Assessment of Magnitude and Associated Factors of Emergence Delirium in the Post Anesthesia Care Unit at Tikur Anbesa Specialized Hospital, Ethiopia

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.

Ketofol versus Dexmedetomidine for preventing postoperative delirium in elderly patients undergoing intestinal obstruction surgeries: a randomized controlled study

PURPOSE

Postoperative delirium (POD) is considered the most common postoperative neurological complication in elderly patients. The aim of this study was to evaluate the efficacy of the administration of ketofol versus dexmedetomidine (DEX) for minimizing POD in elderly patients undergoing urgent exploration for intestinal obstruction.

METHODS

This prospective double-blinded randomized clinical trial was conducted on 120 elderly patients undergoing urgent exploration for intestinal obstruction. Patients were randomly allocated to one of the three groups: Group C (control group) patients received normal saline 0.9%, group D received dexmedetomidine, and group K received ketofol (ketamine: propofol was 1:4). The primary outcome was the incidence of POD. Secondary outcomes were incidence of emergence agitation, postoperative pain, consumption of rescue opioids, hemodynamics, and any side effects.

RESULTS

The incidence of POD was statistically significantly lower in ketofol and DEX groups than in the control group at all postoperative time recordings. Additionally, VAS scores were statistically significantly decreased in the ketofol and DEX groups compared to the control group at all time recordings except at 48 and 72 h postoperatively, where the values of the three studied groups were comparable. The occurrence of emergence agitation and high-dose opioid consumption postoperatively were found to be significant predictors for the occurrence of POD at 2 h and on the evening of the 1st postoperative day.

CONCLUSION

The administration of ketofol provides a promising alternative option that is as effective as DEX in reducing the incidence of POD in elderly patients undergoing urgent exploration for intestinal obstruction.

TRIAL REGISTRATION

This clinical trial was approved by the Institutional Review Board (IRB) at Zagazig University (ZU-IRB# 6704// 3/03/2021) and ClinicalTrials.gov (NCT04816162, registration date 22/03/ 2021). The first research participant was enrolled on 25/03/2021).

Agitation during anaesthetic emergence: An observational study of adult cardiac surgery patients in two Australian intensive care units

BACKGROUND

Anaesthetic emergence agitation among adult patients being recovered after open cardiac and/or thoracic aorta surgery has not been described.

OBJECTIVES

The objective of this study was to characterise emergence agitation in terms of incidence, clinical features, and consequences in a cohort of cardiac surgery patients being recovered in the intensive care unit (ICU).

METHODS

A prospective, observational pilot study was implemented. Over a 5-week period, the study was conducted in two metropolitan hospitals in Victoria, Australia. The cohort comprised all patients admitted to the ICUs aged ≥18 years, who had undergone cardiac surgery via an open sternotomy with general anaesthetic, and whose emergence was directly observed. Emergence agitation was defined as a Richmond Agitation and Sedation Scale score of ≥+2.

RESULTS

Fifty patients were observed. Emergence agitation occurred in 24/50 (48%) of patients. Patients with emergence agitation experienced more clinical consequences than patients with calm emergence, including a significantly greater number of episodes of airway compromise (12/24, 50%, p < 0.001); ventilator dyssynchrony (23/24, 96%, p = 0.004); and hypertension (13/24, 54%, p = 0.004). Significant treatment interference (potentially dangerous patient movements such as pulling tubes) occurred with 23/24 patients (96%, p < 0.0001). Patients who underwent emergence agitation required significantly more interventions during anaesthetic emergence than patients who underwent a calm emergence. Interventions included extra nursing measures (16/24, 67%, p = 0.001) administration of sedative and/or opioid intravenous boluses (22/24, 92%, p = 0.001) and vasoactive agents (15/24, 63%, p = 0.05).

CONCLUSIONS

In patients recovering from cardiac surgery in the ICU, emergence agitation was clinically important. Immediate interventions were required to prevent and manage complications.

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.

