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Bowman EML, Sweeney AM, McAuley DF, Cardwell C, Kane J, Badawi N, Jahan N, Iqbal HK, Mitchell C, Ballantyne JA, Cunningham EL. Assessment and report of individual symptoms in studies of delirium in postoperative populations: a systematic review. Age Ageing 2024; 53:afae077. [PMID: 38640126 PMCID: PMC11028403 DOI: 10.1093/ageing/afae077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/06/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVES Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into 'no delirium' or 'control' groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults. METHODS Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed. RESULTS These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition. CONCLUSIONS The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Aoife M Sweeney
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Danny F McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Chris Cardwell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Joseph Kane
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nadine Badawi
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nusrat Jahan
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Halla Kiyan Iqbal
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Callum Mitchell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Jessica A Ballantyne
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Emma L Cunningham
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
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Yan E, Veitch M, Saripella A, Alhamdah Y, Butris N, Tang-Wai DF, Tartaglia MC, Nagappa M, Englesakis M, He D, Chung F. Association between postoperative delirium and adverse outcomes in older surgical patients: A systematic review and meta-analysis. J Clin Anesth 2023; 90:111221. [PMID: 37515876 DOI: 10.1016/j.jclinane.2023.111221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
STUDY OBJECTIVE To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients. DESIGN A systematic review and meta-analysis with multiple databases searched from inception to February 22, 2022. SETTING Postoperative assessments. PATIENTS Non-cardiac and non-neurological surgical patients aged ≥60 years with and without postoperative delirium. Included studies must report ≥1 postoperative outcome. Studies with a small sample size (N < 100 subjects) were excluded. MEASUREMENTS Outcomes comprised the pooled incidence of postoperative delirium and its postoperative outcomes, including mortality, complications, unplanned intensive care unit admissions, length of stay, and non-home discharge. For dichotomous and continuous outcomes, OR and difference in means were computed, respectively, with a 95% CI. MAIN RESULTS Fifty-four studies (20,988 patients, 31 elective studies, 23 emergency studies) were included. The pooled incidence of postoperative delirium was 19% (95% CI: 16%, 23%) after elective surgery and 32% (95% CI: 25%, 39%) after emergency surgery. In elective surgery, postoperative delirium was associated with increased mortality at 1-month (OR: 6.60; 95% CI: 1.58, 27.66), 6-month (OR: 5.69; 95% CI: 2.33, 13.88), and 1-year (OR: 2.87; 95% CI: 1.63, 5.06). The odds of postoperative complications, unplanned intensive care unit admissions, prolonged length of hospital stay, and non-home discharge were also higher in delirium cases. In emergency surgery, patients with postoperative delirium had greater odds of mortality at 1-month (OR: 3.56; 95% CI: 1.77, 7.15), 6-month (OR: 2.60; 95% CI: 1.88, 3.61), and 1-year (OR: 2.30; 95% CI: 1.77, 3.00). CONCLUSIONS Postoperative delirium was associated with higher odds of mortality, postoperative complications, unplanned intensive care unit admissions, length of hospital stay, and non-home discharge. Prevention and perioperative management of delirium may optimize surgical outcomes.
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Affiliation(s)
- Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Matthew Veitch
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Yasmin Alhamdah
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Nina Butris
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - David F Tang-Wai
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Maria Carmela Tartaglia
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mahesh Nagappa
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada.
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Almuzayyen HA, Chowdhury T, Alghamdi AS. Postoperative cognitive recovery and prevention of postoperative cognitive complications in the elderly patient. Saudi J Anaesth 2023; 17:550-556. [PMID: 37779573 PMCID: PMC10540994 DOI: 10.4103/sja.sja_529_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 10/03/2023] Open
Abstract
Elderly patients undergoing surgery are at higher risk of life-altering and costly complications. This challenge is increasingly recognized with the growing geriatric surgical population. Advanced age and comorbid conditions, such as disability and frailty that often develop with age, are all independent risk factors of postoperative morbidity and mortality. A common factor in this age group is cognitive impairment, which poses a challenge for the patient and clinician in the perioperative setting. It affects the capacity for informed consent and limits optimization before surgery; furthermore, an existing impairment may progress in severity during the perioperative period, and new onset of signs of delirium or postoperative cognitive dysfunction may arise during postoperative recovery. In this article, we aim to review the current literature examining the latest definitions, diagnostic criteria, and preventive strategies that may ameliorate postoperative cognitive complications.
