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Geßele C, Saller T, Smolka V, Dimitriadis K, Amann U, Strobach D. Development and validation of a new drug-focused predictive risk score for postoperative delirium in orthopaedic and trauma surgery patients. BMC Geriatr 2024; 24:422. [PMID: 38741037 DOI: 10.1186/s12877-024-05005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/24/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) is the most common complication following surgery in elderly patients. During pharmacist-led medication reconciliation (PhMR), a predictive risk score considering delirium risk-increasing drugs and other available risk factors could help to identify risk patients. METHODS Orthopaedic and trauma surgery patients aged ≥ 18 years with PhMR were included in a retrospective observational single-centre study 03/2022-10/2022. The study cohort was randomly split into a development and a validation cohort (6:4 ratio). POD was assessed through the 4 A's test (4AT), delirium diagnosis, and chart review. Potential risk factors available at PhMR were tested via univariable analysis. Significant variables were added to a multivariable logistic regression model. Based on the regression coefficients, a risk score for POD including delirium risk-increasing drugs (DRD score) was established. RESULTS POD occurred in 42/328 (12.8%) and 30/218 (13.8%) patients in the development and validation cohorts, respectively. Of the seven evaluated risk factors, four were ultimately tested in a multivariable logistic regression model. The final DRD score included age (66-75 years, 2 points; > 75 years, 3 points), renal impairment (eGFR < 60 ml/min/1.73m2, 1 point), anticholinergic burden (ACB-score ≥ 3, 1 point), and delirium risk-increasing drugs (n ≥ 2; 2 points). Patients with ≥ 4 points were classified as having a high risk for POD. The areas under the receiver operating characteristic curve of the risk score model were 0.89 and 0.81 for the development and the validation cohorts, respectively. CONCLUSION The DRD score is a predictive risk score assessable during PhMR and can identify patients at risk for POD. Specific preventive measures concerning drug therapy safety and non-pharmacological actions should be implemented for identified risk patients.
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Affiliation(s)
- Carolin Geßele
- Hospital Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany.
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Thomas Saller
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Vera Smolka
- Department of Orthopaedics and Trauma Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Ute Amann
- Faculty of Medicine, LMU Munich, Munich, Germany
| | - Dorothea Strobach
- Hospital Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany
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Groene P, Schaller T, Zeuzem-Lampert C, Rudy M, Ockert B, Siebenbürger G, Saller T, Conzen P, Hofmann-Kiefer K. Postoperative cognitive dysfunction after beach chair positioning compared to supine position in orthopaedic surgery in the elderly. Arch Orthop Trauma Surg 2024; 144:575-581. [PMID: 37889318 DOI: 10.1007/s00402-023-05109-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/12/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Postoperative cognitive dysfunction (POCD) occurs in up to 26% of patients older than 60 years 1 week after non-cardiac surgery. Intraoperative beach chair positioning (BCP) is advantageous for some types of shoulder surgery. However, this kind of positioning leads to a downward bound redistribution of blood volume, with possible hypoperfusion of the brain. We hypothesized that patients > 60 years undergoing orthopaedic shoulder surgery in a BCP might experience more POCD than patients operated in the supine position (SP). MATERIAL AND METHODS A single-centre, prospective observational trial of 114 orthopaedic patients was performed. Study groups were established according to the type of intraoperative positioning. Anaesthesiological management was carried out similarly in both groups, including types of anaesthetics and blood pressure levels. POCD was evaluated using the Trail Making Test, the Letter-Number Span and the Regensburger Word Fluency Test. The frequency of POCD 1 week after surgery was considered primary outcome. RESULTS Baseline characteristics, including duration of surgery, were comparable in both groups. POCD after 1 week occurred in 10.5% of SP patients and in 21.1% of BCP patients (p = 0.123; hazard ratio 2.0 (CI 95% 0.794-5.038)). After 4 weeks, the incidence of POCD decreased (SP: 8.8% vs. BCP: 5.3%; p = 0.463). 12/18 patients with POCD showed changes in their Word Fluency Tests. Near-infrared spectroscopy (NIRS) values were not lower in patients with POCD compared to those without POCD (54% (50/61) vs. 57% (51/61); p = 0.671). CONCLUSION POCD at 1 week after surgery tended to occur more often in patients operated in beach chair position compared to patients in supine position without being statistically significant.
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Affiliation(s)
- Philipp Groene
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Tanja Schaller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Catharina Zeuzem-Lampert
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Margret Rudy
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ben Ockert
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Georg Siebenbürger
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Peter Conzen
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Klaus Hofmann-Kiefer
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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Kowark A, Keszei AP, Schneider G, Pilge S, Schneider F, Obert DP, Georgii MT, Heim M, Rossaint R, Ziemann S, van Waesberghe J, Czaplik M, Pühringer FK, Minarski C, May V, Malisi T, Drexler B, Ring CM, Engler P, Tilly R, Bischoff P, Frey U, Wittmann M, Soehle M, Saller T, Kienbaum P, Kretzschmar M, Coburn M. Preoperative Midazolam and Patient-Centered Outcomes of Older Patients: The I-PROMOTE Randomized Clinical Trial. JAMA Surg 2024; 159:129-138. [PMID: 38117527 PMCID: PMC10733850 DOI: 10.1001/jamasurg.2023.6479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/13/2023] [Indexed: 12/21/2023]
Abstract
Importance The effect of oral midazolam premedication on patient satisfaction in older patients undergoing surgery is unclear, despite its widespread use. Objective To determine the differences in global perioperative satisfaction in patients with preoperative administration of oral midazolam compared with placebo. Design, Setting, and Participants This double-blind, parallel-group, placebo-controlled randomized clinical trial was conducted in 9 German hospitals between October 2017 and May 2019 (last follow-up, June 24, 2019). Eligible patients aged 65 to 80 years who were scheduled for elective inpatient surgery for at least 30 minutes under general anesthesia and with planned extubation were enrolled. Data were analyzed from November 2019 to December 2020. Interventions Patients were randomized to receive oral midazolam, 3.75 mg (n = 309), or placebo (n = 307) 30 to 45 minutes prior to anesthesia induction. Main Outcomes and Measures The primary outcome was global patient satisfaction evaluated using the self-reported Evaluation du Vécu de l'Anesthésie Generale (EVAN-G) questionnaire on the first postoperative day. Key secondary outcomes included sensitivity and subgroup analyses of the primary outcome, perioperative patient vital data, adverse events, serious complications, and cognitive and functional recovery up to 30 days postoperatively. Results Among 616 randomized patients, 607 were included in the primary analysis. Of these, 377 (62.1%) were male, and the mean (SD) age was 71.9 (4.4) years. The mean (SD) global index of patient satisfaction did not differ between the midazolam and placebo groups (69.5 [10.7] vs 69.6 [10.8], respectively; mean difference, -0.2; 95% CI, -1.9 to 1.6; P = .85). Sensitivity (per-protocol population, multiple imputation) and subgroup analyses (anxiety, frailty, sex, and previous surgical experience) did not alter the primary results. Secondary outcomes did not differ, except for a higher proportion of patients with hypertension (systolic blood pressure ≥160 mm Hg) at anesthesia induction in the placebo group. Conclusion and Relevance A single low dose of oral midazolam premedication did not alter the global perioperative patient satisfaction of older patients undergoing surgery or that of patients with anxiety. These results may be affected by the low dose of oral midazolam. Further trials-including a wider population with commonplace low-dose intravenous midazolam and plasma level measurements-are needed. Trial Registration ClinicalTrials.gov Identifier: NCT03052660.
