Postoperatory Delirium

7/29/2019 Postoperatory Delirium

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Postoperative delirium

Acute disorder of cognition and attention

after operation

Anytime in perioperative periodMost commonly occurs during postsurgical

period

Underdiagnosed 78%40% routinely screen for delirium


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Postoperative delirium

Associated with

Poor cognitive and functional recovery

Longer hospital stayGreater hospital costs

Risk factor for institutionalization and

morbidityReduced risk by early identification,assessment and treatment


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Incidence/ prevalence of adult older than 65 year experience

delirium during hospitalization

Wide range estimate of postoperativedelirium pending on type of operation

Delirium is likely to increase in future


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Pathogenesis

CNS changes with age

Loss of nerve cells

Decreased in cerebral blood flowChanges in neurotransmitter system

Decreased acetylcholinesterase activity

Carbonic anhydrase activityMuscarinic receptor

Serotonin receptors


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Pathogenesis

Abnormal levels of endorphins, serotonin,

neuropeptides in CSF

EEG : slowing of dominant posterior alpharhythm and abnormal slow wave activity


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Cause of CNS dysfunction after surgery


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Risk factors


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Risk factors

Older ageCognitive impairment

Functional impairment

Decreased postoperative hemoglobin

Markedly abnormal sodium, potassium and glucoseAlcohol abuse

Noncardiac thoracic operation

History of delirium

Preoperative used of narcoticPreoperative used of benzodiazepine

Low postoperative oxygen saturation

History of cardiovascular disease

Untreated pain


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Drug associated withdelirium

Drugs with anticholinergic activityTricyclic antidepressants

Cimetidine

Corticosteroids

Digoxin

Diphenhydramine

Belladonna

DipyridamoleTheophylline

Promethazine

Amantadine

Oxybutyrin


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Drugs associated withdelirium

Analgesics

Narcotics (especially meperidine)NSAIDs

Benzodiazepines

Antiparkinsonian agents


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Diagnosis

Modified from Diagnostic and Statistical Manual of Mental Disorder, 4THed


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features depression delirium dementia


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Clinical features

Change of consciousness and recognition

Cognitive abnormalities

DisorientationLanguage difficulty

Impairment of learning and memory

Fluctuating course


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Clinical features

Emotional disturbances

Anxiety

Fear

Anger

Irritability

Depression


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Clinical features

4 different types

Hypoactive delirium

Hyperactive deliriumMixed delirium

Delirium without psychomotor change


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History

Description of patients behavior

Earlier episode of delirium

Evidence of cognitive impairmentInformation to rule out alcohol or drug

withdrawal


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Physical examination

Vital signs

Oxygen saturation

Sign of trauma or infectionState of hydration

New neurological signs


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Confusion assessmentmethod

Item 1 and 2 and 3 or 4Sensitivity 94-100%Specificity 90-95%


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Diagnostic tests

To identify potentially correctable factors

CBC, electrolytes, creatinine, glucose,

and urinalysisNeuroimaging may be used selectively


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Prevention

Tarketing modifiable risk factors prevent

some case of delirium*

Standardized protocols of known risk factorsfor delirium

Reduction in delirium episodes (15%9.9%)

No effect on delirium severity and rate ofrecurrence

*N Engl J Med 1999;340:669-676

Sleep deprivation

Immobility

DehydrationVisual impairment

Cognitive impairment

Hearing impairment


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Prevention

Patients with fracture neck of femur

Outcome : Postoperative delirium ??

Pre and postoperative geriatric assessments,Oxygen therapy

Early operation

Prevention treatment of perioperative BP fall

Treatment of postoperative complication

J Am Geriatr Soc 1991;39:655-62


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Prevention

Interventions

Decreased postoperative deliriumfrom 61% to 48%

J Am Geriatr Soc 1991;39:655-62


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Prevention

Identify and reduce risk factors can decrease

postoperative delirium in elderly

Preoperative educate the patients


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Management

Treat contributing illness

Providing supportive measures

Symptom control

Identify causes

and treat

Safe environment

Appropiate stimulation

NutritionReserve for agitated ordisruptive individuals


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Supportive measures


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Medication for symptomcontrol

Antipsychotics

Haloperidol or newer antipsychotic agent ??

Goal is to control disruptive symptoms and avoid

obtundation

Taper in 3-5 days

Benzodiazepine

Paradoxical agitation

Treat withdrawal from alcohol of sedative drugs


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Prevention and treatment of postoperative delirium


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Outcome

Sequels of delirium can persist for 6 months

Risk for future cognitive decline

Associated with increase mortality (10-65%)Longer hospital stay and higher nursing

home placement


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Outcomes of delirium

Relationship between delirium and dementia

in 3 years with 203 patients age 65 in

medical services

Incidenceof dementia

5.6% per year in patient without delirium18.1% per year in delirium group

Age aging 1999;28:551-556


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Outcomes of delirium

78 patients with femoral neck fractures

J Am Geriatr Soc 2003;51:1002-1006

Postoperativedelirium

WithoutPostoperative delirium

Dementia

69% 20%5 years


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Conclusion

Risk of postoperative delirium can be

reduced with careful attention to risk factors

Intervention to target problemsSystemic approach to diagnostic workup

Early identification, assessment and

management

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Postoperatory Delirium

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