Delirium In Surgical Patients Research Articles

Evaluation of drug prescriptions on hospital admission in older trauma patients using the Fit fOR The Aged (FORTA) rules.

Orthogeriatric comanagement of older patients with hip fractures has been proven to provide significant benefits concerning functional status, readmissions, nursing home placement, in-hospital complications and mortality. Medication management in older individuals is acornerstone in orthogeriatric comanagement. The aim of the study was to analyze the extent of overprescription and undertreatment in older trauma patients. Personal and medical data of consecutively admitted older trauma patients were analyzed. Evaluation of medication was conducted according to the Fit fOR The Aged (FORTA) criteria. Data were retrieved from an ongoing observational study on the incidence of delirium in surgical patients. Atotal of 492 patients were enrolled. There were 374 cases of overprescription and 575 cases of undertreatment. Only 78(16%) patients had neither overprescription nor undertreatment on admission. Overprescription and undertreatment were most prevalent in cardiovascular disease. Undertreatment was most prevalent concerning osteoporosis. The number of prescribed drugs correlated with the Charlson Comorbidity Index (r = 0.478, p < 0.001), age (r = 0.122; p < 0.01), anticholinergic burden (r = 0.528, p < 0.001), FORTA score (r = 0.352, p < 0.001), and overtreatment (r = 0.492, p < 0.001), but not with undertreatment. Undertreatment also correlated with age (r = 0.172, p < 0.001) and overtreatment (r = 0.364, p < 0.01). The FORTA score correlated significantly with age (r = 0.159, p < 0.001), anticholinergic burden (ACB) score (r = 0.496, p < 0.001), Katz index (r = -0.119, p < 0.01), IADL score (r = -0.243, p < 0.001), and clinical frailty scale (CFS, r = 0.23, p < 0.001). The high numbers of overprescription and undertreatment in older trauma patients underlines the need for orthogeriatric comanagement. Besides the evaluation of multimorbidity and geriatric problems, drug management is acore topic. Future studies should investigate the impact of medication management on outcome parameters such as quality of life, functional status, and mortality. Abenefit can be expected.

Use of sodium thiopental and propofol for intravenous sedation and treatment of delirium in early postoperative period in surgical patient

In emergency surgery with volumetric surgical interventions, there are a number of indications for the continuation of intravenous sedation and artificial lung ventilation (ventilator) in the intensive care unit. Often, this need is due to both the magnitude of the surgical catastrophe and the severe concomitant comorbid back14 ground, high risk of early postoperative complications. There is also the development of delirium of various etiologies in the early postoperative period, which also affects the course of the postoperative process, the duration of stay in the intensive care unit.In connection with the above, on the basis of the Intensive care unit of the Multidisciplinary Hospital No. 1 a comparative characteristic of the effectiveness of the use of sodium thiopental and propofol for intravenous sedation and treatment of delirium in surgical patients was carried out in Karaganda.

328 From delirium detection to correction: enhancing peri-operative care for older patients

Abstract Background Delirium is a common peri-operative complications in older adults. It is associated with poorer outcomes including functional decline, increased length of hospital stays, increased admissions to long term care and higher mortality. Therefore, this project aimed to assess the peri-operative care of older patients admitted under the surgical service in accordance with the standards set by the Collaborative for Peri-operative Optimisation of People (CPOP) and British Geriatrics Society (BGS) Peri-operative Care for People Living with Frailty undergoing Elective and Emergency Surgery Guidelines. Methods The study examined four key aspects of the guidelines: (1) surgical staff training on delirium; (2) proactive screening in for delirium in surgical patients; (3) proactively documenting delirium and implementing delirium guidelines; and (4) documentation of delirium diagnosis in discharge summaries. Results Data were collected from 72 surgical admissions over a fourteen-day period, of which 26 patients were aged &amp;gt;65. Results indicated suboptimal adherence to the guidelines, with only 4/26 older patients (15.4%) being screened for delirium. Three of 4 of these patients screened positive for delirium using the 4AT. No patients had delirium mentioned in their discharge summaries. Additionally, a survey of surgical non-consultant hospital doctors revealed that only 4/16 (25%) had received formal training on delirium. Conclusion In response to these findings, interventions were implemented, including teaching at surgical grand rounds, hospital-wide education for World Delirium Awareness Day, introduction of delirium care bundles, and an updated discharge summary template for surgical patients to include a delirium diagnosis. A reaudit is underway to evaluate the impact of these interventions on guideline adherence and the peri-operative care quality for older patients. These initial findings underscore the need for improved staff education and adherence to CPOP and BGS guidelines. The reaudit will provide valuable insights into the effectiveness of the implemented interventions in enhancing the perioperative care experience for the older patient cohort.

