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Postoperative delirium

Postoperative delirium. R2 楊美惠 2005/3/22. Brief history. 鍾＊＊ , 45-year-old male patient, 62kg, 169.6cm L’t buccal ca. s/p wide excision +L’t SOHND on 93/3/19 Asthma hx without recent attack Allergy hx: Depain, Voltaren Pre-OP vital sign: HR: 95/min, BP: 146/92mmHg, SpO2:99%. OP record.

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Postoperative delirium

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  1. Postoperative delirium R2楊美惠 2005/3/22

  2. Brief history • 鍾＊＊, 45-year-old male patient, • 62kg, 169.6cm • L’t buccal ca. s/p wide excision +L’t SOHND on 93/3/19 • Asthma hx without recent attack • Allergy hx: Depain, Voltaren • Pre-OP vital sign: HR: 95/min, BP: 146/92mmHg, SpO2:99%

  3. OP record • Diagnosis: L’t buccal ca., recurrence • OP method: wide excision + free flap • OP time: 8AM~2:10AM (18hrs10mins) • Intra-OP vital sign:SBP:100-140mmHg/DBP:60mmHgOne episode BP drop to 80/52 (fentanyl 1.5)SpO2:100%, SaO2:99.9%

  4. Input/Output :IVF 10450mlPRBC 4UU/O 5000mlB/L 1000ml-> Hb drop from 11.9 to 9.3 then return to 11.7 after PRBC • CVP level around 10once drop to 5 when large blood loss

  5. At POR • Sent to POR after Fentanyl 1.5ml smoothly • Agitation developed later-> demerol 25mg given • Odd postures found by plasty doctoreyes up gaze and deviate to R’t sideelevated bil. hands, rigidityno significant generalized seizure movement noted

  6. POR(2) • Respond to orders(+) but shortly return to original postureFamily members recognization (+) • No paralysis notedPupils/Light reflex: normal • Suspected diagnosis:1. r/o delirium 2. r/o seizure3. r/o stroke

  7. Follow up the next day • General appearance:no residual odd postures seen • According to his family“much more better and understanding, but fluctuated” • According to himselfNo memory of post-OP period up to 1 dayNot well understanding of his post-OP appearance

  8. Postoperative delirium • Definition: acute fluctuating, transient confusional state emerge from anesthesia, disoriented and inconsolable • Improtance: Delay mobilization and rehabilitation, Delay functional recovery Longer hospital stay, long-term care or rehabilitative facilities Increased morbidity, High motality (2x)< Cole MG, Primeau FJ: Prognosis of delirium in elderly hospital patients. Can Med Assoc J 149:41, 1993>

  9. Incidence • overall postoperative rates of 5% to 15% • open heart and orthopedic surgery: >50% • hip fracture repair surgery: 30% to 45%

  10. Pathogenesis of Delirium • Poorly understood despite studies since 1940 • Global cortical dysfunction that was associated predominantly with specific EEG changes which were slowing of the dominant alpha rhythm and abnormal slow wave activity (except in alcohol and sedative withdrawal syndromes)

  11. Under certain conditions, these abnormalities could be reversed (e.g., hypoxia and hypoglycemia), suggesting that the disorder was one of cerebral oxidative metabolism.

  12. Patients who have suffered subcortical infarcts in the thalamus and basal ganglia not only are at increased risk of developing Parkinson's disease, but also they have increased susceptibility for developing delirium. • Although structural brain disorders increase a patient's risk of developing delirium, most delirious patients have no identifiable abnormalities on imaging studies.

  13. These findings have supported the position that delirium involves derangements on a biochemical and electrophysiologic level. • The fluctuating, transient nature of the disorder has made these derangements difficult to study, however.

  14. Cholinergic pathway • Production of acetylcholine is decreased in specific medical conditions that precipitate delirium. • Serum anticholinergic activity correlates with delirium severity in postoperative patients. • Medications with anticholinergic activity frequently can cause confusion in the elderly, including neuroleptics, tricyclic antidepressants, benzodiazepines, and opiates (Table 1) .

  15. Cholinergic pathways are involved in other disorders of cognition, including Alzheimer's disease. • Other neurotransmitters, such as serotonin and norepinephrine, have been implicated in the pathogenesis of delirium, given their effects on arousal and sleep.

