Risk factors and clinical value of neutrophil-to-lymphocyte ratio in prediction of delirium after free flap surgery for head and neck cancer

doi:10.19438/j.cjoms.2023.02.005

Abstract

Abstract: PURPOSE: To investigate the incidence and risk factors of postoperative delirium (POD) after free flap reconstruction in patients with head and neck cancer, and then establish the risk prediction model and investigate whether neutrophil-to-lymphocyte ratio (NLR) has potential to be a biomarker for prediction of delirium. METHODS: A retrospective analysis of 128 patients who underwent free flap surgery for head and neck cancer in Xuzhou Central Hospital between January 2016 to March 2022 were performed. The patients were evaluated daily after surgery until discharge for delirium with Confusion Assessment Method (CAM), and they were divided into delirium group and non-delirium group. The related risk factors of delirium were analyzed using SPSS 26.0 software package. Logistic regression was used to screen clinical indicators and develop a risk prediction model. The predictive power of the model was verified by the area under the receiver operating characteristic curve(AUC) of the prediction model and the sensitivity and specificity under the optimal threshold. RESULTS: A total of 17(13.3%) patients had POD. Single factor analysis results indicated that POD was associated with age≥65, preoperative NLR, preoperative total protein, time of operation, intraoperative blood transfusion, postoperative ICU observation time, postoperative sleep disorder and postoperative pain. Multiple logistic regression analysis showed that the independent risk factors of POD included age≥65(OR=5.253; 95%CI: 1.146-24.074), preoperative NLR(OR=1.891; 95%CI: 1.050-3.405), intraoperative blood transfusion(OR=6.108; 95%CI: 1.109-33.644), postoperative sleep disorder (OR=9.292; 95%CI: 1.441-59.914) and postoperative pain(OR=1.807; 95%CI: 1.018-3.206). The receiver operating characteristic curve of the NLR-predictive model constructed using these risk factors was AUC=0.913, the Youden's index was 0.522, the best cutoff for NLR was 2.540, the sensitivity was 0.765 and the specificity was 0.757. CONCLUSIONS: NLR predictive model has good predictive value for POD in patients with head and neck cancer after free flap reconstruction. NLR has the potential as a biomarker, which can be used to guide early intervention and treatment in clinical practice.

Key words: Head and neck cancer, Neutrophil-to-lymphocyte ratio, Postoperative delirium, Risk factor Prediction model

CLC Number:

R739.8

SHEN Meng-yuan, ZHANG Xue-ying, ZHAO Shan, XU Xin-chen, LI Xiao-dong, MENG Jian. Risk factors and clinical value of neutrophil-to-lymphocyte ratio in prediction of delirium after free flap surgery for head and neck cancer[J]. China Journal of Oral and Maxillofacial Surgery, 2023, 21(2): 131-136.