Incidence of postoperative delirium in surgical patients: An observational retrospective cohort study.

SummaryPerioperative neurocognitive disorders including postoperative delirium (POD) are common complications of anaesthesia and surgery, associated with morbidity, mortality and a large economic cost. Currently, limited data are available on the incidence of POD in the New Zealand population. The objective of this study was to utilise New Zealand national level datasets to identify the incidence of POD. Our primary outcome was defined as a diagnosis of delirium via ICD 9/10 coding within seven days of surgery. We also analysed demographic, anaesthetic and surgical characteristics. All adult patients undergoing any surgical intervention under sedation, regional, general or neuraxial anaesthesia were included, and patients who received surgical intervention under local anaesthetic infiltration alone were excluded. We reviewed ten years of patient admissions from 2007 to 2016. Our sample size was 2,249,910 patients. The incidence of POD was 1.9%, much lower than previously observed, potentially indicating significant under-reporting of POD in this national level database. With acknowledgement of the limitations of potential undercoding and under-reporting, we found that the incidence of POD was higher with increasing age, male sex, general anaesthesia, Māori ethnicity, increasing comorbidity, surgical severity and emergency surgery. A diagnosis of POD was associated with increased mortality and hospital length of stay. Our results highlight potential risk factors of POD and disparities in health outcomes in New Zealand. Additionally, these findings suggest systemic under-reporting of POD in national level datasets.

A retrospective, cross-sectional analysis of delirium in burn injury compared to other surgical specialities.

BackgroundDelirium is an acute cerebral disorder characterised by a disturbance in cognition, attention, and awareness. Often, it’s undiagnosed and associated with increased morbidity and mortality. For burn patients, the reported prevalence ranges from 16% to 39%, with a multifactorial aetiology, increasing when intensive care is required. A direct comparison of delirium between surgical specialities has not been made. Aim1. To audit the use of the 4AT for those who become delirious during their stay.2. Assess the proportion of patients diagnosed with delirium during hospitalisation by surgical specialities.3. Identification of the factors associated with delirium in surgical patients. MethodsInvestigators at a single centre conducted a two-phase study. An initial retrospective audit of delirious patients under burns, general, and orthopaedic specialities over 16months, as defined by ICD-10 coding, identified compliance screening with the 4 A’s Test. This informed the design of a retrospective, observational cohort study to compare factors associated with delirium and statistical comparison between four specialities to identify delirium-associated factor, where an analysis corrects for age. Results37% of patients with an ICD-10 code indicating delirium had a 4AT test completed. Speciality, number of operations, LOS, ICU hours, age, and discharge destination were all statistically significant independent variables. When all other variables were equal, burns had the highest predicted probability of delirium diagnosis. ConclusionsFurther analysis to identify and diagnose across the specialties is required. From a patient viewpoint, their LOS, ICU hours, and operations are increased for patients coded as delirious compared to non-delirious across the specialities. On a hospital level, the mean difference in cost for a delirious compared to a non-delirious patient is AU$9317. Despite the low incidence of delirium amongst the observed specialities, burns patients were most likely to develop delirium when demographic and clinical profiles were the same, and were more likely to develop delirium at a younger age and if in ICU.

