Incidence and risk factors of acute postoperative delirium in geriatric neurosurgical patients

Understanding the association between pain and delirium in older hospital inpatients: systematic review and meta-analysis

OBJECTIVE

Delirium and pain are common in older adults admitted to hospital. The relationship between these is unclear, but clinically important. We aimed to systematically review the association between pain (at rest, movement, pain severity) and delirium in this population.

METHODS

PubMed, EMBASE, CINAHL, PsycINFO, Cochrane and Web of Science were searched (January 1982-November 2022) for Medical Subject Heading terms and synonyms ('Pain', 'Analgesic', 'Delirium'). Study eligibility: (1) validated pain measure as exposure, (2) validated delirium tool as an outcome; participant eligibility: (1) medical or surgical (planned/unplanned) inpatients, (2) admission length ≥ 48 h and (3) median cohort age over 65 years. Study quality was assessed with the Newcastle Ottawa Scale. We collected/calculated odds ratios (ORs) for categorical data and standard mean differences (SMDs) for continuous data and conducted multi-level random-intercepts meta-regression models. This review was prospectively registered with PROSPERO [18/5/2020] (CRD42020181346).

RESULTS

Thirty studies were selected: 14 reported categorical data; 16 reported continuous data. Delirium prevalence ranged from 2.2 to 55%. In the multi-level analysis, pain at rest (OR 2.14; 95% confidence interval [CI] 1.39-3.30), movement (OR 1.30; 95% CI 0.66-2.56), pain categorised as 'severe' (OR 3.42; 95% CI 2.09-5.59) and increased pain severity when measured continuously (SMD 0.33; 95% CI 0.08-0.59) were associated with an increased delirium risk. There was substantial heterogeneity in both categorical (I2 = 0%-77%) and continuous analyses (I2 = 85%).

CONCLUSION

An increase in pain was associated with a higher risk of developing delirium. Adequate pain management with appropriate analgesia may reduce incidence and severity of delirium.

The role of perioperative sedative anesthetics in preventing postoperative delirium: a systematic review and network-meta analysis including 6679 patients

OBJECTIVE

Postoperative delirium is a common and debilitating complication that significantly affects patients and their families. The purpose of this study is to investigate whether there is an effective sedative that can prevent postoperative delirium while also examining the safety of using sedatives during the perioperative period.

METHODS

The net-meta analysis was used to compare the incidence of postoperative delirium among four sedatives: sevoflurane, propofol, dexmedetomidine, and midazolam. Interventions were ranked according to their surface under the cumulative ranking curve (SUCRA).

RESULTS

A total of 41 RCT studies involving 6679 patients were analyzed. Dexmedetomidine can effectively reduce the incidence of postoperative delirium than propofol (OR 0.47 95% CI 0.25-0.90), midazolam (OR 0.42 95% CI 0.17-1.00), normal saline (OR 0.42 95% CI 0.33-0.54) and sevoflurane (OR 0.39 95% CI 0.18-0.82). The saline group showed a significantly lower incidence of bradycardia compared to the group receiving dexmedetomidine (OR 0.55 95% CI 0.37-0.80). In cardiac surgery, midazolam (OR 3.34 95%CI 2.04-5.48) and normal saline (OR 2.27 95%CI 1.17-4.39) had a higher rate of postoperative delirium than dexmedetomidine, while in non-cardiac surgery, normal saline (OR 1.98 95%CI 1.44-2.71) was more susceptible to postoperative delirium than dexmedetomidine.

CONCLUSION

Our analysis suggests that dexmedetomidine is an effective sedative in preventing postoperative delirium whether in cardiac surgery or non-cardiac surgery. The preventive effect of dexmedetomidine on postoperative delirium becomes more apparent with longer surgical and extubation times. However, it should be administered with caution as it was found to be associated with bradycardia.

Metabolic syndrome and the risk of postoperative delirium and postoperative cognitive dysfunction: a multi-centre cohort study

BACKGROUND

Metabolic syndrome and its components are risk factors for cognitive impairment, but their contribution to perioperative neurocognitive disorders is unknown. We examined their associations with the risk of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) in older patients.

