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Jacqueline M. Leung, M.D., M.P.H., Laura P. Sands, Ph.D., Sudeshna Paul, M.S., Tim Joseph, M.D.,

Does Postoperative Delirium Limit the Use of Patient-controlled Analgesia in Older Surgical Patients?. 术后谵妄是否 会限制老年手术患者 PCA 的使用 ？. Jacqueline M. Leung, M.D., M.P.H., Laura P. Sands, Ph.D., Sudeshna Paul, M.S., Tim Joseph, M.D., Sakura Kinjo, M.D., Tiffany Tsai, B.A.

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Jacqueline M. Leung, M.D., M.P.H., Laura P. Sands, Ph.D., Sudeshna Paul, M.S., Tim Joseph, M.D.,

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  1. Does Postoperative Delirium Limit the Use ofPatient-controlled Analgesia in Older Surgical Patients? 术后谵妄是否 会限制老年手术患者PCA的使用？ Jacqueline M. Leung, M.D., M.P.H., Laura P. Sands, Ph.D., Sudeshna Paul, M.S., Tim Joseph, M.D., Sakura Kinjo, M.D., Tiffany Tsai, B.A. Anesthesiology, V 111, No 3, Sep 2009

  2. BACKGROUND • DELIRIUM is an acute confusional state with alterations in attention and consciousness. • Postoperative delirium is a serious problem for older surgical patients. Although the exact etiology is not identifiable. an independent predictor Postoperative pain Postoperative delirium

  3. BACKGROUND • The current study aimed to determine whether patients with and without delirium differed in the amount of postoperative opioid used. Postoperative delirium PCA Limit？

  4. Materials and Methods Inclusion criteria: • English-speaking patients; • ≥65yr; • Noncardiac surgery; • Stay in the hospital for longer than 48 h; • Received PCA by using intravenous opioid analgesics. Exclusion criteria: • Not provide informed consent.

  5. Patient Assessment • The same trained research assistant conducted preoperative and postoperative patient interviews in person. • Preoperative interview : • ＜ 48 h before surgery; • Depressive symptoms; • Pain(VSA); • Functional status; • Cognitive status(TICS).

  6. Postoperative Pain Management • The postoperative pain management strategy was determined by the attending physicians. • PCA --hydromorphone • Patient pain levels --visual analog scale (VAS)

  7. Postoperative Pain Measurement • Patients were asked to rate their pain at rest preoperatively and on postoperative days 1 and 2. • The daily doses of the PCA opioid analgesic administered postoperatively (hydromorphone) were recorded for the first three postoperative days.

  8. Delirium Assessment • Confusion Assessment Method (CAM) Four clinical criteria: a) Acute onset and fluctuating course; b) Inattention; c) Disorganized thinking; d) Altered level of consciousness. a+b+(c/d )= Delirium • The occurrence of delirium was defined as the patient meeting CAM criteria for delirium on any of the postoperative day assessments. • CAM has a sensitivity of 94–100% and a specificity of 90–95%

  9. The Confusion Assessment Method (CAM) Diagnostic Algorithm • Feature 1: Acute Onset and Fluctuating Course • This feature is usually obtained from a family member or nurse and is shown by positive responses to the following • questions: Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) • behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity? • Feature 2: Inattention • This feature is shown by a positive response to the following question: Did the patient have difficulty focusing • attention, for example, being easily distractible, or having difficulty keeping track of what was being said? • Feature 3: Disorganized thinking • This feature is shown by a positive response to the following question: Was the patient’s thinking disorganized or • incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching • from subject to subject? • Feature 4: Altered Level of consciousness • This feature is shown by any answer other than “alert” to the following question: • Overall, how would you rate this patient’s level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic • [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])

  10. Statistical Methods • t tests • chi-square tests • Fisher exact test • SAS, version 9.1, • SPSS version 16.0 (Chicago,IL).

  11. Results Data lost n=13

  12. Table 1. Demographics and Clinical Characteristics (n=335) • Preoperative patient characteristics and surgical and medical data are shown in table 1

  13. 2.5±0.9vs. 3.3±0.23, P =0.004) 3.3±0.22vs. 4.2±0.23, P = 0.0051) Fig. 2. Shown are the visual analog scale (VAS) pain scores plotted as mean SEM for patients with and without postoperative delirium in the pre- and postoperative periods. * P <0.05.

  14. Table 2. Consistency in Reporting Pain Between Postoperative Day One and Day Two

  15. Table 3. Hydromorphone Dose by Delirium Status on Postoperative Day (POD) 1 Adjusted for Current Pain at Rest, Preoperative Narcotic Use, Surgical Risk, and Use of Other Medications with CNS Effects

  16. Table 4. Hydromorphone Dose by Delirium on Postoperative Day (POD) 2 Adjusted for Current Pain at Rest, Preoperative Narcotic Use, Surgery Risk, and Use of Other Medications with Central Nervous System Effects

  17. Fig. 1. This figure depicts our heuristic model for the association between postoperative delirium and opioid use.

  18. Discussion • Several novel findings • First, we showed that postoperative delirium did not limit patient’s use of on-demand PCA. • Second, despite the use of PCA opioids, patients with postoperative delirium still experienced higher VAS scores than those who were not delirious.

