Rate Of Postoperative Delirium Research Articles

The usefulness of bright light therapy for patients after oesophagectomy

The prevention of delirium is an important issue in the field of perioperative nursing. The objective of this study was to verify the usefulness of acute-stage bright light exposure on patients following oesophagectomy. The participants were oesophagectomy patients that were removed from their ventilators the day after surgery. After extubation, we assigned the participants to either the exposure group or control group. At Day 2 after surgery, the exposure group underwent two hours of bright light exposure for four days. In both groups, we monitored physical activity and autonomic activity. In addition, we scored the participants on the NEECHAM Scale and evaluated their postoperative delirium and postoperative arrhythmia. On the nights of Days 4 and 5, the amount of activity of the exposure group was significantly lower and The sympathetic nervous index was significantly lower on the night of Day 5. The level of arrhythmia was lower in the exposure group and we observed a significant difference on the night of Day 4 and the daytime of Day 5 after surgery. The occurrence rate of postoperative delirium tended to be lower in the exposure group, but there was no significant difference. None of the participants in the exposure group had NEECHAM Scale scores below the cut-off value from the night of Day 4 onwards. We conclude that postoperative bright light exposure adjusted the sleep-wakefulness cycle and improved the bed rest of patients. It was also indicated that bright light therapy is useful for reducing postoperative delirium.

Postoperative Delirium in Elderly Patients After Elective Hip or Knee Arthroplasty Performed Under Regional Anesthesia

Delirium is a major adverse postoperative event in elderly patients. Incidence rates of postoperative delirium are difficult to determine. Because of the accuracy, brevity, and ease of use by clinical interviewers, the Confusion Assessment Method (CAM) has become widely used. This study used the CAM to determine the rate of postoperative delirium in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures under regional anesthesia. Following Institutional Review Board approval, a prospective study of 20 patients per group ages 70 and above undergoing unilateral THA or TKA was initiated. Both groups received a combined spinal-epidural, postoperative patient-controlled epidural anesthesia, and postoperative oral opioids. Patient interviews occurred five times: once preoperatively and two times each on postoperative days1 and 2. Only two patients were assessed as delirious according to the CAM method (one in each group; 5%). Patient assessment by other clinicians indicated that five additional patients experienced acute change in mental status; however, these patients were not delirious at the times of the study interviews. The rate of delirium in the elderly after arthroplasty performed under regional anesthesia is very low. Reasons for this include patient selection criteria and anesthesia type. The study excluded patients with several proposed risk factors for postoperative delirium: prior history of dementia, history of mental illness, and use of benzodiazepines. The use of regional anesthesia may have also reduced the occurrence of postoperative delirium.

Dexmedetomidine and the Reduction of Postoperative Delirium after Cardiac Surgery

Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The authors investigated the effects of postoperative sedation on the development of delirium in patients undergoing cardiac-valve procedures. Patients underwent elective cardiac surgery with a standardized intraoperative anesthesia protocol, followed by random assignment to one of three postoperative sedation protocols: dexmedetomidine, propofol, or midazolam. The incidence of delirium for patients receiving dexmedetomidine was 3%, for those receiving propofol was 50%, and for patients receiving midazolam, 50%. Patients who developed postoperative delirium experienced significantly longer intensive-care stays and longer total hospitalization. The findings of this open-label, randomized clinical investigation suggest that postoperative sedation with dexmedetomidine was associated with significantly lower rates of postoperative delirium and lower care costs.

Postoperative Complications in the Seriously Mentally Ill

To determine the knowledge base on clinical outcomes of surgery among persons diagnosed with serious mental illness. Despite a burgeoning literature during the last 20 years regarding perioperative risk management, little is known about intraoperative and postoperative complications among patients with schizophrenia and other serious mental illnesses. A systematic literature search of Medline (1966-August 2007) and review of studies was conducted. Eligible studies were of any design with at least 10 patients diagnosed with serious mental illness, reporting perioperative medical, surgical, or psychiatric complications. The search identified 1367 potentially relevant publications; only 12 met eligibility criteria. Of 10 studies of patients with schizophrenia, 9 had fewer than 100 patients, whereas one large retrospective study reported higher rates of postoperative complications among 466 schizophrenia patients compared with 338,257 controls. These studies suggest that patients with schizophrenia, compared with those without mental illness, may have higher pain thresholds, higher rates of death and postoperative complications, and differential outcomes (eg, confusion, ileus) by anesthetic technique. Two studies evaluated outcomes in patients with major depressive disorder and found higher rates of postoperative delirium and postoperative confusion. Both schizophrenia and depression patients experienced more postoperative confusion or delirium when psychiatric medications were discontinued preoperatively. We identified no studies of perioperative outcomes in patients with bipolar or posttraumatic stress disorder. There are few studies of perioperative outcomes in patients with serious mental illness. Future research should assess surgical risks among patients with serious psychiatric conditions using rigorous methods and well-defined clinical outcomes.

