Delirium In Post-anaesthesia Care Unit Research Articles

A Multi‐disciplinary Team Approach for Educating Providers to Recognize Delirium in the Post Anesthesia Care Unit

AbstractBackgroundPostoperative delirium is common in older adults and has significant associated morbidity and mortality. However, screening is rarely performed in the post anesthesia care unit (PACU). For this reason, clinical researchers of delirium and a tertiary care interdisciplinary delirium Task Force Team proposed to address this area of patient safety.MethodA multidisciplinary team met to complete 3 hospital learning objectives. First, to develop an educational toolkit on PACU delirium identification with feedback from hospital stakeholders on topics to be trained, implementation into medical records, and finalizing training videos/powerpoint/quiz modules. Second, to train every PACU nurse on delirium identification. An EPIC form was created with detailed instructions for completing and documenting the CAM‐ICU and included in the PACU discharge checklist. All PACU nursing staff were assigned the module, and delirium screening was made mandatory for all patients aged 65 years or older. Following module assignment, perceived value, satisfaction, and barriers were surveyed to inform modification of training and implementation. Third, delirium screening rates were monitored.ResultsNurses (n = 110) were assigned postoperative delirium training modules across 3 PACUs starting July 2022 with a 2‐week deadline. Training completion rate was 83% after 3 months. Nurses provided positive feedback on the importance of delirium. Compliance in delirium screening in the PACU was low (<10%). After meeting with nursing staff to hear concerns/barriers to training and implementation, 1 on 1 training with research staff was initiated and all PACU nursing staff completed additional training between September and October. Before project implementation, no delirium screening was performed in the PACU. Over 3 months following completion of training, of 683 patients aged 65 years and older discharged from the PACU, 83 (12%) had delirium screening documented, and 0% were flagged as positive. Rate of screening differed by surgical service and hospital location.ConclusionThis hospital learning study documents the challenges and promise of implementing a PACU delirium screening program in a tertiary care academic medical center. We present data on improved delirium recognition at the hospital level, but variation in compliance rates by surgical service. Future research needs to examine reasons for variable delirium compliance screening.

Effect of sedative premedication with oral midazolam on postanesthesia care unit delirium in older adults: a secondary analysis following an uncontrolled before-after design

BackgroundSedative premedication with benzodiazepines has been linked with prolonged recovery and inadequate emergence during the immediate postoperative period. We aimed to analyze the association between postanesthesia care unit (PACU) delirium and sedative premedication with oral midazolam.MethodsWe performed a secondary analysis of prospectively collected data before (midazolam cohort) and after (non-midazolam cohort) implementation of a restrictive strategy for oral premedication with midazolam. From March 2015 until July 2018, we included patients 60 years and older, who underwent elective radical prostatectomy for prostate cancer. Exclusion criteria were contraindications to premedication with midazolam, preoperative anxiety, and a history of neurological disorders. Patients, who were scheduled for postoperative admission to the intensive care unit, were excluded. Between 2015 and 2016, patients received 7.5 mg oral midazolam preoperatively (midazolam cohort). Patients included between 2017 and 2018 did not receive any sedative medication preoperatively (non-midazolam cohort). The primary endpoint was the incidence of PACU delirium.ResultsPACU delirium rates were 49% in the midazolam cohort (n = 214) and 33% in the non-midazolam cohort (n = 218). This difference was not statistically significant on multivariable logistic regression analysis (OR 0.847 [95% CI 0.164; 4.367]; P = 0.842). Age (OR 1.102 [95% CI 1.050; 1.156]; P < 0.001), the cumulative dose of sufentanil (OR 1.014 [95% CI 1.005; 1.024]; P = 0.005), and propofol-sufentanil for anesthesia maintenance (OR 2.805 [95% CI 1.497; 5.256]; P = 0.001) were significantly associated with PACU delirium.ConclusionMidazolam for sedative premedication was not significantly associated with PACU delirium. The reduction in the incidence of PACU delirium throughout the study period may be attributable to improvements in perioperative management other than a more restrictive preoperative benzodiazepine administration.

