbuminemia < 3.0 g/dL No Yes Acute infection No Yes Dehydration (ratio of urea nitrogen to creatinine >18) No Yes Hematocrit <30% No Yes Creatinine >2 mg/dLb No Yes Bilirubin, total >2 mg/dLb No Yes PaCO2 45 mm Hg No Yes Anticholinergic drug No Yes
a b

Patients with delirium (n = 120)

Patients without delirium (n = 168)

X2 or t

83 (69.2) 37 (30.8)

138 (82.1) 30 (17.9)

X21 = 6.60

.01

109 (90.8) 11 (9.2)

164 (97.6) 4 (2.4) 98 (58.3) 70 (41.7) 157 (93.5) 11 (6.5) 138 (82.1) 30 (17.9) 153 (91.1) 15 (8.9) 166 (98.8) 2 (1.2) 144 (85.7) 24 (14.3) 130 (77.4) 38 (22.6) 138 (82.1) 30 (17.9) 117 (69.6) 51 (30.4) 154 (91.7) 14 (8.3) 165 (98.2) 3 (1.8) 167 (99.4) 1 (0.6) 161 (95.8) 7 (4.2)

X21 = 6.53

.01

44 (36.7) 76 (63.3) 101 (84.2) 19 (15.8) 85 (70.8) 35 (29.2) 79 (65.8) 41 (34.2) 111 (92.5) 9 (7.5) 72 (60.0) 48 (40.0) 30 (25.0) 90 (75.0) 72 (60.0) 48 (40.0) 53 (44.2) 67 (55.8) 83 (69.2) 37 (30.8) 109 (90.8) 11 (9.2) 110 (91.7) 10 (8.3) 103 (85.8) 17 (14.2)

X21 = 13.15

<.001

X21 = 6.53

.01

X21 = 5.61

.01

X21 = 28.47

<.001

X21 = 7.59

<.001

X21 = 24.69 X21 = 77.79

<.001 <.001

X21 = 17.38

<.001

X21 = 18.78

<.001

X21 = 24.31

<.001

X21 = 8.25

<.001

X21 = 11.41

<.001

X21 = 9.16

<.001

All values are number of patients (%) unless otherwise indicated. Because of rounding, not all percentages total 100. To convert milligrams per deciliter to micromoles per liter, for creatinine, multiply by 88.4; for total bilirubin, multiply by 17.104.

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Table 2 Multivariate, stepwise logistic regression analysis for predictors of delirium after cardiac surgerya

thelium or atherosclerotic plaques in patients with diabetes may be injured during surgery, increasing the risk of microemboli to the brain, leading to ischemia and enhanced risk of delirium.9 In the study by McKhann et al,35 history of stroke, older age, and diabetes were predictive of which patients were at greatest risk for neurological complications after cardiac surgery. We also found that patients with delirium after cardiac surgery had a significantly higher prevalence of emergency cardiac surgery than did patients without delirium. A possible explanation for this finding is that emergency surgical patients might have had more serious disease32 and inadequate psychological preparation before surgery. Indeed, better mental preparation of elderly surgical patients has been associated with lower anxiety, and patients who have scheduled surgery have a lower prevalence of postoperative delirium than do patients who have emergency surgery.9 Among the intraoperative risk factors examined, 4 were significantly more prevalent in patients with postoperative delirium than in patients without: aortic reconstruction surgery, lower body temperature, longer circulatory arrest time, and blood transfusion of more than 1 L. These findings suggest that delirium tends to occur more often with more complex surgical procedures such as aortic reconstruction than with surgery for congenital defects among younger and less ill patients. Such complex procedures involve not only older patients but also longer operations and greater volumes of transfused blood. Thus, our results highlight the importance of maintaining and monitoring adequate brain blood flow during surgery to avoid hemodynamic fluctuations and microemboli.16,36,37 Compared with patients without delirium, those with postoperative delirium had a higher prevalence of the following postoperative conditions: left ventricular ejection fraction of 30% or less, atrial fibrillation, cardiogenic shock, blood transfusion volume greater than 1 L, hematocrit less than 30%, unanticipated reoperation, hypoalbuminemia, acute infection, dehydration, hepatic dysfunction, renal insufficiency, hypercarbia, and treatment with anticholinergic agents. These findings are comparable to those of previous studies.6,12,16,26-27,38-41 Low left ventricular ejection fraction, atrial fibrillation, and cardiogenic shock may enhance thrombus formation associated with delayed embolic strokes38,39 and may reflect patients underlying poor condition, leading to delirium. Postoperative atrial fibrillation is a major cause of stroke after cardiac surgery39 and has been associated with a greater incidence of encephalopathy.35,42 Furthermore, low cardiac output syndrome