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Affiliation(s)
- Hisham A. Almuzayyen
- Department of Anesthesiology, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
- King Fahad Hospital of University, Imam Abdulrahman Bin Faisal University, Khobar, Saudi Arabia
| | - Tumul Chowdhury
- Department of Anesthesia, Toronto Western Hospital, Clinical Investigator, UHN, University of Toronto, Toronto, Canada
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Postoperative cognitive dysfunction: time for enhanced recovery after surgery programmes. Ugeskr Laeger 2022; 39:733-734. [PMID: 35919025 DOI: 10.1097/eja.0000000000001684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Awada HN, Steinthorsdottir KJ, Schultz NA, Hillingsø JG, Larsen PN, Jans Ø, Kehlet H, Aasvang EK. High-dose preoperative glucocorticoid for prevention of emergence and postoperative delirium in liver resection: A double-blinded randomized clinical trial substudy. Acta Anaesthesiol Scand 2022; 66:696-703. [PMID: 35325467 PMCID: PMC9320957 DOI: 10.1111/aas.14057] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Emergence delirium (ED) and postoperative delirium (POD) are associated with increased morbidity and mortality and occur in up to one-third of patients undergoing major non-cardiac surgery, where the underlying pathogenesis is multifactorial, including increased inflammation. We aimed to assess the effect of pre-operative high- versus low-dose glucocorticoid on the occurrence of ED and POD. METHODS This was a substudy from a randomized, double-blinded clinical trial. Patients ≥18 years, undergoing open liver resection were randomized 1:1 to high-dose (HD, 10 mg/kg methylprednisolone) or low-dose (LD, 8 mg dexamethasone) glucocorticoid and assessed for ED and POD for a maximum of 4 days during hospitalization. The 3-min Diagnostic Interview for CAM-defined delirium (3D-CAM) was used for assessment, 15 and 90 min after arrival in the post-anesthesia care unit (PACU), and subsequently once daily in the ward. RESULTS Fifty-three patients were included in this secondary substudy (26 HD-group and 27 LD-group). ED occurred in n = 5 HD versus n = 6 LD patients 15 min after PACU arrival. At 90 min after PACU arrival, 4 patients had ED, all from LD-group, and resulted in significantly longer PACU admission, 273 versus 178 min in ED versus Non-ED patients. During the first 4 days in the ward, n = 5 patients had at least one occurrence of POD, all from LD-group. CONCLUSIONS The primary finding of the current substudy was a lower occurrence of ED/POD in the PACU 90 min after arrival and during the first four postoperative days in patients receiving high-dose glucocorticoid compared with patients receiving low-dose glucocorticoid. The two study groups were not evenly balanced concerning known explanatory factors, i.e., age and size of surgery, which calls for larger studies to elucidate the matter.
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Affiliation(s)
- Hussein Nasser Awada
- Department of AnesthesiologyCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
- Surgical Pathophysiology UnitRigshospitaletCopenhagen University HospitalCopenhagenDenmark
| | - Kristin Julia Steinthorsdottir
- Department of AnesthesiologyCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
- Surgical Pathophysiology UnitRigshospitaletCopenhagen University HospitalCopenhagenDenmark
| | - Nicolai A. Schultz
- Department of Gastrointestinal Surgery and TransplantationCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Jens G. Hillingsø
- Department of Gastrointestinal Surgery and TransplantationCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Peter Nørgaard Larsen
- Department of Gastrointestinal Surgery and TransplantationCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Øivind Jans
- Department of AnesthesiologyCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Henrik Kehlet
- Surgical Pathophysiology UnitRigshospitaletCopenhagen University HospitalCopenhagenDenmark
| | - Eske Kvanner Aasvang
- Department of AnesthesiologyCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
- Department of Clinical MedicineFaculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
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Hughes CG, Boncyk CS, Culley DJ, Fleisher LA, Leung JM, McDonagh DL, Gan TJ, McEvoy MD, Miller TE. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention. Anesth Analg 2020; 130:1572-1590. [PMID: 32022748 DOI: 10.1213/ane.0000000000004641] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.
