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Postoperative Delirium:

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Disturbance of consciousness with reduced ability to focus, sustain, or shift attention ... Belladonna alkaloids- atropine, scopolamine. Tricyclic antidepressants ... – PowerPoint PPT presentation

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Title: Postoperative Delirium:


1
Postoperative Delirium
2
Postoperative Delirium
  • Frequently encountered complication
  • 37 incidence ranging from 0-73 (Winawer)
  • Often unrecognized or misdiagnosed
  • Failure to prevent and identify has significant
    implications on morbidity and mortality
  • First sign of catastrophic event, e.g. MI, sepsis
  • Delayed functional recovery
  • Increased length of stay
  • Higher postoperative complication rates

3
Definition
  • DSM-IV (Diagnostic and statistical manual of
    mental disorders) hallmark features
  • Disturbance of consciousness with reduced ability
    to focus, sustain, or shift attention
  • A change in cognition or the development of a
    perceptual disturbance that is not accounted for
    better by a pre-existing, established, or
    evolving dementia.
  • Disturbance develops during a short period and
    tends to fluctuate during the course of the day
  • Varies based on cause

4
Preoperative Risk Factors
  • Age
  • Pathologic states in the brain
  • Psychiatric illness
  • Drugs used in the perioperative period
  • Intoxication/withdrawal
  • Endocrine/metabolic
  • Hyponatremia
  • Hypoglycemia

5
Operative Risk Factors
  • Type of surgery
  • Orthopedic
  • Ophthalmic
  • Cardiac
  • Anesthetic drugs used

6
Causative Agents
  • More than 500 drugs may induce the syndrome
    (Schultz)
  • Antihistamines
  • Phenothiazines- promethazine
  • Antiparkinsonian drugs- benztropine
  • Belladonna alkaloids- atropine, scopolamine
  • Tricyclic antidepressants
  • Ophthalmic cycloplegics- tropicamide

7
Clinical Features
  • Central
  • Incoherent speech
  • Dementia/delirium
  • Excitation and agitation- violent behavior
  • Stupor, somnolence or coma
  • Hallucinations
  • Central respiratory failure
  • Memory or thought disturbances
  • Ataxia
  • Flaccid paralysis
  • Convulsions/seizures
  • Peripheral
  • Urinary retention
  • Decreased intestinal motility and constipation
  • Decreased to absent sweating with hot and dry
    skin
  • Fever with potential for severe hyperthermia
  • Mydriasis- dilation of pupils
  • Cycloplegia- inability to accommodate causing
    blurred vision
  • Peripheral vasodilatation

8
Postoperative Risk Factors
  • Hypoxia
  • Pain
  • Sepsis
  • Myocardial infarction
  • Electrolyte or metabolic disturbance
  • Sensory deprivation or overload e.g. ICU setting

9
Pathogenesis
  • Poorly understood
  • Structural brain disorders (subcortical
    structures) increase risk, however most patients
    have no identifiable abnormalities
  • Cholinergic pathways play a significant role
  • As oxidative metabolism of the brain decreases
    neurotransmitters including Ach decline
  • Decreased production can precipitate delirium
  • Medications with anticholinergic properties can
    cause confusion/delirium

10
Management
  • Prevention
  • Identification of the underlying disorder
  • Treatment

11
Prevention
  • Identifying and addressing underlying medical
    problems
  • Avoiding precipitant medications
  • Optimizing fluid status
  • Aggressive treatment of pain
  • Ensuring tranquil postoperative care setting

12
Pharmacologic treatment
  • Physostigmine
  • Alleviation of symptoms after its administration
    confirms diagnosis of anticholinergic syndrome
  • It is the specific antidote for anticholinergic
    poisoning
  • Haldol
  • Effective in controlling agitation and psychotic
    behavior
  • Benzodiazepines
  • Drugs of choice in alcohol and sedative
    withdrawal syndromes

13
Physostigmine
  • Acetylcholinesterase inhibitor
  • Tertiary amine, crosses the blood brain barrier
  • The dose is 10-40 mcg/kg (1-2 mg over 2-5 minutes
    for adults or 0.5 mg in children, which may be
    repeated in 40 minutes)
  • Rapid onset with a 30-60 minute duration

14
Adverse effects
  • Anticholinergic properties
  • Muscarinic
  • Bradycardia
  • Profuse perspiration
  • Salivation
  • Nausea/vomiting
  • Hyperperistalsis- loss of bladder and rectal
    control
  • Miosis/difficulty focusing
  • Bronchoconstriction
  • Abdominal cramping
  • Nicotinic
  • Skeletal muscle weakness/paralysis with resultant
    apnea
  • Central Nervous system
  • Confusion
  • Ataxia
  • Seizures
  • Coma
  • Depression of ventilation

15
Summary
  • Delirium
  • Common
  • Associated morbidity and mortality
  • Often overlooked or misdiagnosed
  • Cause multifactorial
  • Pathogenesis incompletely understood
  • Diagnosis is not algorithmic

16
References
  • Feeley, Thomas W Assesment and Management of
    Patients in the Postanesthesia Care Unit. ASA
    1990 159-160.
  • Parikh SS, Chung F. Postoperative Delirium in
    the Elderly. Anesth Analg 1995 80 1223-32.
  • Schultz U, Idelberger R, Rossaint R, Buhre W.
    Central anticholinergic syndrome in a child
    undergoing circumcision. Acta Anaesthesiol
    Scand 2002 46 224-226.
  • Stoelting RK. Pharmacology and Physiology in
    Anesthetic Practice. 1987 226-228.
  • Svirbely, JR. The Medical Algorithms Project.
    2002 32.27 1-3.
  • Szajewski, J. Acute Anticholinergic Syndrome.
    IPCS INTOX 1995 1- 3.
  • Winawer, Neil. Postoperative Delirium. Medical
    Clinics of North America 2001 85 1229-1239.
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