Twelve-Month Patency With the PAS-Port Proximal Connector Device: A Single Center Prospective Randomized Trial

The PAS-Port (Cardica Inc, Redwood City, CA) is an automated system that allows for the clampless anastomosis of vein grafts to the aorta. The intent of this study was to prospectively compare one year graft patency of this system with conventional hand-sewn anastomoses in a prospective, randomized trial. A total of 99 patients undergoing elective off-pump coronary bypass surgery were randomized to receive their proximal anastomoses with either the hand-sewn conventional technique or with the PAS-Port system. Patient follow-up consisted of multislice computed tomographic scans performed at discharge and one year postoperatively. Three patients had to be converted to on-pump due to technical reasons. Fifty-one patients were randomly assigned to the PAS-Port group and 48 patients to the control group. In five patients in the control group severe atherosclerosis of the aorta required cross-over to the use of the PAS-Port device, and in one patient in the PAS-Port group conversion to a hand-sewn anastomosis. Sequential anastomoses were performed in 88% of the control group and 73% of PAS-Port group grafts. Time needed for completion of the proximal anastomosis including graft loading was 187 +/- 19 seconds for the PAS-Port group and 406 +/- 34 seconds for the control group (p < 0.001). One patient died unrelated to cardiac events due to septic multiorgan failure and one stroke was observed in the control group. There was a trend toward a lower rate of postoperative delirium in the PAS-Port group (11.7% vs 25%, p = 0.088). Patency at discharge (100% PAS-Port group vs 97.8% control group) and after one year (97.8% PAS-Port group vs 93.7% control group) were comparable. One patient of the PAS-Port group died during long-term follow-up as a result of a severe stroke due to cerebrovascular disease. This prospective randomized study demonstrated excellent short and midterm patency in both the hand-sewn and PAS-Port grafts. The PAS-Port system allowed for the rapid, safe, and effective creation of a proximal anastomosis without the need to clamp the aorta. Based on this study we consider this product a valid alternative for proximal anastomosis, especially in patients with severe aortic disease, to avoid side clamping of the aorta.

Influence of bright light therapy on postoperative patients: A pilot study

Bright light therapy is a method of maintaining or restoring the natural circadian rhythm by assisting daytime awakening using bright lights. Postoperative delirium is one of the potential complications encountered by patients receiving postoperative care in the intensive care unit (ICU), but there have been no studies on the use of light for the prevention of postoperative delirium. The objective of this study was to examine whether the circadian rhythms of patients after surgery for oesophageal cancer can be adjusted and whether the postoperative delirium crisis rate can be reduced by bright light therapy. The subjects were 11 patients operated on for oesophageal cancer in Osaka University Hospital. After informed consent was obtained, they were divided into a study group and a control group by a random sampling method. After removal of the endotracheal tube, the study group was exposed to light. The light intensity was about 5000lx immediately before the eyes, and the distance from the light source was about 100 cm. The control group was placed in a natural lighting environment after extubation. In both groups, the rhythms of physical activities and autonomic activities were monitored after surgery, and delirium was evaluated. A significant difference was observed in the delirium score between the study group and control group on the morning of day 3 of bright light therapy by the Mann-Whitney U-test (P=0.014). The study group could begin ambulation about 2 days earlier than the control group. Bright light therapy may reduce the rate of postoperative delirium and make early ambulation possible. However, our study involved a very small sample size. We want to increase the sample in the future after having reviewed clinical application methods.

Predisposing factors for delirium in the surgical intensive care unit.