  16. Diagnosis • Most frequently in early post-op period • hyperactive type: Acutely agitation, uncooperative, and confused • hypoactive type: Quiet, withdrawn miss diagnosed • DD: Worsening of the underlying psychiatric illness (depression, schizophrenia) hypoxia, acidosis, or increased intracranial pressure

  17. Acute post-op delirium with significant morbidity and mortality • Hint of AMI, sepsis or other catastrophic event • Review of preexisting factors and underlying medical conditions

  18. DSM-IV • Formal cognitive testsMMSE (mini-mental status exam)CAM (confusion assessment method) scoreDelirium writing test

  19. CAM (confusion assessment method) score • Most commonly used tool in the study of deliriumSensitivity 94~100%, Specificity 90~95%inability to distinguish the severity or duration of delirium

  20. Risk factors • Predictors of postoperative cognitive decline

  21. Patient's factors • Individual: •   Age •   Pre-existing cognitive deficit •   Severe comorbidity •   Previous episode of delirium •   Personality before illness • Perioperative: •   Course of postoperative period •   Type of operation (for example, hip replacement) •   Emergency operation •   Duration of operation • Specific conditions: Burns; AIDS; fracture; hypoxaemia; organ insufficiency; infection; metabolic disturbances (for example, dehydration, low serum albumin concentration)

  22. Pharmacological factors • Treatment with many drugs • Dependence on drugs or alcohol • Use of psychoactive drugs or alcohol • Specific drugs that may cause problemsBenzodiazepinesAnticholinergic agentsNarcotics

  23. Environmental factor • Extremes in sensory experience (for example,   hypothermia) • Deficits in vision or hearing • Immobility or decreased activity • Social isolation • Novel environment • Stress

  24. Surgery • duration: risk of Occult hypoxia • cardiac: hypoperfusion and microemboli formation causing cerebral ischemia, CABG 42% cognitive decline within 5 years • orthopedic: Pulmonary fat emboli, esp. femoral neck fracture repair • ophthalmologic: cataract (visual loss, medication with anticholinergic effects) • greater intraoperative blood lossmore postoperative blood transfusionspostoperative hematocrit lower than 30%

  25. Anesthesia • The type of anesthesia (regional versus general) and intraoperative hemodynamic complications have not been associated with delirium

  26. Post-op care settingUnfamiliar surroundings, ICUSleep deprivation delirium • Uncontrolled or unaddressed pain: Adequate analgesia with opiates or NSAIDs • Pneumonia, UTI, intra-abdominal infections, wound infections

  27. Management-Prevention • Non-modifiable: age, pre-existing CNS disease (dementia) • Identifying and addressing underlying medical problems • eliminating all precipitating medications (sedative-hypnotics, anticholinergics) • optimizing the patient’s fluid status • aggressively treating pain • promoting early ambulation • ensuring a familiar: Inviting the families to visit • tranquil post-op care setting

  28. pain management: Opioids other than meperidine have not been associated with development of postoperative delirium • The postoperative use of epidural analgesia may diminish postoperative delirium in part through superior analgesia and a decrease in pulmonary complications.

  29. Identifying and treating the underlying disorder • cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration • Decrease the incidence of delirium by 34% (15% to 9.9%)

  30. Supportive care & treatment • Administer 0.5-10 mg haloperidol (intramuscularly or intravenously) depending on level of disturbance and likely tolerance (having considered age, physical status, and risk of side effects) • Observe patient for 20-30 minutes. If the patient remains unmanageable but has not had any adverse effects, double the dose and continue monitoring: • effective in controlling agitation and psychotic behavior • minimal hemodynamic or respiratory side effects • side effect of haldol: EPS • Upper limits on doses have not been clearly established, but up to 100 mg of intravenous haloperidol every 24 hours is generally safe as is up to 60 mg intravenous haloperidol every 24 hours if benzodiazepines are used concomitantly

  31. BZDs (diazepam, lorazepam) • drug of choice in alcohol and sedative withdrawal syndromes • adjunct to reduce EPS (Up to 2 mg of lorazepam may be administered intravenously or intramuscularly every four hours ) • quicker onset than neuroleptics • more life threatening side effects than neuroleptics: oversedation, hypotension, respiratory depression

  32. Reassurance from familiar caregivers of family membersProviding support and orientation Providing an unambiguous environmentMaintaining competence

  33. What can we do? • 詳細的術前訪視及解釋 • 術中維持平穩的BP，Spo2,Hct>30 • Peaceful recovery from anesthesia • Quiet POR environment • Adequate pain control • Family accompany as necesary

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