Postanesthesia care unit delirium following robot-assisted vs open retropubic radical prostatectomy: A prospective observational study

Mesial temporal atrophy in preoperative MRI rather than steep Trendelenburg position is associated with postoperative delirium in patients undergoing a major urologic surgery

PURPOSE

To investigate whether steep Trendelenburg in a major urologic surgery is associated with postoperative delirium, and to examine other potential clinical and radiologic factors predictive of postoperative delirium.

METHODS

182 patients who received a major urologic surgery and underwent a 3.0-T brain MRI scan within 1 year prior to the date of surgery were retrospectively enrolled. Preoperative brain MRIs were used to analyze features related to small vessel disease burden and mesial temporal atrophy. Presence of a significant mesial temporal atrophy was defined as Scheltens' scale ≥ 2. Patients' clinico-demographic data and MRI features were used to identify significant predictors of postoperative delirium using the logistic regression analysis. Independent predictors found significant in the univariate analysis were further evaluated in the multivariate analysis.

RESULTS

Incidence of postoperative delirium was 6.0%. Patients with postoperative delirium had lower body mass index (21.3 vs. 25.0 kg/m2, P = 0.003), prolonged duration of anesthesia (362.7 vs. 224.7 min, P < 0.001) and surgery (302.2 vs. 174.5 min, P < 0.001), and had more significant mesial temporal atrophy (64% vs. 30%, P = 0.046). In the univariate analysis, female sex, type of surgery (radical prostatectomy over cystectomy), prolonged duration of anesthesia (≥ 6 h), and presence of a significant mesial temporal atrophy were significant predictors (all P-values < 0.050), but only the presence of significant mesial temporal atrophy was significant in the multivariate analysis [odds ratio (OR), 3.69; 95% CI 0.99-13.75; P = 0.046].

CONCLUSION

Steep Trendelenburg was not associated with postoperative delirium. Significant mesial temporal atrophy (Scheltens' scale ≥ 2) in preoperative brain MRI was predictive of postoperative delirium.

TRIAL REGISTRATION

Not applicable.

Early incident and subsyndromal delirium in older patients undergoing elective surgical procedures: a randomized clinical trial of an avoid delirium protocol

Background

Pharmacological avoidance guidelines for preventing delirium have been suggested; however, there are limited pragmatic studies of these strategies. Early (<24 h) delirium can be observed in the postoperative care unit and is associated with an increased risk of subsequent delirium. We examined the effectiveness of an avoid delirium protocol (ADP) in older (>65 years) patients undergoing elective surgeries.

Methods

The randomized controlled trial assessed an ADP developed using the American Geriatric Society's Clinical Practice Guidelines for Postoperative Delirium in Older Adults, on early (<24 h) incident or subsyndromal delirium. Delirium was assessed using the confusion assessment method before surgery, in the post-anesthesia care unit, and on postoperative day 1. The primary outcome of early delirium was the combined incidence of incident or subsyndromal delirium.

Results

Early delirium was identified in 24/235 patients (10.2%) with a risk ratio of 1.27 (95% CI 0.59-2.73, P = 0.667) for patients randomized to the ADP. In cases with protocol adherence and no benzodiazepine use, early delirium was present in 10/ 73 (13.7%) compared to 14/148 (9.5%) in non-adherent cases [risk ratio 1.45 (95% CI 0.57-3.10, P = 0.362)]. Lower American Society of Anesthesiologists physical class [odds ratio 3.31 (95% CI 1.35-8.92, P = 0.008)] and an inpatient admission [odds ratio 2.67 (95% CI 1.55-4.87, P = 0.0002)] were associated with early delirium.

Conclusions

Our findings suggest that pharmacological avoidance protocols limiting or avoiding the use of specific classes of medications are not effective in reducing early incident or subsyndromal delirium in older patients undergoing elective surgery.

Haemodynamic and respiratory perioperative outcomes for open versus robot-assisted radical cystectomy: A double-blinded, randomised trial

BACKGROUND

The clinical impact of prolonged steep Trendelenburg position and CO₂ pneumoperitoneum during robot-assisted radical cystectomy (RC) on intraoperative conditions and immediate postoperative recovery remains to be assessed. The current study investigates intraoperative and immediate postoperative outcomes for open RC (ORC) versus robot-assisted RC with intracorporal urinary diversion (iRARC) in a blinded randomised trial. We hypothesised that ORC would result in a faster haemodynamic and respiratory post-anaesthesia care unit (PACU) recovery compared to iRARC.

METHODS

This study is a predefined sub-analysis of a single-centre, double-blinded, randomised feasibility study. Fifty bladder cancer patients were randomly assigned to ORC (n = 25) or iRARC (n = 25). Patients, PACU staff, and ward personnel were blinded to the surgical technique. Both randomisation arms followed the same anaesthesiologic procedure, fluid treatment plan, and PACU care. The primary outcome was immediate postoperative recovery using a standardised PACU Discharge Criteria (PACU-DC) score. Secondary outcomes included respiration- and arterial O₂ saturation scores as well as perioperative interventions and recordings.

RESULTS

All patients underwent the allocated treatment. The total PACU-DC score was highest 6 h postoperatively with no difference in the total score between randomisation arms (p = 0.80). Both the ORC and iRARC groups maintained a mean respiration- and arterial O₂ saturation score below 1 (out of 3) throughout PACU stay. The iRARC patients had significantly, but clinically acceptable, higher maximum airway pressure and arterial blood pressure, as well as lower minimum pH levels. The ORC group received significantly more opioids after extubation but marginally less analgesics in the PACU, compared to the iRARC group.