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Affiliation(s)
- Ana Kowark
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
- Department of Anesthesiology, Medical Faculty University Hospital RWTH Aachen, Aachen, Germany
| | - András P. Keszei
- Center for Translational & Clinical Research Aachen, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Stefanie Pilge
- Department of Anesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Frederick Schneider
- Department of Anesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - David P. Obert
- Department of Anesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Marie-Therese Georgii
- Department of Anesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Markus Heim
- Department of Anesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, Medical Faculty University Hospital RWTH Aachen, Aachen, Germany
| | - Sebastian Ziemann
- Department of Anesthesiology, Medical Faculty University Hospital RWTH Aachen, Aachen, Germany
| | - Julia van Waesberghe
- Department of Anesthesiology, Medical Faculty University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Czaplik
- Department of Anesthesiology, Medical Faculty University Hospital RWTH Aachen, Aachen, Germany
| | - Friedrich K. Pühringer
- Department for Anaesthesiology, Intensive Care, Emergency Medicine, Pain Therapy and Palliative Care, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Christian Minarski
- Department for Anaesthesiology, Intensive Care, Emergency Medicine, Pain Therapy and Palliative Care, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Verena May
- Department for Anaesthesiology, Intensive Care, Emergency Medicine, Pain Therapy and Palliative Care, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Tobias Malisi
- Department for Anaesthesiology, Intensive Care, Emergency Medicine, Pain Therapy and Palliative Care, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Berthold Drexler
- Department of Anaesthesiology and Intensive Care, University Hospital Tübingen, Tübingen, Germany
| | - Carmen Maria Ring
- Department of Anaesthesiology and Intensive Care, University Hospital Tübingen, Tübingen, Germany
| | - Phillip Engler
- Department of Anaesthesiology and Intensive Care, University Hospital Tübingen, Tübingen, Germany
- Department of Radiology, University Hospital Tübingen, Tübingen, Germany
| | - Roman Tilly
- Department of Anaesthesiology and Intensive Care, University Hospital Tübingen, Tübingen, Germany
| | - Petra Bischoff
- Department of Anaesthesiology, Surgical Intensive Care, Pain and Palliative Care, Marien Hospital Herne, University Hospital of Ruhr University Bochum, Herne, Germany
| | - Ulrich Frey
- Department of Anaesthesiology, Surgical Intensive Care, Pain and Palliative Care, Marien Hospital Herne, University Hospital of Ruhr University Bochum, Herne, Germany
| | - Maria Wittmann
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Martin Soehle
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Peter Kienbaum
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Moritz Kretzschmar
- Department of Anaesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Mark Coburn
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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Greppmair S, Brinkmann A, Roehr A, Frey O, Hagel S, Dorn C, Marsot A, El-Haffaf I, Zoller M, Saller T, Zander J, Schatz LM, Scharf C, Briegel J, Minichmayr IK, Wicha SG, Liebchen U. Towards model-informed precision dosing of piperacillin: multicenter systematic external evaluation of pharmacokinetic models in critically ill adults with a focus on Bayesian forecasting. Intensive Care Med 2023; 49:966-976. [PMID: 37439872 PMCID: PMC10425489 DOI: 10.1007/s00134-023-07154-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE Inadequate piperacillin (PIP) exposure in intensive care unit (ICU) patients threatens therapeutic success. Model-informed precision dosing (MIPD) might be promising to individualize dosing; however, the transferability of published models to external populations is uncertain. This study aimed to externally evaluate the available PIP population pharmacokinetic (PopPK) models. METHODS A multicenter dataset of 561 ICU patients (11 centers/3654 concentrations) was used for the evaluation of 24 identified models. Model performance was investigated for a priori (A) predictions, i.e., considering dosing records and patient characteristics only, and for Bayesian forecasting, i.e., additionally including the first (B1) or first and second (B2) therapeutic drug monitoring (TDM) samples per patient. Median relative prediction error (MPE) [%] and median absolute relative prediction error (MAPE) [%] were calculated to quantify accuracy and precision. RESULTS The evaluation revealed a large inter-model variability (A: MPE - 135.6-78.3% and MAPE 35.7-135.6%). Integration of TDM data improved all model predictions (B1/B2 relative improvement vs. A: |MPE|median_all_models 45.1/67.5%; MAPEmedian_all_models 29/39%). The model by Kim et al. was identified to be most appropriate for the total dataset (A/B1/B2: MPE - 9.8/- 5.9/- 0.9%; MAPE 37/27.3/23.7%), Udy et al. performed best in patients receiving intermittent infusion, and Klastrup et al. best predicted patients receiving continuous infusion. Additional evaluations stratified by sex and renal replacement therapy revealed further promising models. CONCLUSION The predictive performance of published PIP models in ICU patients varied considerably, highlighting the relevance of appropriate model selection for MIPD. Our differentiated external evaluation identified specific models suitable for clinical use, especially in combination with TDM.
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Affiliation(s)
- Sebastian Greppmair
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Alexander Brinkmann
- Department of Anaesthesiology and Intensive Care Medicine, General Hospital of Heidenheim, 89522, Heidenheim, Germany
| | - Anka Roehr
- Department of Pharmacy, General Hospital of Heidenheim, 89522, Heidenheim, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, 89522, Heidenheim, Germany
| | - Stefan Hagel
- Institute for Infectious Diseases and Infection Control, University Hospital, Friedrich-Schiller-University Jena, 07747, Jena, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, 93053, Regensburg, Germany
| | - Amélie Marsot
- Faculty of Pharmacy, University of Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montréal, QC, H3T 1J4, Canada
| | - Ibrahim El-Haffaf
- Faculty of Pharmacy, University of Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montréal, QC, H3T 1J4, Canada
| | - Michael Zoller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Johannes Zander
- Laboratory Dr. Brunner, Laboratory Medical Care Center Konstanz GmbH, 78464, Constance, Germany
| | - Lea Marie Schatz
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, 48149, Muenster, Germany
| | - Christina Scharf
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Josef Briegel
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Iris K Minichmayr
- Department of Clinical Pharmacology, Medical University Vienna, 1090, Vienna, Austria
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146, Hamburg, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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Rudy M, Saller T. [Postoperative delirium in the recovery room]. Anaesthesiologie 2023:10.1007/s00101-023-01281-5. [PMID: 37233791 DOI: 10.1007/s00101-023-01281-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/25/2023] [Indexed: 05/27/2023]
Abstract
Postoperative delirium during emergence from anesthesia is the most frequent neuropsychiatric complication in the post-anesthesia care unit. In addition to increased medical and especially nursing care efforts, affected patients are threatened with delayed rehabilitation with a longer hospital stay and an increased mortality. It is therefore essential to identify risk factors at an early stage and to implement preventive measures; however, should a postoperative delirium occur in the post-anesthesia care unit despite the use of these preventive measures, it should be detected and treated at an early stage using suitable screening procedures. In this context, working instructions for delirium prophylaxis and standardized test procedures for detection of delirium have been shown to be useful. An additional drug treatment can be indicated when all nonpharmacological options have been exhausted.
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Affiliation(s)
- Margret Rudy
- Klinik für Anaesthesiologie, LMU Klinikum, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | - Thomas Saller
- Klinik für Anaesthesiologie, LMU Klinikum, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
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6
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Saller T, Ney L. [Sedation of critically ill patients with dexmedetomidine]. Anaesthesiologie 2023; 72:209-211. [PMID: 36598530 DOI: 10.1007/s00101-022-01244-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Thomas Saller
- Klinik für Anaesthesiologie, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | - Ludwig Ney
- Klinik für Anaesthesiologie, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
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Saller T, Hubig L, Seibold H, Schroeder Z, Wang B, Groene P, Perneczky R, von Dossow V, Hinske LC. Association between post-operative delirium and use of volatile anesthetics in the elderly: A real-world big data approach. J Clin Anesth 2022; 83:110957. [PMID: 36084424 DOI: 10.1016/j.jclinane.2022.110957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Early post-operative delirium is a common perioperative complication in the post anesthesia care unit. To date it is unknown if a specific anesthetic regime can affect the incidence of delirium after surgery. Our objective was to examine the effect of volatile anesthetics on post-operative delirium. DESIGN Single Center Observational Study. SETTING Post Anesthesia Care Units at a German tertiary medical center. PATIENTS 30,075 patients receiving general anesthesia for surgery. MEASUREMENTS Delirium was assessed with the Nursing Delirium Screening Scale at the end of the recovery period. Subgroup-specific effects of volatile anesthetics on post-operative delirium were estimated using generalized-linear-model trees with inverse probability of treatment weighting. We further assessed the age-specific effect of volatiles using logistic regression models. MAIN RESULTS Out of 30,075 records, 956 patients (3.2%) developed delirium in the post anesthesia care unit. On average, patients who developed delirium were older than patients without delirium. We found volatile anesthetics to increase the risk (Odds exp. (B) for delirium in the elderly 1.8-fold compared to total intravenous anesthesia. Odds increases with unplanned surgery 3.0-fold. In the very old (87 years or older), the increase in delirium is 6.2-fold. This result was confirmed with internal validation and in a logistic regression model. CONCLUSIONS Our exploratory study indicates that early postoperative delirium is associated with the use of volatile anesthetics especially in the sub-cohort of patients aged 75 years and above. Further studies should include both volatile and intravenous anesthetics to find the ideal anesthetic in elderly patients.