Effect of perioperative benzodiazepine use on intraoperative awareness and postoperative delirium: a systematic review and meta-analysis of randomised controlled trials and observational studies

BACKGROUND

Benzodiazepine use is associated with delirium, and guidelines recommend avoiding them in older and critically ill patients. Their perioperative use remains common because of perceived benefits.

METHODS

We searched CENTRAL, MEDLINE, CINAHL, PsycInfo, and Web of Science from inception to June 2021. Pairs of reviewers identified randomised controlled trials and prospective observational studies comparing perioperative use of benzodiazepines with other agents or placebo in patients undergoing surgery. Two reviewers independently abstracted data, which we combined using a random-effects model. Our primary outcomes were delirium, intraoperative awareness, and mortality.

RESULTS

We included 34 randomised controlled trials (n=4354) and nine observational studies (n=3309). Observational studies were considered separately. Perioperative benzodiazepines did not increase the risk of delirium (n=1352; risk ratio [RR] 1.43; 95% confidence interval [CI]: 0.9-2.27; I2=72%; P=0.13; very low-quality evidence). Use of benzodiazepines instead of dexmedetomidine did, however, increase the risk of delirium (five studies; n=429; RR 1.83; 95% CI: 1.24-2.72; I2=13%; P=0.002). Perioperative benzodiazepine use decreased the risk of intraoperative awareness (n=2245; RR 0.26; 95% CI: 0.12-0.58; I2=35%; P=0.001; very low-quality evidence). When considering non-events, perioperative benzodiazepine use increased the probability of not having intraoperative awareness (RR 1.07; 95% CI: 1.01-1.13; I2=98%; P=0.03; very low-quality evidence). Mortality was reported by one randomised controlled trial (n=800; RR 0.90; 95% CI: 0.20-3.1; P=0.80; very low quality).

CONCLUSIONS

In this systematic review and meta-analysis, perioperative benzodiazepine use did not increase postoperative delirium and decreased intraoperative awareness. Previously observed relationships of benzodiazepine use with delirium could be explained by comparisons with dexmedetomidine.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42019128144.

Determinants of postoperative emergence delirium in patient undergoing general anesthesia in Dilla University referral hospital. A case-control study

Background

Delirium is affecting of concentration, decreases the ability to forward-thinking, attention, sustainability, change, and decreases orientation to the environment. Delirium has a serious impact on the overall outcome of the patient. Post-operative emergence delirium (POED) increases hospital mortality by 5% and post-discharge hospitalization by 33%, compared to those without postoperative delirium. Postoperative delirium incidence has different summative risk factors and recognizing the multiple risks of delirium complications may help the clinician to design supportive measures to prevent delirium. Delirium can cause a series of outcomes and is increase the length of hospital stay, independent predictor for intensive care unit (ICU) admission and institutional morbidity and mortality, increase institutional care, for those patients and increase hospital expenses.

Methodology

Unmatched case-control study was employed from September 2019 to October 2020. This study was conducted on 264 patients above 18years. A structured questionnaire prepared in English was used for data collection. Data were analyzed by using the SPSS software. Bivariate and multiple logistic regression models were used to identify associated risk factors for incidence of POED and a P-Value of less than 0.05 was the risk factor for this medical condition.

Result

Out of 264 participants included in the study 56.4% were female. ASA I and II constitute 97.4%. Substance abuse, premediate with diazepam, & ketamine were high risk for POD with p-value of 0.000, 0.005, & 0.047 respectively.

Conclusion

We conclude that older age, current substance use, Coexisting disease, Benzodiazepine exposures, Ketamine, ASA physical status, and coexisting disease were determinant risk factors for postoperative delirium clients undergoing general anesthesia.

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.

Instruments to Identify Delirium in Patients Recovering From Anesthesia: A Scoping Review

PURPOSE

To identify the validated instruments used for screening and detecting postoperative delirium (POD) during Post Anesthesia Recovery (PAR) period, and the incidence and associated risk factors with POD.

DESIGN

A scoping review.

