Inadequate emergence after non-cardiac surgery-A prospective observational study in 1000 patients

A first assessment of the safe brain initiative care bundle for addressing postoperative delirium in the postanesthesia care unit

BACKGROUND

Postoperative delirium (POD) following surgery is a prevalent and distressing condition associated with adverse patient outcomes and an increased healthcare burden.

OBJECTIVES

To assess the effectiveness of the Safe Brain Initiative care bundle (SBI-CB) in reducing POD in the postanesthesia care unit (PACU).

DESIGN

A multicenter, quality-improvement initiative with retrospective analysis of collected data.

SETTING

The study was conducted in the operating rooms and postanesthesia care units (PACUs) of four hospitals across Denmark and Turkey.

PATIENTS

The convenience sample of patients were aged ≥18 years, scheduled for surgery, and could communicate verbally. Age, sex, preoperative delirium, and the American Society for Anesthesiology physical status classification were used in statistical methods to control for potential confounding influences.

INTERVENTION

The SBI-CB, 18 delirium-reducing recommendations aligned with international guidelines. The intervention included patient education, staff training, coordination meetings across centers, and a dashboard for the monitoring of outcomes in the PACU.

MAIN OUTCOME MEASURES

The primary outcome was the POD trend in the PACU during implementation months, assessed through Nu-DESC screening at up to three time points in the PACU. We also examined the length of hospital stay.

RESULTS

Data were collected from 18,697 adult patients across four hospitals. Initial POD incidence in the PACU after the first three months was 16.36% across all sites (n = 1021). POD in the PACU was observed across all age groups, with peak incidence in younger (18-35 years) and older (>75 years) patients. General anesthesia and longer surgical duration (>1 h) were identified as significant risk factors for POD in the PACU. Matched patients who experienced POD in the PACU had longer stays in hospital, with a mean increase from 35 to 69 h (p < 0.001). Implementation of the SBI-CB was associated with a decreased risk of POD in the PACU for each month of SBI-CB implementation (adjusted odds ratio 0.96, 95% confidence interval: [0.94, 0.97], p < 0.001).

CONCLUSIONS

The presented pragmatic implementation of a multidisciplinary care bundle, encompassing pre-, intra-, and postoperative measures alongside outcome monitoring, has the potential to significantly reduce the incidence of POD in the PACU. Improved patient outcomes may be achieved for general surgical departments with patient cohorts not typically considered at risk for developing POD.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier NCT05765162.

Risk Factors for Postanesthetic Emergence Delirium in Adults: A Systematic Review and Meta-analysis

Emergence delirium (ED) is delirium that occurs during or immediately after emergence from general anesthesia or sedation. Effective pharmacological treatments for ED are lacking, so preventive measures should be taken to minimize the risk of ED. However, the risk factors for ED in adults are unclear. In this systematic review and meta-analysis, we evaluated the evidence for risk factors for ED in adults. The PubMed, Scopus, Cochrane Library, Google Scholar, and Embase databases were searched for observational studies reporting the risk factors for ED in adults from inception to July 31, 2023. Twenty observational studies reporting 19,171 participants were included in this meta-analysis. Among the preoperative factors identified as risk factors for ED were age <40 or ≥65 years, male sex, smoking history, substance abuse, cognitive impairment, anxiety, and American Society of Anesthesiologists physical status score III or IV. Intraoperative risk factors for ED were the use of benzodiazepines, inhalational anesthetics, or etomidate, and surgical factors including abdominal surgery, frontal craniotomy (vs. other craniotomy approaches) for cerebral tumors, and the length of surgery. Postoperative risk factors were indwelling urinary catheters, the presence of a tracheal tube in the postanesthetic care unit or intensive care unit, the presence of a nasogastric tube, and pain. Knowledge of these risk factors may guide the implementation of stratified management and timely interventions for patients at high risk of ED. The majority of studies included in this review investigated only hyperactive ED and further research is required to determine risk factors for hypoactive and mixed ED types.

Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Postoperative neurocognitive disorders: A clinical guide

For years, postoperative cognitive outcomes have steadily garnered attention, and in the past decade, they have remained at the forefront. This prominence is primarily due to empirical research emphasizing their potential to compromise patient autonomy, reduce quality of life, and extend hospital stays, and increase morbidity and mortality rates, especially impacting elderly patients. The underlying pathophysiological process might be attributed to surgical and anaesthesiological-induced stress, leading to subsequent neuroinflammation, neurotoxicity, burst suppression and the development of hypercoagulopathy. The beneficial impact of multi-faceted strategies designed to mitigate the surgical and perioperative stress response has been suggested. While certain potential risk factors are difficult to modify (e.g., invasiveness of surgery), others - including a more personalized depth of anaesthesia (EEG-guided), suitable analgesia, and haemodynamic stability - fall under the purview of anaesthesiologists. The ESAIC Safe Brain Initiative research group recommends implementing a bundle of non-invasive preventive measures as a standard for achieving more patient-centred care. Implementing multi-faceted preoperative, intraoperative, and postoperative preventive initiatives has demonstrated the potential to decrease the incidence and duration of postoperative delirium. This further validates the importance of a holistic, team-based approach in enhancing patients' clinical and functional outcomes. This review aims to present evidence-based recommendations for preventing, diagnosing, and treating postoperative neurocognitive disorders with the Safe Brain Initiative approach.

Effects of early postoperative neurocognitive disorders on clinically relevant outcomes: a meta-analysis

BACKGROUND

Early postoperative neurocognitive disorders (ePND), include both emergence delirium, which is defined as very early onset postoperative delirium, and emergence agitation, defined as motor arousal. Although research on anesthesia emergence is limited, ePND are likely associated with unfavorable outcomes. This meta-analysis assessed the effect of ePND on clinically relevant outcomes.

METHODS

A systematic search of studies published between 2002 and 2022 on MEDLINE, PubMed, Google Scholar, and the Cochrane Library was performed. Studies that included adults with emergence agitation and/or delirium and reported at least one of the following outcomes: mortality, postoperative delirium, length of post-anesthesia care unit stay, or length of hospital stay were included. The internal validity, risk of bias, and certainty of the evidence were assessed.

RESULTS

A total of 16,028 patients from 21 prospective observational studies and one case-control retrospective study were included in this meta-analysis. The occurrence rate of ePND was 13% (data excluding the case-control study). The mortality rate was 2.4% in patients with ePND vs. 1.2% in the normal emergence group (risk ratio [RR]: 2.6, P = 0.01, very low quality of evidence). Postoperative delirium occurred in 29% of patients with ePND and 4.5% of patients with normal emergence (RR: 9.5, P < 0.001, I2 = 93%). Patients with ePND had a prolonged length of post-anesthesia care unit stay (P = 0.004) and length of hospital stay (P < 0.001).

CONCLUSIONS

This meta-analysis suggests that ePND are associated with twice the risk of mortality and a 9-fold increased risk of postoperative delirium.

The Thai version of the nursing delirium screening scale-Thai: Adaptation and validation study in postoperative patients

Background

The Nursing Delirium Screening Scale (Nu-DESC) is an effective instrument for assessing postoperative delirium (POD). This study translated the Nu-DESC into Thai (“Nu-DESC-Thai”), validated it, and compared its accuracy with the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5).

Methods

The translation process followed the International Society for Pharmacoeconomics Outcome Research guidelines. Recruited participants were ≥ 70 years old, fluent in Thai, and scheduled for surgery. The exclusion criteria were cancellation or postponement of an operation, severe visual or auditory impairment, and patients with a Richmond Agitation Sedation Scale score of –4 or less before delirium assessment. Post-anesthesia care unit (PACU) nurses and residents on wards each used the Nu-DESC to assess delirium in 70 participants (i.e., 140 assessments) after the operation and after patient arrival at wards, respectively. Geriatricians confirmed the diagnoses using video observations and direct patient contact.

