Atropine eye-drop-induced acute delirium: a case report

Predictors of postoperative delirium in paediatric patients undergoing surgery under general anaesthesia at Amhara Regional State Tertiary Hospitals: a multicenter prospective study

Introduction

Postoperative delirium in paediatric patients is a recognised issue. Nevertheless, in low- and middle-income nations, researchers have had luck in determining its extent and predictors. Identifying predictors of postoperative delirium in paediatric patients having general anaesthesia at Tertiary Hospitals in Ethiopia was the aim of this study.

Methods

A multicenter, prospective follow up study was conducted from April 15 to June 15, 2023 at the study settings. During the study period a total of 424 paediatric surgical patients treated under general anaesthesia in all study locations, ranging in age from birth to sixteen were candidates for this study. Charts and direct observation of patient's with assessment tool [Cornell Assessment of Pediatric Delirium (CAPD)] were used from each available patient. Binary logistic regression analysis was performed to determine predictors of postoperative delirium in paediatric patients undergoing surgery under general anaesthesia.

Results

Postoperative delirium occurred in 160 of the 404 paediatric patients who underwent surgery under general anaesthesia. Ophthalmic surgery, corticosteroid use, anticholinergic use, severe postoperative pain, and preoperative anxiety were found to be predictors of postoperative delirium; whereas, sedative medication premedication and paracetamol used for analgesia were found to be protective against postoperative delirium.

Inference and recommendation

The postoperative delirium in paediatric patients undergoing surgery under general anaesthesia was higher compared to developed countries. Ophthalmic surgery, corticosteroids, anticholinergic medications, postoperative pain, and preoperative anxiety were found to be predictors. The impact of postoperative delirium might be lessened by concentrating on its screening and factor control.

Prevalence of Emergence Delirium and Associated Factors among Older Patients Who Underwent Elective Surgery: A Multicenter Observational Study

Background

Emergence delirium is a common and serious postoperative complication in older surgical patients. It occurs at any time in the perioperative period, during or immediately following emergence from general anesthesia. Unfortunately, it is highly associated with postoperative complications such as a decrease in functional capacity, prolonged hospital stay, an increase in health care costs, and morbidity and mortality. The goal of this study was to determine the prevalence of emergence delirium and associated factors among older patients who underwent elective surgery in the teaching hospitals of Ethiopia at the postanesthesia care unit in 2021.

Methods

A multicenter prospective observational study was conducted at the postanesthetic care unit in the four teaching hospitals of Ethiopia. Older surgical patients admitted to the postanesthesia care unit who underwent elective surgery in the four teaching hospitals of Ethiopia were selected by using simple random sampling. Pretested structured questionnaire was used to collect data. Data were entered into EpiData (version 4.6) and exported to the SPSS (version 25.0). Binary logistic regression was used to identify factors independently associated with the emergence delirium.

Results

Out of 384 older patients included in the study, the prevalence of emergence delirium was 27.6%. Preoperative low hemoglobin levels (AOR: 2.0, 95% CI; 1.77–3.46), opioid (AOR: 8.0, 95% CI; 3.22–27.8), anticholinergic premedications (AOR: 8.5, 95% CI; 6.85–17.35), and postoperative pain (AOR: 3.10, 95 CI; 2.07–9.84) at PACU were independently associated with emergence delirium.

Conclusion

The prevalence of emergence delirium was high among older patients who underwent elective surgery. Opioid and anticholinergic premedication, low preoperative hemoglobin, and the presence of postoperative pain were independently associated with the emergence delirium. Adequate preoperative optimization and postoperative analgesia may reduce the prevalence of emergence delirium.

Pupillary Dilation in Research: More than Meets the Eye

Purpose: Pupil dilation is a commonly used procedure in vision research. While often considered a minimal risk procedure, there is the potential for significant adverse effects. Methods: Currently, there is variance in practices and protocols among researchers and institutions, perhaps due to a lack of guidelines for safe pupil dilation practices in research settings. In this perspective, we explore variables that can increase the potential for adverse effects and provide suggestions to limit their impact. Prior to dilation, an investigator can assess an individual's medical status and drug regimen when deciding upon a mydriatic agent to be used. Results: Assessing the angle through a variety of methods (i.e. penlight test, van Herick slit lamp, optical coherence tomography, gonioscopy) can also prevent inappropriate dilation of pupils with concerning anatomical features. During dilation, an investigator should look to limit the potential of infection and use caution in repeat dosing of dilation-resistant pupils. Conclusions: Post-dilation, an investigator should closely monitor eyes with elevated risk factors and improve an individual's health literacy on angle closure complications. When combined with proper informed consent processes regarding adverse effects, the aforementioned can allow for risk mitigation in studies using pupil dilation.

