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DELIRIUM IN THE PACU PATIENT

DELIRIUM IN THE PACU PATIENT. R. HEWKO MD FRCPC CONSULTATION LIAISON PSYCHIATRY rahewko@shaw.ca. DELIRIUM IN THE PACU PATIENT. COMMON ETIOLOGIES 1. POST ANESTHETIC 2. POST-OP DELIRIUM 3. SECONDARY DELIRIUM. PREVALENCE. SIGNIFICANT VARIABILITY IN STUDIES

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DELIRIUM IN THE PACU PATIENT

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  1. DELIRIUM IN THE PACU PATIENT R. HEWKO MD FRCPC CONSULTATION LIAISON PSYCHIATRY rahewko@shaw.ca

  2. DELIRIUM IN THE PACU PATIENT • COMMON ETIOLOGIES 1. POST ANESTHETIC 2. POST-OP DELIRIUM 3. SECONDARY DELIRIUM

  3. PREVALENCE • SIGNIFICANT VARIABILITY IN STUDIES VARIANCE IN DIAGNOSTIC CRITERIA • POST-ANESTHETIC DELIRIUM <5% ? • POST-OP DELIRIUM GENERAL10- 30 % • ELDERLY >70 YRS OLD 20-30 % • PRE-EXISTING COGNITIVE IMPAIRMENT >80 %

  4. POST ANESTHETIC DELIRIUM • SUB-TYPE OF POST-OP DELIRIUM • TRANSIENT CONFUSIONAL STATE ARISING IN THE ACUTE POST ANESTHETIC PERIOD • RELATED TO ANESTHETIC AGENT(S) PRIMARY ETIOL.-VOLATILE AGENTS/BENZOS/NARCOTIC SEDATION • INABILITY TO ACHIEVE FULL LOC • TWILIGHT STATE PLUS UNFAMILIAR ENVIRONMENT = PANIC / FIGHT OR FLIGHT • TIME LIMITED UNLESS SIG PREMORBID CNS DYSFUNCTION OR IATROGENISIS

  5. POST-OP DELIRIUM • CONFUSIONAL STATE ARISING FROM PERI-OPERATIVE INSULT • COMMON ETIOLOGIES : HYPOXIA / HYPOTENSION / CEREBRAL EMBOLI ETC. • MANIFESTS IN THE ACUTE RECOVERY PHASE POST-ANESTHETIC • DURATION-HRS,DAYS, • MAY BECOME SELF PERPERTUATING STATE

  6. SECONDARY DELIRIUM • ONSET AFTER HOURS /DAYS OF LUCIDITY FOLLOWING POST ANESTHETIC RECOVERY • PERI-OPERATIVE INSULT MAY PREDISPOSE • STANDARD ETIOLOGIES TOXIC, INFECTIONS,RESP,CARDIAC ETC. • MC ETIOLOGY-NARCOTICS - MORPHINE / HYDROMORPHONE METABOLITES 3-GUCURONIDE METABOLITES RENAL EXCRETED/HALLUCINOGENIC/NARCOTIC ANTAGONISTS - ONSET DAY 3 +/- 24 HRS - INCREASED RISK ELDERLY / RENAL IMPAIRMENT

  7. POST ANESTHETIC RISK FACTORS • PRE-EXISTING COGNITIVE IMPAIRMENT • ADVANCED AGE • GENERAL ANESTHETIC • SEVERELY MEDICALLY COMPROMISED • PREVIOUS HISTORY - Variable

  8. POST-OP DELIRIUM - CLINICAL SIGNIFICANCE • Morbidity/Mortality/Prolonged Hosp. • Harm to self /others • Non-compliance • Unrecognized evolving illness • Disruption and demoralization of unit • Psychiatric sequelae- dementia, delusional disorder, post-traumatic stress disorder

  9. PATHOGENESIS OF AGTIATION • DISORIENTATION • HALLUCINATIONS • DELUSIONS - based on hallucinations irrational explanation • PAIN • BEHAVIOR - disorientation, hallucinations, delusions = fight or flight

  10. MANAGEMENT-NONPHARMACOLOGIC • ENVIRONMENTAL MODERATE STIMULI • BEHAVIORAL EYE CONTACT /RE-ORIENTATION / RE-ASSURANCE FAMILY / FAMILIAR FACES BEST RESOURCE ESP. FOR POST ANESTHETIC DELIRIUM RESTRAINT – LEAST POSSIBLE SHORTEST PERIOD OF TIME