Incidence and risk factors of delirium in post-anaesthesia care unit

Post-anaesthesia care unit (PACU) delirium is a potentially preventable condition that results in a significant long-term effect. In a multicentre prospective cohort study, we investigate the incidence and risk factors of postoperative delirium in elderly patients undergoing major non-cardiac surgery. Patients were consented and recruited from 4 major hospitals in Singapore. Research ethics approval was obtained. Patients older than 65 years undergoing non-cardiac surgery >2 hours were recruited. Baseline perioperative data were collected. Preoperative baseline cognition was obtained. Patients were assessed in the post-anaesthesia care unit for delirium 30-60 minutes after arrival using the Nursing Delirium Screening Scale (Nu-DESC). Ninety-eight patients completed the study. Eleven patients (11.2%) had postoperative delirium. Patients who had PACU delirium were older (74.6±3.2 versus 70.6±4.4 years, P=0.005). Univariate analysis showed those who had PACU delirium are more likely to be ASA 3 (63.6% vs 31.0%, P=0.019), had estimated glomerular filtration rate (eGFR) of >60mL/min/1.73m2 (36.4% vs 10.6%, P=0.013), higher HbA1C value (7.8±1.2 vs 6.6±0.9, P=0.011), raised random blood glucose (10.0±5.0mmol/L vs 6.5±2.4mmol/L, P=0.0066), and moderate-severe depression (18.2% vs 1.1%, P=0.033). They are more likely to stay longer in hospital (median 8 days [range 4-18] vs 4 days [range 2-8], P=0.049). Raised random blood glucose is independently associated with increased PACU delirium on multivariate analysis.

Impact of postanesthesia care unit delirium on self-reported cognitive function and perceived health status: a prospective observational cohort study

PurposeThe objective of this study was to determine the influence of postanesthesia care unit (PACU) delirium on self-reported cognitive function and perceived health status 3 months after surgery.MethodsThis prospective observational cohort study was performed in a PACU at a high-volume prostate cancer center. We used a convenience sample of patients > 60 years undergoing elective radical prostatectomy. Patients with a history of cerebrovascular or neurodegenerative disease were excluded. Fifteen, 30, 45, and 60 following extubation, patients were screened for signs of delirium with the Confusion Assessment Method for the Intensive Care Unit. Three months after surgery self-reported cognitive function was assessed with the Cognitive Failures Questionnaire, and health status was evaluated with the 36-item Short-Form Health Survey (SF-36).ResultsSigns of PACU delirium were present in 32.4% (n = 72/222) of patients, and 80.2% (n = 178/222) completed the 3-month follow-up. The presence of PACU delirium signs was not significantly associated with self-reported cognitive failures (B = 0.60, 95% CI: −1.72; 2.92, p = 0.61) or SF-36 physical component scores (B = 0.19, 95% CI: 0.02; 0.36, p = 0.03) or SF-36 mental component scores (B = −0.03, 95% CI: −0.18, 0.11, p = 0.66) 3 months after radical prostatectomy.ConclusionsIn a cohort of educated, highly functioning, elderly male patients who were assessed immediately after surgery and at a 3-month follow-up, we found no association between PACU delirium and self-reported cognitive failures or perceived health status, which implies that PACU delirium may be an event of limited duration and impact.Trial registrationThe study was registered at ClinicalTrials.gov (Identifier: NCT04168268, Date of registration: November 19, 2019).

PT288 - Post-anesthesia care unit delirium following robot-assisted versus open retropubic radical prostatectomy – a prospective observational study

PT288 - Post-anesthesia care unit delirium following robot-assisted versus open retropubic radical prostatectomy – a prospective observational study

Postanesthesia care unit delirium following robot-assisted vs open retropubic radical prostatectomy: A prospective observational study.