METHODS

The study search occurred in May 2021 in the PubMed, Embase, Scopus, CINAHL, Web of Science and LILACS databases. Primary studies that used validated instruments for screening and detecting POD in the PAR period were included.

FINDINGS

A total of 38 articles were included. The most used instruments were CAM-ICU, Nu-DESC, and RASS. The instruments that screened and detected delirium earliest were the Nu-DESC and CAM-ICU. POD incidence was up to 20% in more than half of the included studies. Cardiovascular comorbidities, chronic kidney disease, low functional reserve, chronic obstructive pulmonary disease and postoperative pain were among the primary risk factors.

CONCLUSION

The instrumentsshowing the greatest accuracy for screening and detecting POD in the PAR period were the Nu-DESC and CAM-ICU.

The effect of operating room nursing intervention on the psychological status and incidence of emergence agitation in the recovery period of general anesthesia: A protocol for systematic review and meta-analysis

BACKGROUND

During the recovery period of general anesthesia, patients are disturbed by residual anesthetic drugs, manifesting as clinical signs of confusion, drowsiness and disorientation, and even abnormal psychology and limb agitation at varying degrees in severe cases. These stress reactions are detrimental to the postoperative recovery, which can be life-threatening. Operating room nursing intervention (ORNI) is a novel nursing model that prevents stress reactions during the recovery period of general anesthesia. However, whether ORNI can improve the psychological condition and reduce the incidence of emergence agitation in the recovery period of general anesthesia remains controversial. Therefore, this study aims to evaluate the effect of ORNI on the psychological status and incidence of emergence agitation in the recovery period of general anesthesia through a systematic review and meta-analysis, thus providing clinical evidence to support it.

METHODS

Randomized controlled trials reporting the effect of ORNI on the recovery period of general anesthesia published before October 2021 will be searched in the Chinese Scientific Journal Database, China National Knowledge Infrastructure Database, Wanfang, China Biomedical Literature Database, PubMed, Embase, the Cochrane Library, and Web of Science. Eligible literatures will be screened out according to inclusion and exclusion criteria, and their quality will be assessed using the Cochrane Risk of Bias Assessment Tool. Meta-analysis will be performed using Revman 5.4 software.

RESULTS

This study will evaluate the effect of the ORNI on the recovery period of general anesthesia by calculating the incidence of emergence agitation, and grading the self-rating anxiety scale and self-rating depression scale scores.

CONCLUSION

This study will provide a reliable evidence-based basis for the application of ORNI in the recovery period of general anesthesia.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/P3A4T.

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.

Malnutrition is not related with emergence delirium in older patients after noncardiac surgery

Background

Delirium is one of the most common complications in older surgical patients. Although previous studies reported that preoperative malnutrition was related with postoperative delirium (POD), there was lack of evidence to illustrate the relationship between malnutrition and emergency delirium (ED). The objective of this study was to investigate the relationship between preoperative malnutrition and ED in older patients undergoing noncardiac surgery.

Methods

The study was carried out in accordance with STROBE guidelines. This was a secondary analysis of a prospective cohort study. Older patients (65–90 years) who underwent noncardiac surgery under general anesthesia were enrolled in Peking University First Hospital.

Results

915 patients were enrolled. The incidence of malnutrition was 53.6 % (490/915). The incidence of emergency delirium was 41.8 % (205/490) in malnutrition group and 31.5 % (134/425) in control group, P < 0.001. After adjusting confounding factors (i.e., age, cognitive impairment, American Society of Anesthesiologists classification (ASA), duration of surgery, pain score, low body temperature and allogeneic blood transfusion), malnutrition was not associated with increased risk of emergency delirium (OR = 1.055, 95 % CI 0.767–1.452, P = 0.742).

Conclusions

Malnutrition was common in older patients undergoing non-cardiac surgery, but it’s not related with emergence delirium after adjusted for confounders.

Trial registration

Chinese Clinical Trial Registry (http://www.chictr.org.cn) (ChiCTR-OOC-17,012,734).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02270-2.

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.