CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 6, November/December 2022 AFRICA 297 et al. observed that PLR and platelet-to-WBC ratio (PWR) were predictors of delirium after cardiac surgery.9 The aim of this study was to evaluate the association of inflammatory markers derived from CBC, mean platelet volume (MPV), PLR, NLR, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) with POD in patients operated on for CABG. Methods In this study, the medical records of 1 269 patients who were operated on for isolated CABG with cardiopulmonary bypass (CPB) for coronary artery disease by the same surgical team in the Cardiovascular Surgery Clinic of the University of Health Sciences, Kocaeli Derince Training and Research Hospital between June 2014 and December 2020 were investigated retrospectively. The patients with signs of POD were evaluated using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scores and through the use of anti-psychotics such as dexmedetomidine hydrochloride or haloperidol.15 The exclusion criteria were pre-operative dementia, history of a psychiatric disorder such as depression or cognitive disorder, history of opioid use or drug abuse, advanced age (> 75 years), acute or chronic renal failure, history of head injury, peripheral artery disease, valvular disease, additional procedures such as carotid artery or congenital heart surgery with CABG, chronic obstructive pulmonary disease, left ventricular systolic function disorder (left ventricular ejection fraction < 40%), congestive heart failure, history of myocardial infarction within the previous month, haematological proliferative disease, low haemoglobin levels (≤ 10 g/dl), patients who were severely overweight (body mass index > 30 kg/m2), pre-operative atrial and ventricular arrhythmia, cerebrovascular accident within the last six months prior to surgery, neoplastic disease including benign and malignant tumours, endocrinological disorders (hypothyroidism, hyperthyroidism), autoimmune diseases, systemic inflammatory diseases, the use of steroids or non-steroidal anti-inflammatory drugs, immunosuppressive drug treatment within the final two weeks prior to surgery, the presence of clinical infection signs (fever 37.5°C, CRP ≥ 5 mg/dl, ESR > 20 mm/h or leukocyte count > 11 000 cells/µl) before surgery, application of femoral artery cannulation due to calcification of the ascending aorta, emergency surgery, CABG surgery on a beating heart, patients who were re-operated due to haemodynamic instability or bleeding, patients who required intra-aortic balloon pump, prolonged intubation (> 24 hours) and re-operations. In our clinic, examinations of the anastomosis sites of the aorta are performed by palpation, as we do not perform computed tomography pre-operatively on a regular basis. In patients who were ineligible for side clamping, proximal anastomoses were performed under a single cross-clamping period. These patients were also excluded from our study. A total of 777 patients (597 males, 180 females; mean age 59.8 ± 8.4 years, range 30–75 years) who did not receive any psychiatric treatment in the pre-operative period, who had normal carotid and vertebral artery systems with Doppler ultrasonography and who were operated on for isolated elective CABG were included in the study. The patients were divided into two groups. Group 1 (n = 187) consisted of patients with manifestations of delirium developed within the first 72 hours of surgery, while group 2 (n = 590) included patients with uneventful postoperative follow up. All data were accessed using the archives and the recorded database of the hospital. The demographic and clinical characteristics of the patients, CBC routinely studied pre-operatively and postoperatively (leukocytes, platelets, lymphocytes, neutrophils, MPV, haematocrit and haemoglobin), as well as creatinine, ESR and CRP levels were recorded. Data, including the number of distal anastomoses, the use of blood products and inotropic support, duration of aortic cross-clamp, CPB time, intubation duration and length of stay in the ICU and in hospital were analysed. In addition, the Acute Physiology and Chronic Health Evaluation II (APACHE II) scores for all patients were recorded. Arterial hypertension was considered in patients with measurements of blood pressure above 140 mmHg systolic and 90 mmHg diastolic on at least three occasions or active use of antihypertensive medication. Diabetes mellitus was defined as fasting plasma glucose levels above 126 mg/dl (6.99 mmol/l) in at least two different measurements or active use of antidiabetic drugs. Smoking was defined as current smoking or ex-smokers who quitted smoking in the last six months. Hyperlipidaemia was accepted as total cholesterol > 220 mg/dl (5.7 mmol/l) and low-density lipoprotein cholesterol > 130 mg/dl (3.37 mmol/l) or use of antihyperlipidaemic drugs. Cerebrovascular accident was accepted as acutely developed, temporary or permanent new major (type II) focal or global deficit occurring within the first 24 hours and not lasting for 72 hours postoperatively.16 All patients with a diagnosis of cerebrovascular accident were assessed by the neurologist and the diagnoses were confirmed through imaging studies. Approximately 5 to 7ml venous blood samples were placed into a sterile tube with EDTA for routine blood analysis. Haematological parameters were calculated by an automated blood count device (Abbott CELL-DYN 3700; Abbott Laboratory, Abbott Park, Illinois, USA) following a waiting time of one hour. PLR was calculated by dividing the number of thrombocytes by the number of lymphocytes. NLR was calculated by dividing the number of neutrophils by the number of lymphocytes. Postoperative stroke was accepted as a new focal neurological deficit for a period longer than 24 hours, for which the new ischaemic brain damage was shown with computed tomography or magnetic resonance imaging. The diagnosis of postoperative atrial fibrillation (AF) was made by standard 12-derivation electrocardiography. Morbidity and mortality during the stay in hospital following the operation or during the first 30 postoperative days were accepted as postoperative early-term morbidity and mortality. Prolonged stay in the hospital was defined as seven days or longer. This study complied with the Declaration of Helsinki and was carried out following approval of the Ethics Committee for Clinical Trials of Kocaeli Derince Training and Research Hospital of the University of Health Sciences. All patients received 0.5 mg oral alprazolam anaesthesia on the night before surgery. Intramuscular 5 mg midazolam was injected 30 minutes before the operation as pre-medication. Intravenous midazolam (0.1 mg/kg), fentanyl (0.01 mg/kg) and rocuronium bromide (0.6 mg/kg) were administered for induction. Intravenous rocuronium bromide (0.15 mg/kg) and midazolam (0.03 mg/kg) were given for maintenance.
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