Postoperative delirium in the PACU and intensive care unit

Role of oral melatonin in prevention of postoperative delirium in patients undergoing elective surgery under general anesthesia: A Randomized controlled trial

Background

Postoperative delirium is a common complication in patients undergoing elective surgery under general anesthesia. We aimed to minimize the incidence with an oral dose of 3 mg of melatonin administered the night before surgery.

Methods

Hundred and sixty-two patients aged 40-80 years posted for various urological and gastrointestinal surgeries under general anesthesia with no preoperative cognitive deficits were randomly distributed equally to melatonin or control groups. In the control group, routine premedication was done with tablet alprazolam (0.25 mg) and ranitidine (150 mg), but in the melatonin group, the patients were given 3 mg melatonin orally the night before surgery along with routine premedication. The CAM scale was used for diagnosis of postoperative delirium.

Results

Incidence of delirium was significantly lower in the melatonin group, 23.5%, 8.6%, and 2.5% at 6, 24, and 48 hours, respectively, and the corresponding mean (SD) values of CAM scores were 1.37 (1.30), 1.07 (1.03), and 0.69 (0.80). In contrast, the incidence of delirium was 46.9%, 30.9%, and 16% at 6, 24, and 48 hours, respectively, in the control group. There was a significant reduction in anxiety, a lower incidence of cognitive dysfunction (i.e., MoCA score <26), and improvement in sleep quality in the melatonin group at 6, 24, 48, and 72 hours after the surgical intervention. The generalized estimating equations model (GEE) model was used to study change in MoCA and CAM scores over time between the two groups, and it showed a significant interaction between time and treatment groups (P < 0.001).

Conclusions

Melatonin premedication reduced incidence of postoperative delirium and cognitive dysfunction and was associated with better sleep quality and anxiolysis.

Perioperative knowledge, self-efficacy and clinical practices related to postoperative delirium care in older people across geographical regions in Australia

INTRODUCTION

In older people undergoing surgery, there is a lower tolerance for complications. This highlights the need for documented clinical practices on proper prevention, pre-screening and management of complications such as postoperative delirium (POD). Evidence-based clinical practice guidelines exist for delirium management; however, the management of delirium in clinical settings differs widely.

OBJECTIVE

This study aims to develop an understanding of the knowledge, components of self-efficacy (confidence/competence), and clinical practice related to POD care among preoperative and recovery nurses across different types of geographical locations in Australia.

DESIGN

A 27-item online survey was sent out to professional associations focused on perioperative care across Australia. The participants included practicing registered nurses specialising in perioperative care. The main outcome measures were Knowledge, confidence/competence and clinical practice relating to POD care in older patients.

FINDINGS

Respondents were categorised into two groups-major cities and rural and remote. Mean age was 46.3 years for respondents in Australian major cities and 49.5 for the comparison group. There was a statistically significant difference between Australian major cities and 'rural and remote' in confidence in detecting hyperactive delirium, 25.2% versus 11.7% respectively as well as managing hyperactive delirium, 13.8% versus 1.7%, respectively. Similar results were also observed on hypoactive delirium. Respondents from both groups did not mirror the ideal situation in managing a hyperactive delirium.

DISCUSSION

Results from this study are inconclusive and there is no clear-cut observation in clinical practice or knowledge between the two geographical categories in this study.

CONCLUSION

The absence of a distinct strategy with POD prevention highlights the need for a uniform approach and consensus on POD prevention and management in older people. This can be achieved by creating more awareness and education through professional development related to POD.

Delirium education and post-anaesthetics care unit nurses' knowledge on recognising and managing delirium in older patients

BACKGROUND

Postoperative delirium (POD) is a major complication following a surgical procedure. There is evidence that improving knowledge about POD could enhance POD care and patient outcomes.

AIM

The study aimed to evaluate whether the amount of delirium education among registered nurses working in post-anaesthetics care units (PACU) impacts on their self-reported confidence and competence in recognising and managing delirium as well as prior knowledge on factors that influence the risk of delirium onset for older people.

METHOD

The current study utilised an online survey on delirium care practice among registered nurses in PACUs. The survey consisted of 27 items. There were questions about confidence and competence in delirium care, knowledge about delirium risk factors, and ranked responses to two case scenario questions to evaluate the application of POD care. There were also demographic questions, including previous experience with delirium care education.

RESULTS

A total of 336 responses were generated from registered nurses working in PACU. Our findings found substantial variability among the respondents about their delirium care education. The amount of delirium education did not influence the PACU registered nurses' confidence or competence in delirium care. In addition, previous education did not have an impact on their knowledge about delirium risk factors.

DISCUSSION AND CONCLUSION

These findings suggested that the quantity of prior education about delirium did not improve the confidence, competence, knowledge, or case scenario questions of PACU registered nurses. Thus, delirium care education needs to be transformed to ensure it has a positive effect on delirium care clinical practice by registered nurses in PACU.