339 SURGICAL INPATIENT DELIRIUM: AN AUDIT OF THE DOCUMENTATION OF THE 4AT SCORE

Abstract Background Postoperative delirium and perioperative neurocognitive disorder are the commonest postoperative complications in patients over 65 years old. This has implications for brain health with an increased risk of length of stay, a higher incidence of morbidity and mortality. Internationally, perioperative teams often fail to routinely screen for delirium. Our aim was to audit the documentation of the 4AT score for surgical inpatients over 65 years old and gain insight into the incidence on surgical wards. Methods Using the guideline for Perioperative Care for People Living with Frailty undergoing Elective and Emergency Surgery from the CPOC and BGS as a standard, an audit of surgical inpatients over 65 was carried out on 3 surgical wards over 5 days. Data was collected including 4AT documentation on admission, day 1 and day 3 post operatively, type of surgery &amp; anaesthesia and risk factors for delirium (dementia, polypharmacy, opioids &amp; benzodiazepine use, PD, surgery&amp;gt;2h, stroke, alcohol, &amp;gt;2 medical conditions, multiple ward moves). Results 36 surgical patients over 65 years of age were included in the audit. The average age was 78 years old (range 65-91). 50% were admitted under the orthopaedic team, 31% under general surgical teams, 11% urology and 8% under other surgical specialties. 33% of patients had a 4AT documented at any stage during their admission and 25% of patients had a baseline 4AT documented preoperatively. The incidence of delirium was 18.7%. Surgical risk factors for delirium were found in 69% of older inpatients. Conclusion Delirium screening was underused in our cohort of older surgical patients despite a proportion of patients developing delirium postoperatively. Under recognition of delirium perioperatively is associated with poor outcomes and higher morbidity and mortality. Further interdisciplinary educational sessions are required to increase awareness and screening of delirium in surgical patients &amp;gt;65 years old with the aim to re-audit in 6 months.

A new medication-based prediction score for postoperative delirium in surgical patients: Development and proof of feasibility in a retrospective patient cohort.

Structured risk screening for postoperative delirium (POD) considering prehospital medication is not established. We aimed to develop a POD-risk prediction score based on known risk factors and delirium-risk increasing drugs to be used by pharmacists during medication reconciliation at hospital admission, and to test for feasibility in a retrospective cohort of surgical patients. Therefore, established POD-risk factors and drugs were extracted from the literature and a score was generated. Following this, the score was tested for feasibility in a retrospective 3-month-cohort of surgical patients. For patients with higher scores suggesting higher probability of POD, patient charts were screened for documentation of POD. For development of the score, the following POD-risk factors were defined and points assigned for score calculation: age (≥65 years=1 point/≥75 years=2), male sex (1), renal insufficiency (RI; 1), hepatic impairment (HI; Model-of-endstage-liver-disease (MELD) 10-14=1/≥15=2), delirium-risk increasing drugs (1 point per drug class), anticholinergic drug burden (ACB; ≥3=1). In the retrospective test cohort of 1174 surgical patients these factors concerned: age ≥65 years 567 patients (48%)/≥75 years 303 (26%), male 652 (55%), RI 238 (20%), MELD 10-14 106 (9%)/≥15 65 (5%), ≥ 1 delirium-risk increasing drug 418 (36%), ACB ≥3 106 (9%). The median POD-risk prediction score was 2 (range 0-9). Of 146 patients (12%) with a score ≥ 5, POD was documented for 43 (30%), no evidence for POD for 91 (62%) and data inconclusive for 12 (8%). For scores of ≥ 7, POD was documented for 50% of the patients with sufficient POD documentation. Overall, POD documentation was poor. To summarize, we developed and successfully tested the feasibility of a POD-prediction-score assessable by pharmacists at medication reconciliation at hospital admission.

