Evidence and consensus-based Guidelines on Postoperative Delirium Federico

of Anesthesiology University of Rome “La Sapienza”, Rome, Italy
II International Congress

of Anesthesiologists and Intensivists
Republic of Kazakhstan, Astana
29th April 2018

and can be accompanied by perceptual (hallucinations) and cognitive symptoms

(spatial/temporal disorientation, memory dysfunction).

Can be hyperactive (agitated & combative), hypoactive (decreased alertness/motor activity & anedonia) or mixed.

Clinical relevance, risk factors & diagnosis

3.- Prevention & treatment

Embase till March 2015: 405 articles

pain events are reported to be: “the most clinically relevant”

Ranking for neurocognitive events:
Awareness
Agitation
POD & POCD
In patients undergoing hip surgery, spinal anesthesia is considered: “preferable” (95%)
Depth of anesthesia monitoring is considered: “irrelevant”
Written POD diagnosis & treatment protocol is available in 11% respondents

62 countries: Russia (11%), Germany (8%), Italy (8%), Spain (7%),

Greece (6%), United Kingdom (6%), Austria (5%).

68% delirium is either “very relevant” or “relevant” in clinical practice.
6.7% routinely monitor POD in >50% of patients.

79% use EEG/BIS/EMG intraoperative monitoring to “reduce the risk of intraoperative awareness”

55% assess POD before discharge from PACU, only 14% in the ward.

18% have a standardized institutional treatment protocol

anesthesia
up to 70% of elderly after major orthopedic surgery

There

is a wide discrepancy in the literature regarding rates that range between 7% and 70%
This is partly attributable to different criteria for POD diagnosis.
Studies examining POD have mostly focused on hyperactive POD while hypoactive forms are likely to be overlooked.

(months) and long-term (>1 year) follow up.

Prospective observational study

enrolled 91 patients (>70 years) evaluated for POD in the PACU and while hospitalized
Early POD was independently associated with POCD (at 3 months)

CAM in 199 patients + mortality at 6 months. POD

developed in 57 patients (28%);
Mortality: 28% in POD group VS. 13% in Non-POD; p=0.01

There is a possible association between preoperative cognitive status, occurrence of POD & increased postoperative mortality

Retrospective observational study in 774 patients
Incidence of delirium was

11.5%

Six variables significantly associated with POD:
preexisting cognitive impairment (OR, 3.83; P < .01),
age older than 69 years (OR, 2.43; P < .01),
surgery duration greater than 6 hours (OR, 2.40; P < .01),
MCV greater than 95.0 femtoliters (OR, 2.23; P < .01),
ever being advised to cut back on alcohol (OR, 2.25; P = .01),
not abstaining from alcohol for 1 week in the preceding year (OR, 2.16; P = .02).

hypernatremia
Anticholinergic drug use
Preoperative pain
Additional –specific- risk factors that should be

included in the preoperative evaluation are:

for POD
112 adult postoperative cardiac surgical patients evaluated twice daily

for POD using RASS and CAM-ICU.

Factors independently associated with POD were:
- Increased age, >70 years: OR= 2.5; P <0.0001/ 10 years
- Increased duration of surgery: OR = 1.3; P =0.0002/per 30 minutes

observational study in 364 patients in non cardiac surgery

Pain (at

rest, with movement, maximal pain over previous 24h) was measured with patient interviews and visual analog scale (VAS).
POD was diagnosed with CAM.

Higher pain scores at rest was associated with an increased risk of POD in the first 3 postoperative days

surgery
Intra-operative bleeding
Prospective observational study in 1341 patients in

non cardiac surgery

PACU and up to 5th post-operative day using a validated

delirium score

Nursing Delirium Screening Scale (Nu-DESC):
sensitivity 32%-95% and specificity 87%-92%

Confusion Assessment Method (CAM) or Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).
In PACU: sensitivity 28%-43%, specificity 98%.

70% of the cases, is associated with POCD and higher

mortality;

Risk factors: alcohol (and drugs) abuse, age, pre-op pain and cognitive impairment, blood loss, duration of surgery, malnutrition, etc…

For POD diagnosis, use a standardized scale: NuDesc or CAM-ICU

outcomes: short-term mortality and ICU LOS.
Systematic review (21 RCTs) on

implementation strategies to improve assessment, prevention and treatment of POD.

Multi-component implementation of strategies targeting ICU-POD -assessment, prevention and treatment- lead to better clinical outcomes

SHALL BE performed

procedures) had more POD

Depht of anesthesia SHALL BE monitored

POD in high risk and elderly patients

except in patients with severe anxiety

to propofol or sevoflurane.
No differences in POD in the

2 groups during the first 3 post-op days.

On post-op days 2 and 3
Delirium Rating Scale (DRS) scores were higher in propofol than sevoflurane treated patients
(P < 0.01).

It remains unclear whether different regimes of anaesthesia affect POD: TIVA vs. inhalational

surgery

It is effective in high risk patients


RCTs in 457 patients

(>65 years) undergone non cardiac surgery and scheduled for haloperidol (0.5 mg iv bolus+ continuous infusion at 0.1 mg/h for 12 hrs) or placebo.

Overall POD was lower in the haloperidol group: 15% vs. 23%; p<.031.
Prevalence of POD on 1st and 3rd pop days was lower in the haloperidol group: 7.0% vs. 13.2%; p<.028

randomized of risperidone (0,5 mg x 2/d) or placebo.
POD

was 13.7% VS. 34% in the placebo group (P 0.031).
Administration of risperidone, to elderly patients who experienced SS-POD after on-pump cardiac surgery was associated with a lower incidence of POD.

and treatment protocol effectively improve outcome;
2.- Anesthesia depth –too little

& too much- is associated with POD;
3.- Contrasting results on anesthesia regimens: TIVA> then balanced (?);
4.- Neuroleptics premedication are effective in high risk and in elderly.

systematically evaluated with an established and validated scale up to

the 5th post op day;

Risk factors:
- Age
- Alcohol use disorders
- Pain pre and post operative
- Malnutrition
- Duration of surgery
BDZ premedication facilitates POD in elederly;
Depth of anesthesia (too low and too high) is a predictor for POD
A standardized diagnosis & treatment protocol reduce POD-related M&M

Alpha 2 agonists reduce ED in children;

fraility




Prospective observational study in 566 elderly patients undergoing vascular surgery
Cognitive

imparment was an indipendent risk factors for POD

in elderly patients undergoing cardiac surgery.

The nutritional status was

assessed by Nutritional Risk Screening(NRS-2002) questionnaire the day before surgery.

Malnutrition was higher in POD group (62.5% vs. 20.9%, p<0.0191).
Preoperative hemoglobin level was lower in POD group
(127.8 ± 7.8 vs. 137.1 ± 14.9,p= 0.0442)

sensory impairment
Orientation (clock, communication ….)
Visual – hearing aids
Noise reduction and

maintenance of a day/night rhythm
Avoidance of unnecessary indwelling catheters
Early mobilization
Early nutrition

Systematic review of 7 studies with 1791 patients

Multicomponent interventions significantly reduced incident of POD (RR 0.73, 95% CI 0.63-0.85, P<0.001)

emergence delirium (ED).
Gender is not a risk factor.
ENT surgery

and pain are risk factors for ED;

Monitoring:
Anxiety, pain, ED and POD should be evaluated by a validated scores.
Pain shall be treated according to a validated age adapted scale.

Midazolam and alpha 2 agonists reduce Peds-ED