Risk prediction of delirium and cardiovascular complications after hip and knee surgeries in elderly patients

doi:10.3877/ cma.j.issn.1674-134X.2024.05.003

Abstract

Abstract:

Objective

To explore the risk factors of delirium and cardiovascular complications in ultra-senile patients after hip and knee arthroplasties， and to build a visual risk prediction model.

Methods

The clinical data of 118 super-elderly patients who underwent hip and knee arthroplasty in the First Affiliated Hospital of Sun Yat-sen University from October 2018 to October 2021 were retrospectively collected.The patients who were age over 80 years and underwent primary hip or knee arthroplasty were included， while the patients with severe hip arthritis， femoral head necrosis or hip fracture， revision surgery， infection in lungs or urinary system， severe hepatic or renal dysfunction， and combining other severe diseases were excluded.The grouping was based on whether postoperative complications occurred， and they were divided into control group and complication group. The clinical data of the two groups were compared， and the risk factors for postoperative delirium and cardiovascular complications were analyzed by univariate and multivariate logistic regression. R language software was used to establish an alignment chart for predicting risk and construct an online dynamic prediction model and deploy it to the Shinyapps.io website. The predictive performance of the model was evaluated using the area under the curve （AUC）， calibration curve， and clinical decision curve analysis（DCA）.

Results

This analysis showed that for postoperative delirium complications， age （t=-2.164， P＜0.05），hypertension （F=4.635， P＜0.05）， chronic obstructive emphysema （F=22.861， P＜0.05）， postoperative blood albumin （Alb） level （t=3.539， P＜0.05）， preoperative hemoglobin level （t=2.366， P＜0.05）， rest pain （t=-3.180，P＜0.05） and activity pain （t=-2.240， P＜0.05）， the differences of these factors were statistically significant（P＜0.05）. As for postoperative cardiovascular complications， there were statistically significant differences in postoperative blood albumin levels （t=2.069， P＜0.05）， diabetes mellitus （F=-5.696， P＜0.05）， rest pain （t=-3.758，P＜0.05） and activity pain （t=-2.406， P＜0.05） between the two groups （P＜0.05）. Multivariate logistic regression analysis showed that postoperative pain at res［todds ratio （OR）=3.140， 95% confidence interval （CI）（0.170，2.118）］， chronic obstructive pulmonary emphysema［ OR=20.673， 95%CI （1.333， 4.724）］， and hypertension［OR =14.101， 95%CI （0.268， 5.023）］were independent risk factors for postoperative delirium complications（all P＜0.05）. Postoperative pain at rest ［OR=5.522， 95%CI （0.557， 2.861）］and diabetes［OR=5.220，95%CI （0.026， 3.280）］were independent risk factors for postoperative cardiovascular complications （both P ＜ 0.05）. The study concurrently established a predictive model ［AUC= 0.903， 95% CI （0.810， 0.995）］.The model's internal validation showed C-index of 0.903， indicating a certain level of predictive capability.

Conclusions

This study identified risk factors for delirium and cardiovascular complications in patients undergoing hip and knee arthroplasty at an advanced age. Additionally， a predictive model is developed，suggesting that clinical practitioners can enhance perioperative management based on corresponding predictive results to mitigate the risk of postoperative delirium and cardiovascular complications in such patients.

Key words: Aged, 80 and over, Arthroplasty, replacement, Delirium, Cardiovascular diseases, Forecasting

Xiaoling Chen, Yonglie Zhong, Qiaoli Liu, Na Li, Zhiqi Zhang, Weiming Liao, Guiwu Huang. Risk prediction of delirium and cardiovascular complications after hip and knee surgeries in elderly patients[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2024, 18(05): 575-584.

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URL: https://zhgjwkzz.cma-cmc.com.cn/EN/10.3877/ cma.j.issn.1674-134X.2024.05.003