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Affiliation(s)
- Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Scientific Commission on Gerontoanaesthesiology, German Association for Anaesthesiology and Intensive Care Medicine, Roritzer Str. 19, 90419 Nuremberg, Germany.
| | - Lena Hubig
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Heidi Seibold
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Zoé Schroeder
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Baocheng Wang
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Philipp Groene
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Robert Perneczky
- Department of Psychiatry, University Hospital, LMU Munich, Nussbaumstr. 7, 80336 Munich, Germany; German Center for Neurodegenerative Disorders (DZNE), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Feodor-Lynen-Strasse 17, 81377 Munich, Germany; Ageing Epidemiology Research Unit, School of Public Health, Imperial College London, Level 2 Faculty Building South Kensington Campus, London SW7 2AZ, UK; Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, 385A Glossop Road, Sheffield S10 2HQ, UK
| | - Vera von Dossow
- Scientific Commission on Gerontoanaesthesiology, German Association for Anaesthesiology and Intensive Care Medicine, Roritzer Str. 19, 90419 Nuremberg, Germany; Institute for Anesthesiology, Heart and Diabetes Center NRW, Ruhr University of Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany
| | - Ludwig C Hinske
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; Professorship for Data Management und Clinical Decision Support, Faculty of Medicine, Augsburg University, University Hospital, Stenglinstr. 2, 86156 Augsburg, Germany
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Hindelang V, Dimitriadis K, Saller T, Golla K, Mannell H, Hug MJ, Strobach D. A new medication-based prediction score for postoperative delirium in surgical patients: Development and proof of feasibility in a retrospective patient cohort. Pharmazie 2022; 77:302-306. [PMID: 36273258 DOI: 10.1691/ph.2022.2438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Structured risk screening for postoperative delirium (POD) considering prehospital medication is not established. We aimed to develop a POD-risk prediction score based on known risk factors and delirium-risk increasing drugs to be used by pharmacists during medication reconciliation at hospital admission, and to test for feasibility in a retrospective cohort of surgical patients. Therefore, established POD-risk factors and drugs were extracted from the literature and a score was generated. Following this, the score was tested for feasibility in a retrospective 3-month-cohort of surgical patients. For patients with higher scores suggesting higher probability of POD, patient charts were screened for documentation of POD. For development of the score, the following POD-risk factors were defined and points assigned for score calculation: age (≥65 years=1 point/≥75 years=2), male sex (1), renal insufficiency (RI; 1), hepatic impairment (HI; Model-of-endstage-liver-disease (MELD) 10-14=1/≥15=2), delirium-risk increasing drugs (1 point per drug class), anticholinergic drug burden (ACB; ≥3=1). In the retrospective test cohort of 1174 surgical patients these factors concerned: age ≥65 years 567 patients (48%)/≥75 years 303 (26%), male 652 (55%), RI 238 (20%), MELD 10-14 106 (9%)/≥15 65 (5%), ≥ 1 delirium-risk increasing drug 418 (36%), ACB ≥3 106 (9%). The median POD-risk prediction score was 2 (range 0-9). Of 146 patients (12%) with a score ≥ 5, POD was documented for 43 (30%), no evidence for POD for 91 (62%) and data inconclusive for 12 (8%). For scores of ≥ 7, POD was documented for 50% of the patients with sufficient POD documentation. Overall, POD documentation was poor. To summarize, we developed and successfully tested the feasibility of a POD-prediction-score assessable by pharmacists at medication reconciliation at hospital admission.
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Affiliation(s)
- V Hindelang
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - K Dimitriadis
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - T Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - K Golla
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - H Mannell
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - M J Hug
- Pharmacy, Medical Center - University of Freiburg, Freiburg, Germany
| | - D Strobach
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany
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Nowak H, Wolf A, Rahmel T, Oprea G, Grause L, Moeller M, Gyarmati K, Mittler C, Zagler A, Lutz K, Loeser J, Saller T, Tryba M, Adamzik M, Hansen E, Zech N. Therapeutic Suggestions During General Anesthesia Reduce Postoperative Nausea and Vomiting in High-Risk Patients – A Post hoc Analysis of a Randomized Controlled Trial. Front Psychol 2022; 13:898326. [PMID: 35910976 PMCID: PMC9337244 DOI: 10.3389/fpsyg.2022.898326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/16/2022] [Indexed: 12/14/2022] Open
Abstract
Postoperative nausea and vomiting (PONV) are one of the most adverse events after general anesthesia, a distressing experience, and pose a risk to the patient. Despite advances in drug prophylaxis and PONV treatment, the incidence remains high and additional non-pharmacological treatments are needed. In this post hoc analysis of a recently published double-blind multicenter randomized controlled trial on the efficacy of intraoperative therapeutic suggestions on postoperative opioid dosage, we analyzed the effects of intraoperative therapeutic suggestions on PONV. We focus on patients with a high risk of PONV (Apfel risk score of 3–4) and distinguished early (first two postoperative hours) and delayed PONV (2–24 h). A total of 385 patients with a moderate or high risk for PONV were included. The incidence of early and delayed PONV was reduced (22.7–18.3 and 29.9–24.1%, respectively), without statistical significance, whereas in high-risk patients (n = 180) their incidence was nearly halved, 17.2 vs. 31.2% (p = 0.030) and 20.7 vs. 34.4% (p = 0.040), corresponding to a number needed to treat of 7 to avoid PONV. In addition, there was a significant reduction in PONV severity. In a multivariate logistic regression model, assignment to the control group (OR 2.2; 95% CI: 1.1–4.8) was identified as an independent predictor of the occurrence of early PONV. Our results indicate that intraoperative therapeutic suggestions can significantly reduce the incidence of PONV in high-risk patients. This encourages the expansion of therapeutic suggestions under general anesthesia, which are inexpensive and virtually free of side effects. Clinical Trial Registration: German Clinical Trials Register, https://drks.de, registration number: DRKS00013800.
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Affiliation(s)
- Hartmuth Nowak
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
- *Correspondence: Hartmuth Nowak,
| | - Alexander Wolf
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Tim Rahmel
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Guenther Oprea
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Lisa Grause
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | | | - Katharina Gyarmati
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, University of Cologne, Cologne, Germany
| | - Corinna Mittler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, University of Cologne, Cologne, Germany
| | - Alexandra Zagler
- Department of Anesthesiology, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Katrin Lutz
- Department of Anesthesiology, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Johannes Loeser
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, University of Cologne, Cologne, Germany
| | - Thomas Saller
- Department of Anesthesiology, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Michael Tryba
- Kassel School of Medicine, Kassel, Germany
- Clinic for Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Kassel Hospital, Kassel, Germany
| | - Michael Adamzik
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Ernil Hansen
- Department of Anesthesiology, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Nina Zech
- Department of Anesthesiology, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
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Obermeier KT, Kraus M, Smolka W, Henkel J, Saller T, Otto S, Liokatis P. Postoperative Delirium in Patients with Oral Cancer: Is Intraoperative Fluid Administration a Neglected Risk Factor? Cancers (Basel) 2022; 14:cancers14133176. [PMID: 35804948 PMCID: PMC9265071 DOI: 10.3390/cancers14133176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary Squamous cell carcinoma is the most typical malignant tumor of the oral cavity (OSCC) and surgery, including tumor resection and neck dissection with an appropriate reconstruction, remains the first line of treatment. Postoperative complications delay the healing process, and can have negative consequences for the patient. This study aimed to evaluate the impact of intraoperative fluid administration on developing postoperative delirium, and to identify other parameters leading to an increased risk of delirium. Abstract Squamous cell carcinoma (SCC) is a malignant tumor derived from squamous cells and can be found in different localizations. In the oral cavity especially, it represents the most common type of malignant tumor. First-line therapy for oral squamous cell carcinoma (OSCC) is surgery, including tumor resection, neck dissection, and maybe reconstruction. Although perioperative mortality is low, complications such as delirium are very common, and may have long-lasting consequences on the patient’s quality of life. This study examines if excessive fluid administration, among other parameters, is an aggravating factor for the development of postoperative delirium. A total of 198 patients were divided into groups concerning the reconstruction technique used: group A for primary wound closure or reconstruction with a local flap, and group B for microsurgical reconstruction. The patients with and without delirium in both groups were compared regarding intraoperative fluid administration, fluid balance, and other parameters, such as blood loss, duration of surgery and overall ventilation, alcohol consumption, and creatinine, albumin, natrium, and hematocrit levels. The logistic regression for group A shows that fluid intake (p = 0.02, OR = 5.27, 95% CI 1.27–21.8) and albumin levels (p = 0.036, OR = 0.22, CI 0.054–0.908) are independent predictors for the development of delirium. For group B, gender (p = 0.026, OR = 0.34, CI 0.133–0.879) with a protective effect for females, fluid intake (p = 0.003, OR = 3.975, CI 1.606–9.839), and duration of ventilation (p = 0.025, OR = 1.178, CI 1.021–1.359) are also independent predictors for delirium. An intake of more than 3000 mL for group A, and 4150 mL for group B, increases the risk of delirium by approximately five and four times, respectively. Fluid management should be considered carefully in patients with OSCC, in order to reduce the occurrence of postoperative delirium. Different factors may become significant for the development of delirium regarding different surgical procedures.