METHODS

In 765 male and female participants aged ≥65 years, we measured preoperative metabolic parameters and screened for POD for 7 days or until discharge. POCD was defined through comparison of cognitive change on six neuropsychological tests with non-surgical controls. Multiple logistic regression analyses examined the association of metabolic parameters with risk of POD and POCD with adjustment for age, sex, and surgery type.

RESULTS

A total of 149 patients (19.5% of 765) developed POD and 53 (10.1% of 520 attendees) had POCD at 3 months. Patients with metabolic syndrome were at 1.85-fold higher risk of POD (95% confidence interval [CI] 1.26-2.70). Each 1 mmol L^-1 higher high-density lipoprotein cholesterol (HDL-C) was associated with a 0.47-fold lower POD risk (95% CI 0.30-0.74). Each 1 kg m^-2 higher body mass index (BMI) was associated with a 1.09-fold higher POCD risk (95% CI 1.02- 1.16).

CONCLUSIONS

Older surgical patients with metabolic syndrome were at increased risk of POD. Only reduced HDL-C was significantly associated with POD. For POCD, a higher preoperative BMI was identified as a risk factor. These findings add to mounting evidence of a distinct epidemiology of POD and POCD. Screening programmes taking advantage of HDL-C and BMI measurements and of metabolic interventions in reducing perioperative neurocognitive disorders should be evaluated.

CLINICAL TRIAL REGISTRATION

NCT02265263.

Considerations for the Use of Local Anesthesia in the Frail Elderly: Current Perspectives

The frail, elderly population is at a high risk of postoperative complications. Besides perioperative rehabilitation techniques and management by geriatric teams, the least invasive techniques in anesthesia are required, making regional anesthesia very interesting in terms of benefit-risk ratio. Among them, local anesthesia is a simple, reproducible, inexpensive technique applied to many superficial or deep surgeries, which should make it a gold standard for the frail person. This review provides an update on the current possibilities for various surgeries and exclusion.

Incidence of and Risk Factors for Emergence Delirium and Postoperative Delirium in Neurosurgical Patients- A Prospective Cohort Study

Background

Delirium after surgery is a spectrum of clinical syndrome constituting emergence delirium (ED) and/or postoperative delirium (POD).

Objectives

The primary objective of this study was to evaluate the incidence of ED and POD in patients after neurosurgical procedures. The secondary objectives were to examine the relationship between ED and POD and identify perioperative risk factors of ED and POD.

Materials and Methods

This is a prospective cohort study conducted at the National Institute of Mental Health and Neurosciences. After obtaining the ethics committee approval, consecutive adult patients scheduled for elective neurosurgical procedures from February 2018 to November 2018 were included. We excluded children, patients with preoperative Glasgow Coma score <15, and patients with preoperative delirium. ED was assessed using Riker's Sedation-Agitation Score and POD was assessed using Confusion Assessment Method. Data collection included patient demographics, details of anesthetics and analgesics, and neurosurgical details.

Results

The incidence of ED and POD was 41% (N = 82/200) and 20% (N = 40/200), respectively. The occurrence of ED and POD coexisting as a continuous spectrum was 15%. Patients undergoing spine surgeries were found to have 44% less risk of ED than after cranial surgeries (P = 0.032). Presence of ED was associated with 1.8 times higher risk of POD (P < 0.001) and male gender was associated with 2.5 times higher risk of POD (P = 0.005).

Conclusions

Incidences of ED and POD are higher after neurosurgery as compared with that reported in nonneurosurgical population previously.