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Affiliation(s)
- Christopher G Hughes
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S Boncyk
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Deborah J Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacqueline M Leung
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - David L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, and Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Risk factors for postoperative delirium after colorectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:433-444. [PMID: 31897646 DOI: 10.1007/s00384-019-03498-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Postoperative delirium is common after any type of surgery and can lead to serious outcomes; thus, its prevention is important. Early assessment can help identify patients at higher risk of postoperative delirium. However, the risk factors for postoperative delirium in patients who underwent colorectal surgery are unclear. This meta-analysis aimed to identify the risk factors for postoperative delirium after colorectal cancer surgery. METHODS We selected all articles related to postoperative delirium after colorectal surgery published up to March 2019. Studies using any method for diagnosing delirium were eligible. Ovid-Embase, Ovid-Medline, and the Cochrane library were searched. Two reviewers independently conducted quality assessment and data collection. The risk factors identified in the studies were recorded, and a meta-analysis was conducted. RESULTS Of the 1216 studies initially screened, 1197 were reviewed by two independent reviewers. Finally, 14 articles were identified to be relevant for this review. In total, 11 of the 14 studies reported the risk factors for postoperative delirium. The incidence of postoperative delirium ranged from 8% to 54%. A total of 19 risk factors were identified, and we classified them into two categories as patient-related and treatment-related risk factors. CONCLUSION Postoperative delirium is highly common in those undergoing colorectal surgery including cancer, with advanced old age, history of preoperative delirium and preoperative serum albumin level which are risk factors for POD. Larger multi-institutional randomized studies to address this issue are warranted in the future.
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Kehlet H. Enhanced postoperative recovery: good from afar, but far from good? Anaesthesia 2020; 75 Suppl 1:e54-e61. [DOI: 10.1111/anae.14860] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2019] [Indexed: 12/15/2022]
Affiliation(s)
- H. Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet Copenhagen University Copenhagen Denmark
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Rengel KF, Pandharipande PP, Hughes CG. Special Considerations for the Aging Brain and Perioperative Neurocognitive Dysfunction. Anesthesiol Clin 2019; 37:521-536. [PMID: 31337482 DOI: 10.1016/j.anclin.2019.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Postoperative delirium and postoperative cognitive dysfunction (POCD) occur commonly in older adults after surgery and are frequently underrecognized. Delirium has been associated with worse outcomes, and both delirium and cognitive dysfunction increase the risk of long-term cognitive decline. Although the pathophysiology of delirium and POCD have not been clearly defined, risk factors for both include increasing age, lower levels of education, and baseline cognitive impairment. In addition, developing delirium increases the risk of POCD. This article examines interventions that may reduce the risk of developing delirium and POCD and improve long-term recovery and outcomes in the vulnerable older population.
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Affiliation(s)
- Kimberly F Rengel
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA.
| | - Pratik P Pandharipande
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
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Postoperative cognitive dysfunction is rare after fast-track hip- and knee arthroplasty - But potentially related to opioid use. J Clin Anesth 2019; 57:80-86. [PMID: 30927698 DOI: 10.1016/j.jclinane.2019.03.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Postoperative cognitive dysfunction (POCD) remains a frequent postoperative complication in non-fast-track surgeries, with negative implications for return to daily activities and work. In fast-track total hip and -knee arthroplasty (THA/TKA) an 8-9% incidence of POCD after 3 months has been reported, but without details on specific perioperative risk factors. Thus, we re-investigated the incidence and role of suggested factors for POCD in a well-controlled patient cohort, to guide future preventive interventions. DESIGN A subanalysis of a prospective study. SETTING Hospital ward, patients own home. PATIENTS One-hundred-and-four patients undergoing elective THA/TKA. INTERVENTIONS A full contextual and validated cognitive test battery pre- and 2-3 weeks postoperatively by interview by research nurse. MEASUREMENTS Results from the cognitive test battery were corrected for learning effect by normative data from an age-matched unoperated control group. Potential perioperative risk factors (age, procedure, gender, inflammation, blood-percentage, opioids etc.) associated with POCD was investigated by univariate and multivariate logistic analysis, with a 5% significance level. MAIN RESULTS Four patients (3.9%) developed POCD. POCD-positive patients consumed higher dose of opioids in the acute postoperative period (postoperative days 0-3: median 214 mg), vs. POCD-negative patients (postoperative days 0-3: median 98 mg, p = 0.008), and during the 2-3-week study period (POCD-positive vs. POCD-negative patients, median 739 mg vs. 208 mg, respectively). Other pre and postoperative factors were non-significant but associated with the development of POCD. CONCLUSION POCD is rare in fast-track THA/TKA patients and may be related to postoperative opioid consumption, supporting the ongoing focus on opioid-sparing analgesia.
