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Postoperative Delirium:. Postoperative Delirium. Frequently encountered complication ~37% incidence; ranging from 0-73% (Winawer) Often unrecognized or misdiagnosed Failure to prevent and identify has significant implications on morbidity and mortality

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postoperative delirium2
Postoperative Delirium
  • Frequently encountered complication
    • ~37% incidence; ranging from 0-73% (Winawer)
  • Often unrecognized or misdiagnosed
  • Failure to prevent and identify has significant implications on morbidity and mortality
    • First sign of catastrophic event, e.g. MI, sepsis
    • Delayed functional recovery
    • Increased length of stay
    • Higher postoperative complication rates
definition
Definition
  • DSM-IV (Diagnostic and statistical manual of mental disorders) hallmark features
    • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
    • A change in cognition or the development of a perceptual disturbance that is not accounted for better by a pre-existing, established, or evolving dementia.
    • Disturbance develops during a short period and tends to fluctuate during the course of the day
    • Varies based on cause
preoperative risk factors
Preoperative Risk Factors
  • Age
  • Pathologic states in the brain
  • Psychiatric illness
  • Drugs used in the perioperative period
  • Intoxication/withdrawal
  • Endocrine/metabolic
    • Hyponatremia
    • Hypoglycemia
operative risk factors
Operative Risk Factors
  • Type of surgery
    • Orthopedic
    • Ophthalmic
    • Cardiac
  • Anesthetic drugs used
causative agents
Causative Agents
  • More than 500 drugs may induce the syndrome (Schultz)
  • Antihistamines
  • Phenothiazines- promethazine
  • Antiparkinsonian drugs- benztropine
  • Belladonna alkaloids- atropine, scopolamine
  • Tricyclic antidepressants
  • Ophthalmic cycloplegics- tropicamide
clinical features
Clinical Features
  • Central
    • Incoherent speech
    • Dementia/delirium
    • Excitation and agitation- violent behavior
    • Stupor, somnolence or coma
    • Hallucinations
    • Central respiratory failure
    • Memory or thought disturbances
    • Ataxia
    • Flaccid paralysis
    • Convulsions/seizures
  • Peripheral
    • Urinary retention
    • Decreased intestinal motility and constipation
    • Decreased to absent sweating with hot and dry skin
    • Fever with potential for severe hyperthermia
    • Mydriasis- dilation of pupils
    • Cycloplegia- inability to accommodate causing blurred vision
    • Peripheral vasodilatation
    • Tachycardia
postoperative risk factors
Postoperative Risk Factors
  • Hypoxia
  • Pain
  • Sepsis
  • Myocardial infarction
  • Electrolyte or metabolic disturbance
  • Sensory deprivation or overload e.g. ICU setting
pathogenesis
Pathogenesis
  • Poorly understood
  • Structural brain disorders (subcortical structures) increase risk, however most patients have no identifiable abnormalities
  • Cholinergic pathways play a significant role
    • As oxidative metabolism of the brain decreases neurotransmitters including Ach decline
    • Decreased production can precipitate delirium
    • Medications with anticholinergic properties can cause confusion/delirium
management
Management
  • Prevention
  • Identification of the underlying disorder
  • Treatment
prevention
Prevention
  • Identifying and addressing underlying medical problems
  • Avoiding precipitant medications
  • Optimizing fluid status
  • Aggressive treatment of pain
  • Ensuring tranquil postoperative care setting
pharmacologic treatment
Pharmacologic treatment
  • Physostigmine
    • Alleviation of symptoms after its administration confirms diagnosis of anticholinergic syndrome
    • It is the specific antidote for anticholinergic poisoning
  • Haldol
    • Effective in controlling agitation and psychotic behavior
  • Benzodiazepines
    • Drugs of choice in alcohol and sedative withdrawal syndromes
physostigmine
Physostigmine
  • Acetylcholinesterase inhibitor
    • Tertiary amine, crosses the blood brain barrier
  • The dose is 10-40 mcg/kg (1-2 mg over 2-5 minutes for adults or 0.5 mg in children, which may be repeated in 40 minutes)
  • Rapid onset with a 30-60 minute duration
adverse effects
Adverse effects
  • Anticholinergic properties
    • Muscarinic
      • Bradycardia
      • Profuse perspiration
      • Salivation
      • Nausea/vomiting
      • Hyperperistalsis- loss of bladder and rectal control
      • Miosis/difficulty focusing
      • Bronchoconstriction
      • Abdominal cramping
    • Nicotinic
      • Skeletal muscle weakness/paralysis with resultant apnea
    • Central Nervous system
      • Confusion
      • Ataxia
      • Seizures
      • Coma
      • Depression of ventilation
summary
Summary
  • Delirium
    • Common
    • Associated morbidity and mortality
    • Often overlooked or misdiagnosed
    • Cause multifactorial
    • Pathogenesis incompletely understood
    • Diagnosis is not algorithmic
references
References
  • Feeley, Thomas W: Assesment and Management of Patients in the Postanesthesia Care Unit. ASA 1990; 159-160.
  • Parikh SS, Chung F. Postoperative Delirium in the Elderly. Anesth Analg 1995; 80: 1223-32.
  • Schultz U, Idelberger R, Rossaint R, Buhre W. Central anticholinergic syndrome in a child undergoing circumcision. Acta Anaesthesiol Scand 2002; 46: 224-226.
  • Stoelting RK. Pharmacology and Physiology in Anesthetic Practice. 1987; 226-228.
  • Svirbely, JR. The Medical Algorithms Project. 2002; 32.27: 1-3.
  • Szajewski, J. Acute Anticholinergic Syndrome. IPCS INTOX 1995; 1- 3.
  • Winawer, Neil. Postoperative Delirium. Medical Clinics of North America 2001; 85: 1229-1239.