  19. Discussion • Comparison with Previous Studies • Many studies have showed that delirium was associated with opioid use. The study was the first to use consecutive daily assessments of resting pain, delirium, and opioid dose to show that patients who were delirious used either the same amount or more opioids; • Several studies have investigated the importance of pain management on delirium. Thestudy suggest pain is associated with postoperative delirium not because of patients’ inability to use the on-demand PCA device;

  20. Discussion • Comparison with previous studies • The results suggest that there is room for improvement of pain management in older patients who are at risk of developing postoperative delirium; • We need to be mindful that in addition to pain and opioids, the occurrence of postoperative delirium is likely a multifactorial phenomenon.

  21. Discussion • Clinical Implications • Despite the important side effects known to occur with opioids, complete avoidance of opioids in the postoperative period is generally not feasible. • Adjuvant techniques that are opioid-sparing may be good candidates to be used in patients at risk of postoperative delirium. • Future studies investigating the role of these opioid-sparing techniques to decrease postoperative delirium are indicated. Good postoperative pain control can improve outcome.

  22. Discussion • Potential Limitations • Although we have described an association between postoperative opioids use, VAS scores and postoperative delirium , we cannot determine the mechanism of how these factor interact to precipitate postoperative delirium. • The measurement of pain at one point in time may not accurately represent the dynamic nature of pain over a 24-h period; therefore, our methodology of adjusting opioid usage by VAS scores may be an oversimplification of this complex relationship between opioid usage, delirium, and pain. • No existing standard to determine that the VAS is actually valid in patients with delirium.

  23. CONCLUSION • Postoperative delirium did not appear to limit the patient’s use of on-demand PCA. • Despite more opioid use , visual analog scale scores were higher in patients with delirium. • Future studies on delirium should consider the role of pain and pain management as potential etiologic factors..

  24. Thank you！

  25. 结构方程模型 • 结构方程模型（Structural equation modeling,SEM）是一种建立、估计和检验因果关系模型的方程，融合了因素分析和路径分析的多元统计技术，是当今统计方法的一大发展，成为多变量数据分析的重要手段之一，模型中既包含有可观测的显在变量也可能包含无法直接观测的潜在变量。 • 结构方程模型可以替代多重回归，通径分析，因子分析协方差分析等方法。可以这样说，结构方程模型是一般线性模型的扩展.

  26. 结构方程模型包括两个部分:度量模型和结构方程模型。度量模型描述潜变量与指标之间的关系,结构方程模型描述潜变量之间的关系。结构方程模型包括两个部分:度量模型和结构方程模型。度量模型描述潜变量与指标之间的关系,结构方程模型描述潜变量之间的关系。 • 建模的过程:模型的构建，模型的拟合，模型的评价，模型的修正。

  27. 老年患者术后精神障碍 术后精神障碍分为两类： • 术后谵妄(delirium) • 术后认知功能障碍(postoperative cognitive dysfunction，POCD)

  28. 术后谵妄 • 术后谵妄常发生于术后数小时至数天，是一种可逆的以意识波动和注意不能为特征的精神状态的急性改变，还可伴有思维、认知、记忆、定向、情感、精神运动性反应和睡眠周期等方面的紊乱。 • 意识障碍以对环境认识的清晰度降低为特征，未达到昏迷程度。注意的集中、持久或变换目标能力常常受损，导致患者注意力分散。目前多数文献认为意识障碍仍然是谵妄的基本症状。但较新的观点则认为注意力障碍是其核心症状

  29. 谵妄的诊断与评估 • 对照美国精神障碍诊断与统计手册第4版(DSM-Ⅳ)、国际疾病分类第10版( ICD-10)精神与行为障碍分类、中国精神障碍分类与诊断标准第3版(CCMD-3)。 • 三个诊断标准略有差异,但金标准仍是依据临床检查及病史,这存在诊断耗时长的缺点。作为术后谵妄的诊断, 需要一套简单易行、快速准确、易于床边进行的诊断方法。谵妄量表(DSS),谵妄评定方法(CAM),ICU精神错乱评估法(CAM-ICU) 及ICU 谵妄筛选检查表。 • 谵妄评定方法基于美国精神障碍诊断与统计手册第3R版。

  30. 术后认知功能障碍 • 简述： 术后认知功能障碍常发生于术后数周或数月，是轻微的神经认知功能紊乱。 • 表现：认知能力异常、记忆缺损、人格和社会整合能力改变等，严重的出现痴呆，但大多数症状隐匿，需要通过神经心理测试才能判别。 • 分类：根据持续时间长短，又把术后1周以内发生的称为短期POCD，把术后3个月依然存在的称为长期POCD。POCD在大多数病人是可逆的，一般术后3个月可恢复，但有研究证实,POCD在部分病人中可以持续数年。

  31. 评价POCD的方法 • 简易精神状态量表（mini-mental state examination, MMSE）,国际通用; • 美国国立精神卫生研究所流行病学研究中心的抑郁量表(Center of Epidemiological Survey Depression Scale , SDS); • 韦氏成人智力量表(WAIS)和韦氏记忆量表(WMS); • 瑞文测验、老年画线示踪测验、卡片分类测验、符号数字模式测验、明尼苏达多项人格调查表(MMPI)及老年抑郁量表(GDS)等 。

  32. 术后精神障碍发生的原因和机制目前尚不清楚。一般认为术后谵妄和POCD是多种因素综合作用的结果。主要有术后精神障碍发生的原因和机制目前尚不清楚。一般认为术后谵妄和POCD是多种因素综合作用的结果。主要有 1、年龄 • 2、术前脑功能状态 • 3、合并慢性疾病 • 4、抗胆碱能药物 • 5、手术类型 • 6、麻醉方法和麻醉药物 • 7、围术期因素 • 8、基因标记和生化标记

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