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Dazed and confused how can i prevent my patient from becoming delirious when having surgery?

Dazed and Confused
How can I prevent my patient from
becoming delirious when having surgery?
Learning Objectives
1. To identify which surgical patients are at highest risk of becoming delirious post- operatively 2. To understand ways to prevent delirium in Overview
What is delirium?
z Acute confusional statez Disturbance of consciousness with reduced z Develops over a short period of timez Evidence of medical cause from history, Epidemiology
z Often seen in patients with underlying – Up to 75% among surgical patients (Dyer Arch Int Med 1995) Preoperative Delirium Risk Factors
After Non-cardiac Surgery:
Preoperative psychotropic drug use (e.g. benzos,
narcotics, mood stabilizers)
Cognitive Impairment
Preoperative Delirium Risk Factors
Validated Clinical Prediction Rule (developed among patients > 50 undergoing elective non-cardiac surgery) • Poor cognitive status (TIC score <30) • Poor functional status (SAS class IV) Preoperative Delirium Risk Factors
Outcomes of Postoperative Delirium
Higher rates of discharge to long-term care or Poor functional recovery among hip fracture pts (Marcantonio JAGS 2000; Gustafson JAGS 1988) Diagnosing Delirium
Confusion Assessment Method (CAM)
Diagnosis of delirium if 1, 2, and either 3 or 4 Diagnosing Delirium-CAM
Diagnosing Delirium- CAM
Results for Systematic Review of Delirium Screening Tools:Summary measures from all studies (9 studies): Summary measures when CAM performed by an MD (4 studies): Summary measures when CAM performed by an RN (3 studies): Preventing Delirium
Multi-component Prevention Strategies
3 trials involving hip fracture pts (N = 646) Summary RR 0.75 (95% CI 0.64-0.88)
NNT= 7 (95%CI 4-20)
Multi-component Prevention Strategies
Targeted Risk Factors
Prevention Strategies
High risk medications
- Discontinue/minimize benzodiazepines,
anticholinergics, antihistamines, merperidine
- Modify/eliminate drugs to minimize drug interactions,
adverse effect and redundancies

Fluid and electrolyte
- Restore serum lytes (Na, K, glucose) to normal limits
- Detect and treat dehydration or fluid overload
- Ensure proper use of dentures, proper positioning,
assistance with eating if required, and consider

Multi-component Prevention Strategies
Targeted Risk Factors
Prevention Strategies
Cognitive Impairment
- Orientation protocols
- Provision of clocks and calendars

Functional Impairment - Early mobilization including out of bed regularly and
as tolerated
- Physiotherapy/Occupational therapy as needed

Impaired Vision &
- Appropriate use of glasses, hearing aids and adaptive
- If pain is an issue (especially post-op) consider standing
orders for Acetaminophen rather than prn
- Treatment of breakthrough pain starting with low dose
narcotics; avoiding meperidine

Multi-component Prevention Strategies
Targeted Risk Factors
Prevention Strategies
- D/C urinary catheters
- Screen for urinary retention and incontinence
- Skin care program
- Appropriate bowel regiments

Sleep Deprivation
- Unit wide noise reduction strategies
- Scheduling of medications/procedures to allow for
proper sleep
- Use of nonpharmacologic measures to promote sleep
such as warm milk or herbal tea

Pharmacological Prevention Options
5 trials:z Epidural vs. General anesthesia (N = 57) z Pre-op Intrathecal Morphine vs. Saline (N = 59) z Prophylactic Haldol vs. placebo (N= 430) Pharmacological Prevention Options
Epidural (N=28) vs. General (N=29) Anesthesia Pharmacological Prevention Options
Pre-op Intrathecal Morphine (N=29) vs. Saline (N=30) Pharmacological Prevention Options
Pharmacological Prevention Options
Pharmacological Prevention Options
- benzodiazepines and narcotic continuously from 2000h – 0400h Management of Delirium
assessment and multi-component, targeted management strategies Multi-component Delirium Management

Interventions focused on - Optimizing sensory input - Provision of familiar items and family presence - Use of atypical antipsychotics were indicated - Nutritional supplements where indicated Multi-component Delirium Management Strategies
Summary WMD 3.25 days (95%CI -2.58 – 9.34) Delirium - Clinical Bottom Line
z Limited evidence for delirium prevention and z Evidence supports implementation of multi- component prevention strategies (NNT = 7) z Insufficient evidence to support use of any What should be done for my frail
surgical patient?

z Weigh risks and benefits of surgery with z Considering using the validated clinical prediction rule to better determine risk of delirium z No clear evidence that drugs prevent delirium What should be done for my frail
surgical patient?

z Use multi-component management strategies z No clear evidence that drugs alter course z To control behavioral issues that are disturbing to patient, or – Trial of atypical neuroleptics (after weighing the risks) Risks with Atypical Antipsychotics
z Atypical antipsychotics have the best evidence for use in managing the neuropsychiatric symptoms of dementia (and ?delirium) – Increased risk of stroke (1-2% absolute increase) – Increased risk of death (1% absolute increase) Local Initiatives
Delirium Prevention Among Hip Fracture Pts
z Pragmatic KT intervention among hip fracture patients at
z Interrupted time-series designz Examining the impact of an electronic care pathway on post-op delirium rates and associated outcomes Future Initiatives
z Part of an NCE grant application designed to promote
elder friendly acute care hospitals within Canada z Implementation of the CAM screening tool on SCMz Geriatric-focused order sets ??? QUESTIONS???

Source: http://www.departmentofmedicine.com/rounds/presentations/2009/dazed_and_confused.pdf

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