Delirium After Cardiac Arrest – Can We Do Better?

Background

• Delirium is a common mental state for which there are myriad of known predisposing factors, such as advanced age, surgery, and acute myocardial infarction (MI) (1).

• In patients 60 years of age or older undergoing cardiac surgery, the incidence of post-operative delirium has been estimated to be as high as 55% (2,3). 

• Post-operative delirium is associated with significant emotional distress, financial cost, morbidity and mortality (1,2,3).

• Despite the prevalence and serious implications of post-operative delirium, no targeted treatment exists; rather, the standard of care emphasizes prevention through early mobilization, pain management, re-orientation and preservation of baseline sleep-wake cycle (3).

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• 71-year-old male with past medical history notable for coronary artery disease with previous MI s/p percutaneous coronary intervention x4, paroxysmal atrial fibrillation on anticoagulation, poorly controlled type 2 diabetes and active tobacco use who presented to a local ED with complaints of sudden onset of severe chest pain.

• At the local ED, ECG was notable for inferior STEMI. He was loaded with aspirin, clopidogrel, started on a heparin infusion and promptly transferred by air to the Mayo Clinic for cardiac catheterization. En route, there was a brief loss of consciousness associated with ventricular tachycardia (VT) for which one shock was given with restoration of both mental status and normal sinus rhythm.

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• Arrived at the Mayo ED and subsequently experienced cardiac arrest due to VT for which he received one shock, 100mg of lidocaine and was intubated.

• Upon entry to the procedure suite, he was noted to, again, be in pulseless VT. A code was called and ACLS was initiated. Because of refractory VT, stellate ganglion block was performed, and amiodarone therapy was initiated while undergoing placement of RCA stent.

• Following PCI, he was transferred to the cardiac ICU for continued care.