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Postoperative Delirium:

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 Delirium:

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  1. Postoperative Delirium:

  2. 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

  3. 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

  4. Preoperative Risk Factors • Age • Pathologic states in the brain • Psychiatric illness • Drugs used in the perioperative period • Intoxication/withdrawal • Endocrine/metabolic • Hyponatremia • Hypoglycemia

  5. Operative Risk Factors • Type of surgery • Orthopedic • Ophthalmic • Cardiac • Anesthetic drugs used

  6. 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

  7. 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

  8. Postoperative Risk Factors • Hypoxia • Pain • Sepsis • Myocardial infarction • Electrolyte or metabolic disturbance • Sensory deprivation or overload e.g. ICU setting

  9. 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

  10. Management • Prevention • Identification of the underlying disorder • Treatment

  11. Prevention • Identifying and addressing underlying medical problems • Avoiding precipitant medications • Optimizing fluid status • Aggressive treatment of pain • Ensuring tranquil postoperative care setting

  12. 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

  13. 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

  14. 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

  15. Summary • Delirium • Common • Associated morbidity and mortality • Often overlooked or misdiagnosed • Cause multifactorial • Pathogenesis incompletely understood • Diagnosis is not algorithmic

  16. 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.

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