A Descriptive Cross-Sectional Study on the Incidence, Risk Factor and Outcome of Delirium in Surgical Patients in the Semi-Closed Intensive Care Unit

Introduction: There is a variation in risk factors and outcome of delirium in surgical patients in different studies. This study was conducted to determine the incidence, risk factors, and outcome of delirium in the surgical semiclosed intensive care unit in a developing country. Materials and Methods: This descriptive study was done in 82 patients of age≥18 years that underwent non-neurological surgery and admitted for more than 24 hours in a level three intensive care unit of medical college from January 10, 2021 to January 9, 2022. The whole sampling method was used in our study. The Confusion Assessment Method-ICU and Richmond Agitation Sedation Scale were used to diagnose delirium and sedation, respectively, along with a checklist to assess risk factors. All data was transferred to the excel sheet and transferred to a statistical package for the social sciences-16. Chi-square test and Fisher’s exact probability test were used to detect the difference between groups in the univariate analysis, as appropriate. The risk factors were analysed using binary logistic regression. Result: Of the 82 ICU admissions 28(34.1%) developed delirium. Hyperactive delirium was the most common motor subtype 12(42.8%). The mean duration of delirium was 4.69±5.06 days. Hypertension and alcohol were identified as risk factors for delirium. Delirious patients had a longer length of stay in the ICU (10.1 ±12.7 vs 5.1 ±4.2 days) with no impact on the duration of mechanical ventilation, mortality, reintubation, and unplanned extubation. Conclusion: Early recognition of risk factors for delirium in surgical patients can decrease the mortality and morbidity of surgical patients.

Association between smoking and postoperative delirium in surgical patients with pulmonary hypertension: a secondary analysis of a cohort study

BackgroundPrevious studies have declared that smoking was a risk factor for postoperative delirium (POD), but others have inconsistent results. Up till now, the association between smoking and POD has not been verified. This study investigates the relationship between smoking and POD in patients with pulmonary hypertension (PHTN) in the United States.MethodsPatients with PHTN who underwent non-cardiac, non-obstetric surgery were enrolled in the original research completed by Aalap C. et al. We further excluded the patients undergoing intracranial surgery and the patients with sepsis and perioperative stroke to avoid interference with POD assessment. The generalized linear model and generalized additive model were used to explore the relationship between smoking and POD. The propensity score adjustment was used for sensitivity analyses.ResultsFive hundred thirty-nine patients were included in this study. The overall incidence of POD was 3.0% (16/539). After adjusting the potential confounders (age, systemic hypertension, coronary artery disease, COPD, length of surgery, intrathoracic surgery, vascular surgery), a positive relationship was found between smoking status and POD (OR = 4.53, 95% CI: 1.22 to 16.86, P = 0.0243). In addition, the curvilinear relationship between smoking burden (pack-years) and POD is close to a linear relationship.ConclusionSmoking probably shows a positive correlation with POD in patients with PHTN.

Melatonin intervention to prevent delirium in hospitalized patients: A meta-analysis.

BACKGROUNDEvaluation of the effectiveness of melatonin is necessary to prevent the development of delirium in hospitalized patients. Melatonin (N-acetyl-5-methoxytryptamine) is a hormone produced by the pineal gland of the brain from the amino acid tryptophan. Synthetic melatonin supplements have been used for various medical conditions, especially sleep-related diseases, and have proved to be successful.AIMTo determine the effect of melatonin on the prevention of delirium in hospitalized patients.METHODSA literature search of the CNKI, Wanfang Database, VIP Database, China Biomedical Literature Database, PubMed, Embase, Cochrane Library, Web of Science, and other databases was conducted. The CNKI, Wanfang Database, VIP Database (VIP), and China Biomedical Literature Database were searched for Chinese studies, and PubMed, Embase, Cochrane Library, Web of Science and other databases were searched for international studies. It will be established in June 2021 in a randomized controlled trial (RCT) whether melatonin treatment for 6 mo prevents delirium in hospitalized patients. Literature screening, quality review, and data extraction were carried out using the Cochrane Manual 5.1.0 systematic evaluation method, and Stata 15.0 software and Review Manager 5.3 were used for meta-analysis and processing. RESULTSA total of 18 new RCT articles and 18 experimental subjects were identified. The results of the meta-analysis showed that following the occurrence of delirium, melatonin reduced the incidence of delirium in patients (RR = 0.69, 95%CI: 0.60-0.80), which is of significance, but heterogeneity was significant I2 = 62%. Subgroup analysis was performed to examine the source of heterogeneity, and it was found that different patient types were the source of heterogeneity; the research on subgroup analysis was of high quality and homogeneous. To determine the reliability and robustness of the research results, a sensitivity analysis was carried out. The results showed that after excluding individual studies one by one, the effect size was still within 95%CI, which strengthened the reliability of the original meta-analysis results. Melatonin has a significant preventive effect on delirium in hospitalized medical patients [RR = 0.60, 95%CI: 0.47-0.76), P < 0.001].CONCLUSIONMelatonin can reduce the rate of delirium in medical patients, and the role of melatonin in reducing the incidence of delirium in surgical patients and critical care unit patients requires further study.