Results

The participants’ mean age was 76.5 ± 4.6 years. The sensitivity and specificity of the Nu-DESC-Thai at a threshold of ≥ 2 were 55% (95% CI, 31.5–76.9%) and 90.8% (84.2–95.3%), respectively, with an area under a receiver operating characteristic curve (AUC) of 0.73. At a threshold of ≥ 1, the sensitivity and specificity were 85% (62.1–96.8%) and 71.7% (62.7–79.5%), respectively (AUC, 0.78). Adding 1 point for failing backward-digit counting (30–1) to the Nu-DESC-Thai and screening at a threshold of ≥ 2 increased its sensitivity to 85% (62.1–96.8%) with the same specificity of 90.8% (84.2–95.3%).

Conclusion

The Nu-DESC-Thai showed good validity and reliability for postoperative use. Its sensitivity was inadequate at a cutoff ≥ 2. However, the sensitivity improved when the threshold was ≥ 1 or with the addition of backward counting to Nu-DESC-Thai and screening at a threshold of ≥ 2.

Research status and prospect of peri-extubation delirium

Peri-extubation delirium is a clinical syndrome caused by multiple factors, and it is not a simple disease. It occurs within a period of time after extubation when the effect of general anesthesia is reduced. And the incidence is different in disparate populations, and it is more common in elderly patients. Current studies have shown that iatrogenic factors and patients' own factors are the main risk factors for the syndrome. Early identification of risk factors can help clinicians make early diagnosis. The earlier the diagnosis and treatment begin, the more significantly the prognosis of patients can be improved. At present, the treatment of perioperative delirium is based on non-drug therapy, supplemented by drug therapy. This review will introduce in detail the risk factors, population status and prevention measures of delirium during peri-extubation, and look forward to the new research direction in the future.

Inadequate emergence after anesthesia for elective cancer surgery: a single-center cohort study

Background

Inadequate emergence after anesthesia (IEA) is a common phenomenon in adult patients undergoing anesthesia. The aim of this study was to evaluate the incidence and determinants of IEA for elective cancer surgery, and to study its influence on the quality of recovery.

Methods

In this observational, prospective study, 148 patients scheduled for elective cancer surgery were included. IEA was considered for patients having emergence delirium or hypoactive emergence applying The Richmond Agitation and Sedation Scale (RASS) 10 minutes after admission at PACU. Postoperative Quality of Recovery Scale (PQRS) was used at baseline and after surgery at minutes 15 (T15) and 40 (T40), and days 1 (D1) and 3 (D3).

Results

Of the 148 patients, 48 (32%) had IEA. Complete recovery at PQRS was less frequent in patients with IEA on physiological domain at T15 and D1, and activities of daily living domain at D3. Patients with IEA recovered more frequently in emotive domain at T15, T40, and D3. Determinants of IEA were age, risk of surgery, congestive heart disease, cerebrovascular disease, ASA physical status, RCRI score, and duration of anesthesia. IEA patients had more frequently postoperative delirium and stayed for longer at PACU and at the hospital.

Conclusion

IEA was a common phenomenon after anesthesia for elective curative surgery for cancer. Patients with IEA were older and had more comorbidities and a higher surgical risk. Patients with IEA had a less frequent complete recovery on the PD and in AD domains, and a more frequent complete recovery on the ED.

Risk factors for emergence agitation in adults after general anesthesia: A systematic review and meta-analysis

BACKGROUND

Emergence agitation (EA) is an adverse post-operative complication that increases the risk for injury, self-extubation, hemorrhages, and prolonged hospitalization. This meta-analysis aims to define the risk factors for adult EA after general anesthesia and provide recommendations for clinical practice.

METHODS

Embase, PubMed, Medline, and the Cochrane Library databases were comprehensive retrieved. Observational studies that reported the risk factors for adult EA were enrolled. Review Manager 5.4 was used to analyze the extracted data.