CONCLUSIONS

A prolonged Trendelenburg position and CO₂ pneumoperitoneum was well-tolerated during iRARC, and immediate postoperative recovery was similar for ORC and iRARC patients.

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.

Effect of sedative premedication with oral midazolam on postanesthesia care unit delirium in older adults: a secondary analysis following an uncontrolled before-after design

BACKGROUND

Sedative premedication with benzodiazepines has been linked with prolonged recovery and inadequate emergence during the immediate postoperative period. We aimed to analyze the association between postanesthesia care unit (PACU) delirium and sedative premedication with oral midazolam.

METHODS

We performed a secondary analysis of prospectively collected data before (midazolam cohort) and after (non-midazolam cohort) implementation of a restrictive strategy for oral premedication with midazolam. From March 2015 until July 2018, we included patients 60 years and older, who underwent elective radical prostatectomy for prostate cancer. Exclusion criteria were contraindications to premedication with midazolam, preoperative anxiety, and a history of neurological disorders. Patients, who were scheduled for postoperative admission to the intensive care unit, were excluded. Between 2015 and 2016, patients received 7.5 mg oral midazolam preoperatively (midazolam cohort). Patients included between 2017 and 2018 did not receive any sedative medication preoperatively (non-midazolam cohort). The primary endpoint was the incidence of PACU delirium.

RESULTS

PACU delirium rates were 49% in the midazolam cohort (n = 214) and 33% in the non-midazolam cohort (n = 218). This difference was not statistically significant on multivariable logistic regression analysis (OR 0.847 [95% CI 0.164; 4.367]; P = 0.842). Age (OR 1.102 [95% CI 1.050; 1.156]; P < 0.001), the cumulative dose of sufentanil (OR 1.014 [95% CI 1.005; 1.024]; P = 0.005), and propofol-sufentanil for anesthesia maintenance (OR 2.805 [95% CI 1.497; 5.256]; P = 0.001) were significantly associated with PACU delirium.

CONCLUSION

Midazolam for sedative premedication was not significantly associated with PACU delirium. The reduction in the incidence of PACU delirium throughout the study period may be attributable to improvements in perioperative management other than a more restrictive preoperative benzodiazepine administration.

Impact of postanesthesia care unit delirium on self-reported cognitive function and perceived health status: a prospective observational cohort study

Purpose

The objective of this study was to determine the influence of postanesthesia care unit (PACU) delirium on self-reported cognitive function and perceived health status 3 months after surgery.

Methods

This prospective observational cohort study was performed in a PACU at a high-volume prostate cancer center. We used a convenience sample of patients > 60 years undergoing elective radical prostatectomy. Patients with a history of cerebrovascular or neurodegenerative disease were excluded. Fifteen, 30, 45, and 60 following extubation, patients were screened for signs of delirium with the Confusion Assessment Method for the Intensive Care Unit. Three months after surgery self-reported cognitive function was assessed with the Cognitive Failures Questionnaire, and health status was evaluated with the 36-item Short-Form Health Survey (SF-36).

Results

Signs of PACU delirium were present in 32.4% (n = 72/222) of patients, and 80.2% (n = 178/222) completed the 3-month follow-up. The presence of PACU delirium signs was not significantly associated with self-reported cognitive failures (B = 0.60, 95% CI: −1.72; 2.92, p = 0.61) or SF-36 physical component scores (B = 0.19, 95% CI: 0.02; 0.36, p = 0.03) or SF-36 mental component scores (B =  −0.03, 95% CI: −0.18, 0.11, p = 0.66) 3 months after radical prostatectomy.

Conclusions

In a cohort of educated, highly functioning, elderly male patients who were assessed immediately after surgery and at a 3-month follow-up, we found no association between PACU delirium and self-reported cognitive failures or perceived health status, which implies that PACU delirium may be an event of limited duration and impact.

Trial registration

The study was registered at ClinicalTrials.gov (Identifier: NCT04168268, Date of registration: November 19, 2019).

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03087-1.

Spinal block and delirium in oncologic patients after laparoscopic surgery in the Trendelenburg position: A randomized controlled trial

Delirium is the most common postsurgical neurological complication and has a variable incidence rate. Laparoscopic surgery, when associated with the Trendelenburg position, can cause innumerable physiological changes and increase the risk of neurocognitive changes. The association of general anesthesia with a spinal block allows the use of lower doses of anesthetic agents for anesthesia maintenance and facilitates better control over postoperative pain. Our primary outcome was to assess whether a spinal block influences the incidence of delirium in oncologic patients following laparoscopic surgery in the Trendelenburg position. Our secondary outcome was to analyze whether there were other associated factors. A total of 150 oncologic patients who underwent elective laparoscopic surgeries in the Trendelenburg position were included in this randomized controlled trial. The patients were randomized into 2 groups: the general anesthesia group and the general anesthesia plus spinal block group. Patients were immediately evaluated during the postoperative period and monitored until they were discharged, to rule out the presence of delirium. Delirium occurred in 29 patients in total (22.3%) (general anesthesia group: 30.8%; general anesthesia plus spinal block: 13.8% p = 0.035). Patients who received general anesthesia had a higher risk of delirium than patients who received general anesthesia associated with a spinal block (odds ratio = 3.4; 95% confidence interval: 1.2–9.6; p = 0.020). Spinal block was associated with reduced delirium incidence in oncologic patients who underwent elective laparoscopic surgeries in the Trendelenburg position.