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Affiliation(s)
- Katharina Theresa Obermeier
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, 80337 Munich, Germany; (W.S.); (S.O.); (P.L.)
- Correspondence:
| | - Moritz Kraus
- Musculoskeletal University Center Munich, Department of Orthopaedics and Trauma Surgery, University Hospital, LMU Munich, 80539 Munich, Germany;
| | - Wenko Smolka
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, 80337 Munich, Germany; (W.S.); (S.O.); (P.L.)
| | - Jochen Henkel
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.H.); (T.S.)
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.H.); (T.S.)
| | - Sven Otto
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, 80337 Munich, Germany; (W.S.); (S.O.); (P.L.)
| | - Paris Liokatis
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, 80337 Munich, Germany; (W.S.); (S.O.); (P.L.)
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11
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Saller T, Hofmann-Kiefer KF, Saller I, Zwissler B, von Dossow V. Correction to: Implementation of strategies to prevent and treat postoperative delirium in the post‑anesthesia caring unit : A German survey of current practice. J Clin Monit Comput 2021; 36:289. [PMID: 34665393 PMCID: PMC8894214 DOI: 10.1007/s10877-021-00770-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Isabel Saller
- Department of Intercultural Communications, LMU Munich, Munich, Germany
| | - Bernhard Zwissler
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Vera von Dossow
- Institute for Anaesthesiology, Heart and Diabetes Center NRW, Ruhr University of Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany.
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12
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Tieges Z, Maclullich AMJ, Anand A, Brookes C, Cassarino M, O’connor M, Ryan D, Saller T, Arora RC, Chang Y, Agarwal K, Taffet G, Quinn T, Shenkin SD, Galvin R. Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis. Age Ageing 2021; 50:733-743. [PMID: 33951145 PMCID: PMC8099016 DOI: 10.1093/ageing/afaa224] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 'A's Test (4AT) is a short (<2 minutes) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection. METHODS We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials, from 2011 (year of 4AT release on the website www.the4AT.com) until 21 December 2019. Inclusion criteria were: older adults (≥65 years); diagnostic accuracy study of the 4AT index test when compared to delirium reference standard (standard diagnostic criteria or validated tool). Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model. RESULTS Seventeen studies (3,702 observations) were included. Settings were acute medicine, surgery, a care home and the emergency department. Three studies assessed performance of the 4AT in stroke. The overall prevalence of delirium was 24.2% (95% CI 17.8-32.1%; range 10.5-61.9%). The pooled sensitivity was 0.88 (95% CI 0.80-0.93) and the pooled specificity was 0.88 (95% CI 0.82-0.92). Excluding the stroke studies, the pooled sensitivity was 0.86 (95% CI 0.77-0.92) and the pooled specificity was 0.89 (95% CI 0.83-0.93). The methodological quality of studies varied but was moderate to good overall. CONCLUSIONS The 4AT shows good diagnostic test accuracy for delirium in the 17 available studies. These findings support its use in routine clinical practice in delirium detection. PROSPERO REGISTRATION NUMBER CRD42019133702.
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Affiliation(s)
- Zoë Tieges
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, UK
| | - Alasdair M J Maclullich
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Atul Anand
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Claire Brookes
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Marica Cassarino
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Margaret O’connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- Retrieval, Emergency and Disaster Medicine Research and Development Unit (REDSPoT), Emergency Department, University Hospital Limerick, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Rakesh C Arora
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Yue Chang
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kathryn Agarwal
- Section of Geriatrics, Baylor College of Medicine, Houston, TX, USA
- Houston Methodist Hospital, Houston, TX, USA
| | - George Taffet
- Section of Geriatrics, Baylor College of Medicine, Houston, TX, USA
- Houston Methodist Hospital, Houston, TX, USA
| | - Terence Quinn
- Institute of Cardiovascular Medicine, University of Glasgow, Glasgow, Scotland, UK
| | - Susan D Shenkin
- Geriatric Medicine, Edinburgh Delirium Research Group, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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13
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Tieges Z, MacLullich AMJ, Anand A, Cassaroni M, O'Connor M, Ryan D, Saller T, Arora R, Chang Y, Agarwal K, Taffet G, Quinn T, Shenkin S, Galvin R. 33 Diagnostic Test Accuracy of the 4AT for Delirium Detection: Systematic Review and Meta-Analysis. Age Ageing 2021. [DOI: 10.1093/ageing/afab029.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 ‘A’s Test (4AT; www.the4AT.com) is a short (<2 min) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection.
Methods
We searched the following electronic databases through Ovid: MEDLINE, Embase, and PsycINFO. Additional databases were searched: CINAHL (EBSCOhost), clinicaltrials.gov and Cochrane Central Register of Controlled Trials from 2011 (4AT publication) until 21 December 2019. Inclusion criteria: older adults (≥65) across any setting of care except critical care; validation study of the 4AT against a delirium reference standard (standard diagnostic criteria or validated tool). Two reviewers independently screened abstracts and papers and performed the data extraction. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model.
Results
17 studies (n = 3,701 observations) were included. Various settings including acute medicine, surgery, stroke wards and the emergency department were represented. The overall prevalence of delirium was 24.2% (95% CI 17.8–32.1%; range 10.5–61.9%). The pooled sensitivity was 0.88 (95% CI 0.80–0.93) and the pooled specificity was 0.88 (95% CI 0.82–0.92). The methodological quality of studies was mostly good.
Conclusions
The 4AT is now supported by a substantial evidence base comparable to other well-studied tools such as the Confusion Assessment Method (CAM). The strong pooled sensitivity and specificity findings for the 4AT in this meta-analysis along with its brevity and lack of need for specific training provide support for its use as an effective assessment tool for delirium.