https://zhgjwkzz.cma-cmc.com.cn/EN/Y2024/V18/I05/575

Figures/Tables 12

Table 1 Comparison of postoperative delirium between the two groups

变量Variable		对照组Control group	谵妄并发症组Delirium group	统计值Statistical value	P值
例数Number of cases		106	12
性别Gender	男性Male	40	5	χ ²＜0.0001	＞0.05
性别Gender	女性Female	66	7	χ ²＜0.0001	＞0.05
手术类型Type of surgery	THA	14	2	χ ²=4.236	＞0.05
	TKA	35	1
	股骨头坏死Femoral head necrosis	39	5
	股骨颈骨折内固定Internal fixation of femoral neck fracture	18	4
高血压Hypertension	否No	48	1	χ ²=4.635	0.031
高血压Hypertension	是yes	58	11	χ ²=4.635	0.031
冠心病Coronary disease	否No	93	8	χ ²=2.360	＞0.05
冠心病Coronary disease	是Yes	13	4	χ ²=2.360	＞0.05
麻醉方式Anesthesia	联合椎管内麻醉Combined spinalepidural nesthesia	91	10	χ ²＜0.0001	＞0.05
麻醉方式Anesthesia	全身麻醉General anesthesia	15	2	χ ²＜0.0001	＞0.05
糖尿病Diabetes	否No	77	9	χ ²＜0.0001	＞0.05
糖尿病Diabetes	是Yes	29	3	χ ²＜0.0001	＞0.05
COPD	否No	99	5	χ ²=22.861	＜0.001
COPD	是Yes	7	7	χ ²=22.861	＜0.001
年龄［岁，（ $\bar{x}$ ±s）］Age（year）		83.7±3.4	85.8±3.6	t=-2.164	0.039
术中失血量［ml，（ $\bar{x}$ ±s）］Intraoperative blood loss		186.4±166.5	108.3±41.7	t=1.614	＞0.05
BMI［kg/m²，（ $\bar{x}$ ±s）］		23.0±3.5	22.7±2.7	t=0.265	＞0.05
术前Hb［g/L，（ $\bar{x}$ ±s）］Preoperative Hb		120.8±18.0	107.6±21.2	t=2.366	0.020
术前Alb［g/L，（ $\bar{x}$ ±s）］Preoperative Alb		35.3±4.0	33.9±5.5	t=1.073	＞0.05
术后Hb［g/L，（ $\bar{x}$ ±s）］Postoperative Hb		97.2±16.4	88.9±10.1	t=1.712	＞0.05
术后Alb［g/L，（ $\bar{x}$ ±s）］Postoperative Alb		29.7±2.9	26.6±2.0	t=3.539	＜0.001
手术时长［min，（ $\bar{x}$ ±s）］Time of surgery		107.6±68.7	77.9±30.5	t=1.476	＞0.05
静息疼痛（ $\bar{x}$ ±s）Rest pain		1.3±1.0	2.3±1.1	t=-3.180	0.002
活动疼痛（ $\bar{x}$ ±s）Active pain		4.4±1.3	5.3±1.0	t=-2.240	0.027

Table 1 Comparison of postoperative delirium between the two groups

变量Variable		对照组Control group	谵妄并发症组Delirium group	统计值Statistical value	P值
例数Number of cases		106	12
性别Gender	男性Male	40	5	χ ²＜0.0001	＞0.05
性别Gender	女性Female	66	7	χ ²＜0.0001	＞0.05
手术类型Type of surgery	THA	14	2	χ ²=4.236	＞0.05
	TKA	35	1
	股骨头坏死Femoral head necrosis	39	5
	股骨颈骨折内固定Internal fixation of femoral neck fracture	18	4
高血压Hypertension	否No	48	1	χ ²=4.635	0.031
高血压Hypertension	是yes	58	11	χ ²=4.635	0.031
冠心病Coronary disease	否No	93	8	χ ²=2.360	＞0.05
冠心病Coronary disease	是Yes	13	4	χ ²=2.360	＞0.05
麻醉方式Anesthesia	联合椎管内麻醉Combined spinalepidural nesthesia	91	10	χ ²＜0.0001	＞0.05
麻醉方式Anesthesia	全身麻醉General anesthesia	15	2	χ ²＜0.0001	＞0.05
糖尿病Diabetes	否No	77	9	χ ²＜0.0001	＞0.05
糖尿病Diabetes	是Yes	29	3	χ ²＜0.0001	＞0.05
COPD	否No	99	5	χ ²=22.861	＜0.001
COPD	是Yes	7	7	χ ²=22.861	＜0.001
年龄［岁，（ $\bar{x}$ ±s）］Age（year）		83.7±3.4	85.8±3.6	t=-2.164	0.039
术中失血量［ml，（ $\bar{x}$ ±s）］Intraoperative blood loss		186.4±166.5	108.3±41.7	t=1.614	＞0.05
BMI［kg/m²，（ $\bar{x}$ ±s）］		23.0±3.5	22.7±2.7	t=0.265	＞0.05
术前Hb［g/L，（ $\bar{x}$ ±s）］Preoperative Hb		120.8±18.0	107.6±21.2	t=2.366	0.020
术前Alb［g/L，（ $\bar{x}$ ±s）］Preoperative Alb		35.3±4.0	33.9±5.5	t=1.073	＞0.05
术后Hb［g/L，（ $\bar{x}$ ±s）］Postoperative Hb		97.2±16.4	88.9±10.1	t=1.712	＞0.05
术后Alb［g/L，（ $\bar{x}$ ±s）］Postoperative Alb		29.7±2.9	26.6±2.0	t=3.539	＜0.001
手术时长［min，（ $\bar{x}$ ±s）］Time of surgery		107.6±68.7	77.9±30.5	t=1.476	＞0.05
静息疼痛（ $\bar{x}$ ±s）Rest pain		1.3±1.0	2.3±1.1	t=-3.180	0.002
活动疼痛（ $\bar{x}$ ±s）Active pain		4.4±1.3	5.3±1.0	t=-2.240	0.027