Using the nursing delirium screening scale in assessing postoperative delirium: A meta-regression

The nursing delirium screening scale (Nu-DESC) was developed for the rapid assessment of delirium, but little is known regarding the performance of the Nu-DESC in assessing postoperative delirium. The purpose of this systematic review and meta-analysis was to review and summarize the evidence of the diagnostic accuracy of the Nu-DESC in assessing postoperative delirium. The EMBASE, MEDLINE, Cochrane Library, CINAHL, and a Chinese e-Journal database were searched from the period of the inception of the Nu-DESC to June 18, 2020. Participants were adult (age ≥ 18 years) postoperative patients who received any type of surgery and any method of anesthesia. The quality assessment of diagnostic accuracy studies-2 was employed to assess the risk of bias among the selected studies, and meta-regression analyses were used to detect sources of between-study heterogeneity. Eleven studies involving 2062 postoperative patients in surgical settings were included. The Nu-DESC revealed a pooled sensitivity of 0.73 (95% confidence interval, 0.44-0.90) and a specificity of 0.93 (0.87-0.96). The area under the summary receiver operating characteristics curve was 0.94 (0.91-0.96), which also confirmed the accuracy of the Nu-DESC. Covariates, including the region of study and the standard reference used, were identified as possible sources of heterogeneity in the meta-regression. The findings of this review can update existing clinical guidelines for postoperative delirium. On the basis of its satisfactory diagnostic performance, we suggest that the Nu-DESC could be considered for nurses and allied health professionals for assessing postoperative delirium. However, because of the heterogeneity, the result of this meta-analysis should be considered with caution.

Postoperative Delirium in Older Patients: A Systematic Review of Assessment and Incidence of Postoperative Delirium

BACKGROUND

Postoperative delirium is the most common complication of surgery particularly in older patients.

AIMS

The current study aimed to summarize the commonly used delirium assessment tools in assessing postoperative delirium (POD) and to estimate the incidence rates of POD.

METHODS

A systematic review that included empirical cohort studies reporting the use of delirium assessment tools in assessing POD between 2000 and 2019. Five core databases were searched for eligible studies. The methodological quality assessment of the included studies was undertaken using the Joanna Briggs Institute (JBI) critical appraisal checklist to examine the risk of bias. Pooled incidence estimates were calculated using a random effects model.

RESULTS

Nineteen studies with a total of 3,533 postsurgery older patients were included in this review. The confusion assessment method (CAM) and CAM-ICU were the most commonly used tools to assess POD among older postoperative patients. The pooled incidence rate of POD was 24% (95% CI [0.20, 0.29]). The pooled incidence estimates for mixed (noncardiac) surgery, orthopedic surgery, and tumor surgery were 23% (95% CI [0.15, 0.31]), 27% (95% CI [0.20, 0.33]), and 19% (95% CI [0.15, 0.22]), respectively. More than 50% of included studies used CAM to assess POD in different types of postoperative patients. Using CAM to assess delirium is less time-consuming and it was suggested as the most efficient tool for POD detection.

LINKING EVIDENCE TO ACTION

We identified that CAM could be implemented in different settings for assessing POD. The incidence and risk factors for POD introduced can be used for future research to target these potential indicators. The incidence rate, risk factors, and predictors of POD explored can provide robust evidence for clinical practitioners in their daily practice.

Assessment of Staffing and Service Provision in the Post-Anesthesia Care Unit of Hospitals Found in Amhara Regional State, 2020

Background

Post-anesthesia recovery is a continuous process which is considered to be complete after the patient returns to their preoperative physiological state. Although all patients who have had an operation under anesthesia are in a potentially unstable physiological state, most patients recover safely without significant problems due to better and immediate post-anesthesia care. Therefore, this study aimed to assess the staffing and service provision in the post-anesthesia care unit.

Methods

A multicenter, institution-based cross-sectional study was conducted in post-anesthesia care units from November 28 to December 31, 2020. The data were collected using a questionnaire prepared from standards and guidelines of the American Society of Anesthesiologists, the American Association of Nurse Anesthetists, and the Royal College of Anesthetists by direct observation.

Results

Ten hospitals found in Amhara regional state were examined for their staffing of and service provision in their post-anesthesia care units. The total ratio of nurses assigned in post-anesthesia care units to post-anesthesia care unit beds was around 1:3, with a minimum and a maximum ratio of 1:8 and 1:2, respectively. The average number of patients admitted in post-anesthesia care units per week was 98. Eighty percent of the hospitals' post-anesthesia care units had no policy or caregivers for cardiac arrest management.

Conclusions and Recommendations

Standards, policies, and guidelines are not well prepared and posted so as to be visible to every caregiver. The majority of the hospitals have staff without special training for the management of possible complications in the post-anesthesia care unit. Generally, hospitals need to ensure standardized patient care in the post-anesthesia care unit for better and safer patient outcomes.

The Relationship of Postoperative Delirium and Unplanned Perioperative Hypothermia in Surgical Patients

PURPOSE

The purpose of this study was to investigate associations between postoperative delirium (POD) and unplanned perioperative hypothermia (UPH) among adults undergoing noncardiac surgery.

DESIGN

A retrospective, exploratory design was used.