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Affiliation(s)
- Z Tieges
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - A M J MacLullich
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - A Anand
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - M Cassaroni
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - M O'Connor
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - D Ryan
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - T Saller
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - R Arora
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - Y Chang
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - K Agarwal
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - G Taffet
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - T Quinn
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - S Shenkin
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
| | - R Galvin
- Geriatric Medicine, University of Edinburgh; Cardiovascular Sciences, University of Edinburgh; Health Research Institute, University of Limerick; Ageing & Therapeutics, University Hospital Limerick; Emergency Department, University Hospital Limerick; Max Rady College of Medicine, University of Manitoba; Section of Geriatrics, Baylor College of Medicine, Houston, USA; Houston Methodist Hospital, H
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14
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Nowak H, Zech N, Asmussen S, Rahmel T, Tryba M, Oprea G, Grause L, Schork K, Moeller M, Loeser J, Gyarmati K, Mittler C, Saller T, Zagler A, Lutz K, Adamzik M, Hansen E. Effect of therapeutic suggestions during general anaesthesia on postoperative pain and opioid use: multicentre randomised controlled trial. BMJ 2020; 371:m4284. [PMID: 33303476 PMCID: PMC7726311 DOI: 10.1136/bmj.m4284] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the effect of therapeutic suggestions played to patients through earphones during surgery on postoperative pain and opioid use. DESIGN Blinded randomised controlled study. SETTING Five tertiary care hospitals in Germany. PARTICIPANTS 385 of 400 patients consecutively recruited from January to December 2018 who were to undergo surgery for 1-3 hours under general anaesthesia. In the per protocol analysis 191 patients were included in the intervention group and 194 patients in the control group. INTERVENTION The intervention comprised an audiotape of background music and positive suggestions based on hypnotherapeutic principles, which was played repeatedly for 20 minutes followed by 10 minutes of silence to patients through earphones during general anaesthesia. Patients in the control group were assigned to a blank tape. MAIN OUTCOME MEASURES The main outcome was dose of opioid administered by patient controlled analgesia or nurse controlled analgesia within the first postoperative 24 hours, based on regular evaluation of pain intensity on a numerical rating scale (range 0-10, with higher scores representing more severe pain). RESULTS Compared with the control group, the intervention group required a significantly (P=0.002) lower opioid dose within 24 hours after surgery, with a median of 4.0 mg (interquartile range 0-8) morphine equivalents versus 5.3 (2-12), and an effect size (Cohen's d) of 0.36 (95% confidence interval 0.16 to 0.56). The number of patients who needed opioids postoperatively was significantly (P=0.001) reduced in the intervention group: 121 of 191 (63%, 95% confidence interval 45% to 70%) patients in the intervention group versus 155 of 194 (80%, 74% to 85%) in the control group. The number needed to treat to avoid postoperative opioids was 6. Pain scores were consistently and significantly lower in the intervention group within 24 hours after surgery, with an average reduction of 25%. No adverse events were reported. CONCLUSIONS Therapeutic suggestions played through earphones during general anaesthesia could provide a safe, feasible, inexpensive, and non-drug technique to reduce postoperative pain and opioid use, with the potential for more general use. Based on the finding of intraoperative perception by a considerable number of patients, surgeons and anaesthetists should be careful about background noise and conversations during surgery. TRIAL REGISTRATION German Clinical Trial Register DRKS00013800.
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Affiliation(s)
- Hartmuth Nowak
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
- Contributed equally
| | - Nina Zech
- Department of Anesthesiology, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
- Contributed equally
| | - Sven Asmussen
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Tim Rahmel
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Michael Tryba
- Clinic for Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Kassel Hospital, Kassel, Germany
- Kassel School of Medicine, Kassel, Germany
| | - Guenther Oprea
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Lisa Grause
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Karin Schork
- Medizinisches Proteom-Center, Ruhr University Bochum, Bochum, Germany
| | | | - Johannes Loeser
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, University of Cologne, Cologne, Germany
| | - Katharina Gyarmati
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, University of Cologne, Cologne, Germany
| | - Corinna Mittler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, University of Cologne, Cologne, Germany
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Alexandra Zagler
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Katrin Lutz
- Department of Anesthesiology, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Michael Adamzik
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Ernil Hansen
- Department of Anaesthesiology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93042 Regensburg, Germany
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15
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Kammerer T, Groene P, Sappel SR, Peterss S, Sa PA, Saller T, Giebl A, Scheiermann P, Hagl C, Schäfer ST. Functional Testing for Tranexamic Acid Duration of Action Using Modified Viscoelastometry. Transfus Med Hemother 2020; 48:109-117. [PMID: 33976611 DOI: 10.1159/000511230] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/21/2020] [Indexed: 01/11/2023] Open
Abstract
Introduction Tranexamic acid (TXA) is the standard medication to prevent or treat hyperfibrinolysis. However, prolonged inhibition of lysis (so-called "fibrinolytic shutdown") correlates with increased mortality. A new viscoelastometric test enables bedside quantification of the antifibrinolytic activity of TXA using tissue plasminogen activator (TPA). Materials and Methods Twenty-five cardiac surgery patients were included in this prospective observational study. In vivo, the viscoelastometric TPA test was used to determine lysis time (LT) and maximum lysis (ML) over 96 h after TXA bolus. Additionally, plasma concentrations of TXA and plasminogen activator inhibitor 1 (PAI-1) were measured. Moreover, dose effect curves from the blood of healthy volunteers were performed in vitro. Data are presented as median (25-75th percentile). Results In vivo TXA plasma concentration correlated with LT (r = 0.55; p < 0.0001) and ML (r = 0.62; p < 0.0001) at all time points. Lysis was inhibited up to 96 h (LTTPA-test: baseline: 398 s [229-421 s] vs. at 96 h: 886 s [626-2,175 s]; p = 0.0013). After 24 h, some patients (n = 8) had normalized lysis, but others (n = 17) had strong lysis inhibition (ML <30%; p < 0.001). The high- and low-lysis groups differed regarding kidney function (cystatin C: 1.64 [1.42-2.02] vs. 1.28 [1.01-1.52] mg/L; p = 0.002) in a post hoc analysis. Of note, TXA plasma concentration after 24 h was significantly higher in patients with impaired renal function (9.70 [2.89-13.45] vs.1.41 [1.30-2.34] µg/mL; p < 0.0001). In vitro, TXA concentrations of 10 µg/mL effectively inhibited fibrinolysis in all blood samples. Conclusions Determination of antifibrinolytic activity using the TPA test is feasible, and individual fibrinolytic capacity, e.g., in critically ill patients, can potentially be measured. This is of interest since TXA-induced lysis inhibition varies depending on kidney function.
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Affiliation(s)
- Tobias Kammerer
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Philipp Groene
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Sophia R Sappel
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Paula A Sa
- Department of Anesthesiology, Intensive Care and Emergency, Centro Hospitalar Universitario de Porto, Porto, Portugal
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Giebl
- Department of Transfusion Medicine and Hemostaseology, University Hospital Augsburg, Augsburg, Germany
| | - Patrick Scheiermann
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
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Groene P, Sappel SR, Saller T, Nitschke T, Sa PA, Paulus A, Chappell D, Schäfer ST. Functional testing of tranexamic acid effects in patients undergoing elective orthopaedic surgery. J Thromb Thrombolysis 2020; 51:989-996. [PMID: 32918670 DOI: 10.1007/s11239-020-02272-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 11/30/2022]
Abstract
Tranexamic acid (TXA) can reduce blood loss and transfusion rates in orthopaedic surgery. In this regard, a new viscoelastometric test (TPA-test, ClotPro), enables the monitoring of TXA effects. This prospective observational study evaluated and correlated TXA plasma concentrations (cTXA) following intravenous and oral administration in patients undergoing elective orthopaedic surgery with lysis variables of TPA-test. Blood samples of 42 patients were evaluated before TXA application and 2, 6, 12, 24 and 48 h afterwards. TPA-test was used to determine lysis time (LT) as well as maximum lysis (ML) and cTXA was measured using Ultra-High-Performance-Liquid-Chromatography/Mass-Spectrometry. Data are presented as median (min-max). LTTPA-test and MLTPA-test correlated with cTXA (r = 0.9456/r = 0.5362; p < 0.0001). 2 h after intravenous TXA administration all samples showed complete lysis inhibition (LTTPA-test prolongation: T1: 217 s (161-529) vs. T2: 4500 s (4500-4500);p < 0.0001), whereas after oral application high intraindividual variability was observed as some samples showed only moderate changes in LTTPA-test (T1: 236 s (180-360) vs. T2: 4500 s (460-4500); p < 0.0001). Nevertheless, statistically LTTPA-test did not differ between groups. MLTPA-test differed 2 h after application (i.v.: 9.0% (5-14) vs. oral: 31% (8-97); p = 0.0081). In 17/21 samples after oral and 0/21 samples after intravenous administration cTXA was < 10 µg ml-1 2 h after application. TPA-test correlated with cTXA. MLTPA-test differed between intravenous and oral application 2 h after application. Most patients with oral application had TXA plasma concentration < 10 µg ml-1. The duration of action did not differ between intravenous and oral application. Additional studies evaluating clinical outcomes and side-effects based on individualized TXA prophylaxis/therapy are required.