References

[1] Wilson JE, Mart MF, Cunningham C, et al.Delirium[J]. Nat Rev Dis Primers, 2020, 6: 90-95.
[2] Mattison M. Delirium[J]. Ann Intern Med, 2020, 173(7): ITC49-ITC64.
[3] Kinoshita H, Saito J, Takekawa D, et al.Availability of preoperative neutrophil-lymphocyte ratio to predict postoperative delirium after head and neck free-flap reconstruction: a retrospective study[J]. PLoS One, 2021, 16(7): e254654.
[4] Egberts A, Mattace-Raso FU.Increased neutrophil-lymphocyte ratio in delirium: a pilot study[J]. Clin Interv Aging, 2017, 12: 1115-1121.
[5] Liang M, Du B, Zhang H, et al.NLR is associated with geriatric depression in Chinese women: a community-based cross-sectional study in Eastern China[J]. Front Psychol, 2019, 10: 2941-2947.
[6] Marcantonio ER.Delirium in hospitalized older adults[J]. N Engl J Med, 2017, 377(15): 1456-1466.
[7] 李晓东, 孟箭, 张凌, 等. 238例头颈肿瘤患者重建术后谵妄危险因素分析[J]. 中国口腔颌面外科杂志, 2020, 18(3): 226-230.
Li XD, Meng J, Zhang L, et al.Risk factors analysis of delirium after head and neck reconstruction in 238 consecutive cases[J]. China Journal of Oral and Maxillofacial Surgery, 2020, 18(3): 226-230.
[8] Kazmierski J, Sieruta M, Banys A, et al.The assessment of the T102C polymorphism of the 5HT2a receptor gene, 3723G/A polymorphism of the NMDA receptor 3A subunit gene (GRIN3A) and 421C/A polymorphism of the NMDA receptor 2B subunit gene (GRIN2B) among cardiac surgery patients with and without delirium[J]. Gen Hosp Psychiatry, 2014, 36(6): 753-756.
[9] de Jong L, van Rijckevorsel V, Raats JW, et al. Delirium after hip hemiarthroplasty for proximal femoral fractures in elderly patients: risk factors and clinical outcomes[J]. Clin Interv Aging, 2019, 14: 427-435.
[10] Eshmawey M, Arlt S, Ledschbor-Frahnert C, et al.Preoperative depression and plasma cortisol levels as predictors of delirium after cardiac surgery[J]. Dement Geriatr Cogn Disord, 2019, 48(3-4): 207-214.
[11] Zahorec R.Neutrophil-to-lymphocyte ratio, past, present and future perspectives[J]. Bratisl Lek Listy, 2021, 122(7): 474-488.
[12] Zhang Y, Cao M, Ren J.NLR value and IL-18 level and their clinical significance in patients with deep vein thrombosis after receiving the surgery for spinal degeneration[J]. Am J Transl Res, 2021, 13(6): 7156-7163.
[13] Kotfis K, Bott-Olejnik M, Szylińska A, et al.Could neutrophil-to-lymphocyte ratio (NLR) serve as a potential marker for delirium prediction in patients with acute ischemic stroke? a prospective observational study[J]. J Clin Med, 2019, 8(7): 1075-1091.
[14] 胡小义, 孙珣, 周健, 等. 非心脏手术老年患者术后谵妄预测模型的建立及验证[J]. 中华麻醉学杂志, 2020, 40(11): 1332-1337.
Hu XY, Sun X, Zhou J, et al.Establishment and verification of postoperative delirium prediction model in elderly patients undergoing non-cardiac surgery[J]. Chinese Journal of Anesthesiology, 2020, 40(11): 1332-1337.
[15] Fernández-Jiménez E, Muñoz-Sanjose A, Mediavilla R, et al.Prospective analysis between neutrophil-to-lymphocyte ratio on admission and development of delirium among older hospitalized patients with COVID-19[J]. Front Aging Neurosci, 2021, 13: 764334.
[16] Zhao Y, Yue J, Lei P, et al.Neutrophil-lymphocyte ratio as a predictor of delirium in older internal medicine patients: a prospective cohort study[J]. BMC Geriatr, 2021, 21(1): 334-342.
[17] Li X, Wang G, He Y, et al.White-cell derived inflammatory biomarkers in prediction of postoperative delirium in elderly patients undergoing surgery for lower limb fracture under non-general anaesthesia[J]. Clin Interv Aging, 2022, 17: 383-392.
[18] Cheng G, Liu F, Niu X, et al.Role of the pretreatment neutrophil-to-lymphocyte ratio in the survival of primary parotid cancer patients[J]. Cancer Manag Res, 2019, 11: 2281-2286.
[19] Chargi N, Breik O, Forouzanfar T, et al.Association of low skeletal muscle mass and systemic inflammation with surgical complications and survival after microvascular flap reconstruction in patients with head and neck cancer[J]. Head Neck, 2022, 44(10): 2077-2094.
[20] Ueda T, Chikuie N, Takumida M, et al.Baseline neutrophil-to-lymphocyte ratio (NLR) is associated with clinical outcome in recurrent or metastatic head and neck cancer patients treated with nivolumab[J]. Acta Otolaryngol, 2020, 140(2): 181-187.
[21] Homa-Mlak I, Brzozowska A, Mlak R, et al.Neutrophil-to-lymphocyte ratio as a factor predicting radiotherapy induced oral mucositis in head neck cancer patients treated with radiotherapy[J]. J Clin Med, 2021, 10(19): 4444-4459.
[22] He R, Wang F, Shen H, et al.Association between increased neutrophil-to-lymphocyte ratio and postoperative delirium in elderly patients with total hip arthroplasty for hip fracture[J]. BMC Psychiatry, 2020, 20(1): 496-503.
[23] Li L, Wu W, Yin M.Effect of Hematocrit injury on the survival rate of advanced malignant tumors and its clinical significance[J]. Comput Math Methods Med, 2022: 4968754.
[24] Zhu C, Yin J, Wang B, et al.Restrictive versus liberal strategy for red blood-cell transfusion in hip fracture patients: a systematic review and meta-analysis[J]. Medicine (Baltimore), 2019, 98(32): e16795.
[25] Yang XX, Dai XC, Liu CX, et al.Restrictive versus liberal transfusion strategies in patients with malignant neoplasm -a meta-analysis of randomized controlled trials[J]. Transfus Apher Sci, 2020, 59(5): 102825.
[26] Devlin JW, Skrobik Y, Gelinas C, et al.Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU[J]. Crit Care Med, 2018, 46(9): e825-e873.
[27] Thom RP, Levy-Carrick NC, Bui M, et al.Delirium[J]. Am J Psychiatry, 2019, 176(10): 785-793.
[28] Sampson EL, West E, Fischer T.Pain and delirium: mechanisms, assessment, and management[J]. Eur Geriatr Med, 2020, 11(1): 45-52.
[29] Kulaksizoglu B, Kulaksizoglu S.Relationship between neutrophil/lymphocyte ratio with oxidative stress and psychopathology in patients with schizophrenia[J]. Neuropsychiatr Dis Treat, 2016, 12: 1999-2005.
[30] Zhu Y, Wang G, Liu S, et al.Risk factors for postoperative delirium in patients undergoing major head and neck cancer surgery: a meta-analysis[J]. Jpn J Clin Oncol, 2017, 47(6): 505-511.