Intensive Care Unit Delirium in Surgical Patients Is Associated with Upregulation in Tryptophan Metabolism.

In intensive care unit (ICU) patients, delirium is frequent, occurs early in ICU admission, and is associated with poor outcomes. Risk models based on clinical factors have shown variable performance in terms of predictive ability. Identification of a candidate biomarker that associates with delirium may lead to a better understanding of disease mechanism, validation biomarker studies, and the ability to develop targeted interventions for prevention and treatment of delirium. This study analyzed metabolite concentrations early in the course of ICU admission to assess the association with delirium onset. Within 24hours of ICU admission, blood samples for global and targeted metabolomics analyses in adult surgical ICU patients were collected prospectively. Metabolites were determined using mass spectrometry/ultra-high-pressure liquid chromatography and analyzed in patients with delirium and a group of controls matched on age, sex, and admission Sequential Organ Function Assessment (SOFA) score. Patients in the study (65 per group) were a mean age of 59years, had a median SOFA score of 6, and were most commonly admitted to the ICU following major trauma. In the delirium group, median onset of delirium was 3 (interquartile range 1-6) days, and the most common delirium subtype was mixed (56%). Kynurenic acid was significantly increased, and tryptophan concentration was significantly decreased in the delirium group (p=0.04). The ratio of kynurenine-to-tryptophan concentration was significantly higher in the delirium group (p=0.005). Evidence of upregulation was found in the tryptophan metabolic pathway in delirious patients because tryptophan concentrations were lower, tryptophan metabolites were higher, and the kynurenine-to-tryptophan ratio was increased. These findings suggest a role of increased inflammation and accumulation of neurotoxic metabolites in the pathogenesis of ICU delirium. Future studies should target this pathway to validate metabolites in the tryptophan pathway as risk biomarkers in patients with ICU delirium.

&lt;br /&gt;DOENTE CIRÚRGICO COM DELIRIUM: NORMA DE ORIENTAÇÃO CLÍNICA &lt;br /&gt;

Objectives: To create a Clinical Practice Guideline to manage delirium in surgical patients, based on existing Clinical Practice Guideline, and to assess whether the application of a multi-component interventions promote the safety of surgical patients with delirium, ad-mitted in a Surgical Care Unit at a Central Hospital. Methodology: A Clinical Practice Guideline based on current scientific evidence was adap-ted, using the ADAPTE process. Subsequently, the effectiveness of its application was eva-luated through a retrospective analysis, relating to the month of December in 2016 and in 2017. A data collection instrument was created and its statistical analysis was perfor-med using spreadsheets in Excel. Results: The Clinical Practice Guideline Approach to delirium in the surgical was created. After its implementation there was a decreasing on delirium incidence, length of stay and associated consequences. Conclusion: The multi-component interventions implementation, included in evidence- -based Clinical Practice Guideline, has shown a good influence in quality of care, patient safety and health care results. Keywords: Delirium; patient safety; practice guidelines as topic; evaluation of results of therapeutic interventions.