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Affiliation(s)
- Philipp Groene
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Sophia R Sappel
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Tobias Nitschke
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Paula A Sa
- Department of Anesthesiology, Intensive Care and Emergency, Centro Hospitalar, Universitario de Porto, Porto, Portugal
| | - Alexander Paulus
- Department of Orthopaedics, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Chappell
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Simon T Schäfer
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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Saller T, Peterss S, Scheiermann P, Eser-Valeri D, Ehler J, Bruegger D, Chappell D, Kofler O, Hagl C, Hofmann-Kiefer K. Natriuretic Peptides as a Prognostic Marker for Delirium in Cardiac Surgery-A Pilot Study. ACTA ACUST UNITED AC 2020; 56:medicina56060258. [PMID: 32471143 PMCID: PMC7353880 DOI: 10.3390/medicina56060258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Delirium is a common and major complication subsequent to cardiac surgery. Despite scientific efforts, there are no parameters which reliably predict postoperative delirium. In delirium pathology, natriuretic peptides (NPs) interfere with the blood–brain barrier and thus promote delirium. Therefore, we aimed to assess whether NPs may predict postoperative delirium and long-term outcomes. Materials and Methods: To evaluate the predictive value of NPs for delirium we retrospectively analyzed data from a prospective, randomized study for serum levels of atrial natriuretic peptide (ANP) and the precursor of C-type natriuretic peptide (NT-proCNP) in patients undergoing coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (off-pump coronary bypass grafting; OPCAB). Delirium was assessed by a validated chart-based method. Long-term outcomes were assessed 10 years after surgery by a telephone interview. Results: The overall incidence of delirium in the total cohort was 48% regardless of the surgical approach (CABG vs. OPCAB). Serum ANP levels > 64.6 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 100% (75.3–100) and specificity of 42.9% (17.7–71.1). Serum NT-proCNP levels >1.7 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 92.3% (64.0–99.8) and specificity of 42.9% (17.7–71.1). Both NPs could not predict postoperative survival or long-term cognitive decline. Conclusions: We found a positive correlation between delirium and preoperative plasma levels of ANP and NT-proCNP. A well-powered and prospective study might identify NPs as biomarkers indicating the risk of delirium and postoperative cognitive decline in patients at risk for postoperative delirium.
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Affiliation(s)
- Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
- Correspondence: ; Tel.: +49-89-4400-73410
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (S.P.); (C.H.)
| | - Patrick Scheiermann
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
| | - Daniela Eser-Valeri
- Department of Psychiatry, University Hospital, LMU Munich, 80336 Munich, Germany;
| | - Johannes Ehler
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center, 18057 Rostock, Germany;
| | - Dirk Bruegger
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
| | - Daniel Chappell
- Clinic for Anaesthesia, Surgical Intensive Care, Emergency Medicine and Pain Therapy, Klinikum Frankfurt Hoechst, 65929 Frankfurt/Main, Germany;
| | - Othmar Kofler
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (S.P.); (C.H.)
| | - Klaus Hofmann-Kiefer
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
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Saller T, Hofmann-Kiefer KF, Saller I, Zwissler B, von Dossow V. Implementation of strategies to prevent and treat postoperative delirium in the post-anesthesia caring unit : A German survey of current practice. J Clin Monit Comput 2020; 35:599-605. [PMID: 32388654 PMCID: PMC8526467 DOI: 10.1007/s10877-020-00516-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
Abstract
Postoperative delirium is associated with worse outcome. The aim of this study was to understand present strategies for delirium screening and therapy in German Post-Anesthesia-Caring-Units (PACU). We designed a German-wide web-based questionnaire which was sent to 922 chairmen of anesthesiologic departments and to 726 anesthetists working in ambulatory surgery. The response rate was 30% for hospital anesthesiologists. 10% (95%-confidence interval: 8–12) of the anesthesiologists applied a standardised screening for delirium. Even though not on a regular basis, in 44% (41–47) of the hospitals, a recommended and validated screening was used, the Nursing Delirium Screening Scale (NuDesc) or the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). If delirium was likely to occur, 46% (43–50) of the patients were examined using a delirium tool. 20% (17–23) of the patients were screened in intensive care units. For the treatment of delirium, alpha-2-agonists (83%, 80–85) were used most frequently for vegetative symptoms, benzodiazepines for anxiety in 71% (68–74), typical neuroleptics in 77% (71–82%) of patients with psychotic symptoms and in 20% (15–25) in patients with hypoactive delirium. 45% (39–51) of the respondents suggested no therapy for this entity. Monitoring of delirium is not established as a standard procedure in German PACUs. However, symptom-oriented therapy for postoperative delirium corresponds with current guidelines.
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Affiliation(s)
- Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Isabel Saller
- Department of Intercultural Communications, LMU Munich, Munich, Germany
| | - Bernhard Zwissler
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Vera von Dossow
- Institute for Anaesthesiology, Heart and Diabetes Center NRW, Ruhr University of Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany.
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Ortner F, Eberl M, Otto S, Wang B, Schauberger G, Hofmann-Kiefer K, Saller T. Patient-related and anesthesia-dependent determinants for postoperative delirium after oral and maxillofacial surgery. Results from a register-based case-control study. J Stomatol Oral Maxillofac Surg 2020; 122:62-69. [PMID: 32302798 DOI: 10.1016/j.jormas.2020.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/06/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify risk factors for postoperative delirium (POD) after general oral and maxillofacial surgery. MATERIAL AND METHODS 2420 patients were screened postoperatively for POD using the Nursing Delirium Screening Scale (NuDESC) before discharge from the post anesthesia caring unit (PACU). Basic health data and risk factors were collected. For analysis the study group (n=41) was compared to a control group of 164 randomly selected patients (case-control-ratio=1:4). To identify risk factors for POD multivariable logistic regression models were used. To see whether estimations remain stable, regression analysis was repeated for the subgroup of patients not undergoing dentoalveolar surgery (n=105). To estimate the risk for dentoalveolar surgery a logistic regression model was performed. RESULTS Dementia was the only significant risk factor for POD (Odds ratio 41.5; 95% CI 5.48-314), also for patients undergoing other than dentoalveolar surgery (58.1; 1.70-1983). Patients undergoing dentoalveolar surgery were more often suffering from dementia (35.5; 2.85-441), other psychiatric and neurological disorders (3.15; 1.05-9.43), were of younger age (0.97; 0.94-1.00) and had higher anesthesiological risk (3.95; 1.04-14.9). CONCLUSION Patients with dementia are at higher risk to develop POD after oral and maxillofacial surgery. We found a strong interdependence between age, dementia, ASA-Score and dentoalveolar surgery.
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Affiliation(s)
- Florian Ortner
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; Department of Oral and Maxillofacial Surgery, University Hospital, LMU Munich, Lindwurmstraße 2a, 80337 Munich, Germany
| | - Marian Eberl
- Chair of Epidemiology, Faculty of Sport and Health Science, Technical University of Munich (TUM), Georg-Brauchle-Ring 60/62, 80992 Munich, Germany
| | - Sven Otto
- Department of Oral and Maxillofacial Surgery, University Hospital, LMU Munich, Lindwurmstraße 2a, 80337 Munich, Germany.