A delirium prevalence audit and a pre and post evaluation of an interprofessional education intervention to increase staff knowledge about delirium in older adults

Background

Delirium is more prevalent in older people and estimated to occur in up to 50% of the hospital population. Delirium comprises a spectrum of behaviours, including cognitive and attention deficits, and fluctuating levels of consciousness, often associated with an underlying physiological disturbance. Delirium has been increasingly associated with adverse outcomes. Although often preventable or can at least be mitigated, delirium may not be a standard part of assessment and thus may not be recognized in the early stages when it is most likely to be treated successfully. The aim of this study was to evaluate the level of knowledge of delirium amongst clinicians caring for patients at high risk of developing delirium and to determine whether education can improve clinical assessment of delirium.

Methods

Two hundred and forty-six case notes were audited before and 149 were reviewed after the education intervention and implementation of a delirium screening tool. Clinicians at the hospital were invited to complete a questionnaire on knowledge of delirium. The questionnaire was based on a validated tool which contained 39 questions about delirium. The questionnaire also contained 28 questions on delirium knowledge. Additional questions were included to gather demographic information specific to the hospital. Descriptive statistics, chi square and independent t-tests were conducted to test for differences in knowledge between the pre and post periods. The Squire Checklist Reporting Guidelines for Quality Improvement Studies informed the preparation of the manuscript.

Results

The audit demonstrated that the use of a cognitive assessment tool overall increased from 8.5% in pre education to 43% in the post education period. One hundred and fifty-nine staff completed the questionnaire in total, 118 the pre and 41 post. The knowledge subscale score was high pre and post education and no statistically significant difference was observed. The greatest increase in knowledge was related to knowledge of the risk factors subscale. The increase in knowledge (6.8%) was statistically significant.

Conclusion

An interprofessional approach to delirium education was effective in not only increasing awareness of the factors associated with this syndrome but also increased the use of a delirium assessment tool.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00692-2.

Malignant syndromes: current advances

Introduction: Many drugs are known to induce malignant syndromes. The most common malignant syndromes are induced by the use of antipsychotics and anesthetics and the withdrawal of anti-Parkinson drugs. As the clinical manifestations of antipsychotic malignant syndrome, Parkinson's disease hyperpyrexia syndrome and anesthetic-induced malignant syndrome are very similar, they are easily confused in the clinic.Areas covered: We reviewed articles published between 1960 and April 2021 describing malignant syndromes. This paper provides a detailed literature review of malignant syndromes and important guidance for the diagnosis and treatment of malignant syndromes to clinicians.Expert opinion: Although malignant syndromes are rare conditions with a low incidence, these conditions usually progress rapidly and can endanger patients' lives, meriting attention from clinicians. The typical clinical manifestations of malignant syndromes are hyperpyrexia, muscular rigidity, an altered mental status and increased levels of creatine kinase; however, the pathophysiology, treatment and prognosis of different malignant syndromes are quite different. Prompt diagnosis and treatment may significantly improve the prognosis of patients with malignant syndromes.

Aqueous Misdirection After Trabeculectomy in a Down Syndrome Patient With Angle-closure Glaucoma

Down syndrome is a genetic disease caused by trisomy of chromosome 21 that is characterized by numerous systemic abnormalities including intellectual disability, stereotypical facies, and congenital heart malformations. Ocular abnormalities are commonly seen with Down syndrome including corneal disease (keratoconus), refractive error, and atypical irides (Brushfield spots). We report the first case of aqueous misdirection in a patient with Down syndrome after trabeculectomy. Patients with Down syndrome often have small, hyperopic eyes with narrow iridocorneal angles and may be at increased risk for aqueous misdirection associated with surgical procedures. Awareness of this risk may aid surgical planning and postoperative management.