  11. MANAGEMENT PHARMACOTHERAPY • HALOPERIDOL HIGH POTENCY ANTI-PSYCHOTIC MINIMAL ALPHA BLOCK / ANTICHOLINERGIC EFFECT LEAST SEDATIVE DOC FOR MANAGEMENT OF DELIRIUM? PLACEBO CONTROLLED STUDIES? COMPARISON TO OTHER AGENTS - SUPERIORITY? POETENTIAL FOR ACUTE DYSTONIA / OTHER EPS CARDIAC SE-PROLOGATION OF QT INTERVAL TORSADES ARRYTHMIA ROUTES PO/IV/IM IV PEAK 5-15 MINUTES

  12. MANAGEMENTPHARMACOTHERAPY • NOZINAN (METHOTRIMEPRAZINE) LOW POTENCY ANTI-PSYCHOTIC SIG. ALPHA BLOCK / ANTI-CHOLINERGIC EFFECT HYPOTENSION WITH IV BOLUS DOSES >5mg ANTICHOLINERGIC EFFECT DOSES > 200mg SIG SEDATIVE EFFECT ANXIOLYTIC ANALGESIC MINIMAL EFFECT ON RESP DRIVE MINIMAL INCIDENCE EPS ROUTES PO/IV/IM/SC IV PEAK 15-20 MIN

  13. MANAGEMENTPHARMACOTHERAPY • LOXAPINE MID POTENCY ANTIPSYCHOTIC MID POTENCY SEDATION ROUTES PO/IM/SC PEAK 45-60 MINUTES PRIMARY AGENT VGH PSYCH CONSULT SERVICE DATA BASE ON >15,000 PATIENTS >2,000 CARDIAC SURG. PATIENTS

  14. MANAGEMENT PHARMACOTHERAPY • MIDAZOLAM ULTRA SHORT BENZODIAZEPINE ONSET MINUTES DURATION 10-15 MINUTES REDISTRIBUTION CONTINUOUS INFUSION LONGER T ½ CAN EFFECT RESPIRATORY DRIVE

  15. DEXMEDETOMIDINE • ALPH 2 AGONIST • ANESTHETIC AGENT • MINIMAL EFFECT RESP. DRIVE • LIMITED EFFECT ON BP • DAMPENS SYMPATHETIC AROUSAL Fight or flight response • VERY EXPENSIVE

  16. PACU PHARMACOTHERAPY • FAILED BEHAVIORAL MANAGEMENT • DANGER TO PATIENT OR STAFF • OPTIONS – MIDAZOLAM HALOPERIDOL NOZINAN LOXAPINE DEXMEDETOMIDINE

  17. ADVANTAGES / DISADVANTAGES • MIDAZLOAM fast onset may exacerbate / perpetuate process may disinhibit most likely to effect resp. drive esp. at “effective dose”

  18. ADVANTAGES / DISADVANTAGES • NEUROLEPTICS HALOPERIDOL, NOZINAN, LOXAPINE MINIMAL EFFECT ON RESP. DRIVE WILL NOT EXACERBATE CONFUSION SLOWER ONSET MAY EFFECT BLOOD PRESSURE ESP. NOZINAN

  19. PHARMACOLOGIC OPTIONS • ELDERLY – FRAGILE HALOPERIDOL – 2.5 to 5 mg IV Max. 10-15 mg LIMITED RESPONSE – NOZINAN 2.5 to 5 mg IV Max 25 to 30 mg

  20. PHARMACOLOGIC OPTIONS • YOUNGER / ROBUST NOZINAN – 2.5 to 5 or 5 to 10 mg IV max 50 mg IV HALOPERIDOL Incomplete response to Nozinan Problematic BP

  21. PHARMACOLOGIC OPTIONS • PERSISTANT DELIRIUM - LOXAPINE 5-10 / 10-20 mg QIH • TRANSITION TO WARD

  22. PHARMACOLOGIC OPTIONS • REFRACTORY “WEENERS” NEUROLEPTICS VS DEXMEDETOMIDINE NEUROLEPTICS – HOURS TO SEDATE “DEX” – ALPHA 2 AGONIST RAPID ONSET SEDATION WITHOUT RESP. EFFECT DOWNSIDE – COST VS COST OF DELAYED EXTUBATION

  23. ONGOING PROCESS • CONTINUE RE-ORIENTATION • EVALUATE AND MANAGE PAIN • MOBILIZE FAMILIAR FACES • MAINTAIN FLEXIBLITY IN MANAGEMENT

  24. CONCLUSIONS ANTICPATE INCREASED INCIDENCE FORMALIZE MANAGEMENT MODEL OPTIMIZE BEHAVIORAL TREATMENT RATIONAL PHARMACOTHERAPY RESEARCH ?

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