| | - Baocheng Wang
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Gunther Schauberger
- Chair of Epidemiology, Faculty of Sport and Health Science, Technical University of Munich (TUM), Georg-Brauchle-Ring 60/62, 80992 Munich, Germany
| | - Klaus Hofmann-Kiefer
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Thomas Saller
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
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Affiliation(s)
- T Saller
- Edinburgh Royal Infirmary, Edinburgh, UK
- German Center for Neurodegenerative Diseases, Munich, Germany
| | - A M J MacLullich
- Edinburgh Royal Infirmary, Edinburgh, UK
- German Center for Neurodegenerative Diseases, Munich, Germany
| | - R Perneczky
- Edinburgh Royal Infirmary, Edinburgh, UK
- German Center for Neurodegenerative Diseases, Munich, Germany
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Brown A, Schuetz D, Han Y, Daria D, Nattamai KJ, Eiwen K, Sakk V, Pospiech J, Saller T, van Zant G, Wagner W, Geiger H. The lifespan quantitative trait locus gene Securin controls hematopoietic progenitor cell function. Haematologica 2020; 105:317-324. [PMID: 31073078 PMCID: PMC7012499 DOI: 10.3324/haematol.2018.213009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 05/09/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- Andreas Brown
- Institute of Molecular Medicine and Stem Cell Aging, Ulm University, Ulm, Germany
| | - Desiree Schuetz
- Institute of Molecular Medicine and Stem Cell Aging, Ulm University, Ulm, Germany
| | - Yang Han
- Helmholtz-Institute for Biomedical Engineering, Stem Cell Biology and Cellular Engineering, RWTH Aachen University Medical School, Aachen, Germany
| | - Deidre Daria
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH, USA
| | - Kalpana J Nattamai
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH, USA
| | - Karina Eiwen
- Institute of Molecular Medicine and Stem Cell Aging, Ulm University, Ulm, Germany
| | - Vadim Sakk
- Institute of Molecular Medicine and Stem Cell Aging, Ulm University, Ulm, Germany
| | - Johannes Pospiech
- Institute of Molecular Medicine and Stem Cell Aging, Ulm University, Ulm, Germany
| | - Thomas Saller
- Institute of Molecular Medicine and Stem Cell Aging, Ulm University, Ulm, Germany
| | - Gary van Zant
- University of Kentucky College of Medicine, UK Medical Center, Lexington, KY, USA
| | - Wolfgang Wagner
- Helmholtz-Institute for Biomedical Engineering, Stem Cell Biology and Cellular Engineering, RWTH Aachen University Medical School, Aachen, Germany
| | - Hartmut Geiger
- Institute of Molecular Medicine and Stem Cell Aging, Ulm University, Ulm, Germany .,Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH, USA
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Saller T, Petzold A, Zetterberg H, Kuhle J, Chappell D, von Dossow V, Klawitter F, Schurholz T, Hagl C, Reuter DA, Zwissler B, Ehler J. A case series on the value of tau and neurofilament protein levels to predict and detect delirium in cardiac surgery patients. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2019; 163:241-246. [PMID: 31530945 DOI: 10.5507/bp.2019.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 08/22/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Delirium following cardiac surgery is a relevant complication in the majority of elderly patients but its prediction is challenging. Cardiopulmonary bypass, essential for many interventions in cardiac surgery, is responsible for a severe inflammatory response leading to neuroinflammation and subsequent delirium. Neurofilament light protein (NfL) and tau protein (tau) are specific biomarkers to detect neuroaxonal injury as well as glial fibrillary acidic protein (GFAP), a marker of astrocytic activation. METHODS We thought to examine the perioperative course of these markers in a case series of each three cardiac surgery patients under off-pump cardiac arterial bypass without evolving delirium (OPCAB-NDEL), patients with a procedure under cardio-pulmonary bypass (CPB) without delirium (CPB-NDEL) and delirium after a CPB procedure (CPB-DEL). Delirium was diagnosed by the Confusion Assessment Method for the ICU and chart reviews. RESULTS We observed increased preoperative levels of tau in patients with later delirium, whereas values of NfL and GFAP did not differ. In the postoperative course, all biomarkers increased multi-fold. NfL levels sharply increased in patients with CPB reaching the highest levels in the CPB-DEL group. CONCLUSION Tau and NfL might be of benefit to identify patients in cardiac surgery at risk for delirium and to detect patients with the postoperative emergence of delirium.
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Affiliation(s)
- Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Axel Petzold
- UCL Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, Moorfields Eye Hospital, London, United Kingdom and Amsterdam UMC, The Netherlands
| | - Henrik Zetterberg
- UK Dementia Research Institute at UCL, London, United Kingdom.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Molndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Molndal, Sweden
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Switzerland
| | - Daniel Chappell
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Vera von Dossow
- Institute for Anesthesiology, Heart and Diabetes Center NRW, Ruhr University of Bochum, Bad Oeynhausen, Germany
| | - Felix Klawitter
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
| | - Tobias Schurholz
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Daniel A Reuter
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
| | - Bernhard Zwissler
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Ehler
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
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Kowark A, Rossaint R, Keszei AP, Bischoff P, Czaplik M, Drexler B, Kienbaum P, Kretzschmar M, Rex C, Saller T, Schneider G, Soehle M, Coburn M. Impact of PReOperative Midazolam on OuTcome of Elderly patients (I-PROMOTE): study protocol for a multicentre randomised controlled trial. Trials 2019; 20:430. [PMID: 31307505 PMCID: PMC6632125 DOI: 10.1186/s13063-019-3512-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 06/10/2019] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Premedication of surgical patients with benzodiazepines has become questionable regarding risk-benefit ratio and lack of evidence. Though preoperative benzodiazepines might alleviate preoperative anxiety, a higher risk for adverse events is described, particularly for elderly patients (≥ 65 years). Several German hospitals already withhold benzodiazepine premedication from elderly patients, though evidence for this approach is lacking. The patient-centred outcome known as global postoperative patient satisfaction is recognised as a substantial quality indicator of anaesthesia care incorporated by the American Society of Anesthesiologists. Therefore, we aim to assess whether the postoperative patient satisfaction after premedication with placebo compared to the preoperative administration of 3.75 mg midazolam in elderly patients differs. METHODS This study is a multicentre, randomised, placebo-controlled, double-blinded, two-arm parallel, interventional trial, conducted in nine German hospitals. In total 614 patients (≥ 65-80 years of age) undergoing elective surgery with general anaesthesia will be randomised to receive either 3.75 mg midazolam or placebo. The primary outcome (global patient satisfaction) will be assessed with the validated EVAN-G questionnaire on the first postoperative day. Secondary outcomes will be assessed until the first postoperative day and then 30 days after surgery. They comprise among other things: functional and cognitive recovery, postoperative delirium, health-related quality of life assessment, and mortality or new onset of serious cardiac or pulmonary complications, acute stroke, or acute kidney injury. Analysis will adhere to the intention-to-treat principle. The primary outcome will be analysed with the use of mixed linear models including treatment effect and study centre as factors and random effects for blocks. Exploratory adjusted and subgroup analyses of the primary and secondary outcomes with regard to gender effects, frailty, pre-operative anxiety level, patient demographics, and surgery experience will also be performed. DISCUSSION This is, to the best of our knowledge, the first study analysing patient satisfaction after premedication with midazolam in elderly patients. In conclusion, this study will provide high-quality data for the decision-making process regarding premedication in elderly surgical patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT03052660 . Registered on 14 February 2017. EudraCT 2016-004555-79 .
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Affiliation(s)
- Ana Kowark
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - András P Keszei
- Center for Translational & Clinical Research Aachen (CTC-A), Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Petra Bischoff
- Department of Anaesthesiology, Surgical Intensive Care, Pain and Palliative Care, Marien Hospital Herne, University Hospital of Ruhr University Bochum, Herne, Germany
| | - Michael Czaplik
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Berthold Drexler
- Department of Anaesthesiology and Intensive Care, University Hospital Tübingen, Tübingen, Germany
| | - Peter Kienbaum
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Moritz Kretzschmar
- Department of Anaesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Christopher Rex
- Department for Anaesthesiology, Intensive Care, Emergency Medicine, Pain Therapy and Palliative Care, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Gerhard Schneider
- Department of Anaesthesiology, Technical University of Munich (TUM), Munich, Germany
| | - Martin Soehle
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Mark Coburn
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Aachen, Germany.