Table 2 Comparison of postoperative cardiovascular complications between the two groups

变量Variable		对照组Control group	心血管并发症组Cardiovascular complications group	统计值Statistical value	P值
例数Number of cases		109	9
性别Gender	男性Male	42	3	χ ²＜0.0001	＞0.05
性别Gender	女性Female	67	6	χ ²＜0.0001	＞0.05
手术类型Type of surgery	THA	14	2	χ ²=5.372	＞0.05
	TKA	36	0
	股骨头坏死Femoral head necrosis	39	5
	股骨颈骨折内固定Internal fixation of femoral neck fracture	20	2
高血压Hypertension	否No	45	4	χ ²＜0.0001	＞0.05
高血压Hypertension	是Yes	64	5	χ ²＜0.0001	＞0.05
冠心病Coronary disease	否No	94	7	χ ²=0.040	＞0.05
冠心病Coronary disease	是Yes	15	2	χ ²=0.040	＞0.05
麻醉方式Anesthesia	联合椎管内麻醉Combined spinalepidural anesthesia	93	8	χ ²＜0.0001	＞0.05
麻醉方式Anesthesia	全身麻醉General anesthesia	16	1	χ ²＜0.0001	＞0.05
糖尿病Diabetes	否No	83	3	χ ²=5.696	0.017
糖尿病Diabetes	是Yes	26	6	χ ²=5.696	0.017
COPD	否No	96	8	χ ²＜0.0001	＞0.05
COPD	是Yes	13	1	χ ²＜0.0001	＞0.05
年龄［岁，（ $\bar{x}$ ±s）］Age（year）		83.9±3.5	83.2±2.6	t=0.602	＞0.05
术中失血量［ml，（ $\bar{x}$ ±s）］Intraoperative blood loss		174.9±145.3	222.2±294.9	t=-0.853	＞0.05
BMI［kg/m²，（ $\bar{x}$ ±s）］		23.1±3.5	22.2±3.5	t=0.745	＞0.05
术前Hb［g/L，（ $\bar{x}$ ±s）］Preoperative Hb		119.5±18.6	119.7±21.1	t=-0.033	＞0.05
术前Alb［g/L，（ $\bar{x}$ ±s）］Preoperative Alb		35.3±4.1	32.7±3.5	t=1.832	＞0.05
术后Hb［g/L，（ $\bar{x}$ ±s）］Postoperative Hb		96.6±15.9	93.3±18.3	t=0.589	＞0.05
术后Alb［g/L，（ $\bar{x}$ ±s）］Postoperative Alb		29.5±3.0	27.4±2.4	t=2.069	0.041
手术时长［min，（ $\bar{x}$ ±s）］Time of surgery		102.0±62.4	136.1±103.0	t=-1.492	＞0.05
静息疼痛（ $\bar{x}$ ±s）Rest pain		1.3±1.0	2.6±1.0	t=-3.758	＜0.001
活动疼痛（ $\bar{x}$ ±s）Active pain		4.4±1.3	5.4±1.2	t=-2.406	0.018

Table 2 Comparison of postoperative cardiovascular complications between the two groups