The aim of this study was to compare the incidence of early postoperative delirium in the postanesthesia care unit (PACU) between robot-assisted radical prostatectomy (RARP) in the extreme Trendelenburg position and open retropubic radical prostatectomy (ORP) in supine position. Patients were screened for delirium signs 15, 30, 45, and 60 minutes following extubation. PACU delirium was present in 39.3% of RARP (64/163) patients and 41.8% of ORP (77/184) patients. Higher age (OR 1.072, 95%CI: 1.034-1.111, P < .001), total intravenous anesthesia (OR 2.001, 95%CI: 1.243-3.221, P = .004), and anesthesia duration (OR 1.255, 95%CI: 1.067-1.476, P = .006) were associated with PACU delirium, but no association was found between surgical technique and PACU delirium. Compared with inhalational anesthesia, total intravenous anesthesia using propofol-sufentanil, higher age, and longer duration of anesthesia were associated with PACU delirium. Based on these findings, adverse effects on postoperative recovery and delirium signs do not have to be considered in the choice of surgical approach for radical prostatectomy. https://www.drks.de/, identifier: DRKS00010014.

Patient-reported Outcome Measures After Post-anesthesia Care Unit Delirium

Patient-reported Outcome Measures After Post-anesthesia Care Unit Delirium

No convincing association between post‐operative delirium and post‐operative cognitive dysfunction: a secondary analysis

Post-operative delirium and post-operative cognitive dysfunction (POCD) are both common but it has not been clarified how closely they are associated. We aimed to assess the possible relationship in a secondary analysis of data from the 'Surgery Depth of anaesthesia and Cognitive outcome'- study. We included patients aged ≥ 60 years undergoing non-cardiac surgery planned for longer than 60 min. Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders IV criteria in the post-anaesthesia care unit (PACU) as well as within the first week after surgery. Cognitive function was assessed with a neuropsychological test battery. Multivariable analysis of POCD was performed with consideration of predisposing and precipitating factors. Of 1277 randomized patients, 850 (66.6%) had complete data. Delirium was found in 270 patients (32.9% of 850). We detected POCD in 162 (20.9% of 776) at 1 week and in 52 (9.4% of 553) at 3 months. In multivariable analysis (n = 808), delirium had no overall effect on POCD (P = 0.30). Patients with no delirium in PACU but with postoperative delirium within 7 days had an increased risk of POCD at 3 months (OR = 2.56 (95%-confidence interval: 1.07-6.16), P = 0.035). No significant association was found for the other subgroups. There is no clear evidence that postoperative delirium is independently associated with POCD up to 3 months.

Long-Term Outcomes of Older Adults with and Without Delirium Immediately After Recovery from General Anesthesia for Surgery.

Postoperative delirium, occurring days after surgery, is associated with both short- and long-term adverse events. Postanesthesia care unit (PACU) delirium, immediately after recovery from anesthesia, is associated with continued delirium in the succeeding days and adverse cognitive outcomes at discharge. Longer-term consequences are unclear. The objective was to evaluate 18-month outcomes of patients with versus without delirium in the PACU after surgery with general anesthesia. In a prospective, observational, cohort study, 91 consecutive English-speaking patients, aged at least 70 years and capable of independently providing informed consent before surgery, were followed after admission for a surgical procedure in one teaching hospital. Patients completed cognitive testing before surgery. After recovery from general anesthesia, they were evaluated for a DSM-IV diagnosis of delirium. Participants or proxies were evaluated, at a median of 19 months after surgery (interquartile range: 18-20 months), for survival, cognitive and physical functioning, and healthcare utilization outcomes. All 91 patients or proxies (41 with delirium [45%]) were contacted at follow-up, with 7 deaths (8%) and 3 declining further participation (3%); 81 (96% of survivors) completed follow-up evaluations, demonstrating no significant cognitive or functional decline from baseline, with 75% of the cohort living independently in the community, and no differences in any outcomes between patients with versus without PACU delirium. In a small cohort of older patients evaluated 18 months after surgery, we could not detect an association of delirium diagnosed in the PACU with patient survival, cognitive/physical functioning, and healthcare utilization.