Incidence, risk factors and outcome of delirium in a surgical intensive care unit of a tertiary care hospital

Background and Objective: Delirium in critically ill patients is common and distressing.1 The incidence of delirium in intensive care units (ICU) has been reported to range from 45-87%.2,3 Arguably, delirium is a well-recognized cause of morbidity and mortality among ICU patients. It can lead to longer hospital stays, lower six-month survival, and cognitive impairment persisting even years after discharge.3 It has therefore been recommended that all ICU patients are assessed for delirium using a validated tool.3 To date, limited data is available on the prevalence of delirium in surgical patients. In a study published in 2008, the observed risk was 73% in surgical and trauma patients.4This study aimed to evaluate the incidence and modifiable risk factors of delirium in the surgical intensive care unit (SICU) of a tertiary care hospital in a developing country. Methods: We conducted a prospective observational study in patients over 18 years of age who were admitted to the SICU for more than 24 hours in Aga Khan University Hospital, Pakistan, from January 2016 to December 2016. The SICU has 9 beds and is run by trained intensivists with 24/7 coverage. Nurse to bed ratio is 1:1. Admissions are received from the emergency department, operating room, and surgical wards. After approval from the University's ethical review committee, written informed consent was taken from the patient's next of kin. Patients who had a preexisting cognitive dysfunction, signed a Do-Not-Resuscitate order, or stayed in the SICU for less than 24 hours were excluded from the study. Delirium was assessed by the Intensive Care Delirium Screening Checklist (ICDSC).5 The incidence of delirium was computed and univariate and multivariable analyses were performed to observe the relationship between outcome and associated factors. Results: The average patient age was 43.29 ± 17.38 years and BMI was 26.25 ± 3.57 kg/m2 (Table 1). Delirium was observed in 19 of 87 patients with an incidence rate of 21.8%. In univariate analysis, chronic obstructive pulmonary disease (COPD), fever, pain score >4/10, agitation, sedation, hypernatremia, length of ICU stay ≥ 7 days, and mortality were significantly higher in patients who developed delirium (Table 2). Patients on midazolam and propofol were four times more likely to develop delirium. Patients on pethedine were also more likely to develop delirium. Multivariable analysis showed that COPD, pain score >4, and hypernatremia were strong predictors of delirium (Table 3). Midazolam [aOR = 7.37; 95% CI: 2.04-26.61] and propofol exposure [aOR = 7.02; 95% CI: 1.92-25.76] were the strongest independent delirium predictors while analgesic exposures was not statistically significant to predict delirium on multivariable analysis. Conclusion: Delirium assessment is taken seriously and has been done for a long period of time in our unit. Our lower indicence rate of delirium concerns only the surgical patient population and reflects different assessment modalities used as well as pharmacological and non-pharmacological therapeutic options in comparison to the traditional approaches. In addition, we use different strategies such as bundles, sedation and pain protocol, and appropriate family interactions with the patients to minimize delirium. Delirium is a significant risk factor of poor outcome in SICU. This study showed an independent association between inadequate pain control, sedative medication, COPD, hypernatremia, and fever in developing delirium.

Perioperative Management of Delirium in Geriatric Patients

We review the current literature on predictors, pathophysiology, and prevention of delirium in surgical patients. The focus is on the role of the anesthesiologist in the prevention and management of delirium in the perioperative setting. Recent literature has examined how surgery and anesthetic management can affect the incidence of delirium. Anesthesiologists play a critical role in identifying those at risk of developing delirium and adjusting their anesthetic management and perioperative course to minimize this risk. Delirium research is evolving rapidly. Current evidence suggests that environmental interventions, pre-operative optimization, and choice of anesthetic plan, such as the use of regional anesthesia and specific medications, can reduce the incidence of delirium in surgical patients.

Obstructive sleep apnoea, positive airway pressure treatment and postoperative delirium: protocol for a retrospective observational study

IntroductionObstructive sleep apnoea (OSA) is common among older surgical patients, and delirium is a frequent and serious postoperative complication. Emerging evidence suggests that OSA increases the risk for postoperative delirium....

Perioperative Epidural Use and Risk of Delirium in Surgical Patients: A Secondary Analysis of the PODCAST Trial.