Music to prevent deliriUm during neuroSurgerY (MUSYC) Clinical trial: a study protocol for a randomised controlled trial

INTRODUCTION

Delirium is a neurocognitive disorder characterised by an acute and temporary decline of mental status affecting attention, awareness, cognition, language and visuospatial ability. The underlying pathophysiology is driven by neuroinflammation and cellular oxidative stress.Delirium is a serious complication following neurosurgical procedures with a reported incidence varying between 4% and 44% and has been associated with increased length of hospital stay, increased amount of reoperations, increased costs and mortality.Perioperative music has been reported to reduce preoperative anxiety, postoperative pain and opioid usage, and attenuates stress response caused by surgery. We hypothesize that this beneficial effect of music on a combination of delirium eliciting factors might reduce delirium incidence following neurosurgery and subsequently improve clinical outcomes.

METHODS

This protocol concerns a single-centred prospective randomised controlled trial with 6 months follow-up. All adult patients undergoing a craniotomy at the Erasmus Medical Center in Rotterdam are eligible. The music group will receive recorded music through an overear headphone before, during and after surgery until postoperative day 3. Patients can choose from music playlists, offered based on music importance questionnaires administered at baseline. The control group will receive standard of clinical careDelirium is assessed by the Delirium Observation Scale and confirmed by a delirium-expert psychiatrist according to the DSM-5 criteria. Risk factors correlated with the onset of delirium, such as cognitive function at baseline, preoperative anxiety, perioperative medication use, depth of anaesthesia and postoperative pain, and delirium-related health outcomes such as length of stay, daily function, quality of life (ie, EQ-5D, EORTC questionnaires), costs and cost-effectiveness are collected.

ETHICS AND DISSEMINATION

This study is being conducted in accordance with the Declaration of Helsinki. The Medical Ethics Review Board of Erasmus University Medical Center Rotterdam, The Netherlands, approved this protocol. Results will be disseminated via peer-reviewed scientific journals and conference presentations.

TRIAL REGISTRATION NUMBERS

NL8503 and NCT04649450.

Postoperative Delirium in Patients After Brain Tumor Surgery

BACKGROUND

Postoperative delirium is a common surgical complication that can be associated with poorer outcome. Many patients with brain tumors experience delirium after surgery. We hypothesize that patients who experience delirium after resection of a brain tumor will have worse outcomes post surgery in terms of mortality, disposition, and length of stay compared with those without postoperative delirium. We also examine differences between nurse and physician diagnoses of delirium.

METHODS

Data from patients undergoing brain tumor resection at University of Missouri Hospital were retrospectively collected. Delirium was defined using Diagnostic and Statistical Manual-5 criteria. Patients with delirium were compared with patients without delirium using chi-squared test, Cohen Kappa value, and binomial proportion analysis at 95% confidence intervals or P < 0.05.

RESULTS

Of 500 patients having brain tumor resections, 93 (18.6%) were diagnosed with postoperative delirium. Patients with delirium had higher 30-day mortality (9.78% vs. 1.48%; P < 0.0001), required restraints more often (42.39% vs. 5.91%, P < 0.0001), had longer hospital length of stay (14.3 vs. 6.3 days; P < 0.0001), and increased skilled nursing facility disposition (57.3% vs. 26.11%; P < 0.0001) than patients without delirium. Diagnosis of delirium between nursing staff and clinicians moderately correlated (Kappa 0.5677 ± 0.0536).

CONCLUSIONS

Delirium, a common postoperative complication after brain tumor surgery, is associated with longer length of stay, increased disposition to skilled nursing facility, and increased 30-day mortality. These findings reinforce the importance of early recognition, diagnosis, and treatment of postoperative delirium in brain tumor resection patients.

Delirium in neurosurgery: a systematic review and meta-analysis

Delirium is a frequent occurring complication in surgical patients. Nevertheless, a scientific work-up of the clinical relevance of delirium after intracranial surgery is lacking. We conducted a systematic review (CRD42020166656) to evaluate the current diagnostic work-up, incidence, risk factors and health outcomes of delirium in this population. Five databases (Embase, Medline, Web of Science, PsycINFO, Cochrane Central) were searched from inception through March 31st, 2021. Twenty-four studies (5589 patients) were included for qualitative analysis and twenty-one studies for quantitative analysis (5083 patients). Validated delirium screening tools were used in 70% of the studies, consisting of the Confusion Assessment Method (intensive care unit) (45%), Delirium Observation Screening Scale (5%), Intensive Care Delirium Screening Checklist (10%), Neelon and Champagne Confusion Scale (5%) and Nursing Delirium Screening Scale (5%). Incidence of post-operative delirium after intracranial surgery was 19%, ranging from 12 to 26% caused by variation in clinical features and delirium assessment methods. Meta-regression for age and gender did not show a correlation with delirium. We present an overview of risk factors and health outcomes associated with the onset of delirium. Our review highlights the need of future research on delirium in neurosurgery, which should focus on optimizing diagnosis and assessing prognostic significance and management.