RESULTS

Eighteen observational studies involving 16, 678 adult patients were enrolled in this study. Eighteen pre-operative and nineteen intraoperative factors with unadjusted data, and five pre-operative and five intraoperative factors with adjusted data were meta-analyzed separately. Among them, seven factors (age, male, smoking, history of substance misuse, inhalational anesthesia, urinary catheter, complain of pain, or need analgesic drug use in post-anesthetic care unit) were the risk factors no matter meta-analyzed by unadjusted data or adjusted data. Intraoperative use of benzodiazepines was the risk factor when meta-analyzed by adjusted data, but not unadjusted data. Moreover, age and inhalational anesthesia were not the risk factors when omitted one study for sensitivity analysis, and history of substance misuse could not do sensitivity analysis.

CONCLUSION

Based on this meta-analysis, male, smoking, urinary catheter, and post-operative pain are the risk factors, while age, inhalational anesthesia, history of substance misuse, and intraoperative use of benzodiazepines are the possible risk factors for adult EA.

EDITORIAL COMMENT

This systematic review and meta-analysis identify risk factors associated with the occurrence of agitation during emergence from general anesthesia. As might be expected, the strongest factors are generally things which are irritating or painful for patients, but cannot necessarily be avoided.

Delayed Emergence from Anesthesia: What We Know and How We Act

The emergence from anesthesia is the stage of general anesthesia featuring the patient’s progression from the unconsciousness status to wakefulness and restoration of consciousness. This complex process has precise neurobiology which differs from that of induction. Despite the medications commonly used in anesthesia allow recovery in a few minutes, a delay in waking up from anesthesia, called delayed emergence, may occur. This phenomenon is associated with delays in the operating room, and an overall increase in costs. Together with the emergence delirium, the phenomenon represents a manifestation of inadequate emergence. Nevertheless, in delayed emergence, the transition from unconsciousness to complete wakefulness usually occurs along a normal trajectory, although slowed down. On the other hand, this awakening trajectory could proceed abnormally, possibly culminating in the manifestation of emergence delirium. Clinically, delayed emergence often represents a challenge for clinicians who must make an accurate diagnosis of the underlying cause to quickly establish appropriate therapy. This paper aimed at presenting an update on the phenomenon, analyzing its causes. Diagnostic and therapeutic strategies are addressed. Finally, therapeutic perspectives on the “active awakening” are reported.

Emergence delirium is associated with increased postoperative delirium in elderly: a prospective observational study

Background

The clinical significance of emergence delirium remains unclear. The purpose of this study was to investigate the association between emergence delirium and postoperative delirium in elderly after general anesthesia and surgery.

Methods

This prospective observational study was done in a tertiary hospital in Beijing, China. Elderly patients (65–90 years) who underwent major noncardiac surgery under general anesthesia and admitted to the postanesthesia care unit (PACU) after surgery were enrolled. Emergence delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit during PACU stay. Postoperative delirium was assessed with the Confusion Assessment Method during the first 5 postoperative days. The association between emergence delirium and postoperative delirium was analyzed with a multivariable logistic regression model.

Results

A total of 942 patients were enrolled and 915 completed the study. Emergence delirium developed in 37.0% (339/915) of patients during PACU stay; and postoperative delirium developed in 11.4% (104/915) of patients within the first 5 postoperative days. After adjusted confounding factors, the occurrence of emergence delirium is independently associated with an increased risk of postoperative delirium (OR 1.717, 95% CI 1.078–2.735, P = 0.023). Patients with emergence delirium stayed longer in PACU and hospital after surgery, and developed more non-delirium complications within 30 days.

Conclusions

Emergence delirium in elderly admitted to the PACU after general anesthesia and major surgery is independently associated with an increased risk of postoperative delirium. Patients with emergence delirium had worse perioperative outcomes.

Chinese Clinical Trial Registry (chictr.org.cn) ChiCTR-OOC-17012734

Electronic supplementary material

The online version of this article (10.1007/s00540-020-02805-8) contains supplementary material, which is available to authorized users.