Postoperative delirium is an important public health concern without effective prevention strategies. This study tested the hypothesis that perioperative epidural use would be associated with decreased risk of delirium through postoperative day 3. This was a secondary, observational, nonrandomized analysis of data from The Prevention of Delirium and Complications Associated With Surgical Treatments Trial (PODCAST; NCT01690988). The primary outcome of the current study was the incidence of delirium (ie, any positive delirium screen, postanesthesia care unit through postoperative day 3) in surgical patients (gastrointestinal, hepatobiliary-pancreatic, gynecologic, and urologic) receiving postoperative epidural analgesia compared to those without an epidural. As a secondary outcome, all delirium assessments were then longitudinally analyzed in relation to epidural use throughout the follow-up period. Given the potential relevance to delirium, postoperative pain, opioid consumption, sleep disturbances, and symptoms of depression were also analyzed as secondary outcomes. A semiparsimonious multivariable logistic regression model was used to test the association between postoperative epidural use and delirium incidence, and generalized estimating equations were used to test associations with secondary outcomes described. Models included relevant covariates to adjust for confounding. In total, 263 patients were included for analysis. Epidural use was not independently associated with reduced delirium incidence (adjusted odds ratio, 0.65 [95% CI, 0.32-1.35]; P = .247). However, when analyzing all assessments over the follow-up period, epidural patients were 64% less likely to experience an episode of delirium (adjusted odds ratio, 0.36 [95% CI, 0.17-0.78]; P = .009). Adjusted pain scores (visual analog scale, 0-100 mm) were significantly lower in the epidural group on postoperative day 1 (morning, -16 [95% CI, -26 to -7], P < .001; afternoon, -15 [95% CI, -25 to -5], P < .01) and postoperative day 3 (morning, -13 [95% CI, -20 to -5], P < .01). Adjusted mean oral and IV morphine equivalents were also significantly lower on postoperative day 1 in the epidural group (74% lower [95% CI, 55%-85%]; P < .0001). Finally, postoperative epidural use was not significantly associated with new sleep disturbances or changes in depression symptoms. Postoperative epidural use was not associated with a reduced overall incidence of delirium. However, longitudinal analysis revealed reduced adjusted odds of experiencing an episode of delirium in the epidural group. Epidural use was also associated with reduced postoperative pain and opioid consumption. An appropriately designed follow-up study is warranted to further analyze the relationship among epidural use, postoperative delirium, and related outcomes.

Acute Confusional States in Hospital.

Acute confusional state (delirium) is an acute disturbance of brain function. The incidence of such states varies according to the group of patients con- cerned: it ranges from 30% to 80% among patients in intensive care and from 5.1% to 52.2% among surgical patients, depending on the type of procedure. The earlier German term "Durchgangssyndrom" (usually rendered as "transitory psychotic syn- drome") tended to imply a self-limited and thus relatively harmless condition. In fact, however, delirium is associated with longer hospital stays, poorer treatment out- comes, and higher mortality. Approximately 25% of patients who have experienced an acute confusional state have residual cognitive deficits thereafter. This review is based on publications retrieved by a selective search in MEDLINE, PubMed, the Cochrane Library, and in the International Standard Randomised Controlled Trial Number (ISRCTN) registry. Validated instruments are available for the reliable diagnosis of an acute confusional state, e.g., the Confusion Assessment Method for the ICU (CAM-ICU) for patients in intensive care and the 3D-CAM or CAM-S for patients on regular hospital wards. The prevention and treatment of this condition are achieved primarily by a nonpharmacological, multidimensional approach including early mobilization, reorientation, improvement of sleep, adequate pain relief, and the avoidance of polypharmacy. A meta-analysis has shown that these measures lower the incidence of delirium by 44%. The authors find no basis in the current literature for recommending prophylactic medication, although current data promisingly suggest that the incidence of delirium in surgical patients can be lowered by the perioperative administration of dexmedetomidine (odds ratio 0.35). The pharmaco- therapy of acute confusional states involves a careful choice of drug based on the clinical manifestations in the individual case. The key elements of success in the treatment of acute confusional states in the hospital are adequate prevention, rapid diagnosis, the identification of precipitating factors, and the rapid initiation of both causally oriented and symptom- directed treatment.