Perioperative risk factors for recovery room delirium after elective non-cardiovascular surgery under general anaesthesia

Background

Although postoperative delirium is a frequent complication of surgery, little is known about risk factors for delirium occurring in the post-anaesthesia care unit (PACU). The aim of this study was to determine pre- and intraoperative risk factors for the development of recovery room delirium (RRD) in patients undergoing elective non-cardiovascular surgery.

Methods

RRD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We collected perioperative data in 228 patients undergoing elective non-cardiovascular surgery under general anaesthesia and performed univariate and multivariate logistic regression to identify risk factors related to RRD. PACU and postoperative events were recorded to assess the outcome of RRD.

Results

Fifty-seven patients (25%) developed RRD. On multivariate analysis, maintenance of anaesthesia with inhalation anaesthetic agents (OR = 6.294, 95% CI 1.4–28.8, corrected p = 0.03), malignant primary disease (OR = 3.464, 95% CI = 1.396–8.592, corrected p = 0.018), American Society of Anaesthesiologists Physical Status (ASA-PS) III–V (OR = 3.389, 95% CI = 1.401–8.201, corrected p = 0.018), elevated serum total or direct bilirubin (OR = 2.535, 95% CI = 1.006–6.388, corrected p = 0.049), and invasive surgery (OR = 2.431, 95% CI = 1.103–5.357, corrected p = 0.035) were identified as independent risk factors for RRD. RRD was associated with higher healthcare costs (31,428 yuan [17,872–43,674] versus 16,555 yuan [12,618–27,788], corrected p = 0.002), a longer median hospital stay (17 days [12–23.5] versus 11 days [9–17], corrected p = 0.002), and a longer postoperative stay (11 days [7–15] versus 7 days [5–10], corrected p = 0.002]).

Conclusions

Identifying patients at high odds for RRD preoperatively would enable the formation of more timely postoperative delirium management programmes.

Effect of General Versus Spinal Anesthesia on Postoperative Delirium and Early Cognitive Dysfunction in Elderly Patients

Background

Postoperative cognitive dysfunction (POCD) and delirium are common in the elderly patients, given the controversial results of previous studies about the impact of anesthesia type on the occurrence of these complications.

Objectives

This study was planned to compare the effects of general and spinal anesthesia on the prevalence of POCD and delirium.

Methods

A single-blind non-randomized clinical trial. Setting was in two academic hospitals. Ninety-four patients over 50 years old scheduled for hip fracture fixation. Patients were divided into two groups to receive either general (GA) or spinal (SA) anesthesia. Both Mini-Mental State examination (MMSE) and Wechsler tests were used before the operation and 3 times postoperatively to assess the cognitive function and detect early POCD. The DSM-IV criteria were also used for the diagnosis of delirium. The incidence of delirium and POCD and their precipitating factors were compared between the two groups.

Results

Ninety-four patients with a mean age of 67.12 years were studied. The overall prevalence of POCD and delirium was 17.02%; however, it was significantly higher in the GA group rather than the SA group, 29.7%, and 4.25%, respectively (P < 0.001). There was a significant relationship between age (P = 0.048), ASA class (P = 0.034), and educational level with the incidence of POCD, meaning that the probability of developing cognitive impairment decreases with patients' higher level of education and lower ASA-physical status. Also, the rate of POCD in men was significantly higher than in women (P = 0.026).

