Cerebral Overperfusion Despite Reduced Cortical Metabolism Is Associated with Postoperative Delirium in Cardiac Surgery Patients: A Prospective Observational Study

<b>Background</b>: Decreased cerebral oximetry (rSO₂) in cardiac surgery is associated with postoperative delirium (POD). However, interventions optimizing intraoperative rSO₂ are inconclusive. <b>Methods</b>: In this prospective observational cohort study, the relationship between rSO₂, middle cerebral artery blood flow velocity (MCAV), and processed EEG was assessed in cardiac surgery patients with and without POD. MCAV was continuously recorded by transcranial Doppler sonography (TCD), together with continuous rSO₂ and bispectral index (BIS) monitoring. Cardiopulmonary bypass (CPB) flow rate was adjusted according to body surface area. The cohort was divided into the POD and control groups, according to the postoperative results of the confusion assessment method (CAM/CAM-ICU), the 4A's test (4AT), and the Delirium Observation Scale (DOS). A mixed model analysis was performed for intraoperative raw data. The cerebral autoregulation index was calculated from TCD, rSO₂, and arterial pressure values. Differences in impaired autoregulation were compared using the Mann-Whitney U test. <b>Results</b>: A total of 41 patients were included in this study. A total of 13 patients (36.11%) developed postoperative delirium. There were no significant differences in the baseline characteristics of patients with or without POD. Patients with POD had lower BIS values during CPB (adjusted mean difference -4.449 (95% CI [-7.978, -0.925])). RSO₂ was not significantly reduced in POD, (adjusted mean difference: -5.320, 95% CI [-11.508, 0.874]). In contrast, MCAV was significantly increased in POD (10.655, 95% CI [0.491, 20.819]). The duration of cerebral autoregulation impairment did not differ significantly for TCD and cerebral oximetry-derived indices (<i>p</i> = 0.4528, <i>p</i> = 0.2715, respectively). <b>Conclusions</b>: Our results suggest that disturbed cerebral metabolism reflects a vulnerable brain which may be more susceptible to overperfusion during CPB, which can be seen in increased MCAV values. These phenomena occur irrespectively of cerebral autoregulation.