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Monacelli F, Signori A, Prefumo M, Giannotti C, Nencioni A, Romairone E, Scabini S, Odetti P. Delirium, Frailty, and Fast-Track Surgery in Oncogeriatrics: Is There a Link? Dement Geriatr Cogn Dis Extra 2018. [PMID: 29515621 PMCID: PMC5836168 DOI: 10.1159/000486519] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background/Aims Postoperative delirium (POD) is more frequent in elderly patients undergoing major cancer surgery. The interplay between individual clinical vulnerability and a series of perioperative factors seems to play a relevant role. Surgery is the first-line treatment option for cancer, and fast-track surgery (FTS) has been documented to decrease postoperative complications. The study sought to assess, after comprehensive geriatric assessment (CGA) and frailty stratification (Rockwood 40 items index), which perioperative parameters were predictive of POD development in elderly patients undergoing FTS for colorectal cancer. Methods A total of 107 consecutive subjects admitted for elective colorectal FTS were enrolled. All patients underwent CGA, frailly stratification, Timed up & go (TUG) test, 4AT test for delirium screening, anesthesiologists physical status classification, and Dindo-Clavien classification. Results The incidence of POD was 12.3%. Patients’ prevalent clinical phenotype was pre-frail. The multivariate analysis indicated physical performance (TUG in seconds) as the most significant predictor of POD for each second of increase. Conclusions Only few procedure-specific studies have examined the impact of FTS for colorectal cancer on POD. This is the first study to investigate the risk factors for POD, in a vulnerable octogenarian oncogeriatric population submitted to FTS surgery and frailty stratification.
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Affiliation(s)
- Fiammetta Monacelli
- aHospital Policlinic San Martino, Section of Geriatric Medicine, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy.,dI.R.C.C.S. per l'Oncologia, Hospital Policlinic San Martino, Genoa, Italy
| | - Alessio Signori
- bDISSAL, Department of Health Science, University of Genoa, Genoa, Italy
| | - Matteo Prefumo
- aHospital Policlinic San Martino, Section of Geriatric Medicine, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy.,dI.R.C.C.S. per l'Oncologia, Hospital Policlinic San Martino, Genoa, Italy
| | - Chiara Giannotti
- aHospital Policlinic San Martino, Section of Geriatric Medicine, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy.,dI.R.C.C.S. per l'Oncologia, Hospital Policlinic San Martino, Genoa, Italy
| | - Alessio Nencioni
- aHospital Policlinic San Martino, Section of Geriatric Medicine, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy.,dI.R.C.C.S. per l'Oncologia, Hospital Policlinic San Martino, Genoa, Italy
| | - Emanuele Romairone
- cOncological Surgery and Implantable Systems, Hospital Policlinic San Martino, Genoa, Italy
| | - Stefano Scabini
- cOncological Surgery and Implantable Systems, Hospital Policlinic San Martino, Genoa, Italy
| | - Patrizio Odetti
- aHospital Policlinic San Martino, Section of Geriatric Medicine, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy
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Petersen PB, Jørgensen CC, Kehlet H. Delirium after fast-track hip and knee arthroplasty - a cohort study of 6331 elderly patients. Acta Anaesthesiol Scand 2017; 61:767-772. [PMID: 28681427 DOI: 10.1111/aas.12932] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/26/2017] [Accepted: 06/06/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postoperative delirium (PD) is a well-known complication among elderly surgical patients and associated with increased morbidity, mortality and length of stay (LOS). In elective orthopedic surgery, including hip and knee arthroplasty (THA/TKA), most studies report incidences between 5% and 10%. The multimodal optimization of perioperative care (fast-track) aims to enhance recovery and reduce morbidity and LOS, but limited data are available on the effect on PD. Consequently, the study investigated signs of PD associated with LOS > 4 days. METHODS Prospective risk assessment study with retrospective analysis of discharge notes or medical records of signs of PD in 6331 elective primary unilateral THA and TKA patients ≥ 70 years, and LOS > 4 days. Preoperative patient characteristics collected from eight high volume centers with similar standardized fast-track protocols from January 2010 to November 2013. RESULTS We identified 43 (0.7%) cases of PD symptoms mentioned as a reason for LOS > 4 days among the 789 patients with LOS > 4 days (12.5% of all THA and TKA). PD patients had a mean age of 80.7 [[95% CI] 79.3-82.1] years, being 4.0 [[95% CI] 2.5-5.5] years older compared to patients without PD (P < 0.001). LOS was median 10 [[Q2-Q3] 7-14] days in the PD group vs. 3 [2-3] days in the non-PD group (P < 0.001), without differences in gender or site of arthroplasty (P = 0.139 and 0.499, respectively). CONCLUSION Postoperative delirium symptoms contributing to LOS > 4 days in fast-track THA and TKA are rare in elderly patients.