Conclusions

The finding of this study showed that, if there is no specific contraindication, neuraxial anesthesia may be preferred over general anesthesia in elderly patients.

Risk factors for postoperative delirium in elderly patients after spinal fusion surgery

Background

Postoperative delirium (POD) has an incidence rate of 9% to 41%. It is directly linked to decreasing cognitive function, increasing length of hospitalization and cost, as well as other complications and mortality. We aimed to assess the risk factors for POD among elderly patients by analyzing data from those who underwent spinal surgery.

Methods

This study included 446 patients aged 65 years or older who underwent spinal surgery at our institution between March 2013 and May 2018. Data were collected retrospectively from the patients' electronic medical records, and logistic regression was used to identify the risk factors associated with POD. The diagnosis of POD was based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and was made through consultation with a psychiatrist during postoperative hospitalization and before discharge.

Results

Seventy-eight (78/446, 17.4%) patients were diagnosed with POD. The most relevant risk factor for POD was preoperative cognitive dysfunction (odds ratio [OR], 4.37; 95% confidence interval [CI], 1.60 to 11.93; P = 0.004), followed by emergency surgery (OR, 2.70; 95% CI, 1.27 to 5.74; P = 0.01), age (OR, 1.19; 95% CI, 1.13 to 1.26; P < 0.001), and anesthesia time (OR, 1.01; 95% CI 1.00 to 1.01; P = 0.002).

Conclusions

Preoperative cognitive dysfunction, emergency surgery, age, and anesthesia time were factors that affected POD occurrence after spinal surgery. Patients with such associated factors may be at a higher risk for POD when undergoing spinal surgery, and hence, careful management may be necessary for these patients.

Incidence and risk factors of subsyndromal delirium after curative resection of gastric cancer

Background

Subsyndromal delirium, a condition in which patients exhibit some, but not all, of the symptoms of delirium, can negatively affect the outcomes of patients with cancer. However, the incidence of subsyndromal delirium in patients with gastric cancer is unknown. Here, we investigated the incidence and risk factors of subsyndromal delirium after curative resection of gastric cancer.

Methods

We recruited consecutive patients with gastric cancer who were scheduled for curative resection at a tertiary hospital. Patients’ subsyndromal delirium symptoms were serially assessed preoperatively and 1, 2, 3, and 7 days postoperatively using the Delirium Rating Scale-Revised-98 (DRS-R-98). A DRS-R-98 score of 8–14 at any postoperative assessment was considered to indicate subsyndromal delirium. Sociodemographic and pre−/intra-operative clinical data were also assessed. Logistic regression analyses were used to determine the associated risk factors.

Results

Data were analysed from 163 out of 217 eligible patients. Postoperative delirium occurred in one patient (0.6%) and subsyndromal delirium occurred in 19 patients (11.7%). Age ≥ 70 years (odds ratio, [OR] 3.85; 95% confidence interval [CI], 1.36–10.92; p = 0.011) and education level ≤ 9 years (OR, 3.98; 95% CI, 1.39–11.41; p = 0.010) were independent risk factors of subsyndromal delirium after adjusting for preoperative cognitive function. Other pre−/intra-operative variables including anxiety/depression, poor sleep quality, and anaesthesia duration were not associated with subsyndromal delirium.

Conclusions

In contrast to the low incidence of delirium among patients undergoing curative resection of gastric cancer, a substantial proportion of such patients experienced subsyndromal delirium. Considering the prognostic implications, more careful detection and management of subsyndromal delirium may be warranted in patients with gastric cancer.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4681-2) contains supplementary material, which is available to authorized users.