Delirium in Postoperative Patients Admitted to the Intensive Care Unit

Postoperative delirium (POD) is common among surgical patients admitted to the intensive care unit (ICU) and is associated with increased resource utilization, morbidity, and death. Our primary aim was to compare rates of POD using administrative International Classification of Diseases, Ninth Revision, records and automated interrogation of electronic health records from Confusion Assessment Method for the ICU (CAM-ICU) screening. The secondary aim was to assess POD risk associated with patient and perioperative characteristics. Electronic health records of surgical patients admitted to the ICU during 2011 through 2014 were abstracted for POD assessment by CAM-ICU and by administrative codes, Charlson comorbidity index, surgical characteristics, and Acute Physiology, Age, Chronic Health Evaluation III scores. Of 6338 patients, CAM-ICU identified 606 (9.6%) and administrative records identified 55 (0.9%) POD cases, with agreement on 50 cases. In multivariable logistic regression based on POD identified with CAM-ICU, preexisting dementia had the strongest association with POD (odds ratio [95% confidence interval], 6.47 [3.68-11.37]; P < 0.001). Other associations found were older age, congestive heart failure, chronic pulmonary disease, increased surgical duration, emergency cases, blood transfusions, postoperative ventilation, and higher Acute Physiology, Age, Chronic Health Evaluation III scores (all P ≤ 0.01). POD cases had lengthier ICU and hospital stays and a higher mortality rate (all P < 0.001). CAM-ICU scores identified higher rates of POD than a search for POD based on administrative codes. Preoperative presence of dementia and major comorbidities were associated with POD. Delirium in surgical patients is associated with worse outcomes.

Effects of Haloperidol on Delirium in Adult Patients: A Systematic Review and Meta-Analysis

Objective: The aim of this systematic review and meta-analysis was to investigate whether or not the use of haloperidol could reduce the incidence of delirium in adult patients. Subjects and Methods: PubMed, Embase, the Cochrane Library, Elsevier, Wiley, and Ovid were searched for randomized controlled trials and prospective interventional cohort studies that compared haloperidol with placebo for delirium prophylaxis or with second generation antipsychotics for delirium treatment. The primary end point was the incidence and severity of delirium. After reviewing 272 relevant articles, 10 studies with 1,861 patients were finally included (haloperidol vs. placebo in 8 studies [n = 1,734], and haloperidol vs. second-generation antipsychotics in 2 studies [n = 127]). Revman 5.3 was used for the data analysis. Results: Compared with placebo, a high dose of prophylactic haloperidol (≥5 mg/day) may help reduce the incidence of delirium in surgical patients (risk ratio 0.50, 95% CI 0.32, 0.79). There were no differences in the duration of delirium, QTc interval prolongation, extrapyramidal symptoms, intensive care unit stay, hospital stay, or mortality between the haloperidol and placebo groups. For delirium treatment, haloperidol exhibited similar effects as the second-generation antipsychotics. Conclusions: In this study, the limited available data revealed that prophylaxis haloperidol at a dose of ≥5 mg/day might help reduce delirium in adult surgical patients. Further outcome studies with larger sample sizes are required to confirm these findings.

The Burden of Postoperative Delirium after Vascular Surgery

Postoperative delirium, characterised by an acute onset, a fluctuating course, and an altered level of consciousness and global disturbances of attention, orientation, perception, and sleepeawake cycles, is a common complication after surgical procedures. Its incidence averages 20e40% but can vary from 0% to as high as 73%, and its recognition may be missed by medical providers in up to 50% of cases. Delirium is linked to a reversible impairment of cerebral oxidative metabolism and neurotransmission caused by hypoxia, but its physiopathology remains partly unclear. One hypothesis is that serotonin deficiency resulting from tryptophan depletion and phenylalanine elevation is involved in the pathogenesis of postoperative delirium. Encephalography or other diagnostic measures have demonstrated no specific findings, and most patients completely recover within a few days. However, delirium in surgical patients is associated with multiple medical complications, such as falls, fractures, disruptive behaviour, and incontinence leading to bladder catheterisation and an increased risk for infections. It increases nursing care, length of hospital stay, likelihood of being discharged to a nursing home, and health care costs. Numerous preoperative, intraoperative, and postoperative risk factors for developing postoperative delirium have been identified, with significant differences across studies. The multiple and different factors identified as