The Anesthesia Enigma: Decoding Sedation and Cognitive Aftermath

On This Episode:

Today, we will closely examine a phenomenon that’s growing in frequency and importance and getting more and more attention in the anesthesia community: postoperative delirium. As our population ages and more and more elderly people are having surgery for more and more procedures, are concerned about postop with delirium and its complications and long-term implications have become more and more critical. So, hang onto your scrub caps, ladies and gentlemen, as we explore postoperative delirium, its antecedents, consequences, and how to reduce its incidence.

The episode covers various factors contributing to postoperative delirium, including patient characteristics, preexisting conditions, medications, and intraoperative variables. We’ll emphasize the importance of identifying patients at risk, using screening tools, and implementing risk mitigation strategies. Plus, we’ll discuss the impact of medications, such as benzodiazepines and anticholinergics, and delve into the Beers criteria, providing guidelines to limit exposure to harmful medications for elderly patients.

Throughout the conversation, Terry and Garry blend their expertise to provide a comprehensive overview of postoperative delirium, offering valuable insights for anesthesia providers, healthcare professionals, and anyone interested in understanding and mitigating the impact of delirium in surgical patients.

 

Here’s some of what we discuss in this episode:

What delirium looks like and what you can anticipate from patients who are experiencing it.

The characteristics of patients that increase their risk of experiencing delirium.

Some of the precipitating factors that happen around the operating room.

The debate over the impact of depth of anesthesia and the duration of surgery on delirium risk.

Good habits that can reduce the risk of delirium.

 

References

Hughes, C.G., Boncyk, C.S., Culley, D.J., et al. (2020). American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention. Anesthesia and Analgesia 130 (6) 1572-1590.

Donovan, A.L., Braehler, M.R., Rabinowitz, D.L., et al (2020). An implementation-effectiveness study of a perioperative delirium prevention initiative in older adults. Anesthesia and Analgesia 131 (6) 1911-1922.

Kim, E.M., Guohua, L., Kim, M. (2020). Development of a risk score to predict postoperative delirium in patients with hip fracture. Anesthesia and Analgesia 130 (1) 79-86.

Tiwary, N., Treggiari, M.M., Yanez, D., Kirsch, J.R., et al. (2021). Agreement between the MiniCog in the preoperative clinic and on the day of surgery and association with post anesthesia care unit delirium: A cohort study of cognitive screening in older adults. Anesthesia and Analgesia 132 (4) 1112-1119.

Wachtendorf, L.J., Azimaraghi, O., Santer, P. et al. (2022) Association between intraoperative hypotension and postoperative delirium after noncardiac surgery: a retrospective multicenter cohort study. Anesthesia and Analgesia 134 (4) 822-833.

Wright, M.C., Bunning, T., Eleswarpu, S.S., et al. (2022) A processed electroencephalogram-based brain anesthetic resistance index is associated with postoperative delirium in older adults: a dual center study. Anesthesia and Analgesia 134 (1) 149-158.

Niu, J., Yang, N., Tao, Q., et al. (2023) Effect of different administration routes of dexmedetomidine on postoperative delirium in elderly patients undergoing elective spine surgery: A prospective randomized double-blinded controlled trial. Anesthesia and Analgesia 136 (6) 1075-1083.

Shin, H., Nam, S.W., Kim, H. et al. (2013). Postoperative delirium after dexmedetomidine versus propofol sedation in healthy older adults undergoing orthopedic lower limb surgery with spinal anesthesia: A randomized controlled trial. Anesthesiology 138 (2) 164-171.

Lopez, M.G., Hughes, C.G., O’Neal, J.B., et al. Intraoperative oxidative damage and delirium after cardiac surgery. Anesthesiology 132 (3) 551-561.

Zhang, Y., Jun, H., Zuo, W. et al. (2022) Longitudinal profiling of plasma cytokines and its association with postoperative delirium in elderly patients undergoing major lower limb surgery: A prospective observational study. Anesthesia and Analgesia 136 (1) 34-42.

Wiredu, K., Aduse-Poku, E., Shaefi, S., Gerber, S.A. (2023) Proteomics for the discovery of clinical delirium biomarkers: A systematic review of major studies. Anesthesia and Analgesia 136 (3) 422-432.

Fislage, M., Feinkohl, I., Pischon, T., et al. (2022) Presurgical thalamus volume in postoperative delirium: A longitudinal observational cohort study in older patients. Anesthesia and Analgesia 135 (1) 136-142.

Maheshwari, K., Ahuja, S., Khanna, A.K. et al (2020) Association between perioperative hypotension and delirium in postoperative critically ill patients: A retrospective cohort analysis. Anesthesia and Analgesia 130 (3) 636-643.

Hughes, C.G., Hayhurst, C.J., Pandharipande, P.P. et al (2021) Association of delirium during critical illness with mortality: Multicenter prospective cohort study. Anesthesia and Analgesia 133 (5) 1152-1161.

Cohen, C.L., Atkins, K.J., Evered, L.A. et al (2023) Examining subjective psychological experiences of postoperative delirium in older cardiac surgery patients. Anesthesia and Analgesia 136 (6) 1174-1181.

Whitlock, E.L., Braehler, M.R., Kaplan, J.A. (2020) Derivation, validation, sustained performance, and clinical impact of an electronic medical record-based perioperative delirium risk stratification tool. Anesthesia and Analgesia 131 (6) 1901-1910.

Kim, E.M., Li, G., and Kim, M. (2020) Development of a risk score to predict postoperative delirium in patients with hip fracture. Anesthesia and Analgesia 130 (1) 79-86.

Sun, Yi., Ye, F., Wang, J. et al (2020) Electroencephalography-guided anesthetic delivery for preventing postoperative delirium in adults: An updated meta-analysis. Anesthesia and Analgesia 131 (3) 712-719.

Duprey, M.S., Devlin, J.W., Griffith, J.L. et al (2022) Association between perioperative medication use and postoperative delirium and cognition in older adults undergoing elective noncardiac surgery. Anesthesia and Analgesia 134 (6) 1154-1163.

Wang, M.L., Min, J. Sands, L.P. et al (2021) Midazolam premedication immediately before surgery is not associated with early postoperative delirium. Anesthesia and Analgesia 133 (3) 765-771.

Ragheb, J., Norcott, A.E., Iskander, M., et at (2022) Anesthetic practice trends and perceptions toward postoperative delirium: A mixed methods analysis. Anesthesia and Analgesia 136 (1) 130-139.

Koch, S., Windmann, V., Chakravarty, S. et al (2021) Perioperative electroencephalogram spectral dynamics related to postoperative delirium in older patients. Anesthesia and Analgesia 133 (6) 1598-1607.

Jiang, J.L., Zhang, L., He, L. et at (2023) Volatile versus total intravenous anesthesia on postoperative delirium in adult patient undergoing cardiac valve surgery: A randomized clinical trial. Anesthesia and Analgesia 136 (1) 60-69.

American Geriatrics Society Beers Criteria Update Expert Panel (2023) American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 71:2052-2081. DOI: 10.1111/jgs.18372.

Link for Mini-Cog: Mini-Cog screen for cognitive impairment and may identify patients for higher risk of POD (https://mini-cog.com/wp-content/uploads/2022/04/Graphical-Mini-Cog-for-pocket-card-mar2018-2.pdf.)

 

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