Bi-frontal pneumocephalus is an independent risk factor for early postoperative agitation in adult patients admitted to intensive care unit after elective craniotomy for brain tumor: A prospective cohort study

Postoperative agitation frequently occurs after general anesthesia and may be associated with serious consequences. However, studies in neurosurgical patients have been inadequate. We aimed to investigate the incidence and risk factors for early postoperative agitation in patients after craniotomy, specifically focusing on the association between postoperative pneumocephalus and agitation. Adult intensive care unit admitted patients after elective craniotomy under general anesthesia were consecutively enrolled. Patients were assessed using the Sedation-Agitation Scale during the first 24 hours after operation. The patients were divided into two groups based on their maximal Sedation-Agitation Scale: the agitation (Sedation-Agitation Scale ≥ 5) and non-agitation groups (Sedation-Agitation Scale ≤ 4). Preoperative baseline data, intraoperative and intensive care unit admission data were recorded and analyzed. Each patient's computed tomography scan obtained within six hours after operation was retrospectively reviewed. Modified Rankin Scale and hospital length of stay after the surgery were also collected. Of the 400 enrolled patients, agitation occurred in 13.0% (95% confidential interval: 9.7-16.3%). Body mass index, total intravenous anesthesia, intraoperative fluid intake, intraoperative bleeding and transfusion, consciousness after operation, endotracheal intubation kept at intensive care unit admission and mechanical ventilation, hyperglycemia without a history of diabetes, self-reported pain and postoperative bi-frontal pneumocephalus were used to build a multivariable model. Bi-frontal pneumocephalus and delayed extubation after the operation were identified as independent risk factors for postoperative agitation. After adjustment for confounding, postoperative agitation was independently associated with worse neurologic outcome (odd ratio: 5.4, 95% confidential interval: 1.1-28.9, P = 0.048). Our results showed that early postoperative agitation was prevalent among post-craniotomy patients and was associated with adverse outcomes. Improvements in clinical strategies relevant to bi-frontal pneumocephalus should be considered.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02318199).

Perioperative hyperglycemia and neurocognitive outcome after surgery: a systematic review

INTRODUCTION

Preliminary evidence suggest a possible relationship between perioperative hyperglycemia, postoperative delirium (POD) or cognitive dysfunction (POCD). We aim to present the available clinical evidence related to chronic (i.e. diabetes mellitus) or acute perioperative hyperglycemia as risk factors for POD/POCD.

EVIDENCE ACQUISITION

A literature search of EMBASE (via Ovid, 1974-present) online medical database and MEDLINE (via PubMed or Ovid, 1946-present) was performed. All types of clinical studies including randomized controlled trials, prospective, as well as retrospective cohort studies were screened. Clinical studies that reported original information on the relationship between diabetes mellitus (DM) and/or acute perioperative abnormal glucose levels and POD or POCD were selected. Reviews and editorials (i.e. articles not presenting original preclinical or clinical research) were excluded and case-reports were not considered for analysis.

EVIDENCE SYNTHESIS

Our search resulted in 2356 papers for screening, from which we selected 29 studies that met our inclusion criteria. DM was investigated in 24 observational papers, acute perioperative hyperglycemia in six observational studies and two randomized controlled trials examined the effect of perioperative glucose lowering on POD/POCD. Diabetes was associated with POD or POCD in 18/24 observational studies and 6/6 of the included observational studies found that perioperative hyperglycemia was associated with POD/POCD, independent of diabetes. The two randomized controlled trials had a different trial design and reported conflicting results.

CONCLUSIONS

According to the available evidence, DM and acute perioperative hyperglycemia may be associated with an increased risk for POD/POCD. These conclusions are based mostly on observational studies and deserve more and dedicated research. This systematic review may direct the design of future studies.

Neuroprotective Effects Against POCD by Photobiomodulation: Evidence from Assembly/Disassembly of the Cytoskeleton

Postoperative cognitive dysfunction (POCD) is a decline in memory following anaesthesia and surgery in elderly patients. While often reversible, it consumes medical resources, compromises patient well-being, and possibly accelerates progression into Alzheimer's disease. Anesthetics have been implicated in POCD, as has neuroinflammation, as indicated by cytokine inflammatory markers. Photobiomodulation (PBM) is an effective treatment for a number of conditions, including inflammation. PBM also has a direct effect on microtubule disassembly in neurons with the formation of small, reversible varicosities, which cause neural blockade and alleviation of pain symptoms. This mimics endogenously formed varicosities that are neuroprotective against damage, toxins, and the formation of larger, destructive varicosities and focal swellings. It is proposed that PBM may be effective as a preconditioning treatment against POCD; similar to the PBM treatment, protective and abscopal effects that have been demonstrated in experimental models of macular degeneration, neurological, and cardiac conditions.