Delirium is a sign of deterioration in the homeostasis and physical status of the patient. The objective of our study was to investigate the predisposing factors for delirium in a surgical intensive care unit (ICU) setting. Between January 1996 and 1997, we screened prospectively 818 patients who were consecutive applicants to the general surgery service of Dicle-University Hospital and had been kept in the ICU for delirium. All patients were hospitalized either for elective or emergency services and were treated either with medication and/or surgery. Suspected cases of delirium were identified during daily interviews. The patients who had changes in the status of consciousness (n = 150) were consulted with an experienced consultation-liaison psychiatrist. The diagnosis of delirium was based on Diagnostic and Statistical Manual of Mental Disorders (revised third edition) criteria and established through psychiatric interviews. Patients were divided into two groups: the "delirious group" (DG) (n = 90) and the "non-delirious group" (NDG) (n = 728). During delirium, all abnormal findings related to physical conditions, laboratory features, and additional diseases were evaluated as probable risk factors of delirium. Of 818 patients, 386 (47.2%) were male and 432 (52.8%) were female. Delirium developed in 90 of 818 patients (11%). The cases of delirium in the DG were more frequent among male patients (63.3%) than female patients (36.7%) (chi2 = 10.5, P = 0.001). The mean age was 48.9 +/- 18.1 and 38.5 +/- 13.8 years in the DG and NDG, respectively (t = 6.4, P = 0.000). Frequency of delirium is higher in the patients admitted to the Emergency Department (chi2 = 43.6, P = 0.000). The rate of postoperative delirium was 10.9%, but there was no statistical difference related to operations between the DG and NDG (chi2 = 0.13, P = 0.71). The length of stay in the ICU was 10.7 +/- 13.9 and 5.6 +/- 2.9 days in the DG and NDG, respectively (t = 0.11, P = 0.000). The length of stay in hospital was 15.6 +/- 16.5 and 8.1 +/- 2.7 days in the DG and NDG, respectively (t = 11.08, P = 0.000). Logistic regression was used to explore the associations between probable risk factors and delirium. Delirium was not correlated with conditions such as hypertension, hypo/hyperpotassemia, hypernatremia, hypoalbuminemia, hypo/hyperglycemia, cardiac disease, emergency admission, age, length of stay in the ICU, length of stay in hospital, and gender. It was determined that conditions such as respiratory diseases (odds ratio [OR] = 30.6, 95% confidence interval [CI] = 9.5-98.4), infections (OR = 18.0, 95% CI = 3.5-90.8), fever (OR = 14.3, 95% CI = 4.1-49.3), anemia (OR = 5.4, 95% CI = 1.6-17.8), hypotension (OR = 19.8, 95% CI = 5.3-74.3), hypocalcemia (OR = 30.9, 95% CI = 5.8-163.2), hyponatremia (OR = 8.2, 95% CI = 2.5-26.4), azotemia (OR = 4.6, 95% CI = 1.4-15.6), elevated liver enzymes (OR = 6.3, 95% CI = 1.2-32.2), hyperamylasemia (OR = 43.4, 95% CI = 4.2-442.7), hyperbilirubinemia (OR = 8.7, 95% CI = 2.0-37.7) and metabolic acidosis (OR = 4.5, 95% CI = 1.1-17.7) were predicting factors for delirium. We determined that conditions such as respiratory diseases, infections, fever, anemia, hypotension, hypocalcemia, hyponatremia, azotemia, elevated liver enzymes, hyperamylasemia, hyperbilirubinemia and metabolic acidosis were predicting factors for delirium.

A Clinical Prediction Rule for Delirium After Elective Noncardiac Surgery

To develop and validate a clinical prediction rule for postoperative delirium using data available to clinicians preoperatively. Prospective cohort study. General surgery, orthopedic surgery, and gynecology services at Brigham and Women's Hospital, Boston, Mass. Consenting patients older than 50 years admitted for major elective noncardiac surgery between November 1, 1990, and March 15, 1992 (N = 1341). All patients underwent preoperative evaluations, including a medical history, physical examination, laboratory tests, and assessments of physical and cognitive function using the Specific Activity Scale and the Telephone Interview for Cognitive Status. Postoperative delirium was diagnosed using the Confusion Assessment Method or using data from the medical record and the hospital's nursing intensity index. Patients were followed up for the duration of hospitalization to determine major complication rates, length of stay, and discharge disposition. Postoperative delirium occurred in 117 (9%) of the 1341 patients studied. Independent correlates included age 70 years or older; self-reported alcohol abuse; poor cognitive status; poor functional status; markedly abnormal preoperative serum sodium, potassium, or glucose level; noncardiac thoracic surgery; and aortic aneurysm surgery. Using these seven preoperative factors, a simple predictive rule was developed. In an independent population, the rule stratified patients into groups with low (2%), medium (8%, 13%), and high (50%) rates of postoperative delirium. Patients who developed delirium had higher rates of major complications, longer lengths of stay, and higher rates of discharge to long-term care or rehabilitative facilities. Using data available preoperatively, clinicians can stratify patients into risk groups for the development of delirium. Since delirium is associated with a variety of adverse outcomes, patients with substantial risk for this complication could be candidates for interventions to reduce the incidence of postoperative delirium and potentially improve overall surgical outcomes.