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Affiliation(s)
- P. B. Petersen
- Section for Surgical Pathophysiology; The Juliane Marie Centre; Rigshospitalet; Copenhagen Denmark
- Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement; Copenhagen Denmark
| | - C. C. Jørgensen
- Section for Surgical Pathophysiology; The Juliane Marie Centre; Rigshospitalet; Copenhagen Denmark
- Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement; Copenhagen Denmark
| | - H. Kehlet
- Section for Surgical Pathophysiology; The Juliane Marie Centre; Rigshospitalet; Copenhagen Denmark
- Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement; Copenhagen Denmark
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16
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Wada S, Inoguchi H, Hirayama T, Matsuoka YJ, Uchitomi Y, Ochiai H, Tsukamoto S, Shida D, Kanemitsu Y, Shimizu K. Yokukansan for the treatment of preoperative anxiety and postoperative delirium in colorectal cancer patients: a retrospective study. Jpn J Clin Oncol 2017; 47:844-848. [DOI: 10.1093/jjco/hyx080] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Affiliation(s)
- Saho Wada
- Department of Psycho-oncology, National Cancer Center Hospital
- Division of Health Care Research, QOL Research Group, Center for Public Health Sciences, National Cancer Center
| | | | | | - Yutaka J. Matsuoka
- Department of Psycho-oncology, National Cancer Center Hospital
- Division of Health Care Research, QOL Research Group, Center for Public Health Sciences, National Cancer Center
- Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center Hospital
| | - Yosuke Uchitomi
- Department of Psycho-oncology, National Cancer Center Hospital
- Division of Health Care Research, QOL Research Group, Center for Public Health Sciences, National Cancer Center
- QOL Research Group, Center for Public Health Sciences, National Cancer Center
| | - Hiroki Ochiai
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Shunsuke Tsukamoto
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Dai Shida
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Ken Shimizu
- Department of Psycho-oncology, National Cancer Center Hospital
- Division of Health Care Research, QOL Research Group, Center for Public Health Sciences, National Cancer Center
- Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center Hospital
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17
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Chen W, Ke X, Wang X, Sun X, Wang J, Yang G, Xia H, Zhang L. Prevalence and risk factors for postoperative delirium in total joint arthroplasty patients: A prospective study. Gen Hosp Psychiatry 2017. [PMID: 28622817 DOI: 10.1016/j.genhosppsych.2017.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The aim of this prospective study was to investigate the incidence and clinical features of delirium after total joint arthroplasty, and to establish the potential risk factors for postoperative delirium. METHODS A total of 212 consecutive patients undergoing hip or knee arthroplasty, who met the inclusion and exclusive criteria were enrolled. The general characteristics, preoperative and postoperative hematological variables were documented respectively. According to the presence of delirium, all patients were divided into the delirium group and non-delirium group. Univariate and multivariate logistic regression were performed to identify the possible predictors for postoperative delirium. RESULTS At a minimum of 6months of follow-up, 35 patients were observed with postoperative delirium at an estimated total incidence of 16.5%. The incidence of delirium was statistically higher in hip arthroplasty (22.8%) than that in knee arthroplasty (7.1%). The multivariate regression analysis identified older age (OR=1.590, P=0.023), a history of stroke (OR=190.23, P=0.036), preoperative PaO2 (OR=1.277, P=0.018) and equivalent fentanyl dose (OR=1.010, P=0.012) as the predictive factors for postoperative delirium after total joint arthroplasty. CONCLUSIONS The incidence of postoperative delirium after total joint arthroplasty is higher than expected. Based on our findings, we suggest that the surgeons should focus on those patients who have these risk factors and ensure the appropriate management to avoid postoperative delirium.
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Affiliation(s)
- Wenliang Chen
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Xiurong Ke
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Xiaoqing Wang
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Xiaoliang Sun
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Juncheng Wang
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Guojing Yang
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Haijie Xia
- Department of anesthesia, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Lei Zhang
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China.
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18
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European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34:192-214. [DOI: 10.1097/eja.0000000000000594] [Citation(s) in RCA: 491] [Impact Index Per Article: 70.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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19
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Benhamou D, Brouquet A. Postoperative cerebral dysfunction in the elderly: Diagnosis and prophylaxis. J Visc Surg 2016; 153:S27-S32. [DOI: 10.1016/j.jviscsurg.2016.09.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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