The impact of preoperative testing for blood glucose concentration and haemoglobin A1c on mortality, changes in management and complications in noncardiac elective surgery: a systematic review

BACKGROUND

The risks associated with surgery are elevated in patients with diabetes mellitus. For this reason, preoperative diagnostics frequently include the measurement of blood glucose and haemoglobin A1c (HbA1c), but it is unclear whether these tests contribute to improved perioperative or postoperative outcomes.

OBJECTIVES

This systematic review aimed to evaluate the evidence that preoperative testing for blood glucose and HbA1c might influence the following outcome parameters: changes in clinical management; mortality; and the incidence of perioperative and postoperative complications in patients undergoing elective, noncardiac surgery.

DESIGN

We performed a systematic search of the literature from January 2001 to March 2013, thus updating a review carried out by the National Institute for Health and Clinical Excellence (NICE) up to the year 2001.

ELIGIBILITY CRITERIA

Controlled studies including cohort and case-control studies with a population of at least 60 patients were eligible.

RESULTS

The search retrieved 1346 records (including hand-search). Twenty-two studies met all inclusion criteria and were included in the review. Fifteen cohort and two case-control studies evaluated the effectiveness of preoperative blood glucose testing and nine studies the effectiveness of testing HbA1c. Four of the included studies evaluated both tests. There were no data derived from high-quality studies supporting routine preoperative testing for blood glucose or HbA1c in otherwise healthy adult patients undergoing elective noncardiac surgery. Only in vascular and orthopaedic surgery may screening identify patients at an increased risk.

CONCLUSION

Preoperative blood glucose testing and testing for HbA1c is not required in nondiabetic patients unless there are clinical sings arousing suspicion. Patients scheduled for vascular and orthopaedic surgery carry an elevated risk justifying preoperative testing for blood glucose or HbA1c as a screening tool.

Risk factors for delirium after spine surgery in elderly patients

Objective

Postoperative delirium is a common complication in the elderly after surgery but few papers have reported after spinal surgery. We analyzed various risk factors for postoperative delirium after spine surgery.

Methods

Between May 2012 and September 2013, 70 patients over 60 years of age were examined. The patients were divided into two groups : Group A with delirium and Group B without delirium. Cognitive function was examined with the Mini-Mental State Examination-Korea (MMSE-K), Clinical Dementia Rating (CDR) and Global Deterioration Scale (GDS). Information was also obtained on the patients' education level, underlying diseases, duration of hospital stay and laboratory findings. Intraoperative assessment included Bispectral index (BIS), type of surgery or anesthesia, blood pressure, fluid balance, estimated blood loss and duration of surgery.

Results

Postoperative delirium developed in 17 patients. The preoperative scores for the MMSE, CDR, and GDS in Group A were 19.1±5.4, 0.9±0.6, and 3.3±1.1. These were significantly lower than those of Group B (25.6±3.4, 0.5±0.2, and 2.1±0.7) (p<0.05). BIS was lower in Group A (30.2±6.8 compared to 35.4±5.6 in group B) (p<0.05). The number of BIS <40 were 5.1±3.1 times in Group A, 2.5±2.2 times in Group B (p<0.01). In addition, longer operation time and longer hospital stay were risk factors.

Conclusion

Precise analysis of risk factors for postoperative delirium seems to be more important in spinal surgery because the surgery is not usually expected to have an effect on brain function. Although no risk factors specific to spinal surgery were identified, the BIS may represent a valuable new intraoperative predictor of the risk of delirium.

Effect of the intraoperative wake-up test in sevoflurane-sufentanil combined anesthesia during adolescent idiopathic scoliosis surgery: a randomized study

STUDY OBJECTIVE

To investigate the effect of the intraoperative wake-up test on sevoflurane-sufentanil anesthesia for adolescent idiopathic scoliosis (AIS) surgery.