METHODS

A retrospective, exploratory study was conducted using electronic medical record data abstracted from a purposive convenience sample of adult patients undergoing noncardiac surgery from January 2014 to June 2017.

FINDINGS

The analyzed data set included 22,548 surgeries, of which 9% experienced POD. Logistic regression indicated that American Society of Anesthesiologists (ASA) class was the strongest predictor of POD (χ² = 1,207.11, df = 4, inclusive of all ASA class terms). A significant relationship between UPH and POD (χ² = 54.94, df = 4, inclusive of all UPH terms) and a complex relationship among UPH, patient age, ASA class, and POD were also found.

CONCLUSIONS

Results support a relationship between UPH and POD. Notably, there is also a complex relationship in the noncardiac surgery population among UPH, age, ASA class, and POD. Preliminary understanding of this relationship is based on the pathophysiological response to surgical stress. Further research is indicated.

Preoperative STOP-BANG Scores and Postoperative Delirium and Coma in Thoracic Surgery Patients

BACKGROUND

Obstructive sleep apnea (OSA) is associated with higher rates of postoperative delirium. The relationship between preoperative OSA risk and postoperative delirium and coma in thoracic surgery patients hospitalized in the intensive care unit (ICU) is not well understood. This study tests the hypothesis that thoracic surgery patients hospitalized in ICU with a higher preoperative risk for OSA are more likely to develop postoperative delirium and coma, resulting in longer hospital stays.

METHODS

Preoperative OSA risk was measured using the STOP-BANG questionnaire. STOP-BANG scores of greater than or equal to 3 were defined as intermediate-high risk for OSA; 128 patients who underwent major thoracic surgery completed the STOP-BANG questionnaire preoperatively. The Richmond Agitation and Sedation Scale was used to assess level of consciousness. The Confusion Assessment Method for the ICU was used to assess for delirium. Linear regression was used to assess the relationship between risk of OSA and outcome measures. Results were adjusted for age, sex, body mass index, Charlson Comorbidity Index, instrumental activities of daily living, and surgery type.

RESULTS

A total of 96 of 128 patients (76%) were in the intermediate-high-risk OSA group. Adjusted analyses showed that the intermediate-high-risk OSA group had a longer duration of postoperative ICU delirium and coma compared with the low-risk OSA group (1.4 ± 1.3 days versus 0.9 ± 1.4 days; P = 0.04). Total number of hospital days was not significantly different.

CONCLUSIONS

Higher preoperative risk for OSA in thoracic surgery patients was associated with a longer duration of postoperative delirium and coma.

Music intervention to prevent delirium among older patients admitted to a trauma intensive care unit and a trauma orthopaedic unit

PURPOSE

Evaluate music listening for delirium prevention among patients admitted to a Trauma Intensive Care and Trauma Orthopaedic Unit. The Roy Adaptation Model provided the theoretical framework focusing on modifying contextual stimuli.

METHODS

Randomised controlled trial, 40 patients aged 55 and older.

INTERVENTION

Participants randomly assigned to receive music listening or usual care for 60 minutes, twice a day, over three days. Pre-recorded self-selected music using an iPod and headsets, with slow tempo, low pitch and simple repetitive rhythms to alter physiologic responses.

OUTCOMES

Heart rate, respiratory rate, systolic and diastolic blood pressure, confusion assessment method.

RESULTS

Repeated measures ANOVA, F(4, 134) = 4.75, p = .001, suggested statistically significant differences in heart rate pre/post music listening, and F(1, 37) = 10.44, p = .003 in systolic blood pressure pre/post music listening. Post-hoc analysis reported changes at three time periods of statistical significance; (p = .010), (p = .005) and (p = .039) and a change in systolic blood pressure pre/post music listening; (p = .001) of statistical significance. All participants screened negative for delirium.

CONCLUSION

Music addresses pathophysiologic mechanisms that contribute to delirium; neurotransmitter imbalance, inflammation and acute physiologic stressors. Music to prevent delirium is one of few that provide support in a critical care setting.

Intravenous Patient-controlled Analgesia Has a Positive Effect on the Prognosis of Delirium in Patients Undergoing Orthopedic Surgery

BACKGROUND

Postoperative delirium is relatively common. However, the relationship between intravenous patient-controlled analgesia (IV-PCA) and delirium has not been thoroughly investigated. The aim of this study was to evaluate the effects of IV-PCA on the prognosis of postoperative delirium in patients undergoing orthopedic surgery.

METHODS

Medical records of 129 patients with postoperative delirium were reviewed. Patients were divided into two groups according to whether they used IV-PCA with fentanyl and ketorolac. The IV-PCA group consisted of 73 patients who were managed with IV-PCA; the NO-PCA group consisted of 56 patients who were managed without PCA.

RESULTS

Incidences of multiple psychiatric consultations and prolonged delirium were significantly lower in patients using IV-PCA with fentanyl and ketorolac than in those without PCA.

CONCLUSIONS

We recommend the use of IV-PCA for pain control and management of delirium in patients with postoperative delirium.