变量Variable		对照组Control group	心血管并发症组Cardiovascular complications group	统计值Statistical value	P值
例数Number of cases		109	9
性别Gender	男性Male	42	3	χ ²＜0.0001	＞0.05
性别Gender	女性Female	67	6	χ ²＜0.0001	＞0.05
手术类型Type of surgery	THA	14	2	χ ²=5.372	＞0.05
	TKA	36	0
	股骨头坏死Femoral head necrosis	39	5
	股骨颈骨折内固定Internal fixation of femoral neck fracture	20	2
高血压Hypertension	否No	45	4	χ ²＜0.0001	＞0.05
高血压Hypertension	是Yes	64	5	χ ²＜0.0001	＞0.05
冠心病Coronary disease	否No	94	7	χ ²=0.040	＞0.05
冠心病Coronary disease	是Yes	15	2	χ ²=0.040	＞0.05
麻醉方式Anesthesia	联合椎管内麻醉Combined spinalepidural anesthesia	93	8	χ ²＜0.0001	＞0.05
麻醉方式Anesthesia	全身麻醉General anesthesia	16	1	χ ²＜0.0001	＞0.05
糖尿病Diabetes	否No	83	3	χ ²=5.696	0.017
糖尿病Diabetes	是Yes	26	6	χ ²=5.696	0.017
COPD	否No	96	8	χ ²＜0.0001	＞0.05
COPD	是Yes	13	1	χ ²＜0.0001	＞0.05
年龄［岁，（ $\bar{x}$ ±s）］Age（year）		83.9±3.5	83.2±2.6	t=0.602	＞0.05
术中失血量［ml，（ $\bar{x}$ ±s）］Intraoperative blood loss		174.9±145.3	222.2±294.9	t=-0.853	＞0.05
BMI［kg/m²，（ $\bar{x}$ ±s）］		23.1±3.5	22.2±3.5	t=0.745	＞0.05
术前Hb［g/L，（ $\bar{x}$ ±s）］Preoperative Hb		119.5±18.6	119.7±21.1	t=-0.033	＞0.05
术前Alb［g/L，（ $\bar{x}$ ±s）］Preoperative Alb		35.3±4.1	32.7±3.5	t=1.832	＞0.05
术后Hb［g/L，（ $\bar{x}$ ±s）］Postoperative Hb		96.6±15.9	93.3±18.3	t=0.589	＞0.05
术后Alb［g/L，（ $\bar{x}$ ±s）］Postoperative Alb		29.5±3.0	27.4±2.4	t=2.069	0.041
手术时长［min，（ $\bar{x}$ ±s）］Time of surgery		102.0±62.4	136.1±103.0	t=-1.492	＞0.05
静息疼痛（ $\bar{x}$ ±s）Rest pain		1.3±1.0	2.6±1.0	t=-3.758	＜0.001
活动疼痛（ $\bar{x}$ ±s）Active pain		4.4±1.3	5.4±1.2	t=-2.406	0.018

Table 3 Multivariatelogistic regression analysis of risk factors for delirium after knee/hip surgery

变量Variables	B值	S.E.	Wald χ ²值	P值	Exp（B）	Exp（B）的95%CI 95%CI for Exp（B）
高血压Hypertension	2.646	1.213	4.758	0.029	14.101	（0.268，5.023）
COPD	3.029	0.865	12.257	＜0.001	20.673	（1.333，4.724）
静息疼痛Rest pain	1.144	0.497	5.301	0.021	3.140	（0.170，2.118）
常量Constant	-7.082	1.698	17.393	＜0.001	0.001	-

Table 4 Logistic regression analysis of risk factors for cardiovascular complications after knee/hip surgery

变量Variables	B值	S.E.	Wald χ ²值	P值	Exp（B）	Exp（B）的95%CI 95%CI for Exp（B）
糖尿病Diabetes	1.653	0.830	3.965	0.046	5.220	（0.026，3.280）
静息疼痛Rest pain	1.709	0.588	8.454	0.004	5.522	（0.557，2.861）
常量Constant	-6.677	1.587	17.700	＜0.001	0.001	-

Figure 1 Nomogram for predicting delirium after knee/hip surgery

Figure 2ROC prediction model for delirium after knee/hip surgery

Figure 3 Calibration curve of the nomogram for delirium after knee/hip surgery

Figure 4 Model decision curve analysis for delirium after knee/hip surgery

Figure 5 Nomogram for predicting cardiovascular complications after knee/hip surgery

Figure 6ROC prediction model for cardiovascular complications after knee/hip surgery

Figure 7 Calibration curve of the nomogram for cardiovascular complications after knee/hip surgery

Figure 8 Model decision curve analysis for cardiovascular complications after knee/hip surgery

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