DESIGN

Randomized, double-blind, parallel trial.

SETTING

Operating room.

PATIENTS

30 ASA physical status 1 patients, aged 13 to 20 years, scheduled for AIS surgery.

INTERVENTIONS

Patients were randomized to two groups: Group W patients received sevoflurane-sufentanil combined anesthesia and underwent the intraoperative wake-up test; Group NW received sevoflurane-sufentanil combined anesthesia without the wake-up test. Anesthesia was induced with an intravenous (IV) injection of midazolam, propofol, and sufentanil and maintained with sevoflurane inhalation, a target-controlled infusion (TCI) of sufentanil, and IV infusion of cisatracurium besylate.

MEASUREMENTS

The primary outcome was postoperative delirium. Secondary outcomes were duration of surgery, duration of anesthesia, intraoperative blood loss and transfusion, exposure of drugs administered, time to eye opening, extubation, and consciousness.

MAIN RESULTS

Postoperative delirium occurred in one patient from each group (P > 0.05). There were no significant differences between the two groups in duration of surgery (322 ± 65 min vs 336 ± 72 min), duration of anesthesia (356 ± 76 min vs 368 ± 81 min), intraoperative blood loss (1847 ± 423 mL vs 1901 ± 451 mL) and transfusion (1663 ± 398 mL vs 1649 ± 382 mL), average exposure of drugs (72 ± 13 mg vs 75 ± 15 mg for propofol, 116 ± 28 μg vs 109 ± 25 μg for sufentanil, and 22 ± 5 vs 23 ± 4 mg for cisatracurium), time to eye opening (4.7 ± 1.5 min vs 4.8 ± 1.4 min), extubation (7.5 ± 2.0 min vs 7.3 ± 2.2 min), and consciousness (8.9 ± 1.8 min vs 9.1 ± 2.1 min) (all P > 0.05).

CONCLUSIONS

Sevoflurane-sufentanil combined anesthesia provides hemodynamic stability and rapid recovery from AIS surgery. There is no correlation between the intraoperative wake-up test and postoperative delirium after sevoflurane-sufentanil combined anesthesia.

The experience of delirium care and clinical feasibility of the CAM-ICU in a Korean ICU

This study aimed to assess intensive care unit (ICU) nurses' experiences caring for delirious patients and the empirical evaluation of the clinical feasibility of the confusion assessment method (CAM) for ICU (CAM-ICU). In Korea, neither regular assessment of early-stage delirium nor preventive interventions are carried out properly in the ICU. This study was conducted using a qualitative research design with focus group interviews. Nurses received training about the CAM-ICU, and used it to assess surgical ICU patients for the presence of delirium during a 5-month period. None of the nurses had heard of the CAM-ICU before the study, and many complained that it was very challenging to use. One positive outcome of the CAM-ICU trial was that the clinical interest in delirium increased. The CAM-ICU could be used to facilitate communication once the instrument becomes well-known among health care professionals.

[Delirium in the intensive care unit]

In recent years delirium in the intensive care unit (ICU) has internationally become a matter of rising concern for intensive care physicians. Due to the design of highly sophisticated ventilators the practice of deep sedation is nowadays mostly obsolete. To assess a ventilated ICU patient for delirium easy to handle bedside tests have been developed which permit a psychiatric scoring. The significance of ICU delirium is equivalent to organ failure and has been proven to be an independent prognostic factor for mortality and length of ICU and hospital stay. The pathophysiology and risk factors of ICU delirium are still insufficiently understood in detail. A certain constellation of pre-existing patient-related conditions, the current diagnosis and surgical procedure and administered medication entail a higher risk for the occurrence of ICU delirium. A favored hypothesis is that an imbalance of the neurotransmitters acetylcholine and dopamine serotonin results in an unpredictable neurotransmission. Currently, the administration of neuroleptics, enforced physiotherapy, re-orientation measures and appropriate pain treatment are the basis of the therapeutic approach.