Predictor Postoperative hypoalbuminemia (serum albumin <3.0 g/dL) Postoperative hematocrit <30% Postoperative cardiogenic shock Postoperative acute infection
a

Odds ratio (95% condence interval)

2.4 (0.197-0.884) 2.16 (1.155-4.034) 2.75 (0.160-0.826) 6.9 (0.077-0.269)

.02 .02 .02 <.001

Hosmer-Lemeshow goodness-of-t: P =.71; overall these 4 predictors accurately classied 79.2% of patients delirium.

has been associated with stroke due to wide fluctuations in arterial blood pressure, increased thrombogenicity, and cerebral hypoperfusion.40 The critical postoperative blood transfusion volume predictive of delirium in this study was 1 L, which is lower than that previously reported (>2 L),16 a difference that may be explained by the smaller body size of Chinese patients compared with Western patients. Low hematocrit (<30%) was more prevalent in patients with postoperative delirium, as previously reported,26 and may be associated with organ dysfunction due to insufficient oxygen delivery.41 The higher prevalence of unanticipated reoperation in patients with delirium might have been due to massive bleeding within 12 hours after cardiotomy or even cardiac tamponade, which would aggravate circulatory status and hinder brain circulation, possibly leading to delirium. To determine the predictive risk factors for postoperative delirium, we used logistic regression analysis to analyze the 29 significantly prevalent risk factors. The results indicated that postoperative hematocrit less than 30%, postoperative cardiogenic shock, postoperative hypoalbuminemia, and postoperative acute infection were independent, significant predictors of postoperative delirium. As mentioned before, low hematocrit may cause inadequate delivery of oxygen to the brain, resulting in organ dysfunction and delirium.26,41 Postoperative cardiogenic shock also compromises brain circulation and the oxygencarrying ability of blood.37,43 Hypoalbuminemia may be caused by poor nutrition or metabolic disturbance,44 especially in critically ill patients. Low plasma levels of albumin reduce colloid oncotic pressure, in part because albumin moves from the vascular space to the interstitial space during acute inflammation, leading to organ dysfunction45 and delirium. Acute infection or sepsis creates a relatively high risk for acute confusion, probably

Acute infection or sepsis creates a relatively high risk for acute confusion.

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because of neurotransmitter imbalance and metabolic problems.9,27 Although health care providers understand the importance of controlling postoperative factors such as hematocrit, cardiogenic shock, hypoalbuminemia, and acute infection, our results narrow the range of delirium risk factors to watch for after cardiac surgery. Thus, clinicians can review successful strategies to keep postoperative hematocrit greater than 30% by evaluating their transfusion strategy26,46 and can actively manage concurrent medical conditions to avoid cardiogenic shock.43,46 Infection can be controlled by avoiding prolonged immobilization and encouraging earlier ambulation.46 In patients with hypoalbuminemia, nutritional intake should be assessed46 and albumin supplements should be administered to prevent decreased contractility of cardiac muscle cells, improve neurologic function, and decrease brain edema after cerebral ischemia.44,47

ACKNOWLEDGMENTS This research was performed at Chang Gung Memorial Hospital in Taiwan. FINANCIAL DISCLOSURES None reported. eLetters
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Study Limitations
This study was limited by its design. We used a retrospective chart review, which may have been limited by the quality of clinicians documentation in patients medical records. With this design, the subtle, fluctuating features of delirium may have been missed.

Conclusion
Our study is the first in which the prevalence of and risk factors for delirium were explored among a single sample of postoperative cardiac patients in an ICU. Our sample of cardiac patients had a high prevalence (41.7%) of delirium after surgery. Four postoperative factors, hematocrit less than 30%, cardiogenic shock, hypoalbuminemia, and acute infection, were significant, independent predictors of postoperative delirium. We suggest that clinicians pay special attention to cardiac patients with prevalent predisposing risk factors and review successful strategies to minimize or avoid prevalent intraoperative or postoperative risk factors. Because research related to delirium after cardiac surgery is rare, most health care providers do not fully understand the syndrome and etiology of delirium. Our results can serve as the basis for developing a revised checklist of 29 prevalent preoperative, intraoperative, and postoperative risk factors for delirium. Such a checklist could then be regularly used by clinicians on cardiovascular surgery ICUs to prevent or detect delirium early and provide suitable treatment.

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