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Saller T, Schäfer ST. Einfluss von EEG-gesteuerter Narkoseführung auf postoperatives Delir bei älteren Patienten. Anaesthesist 2019; 68:483-484. [DOI: 10.1007/s00101-019-0624-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Saller T, MacLullich AMJ, Schäfer ST, Crispin A, Neitzert R, Schüle C, Dossow V, Hofmann‐Kiefer KF. Screening for delirium after surgery: validation of the 4 A's test (4AT) in the post‐anaesthesia care unit. Anaesthesia 2019; 74:1260-1266. [DOI: 10.1111/anae.14682] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2019] [Indexed: 12/19/2022]
Affiliation(s)
- T. Saller
- Department of Anaesthesiology University Hospital LMU Munich Germany
- German Association for Anaesthesiology and Intensive Care Medicine NurembergGermany
| | - A. M. J. MacLullich
- Edinburgh Delirium Research Group Geriatric Medicine Unit Edinburgh Royal Infirmary of Edinburgh UK
| | - S. T. Schäfer
- Department of Anaesthesiology University Hospital LMU Munich Germany
- German Association for Anaesthesiology and Intensive Care Medicine NurembergGermany
| | - A. Crispin
- Institute of Medical Data Processing, Biometrics and Epidemiology (IBE) Faculty of Medicine LMU Munich Germany
| | - R. Neitzert
- Department of Anaesthesiology University Hospital LMU Munich Germany
| | - C. Schüle
- Department of Psychiatry and Psychotherapy University Hospital LMU Munich Germany
| | - V. Dossow
- German Association for Anaesthesiology and Intensive Care Medicine NurembergGermany
- Institute for Anaesthesiology, Heart and Diabetes Center NRW Ruhr University of Bochum Bad Oeynhausen Germany
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Saller T, Hagl C, Woitsch S, Li Y, Niedermayer S, Born F, Luehr M, Kammerer T, Pichlmaier M, Scheiermann P, Peterss S. Haemadsorption improves intraoperative haemodynamics and metabolic changes during aortic surgery with hypothermic circulatory arrest. Eur J Cardiothorac Surg 2019; 56:731-737. [DOI: 10.1093/ejcts/ezz074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/13/2019] [Accepted: 02/15/2019] [Indexed: 01/28/2023] Open
Abstract
Abstract
OBJECTIVES:
Aortic surgery involving hypothermic circulatory arrest (HCA) results in a systemic inflammatory response that may negatively influence outcome. An extracorporeal haemadsorption (HA) device (CytoSorb®) that removes inflammatory triggers may improve haemodynamic and metabolic reactions due to excessive inflammation and, ultimately, outcome.
METHODS:
As a single-centre experience, the data of 336 patients who had undergone aortic surgery with HCA between 2013 and 2017 were retrospectively analysed. Patients with HA were matched to patients receiving standard therapy without HA (Control) by propensity score matching and compared subsequently.
RESULTS:
During aortic surgery with HCA, HA significantly reduced the requirement of norepinephrine (HA: 0.102 µg/kg/min; Control: 0.113; P = 0.043). Severe disturbances of acid–base balance as reflected by a pH lower than 7.19 (HA: 7.1%; Control: 11.6%; P = 0.139), maximum lactate concentrations (HA: 3.75 mmol/l; Control: 4.23 P = 0.078) and the need for tris-hydroxymethylaminomethane buffer (HA: 6.5%; Control: 13.7%; P = 0.045) were less frequent with HA. Compared to standard therapy, HA decreased the need for transfusion of packed red blood cells (1 unit; P = 0.021) and fresh frozen plasma (3 units; P = 0.001), but increased the requirement of prothrombin complex concentrate (800 IE, P = 0.0036). HA did not affect inflammatory laboratory markers on the first postoperative day. Differences in operative mortality (HA: 4.8%; Control: 8.8%) and the length of hospital stay (HA: 13.5 days; Control: 14) were not statistically significant.
CONCLUSIONS:
HA significantly reduces the need for vasopressors, the amount of transfusion and improves acid–base balance in aortic surgery with HCA. Multicentre prospective trials are required to confirm these results.
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Affiliation(s)
- Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Stefan Woitsch
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Yupeng Li
- Department of Political Science and Economics, Rowan University, Glassboro, NJ, USA
| | | | - Frank Born
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Luehr
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Tobias Kammerer
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Patrick Scheiermann
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
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Frey K, Rehm M, Chappell D, Eisenlohr J, Crispin A, Saller T, Groene P, Ockert B, Hofmann-Kiefer KF. Preemptive volume therapy to prevent hemodynamic changes caused by the beach chair position: hydroxyethyl starch 130/0.4 versus Ringer's acetate-a controlled randomized trial. J Shoulder Elbow Surg 2018; 27:2129-2138. [PMID: 30322751 DOI: 10.1016/j.jse.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/02/2018] [Accepted: 08/05/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hemodynamic instability frequently occurs in beach chair positioning for surgery, putting patients at risk for cerebral adverse events. This study examined whether preoperative volume loading with crystalloids alone or with a crystalloid-colloid combination can prevent hemodynamic changes that may be causative for unfavorable neurologic outcomes. METHODS The study randomly assigned 43 adult patients undergoing shoulder surgery to 3 study groups. Each group received an infusion of 500 mL of Ringer's acetate between induction of anesthesia and being placed in the beach chair position. The crystalloid group received an additional bolus of 1000 mL Ringer's acetate. The hydroxyethyl starch group was administered an additional bolus of 500 mL of 6% hydroxyethyl starch 130/0.4. Hemodynamic monitoring was accomplished via an esophageal Doppler probe. Cerebral oxygen saturation was examined with near-infrared spectroscopy. Changes in stroke volume variation between the prone and beach chair positions were defined as the primary outcome parameter. Secondary outcomes were changes in cardiac output and cerebral oxygen saturation. RESULTS The control group was prematurely stopped after enrollment of 4 patients because of adverse events. In the hydroxyethyl starch group, stroke volume variation remained constant during positioning maneuvers (P = .35), whereas a significant increase was observed in the Ringer's acetate group (P < .01; P = .014 for intergroup comparison). This was also valid for changes in cardiac output. Cerebral oxygen saturation significantly decreased in both groups. CONCLUSIONS Preprocedural boluses of 500 mL of 6% hydroxyethyl starch 130/0.4 as well as 1000 mL of Ringer's acetate were efficient in preserving hemodynamic conditions during beach chair position.
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Affiliation(s)
- Konstantin Frey
- Clinic of Anesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus Rehm
- Clinic of Anesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Daniel Chappell
- Clinic of Anesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jana Eisenlohr
- Clinic of Anesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexander Crispin
- Department of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Thomas Saller
- Clinic of Anesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Philipp Groene
- Clinic of Anesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ben Ockert
- Department of Trauma Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
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Saller T, V Dossow V, Hofmann-Kiefer K. [Knowledge and implementation of the S3 guideline on delirium management in Germany]. Anaesthesist 2016; 65:755-762. [PMID: 27646394 DOI: 10.1007/s00101-016-0218-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 07/18/2016] [Accepted: 08/04/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Delirium is a common complication in critical care. The syndrome is often underestimated due to its potentially no less dangerous course as a hypoactive delirium. Therefore, current guidelines ask for a structured, regular and routine screening in all intensive care units. If delirium is diagnosed, symptomatic therapy should be initiated promptly. OBJECTIVES The aim of the current study was to evaluate recent German anesthetists' strategies regarding delirium care compared to the German guidelines for sedation and delirium in intensive care. METHODS In an online survey German hospitals' senior anesthetists (n = 922) were interviewed anonymously between May and June 2015 regarding guideline use in delirium management in German intensive care units. In 33 direct questions the anesthetists were invited to answer items regarding the structure of their hospitals, intensive care and delirium therapy in order to review their knowledge of the German delirium guidelines that expired in 2014. RESULTS The 249 senior anesthetists who responded to the survey, can be associated with (or represent) a quarter of German intensive care beds and cases, respectively. In every tenth clinic that runs an intensive care unit the guideline was unknown. In three of four intensive care units physicians specified a preferred delirium score, the CAM-ICU (49.4 %) is used most frequently. With knowledge of the guidelines more often a recommended delirium score is used (p = 0.017). However, only 53.6 % of the respondents ascertain a score every eight hours and 36 % have no facility for standardized documentation in the records. At intensive care rounds, a possible diagnosis of delirium is an inherent part in only 34.9 % of the responders even with guideline knowledge. The particular gold standard for the therapy of delirium (alphaagonists for vegetative symptoms; 89.6 %, benzodiazepines for anxiety, 77.5 %; antipsychotics in 86.7 % for psychotic symptoms) is implemented more often with growing knowledge of the guidelines. The latter applies to the implementation of structured programs for delirium prophylaxis, cognition and therapy. CONCLUSION For the first time, this study documents knowledge and implementation of the German S3 guidelines for delirium in intensive care. Overall, the guidelines for delirium care are less well executed than those for sedation. With growing knowledge of the guidelines, diagnosis and treatment of delirium fits the guidelines more frequently. The facility to document a delirium score in intensive records is insufficient. Especially a nursing-based delirium strategy could possibly improve implementation of the guidelines, claiming an eight-hour screening and documentation. However, the small number of hospitals that have integrated the guidelines into in-house standard operating procedures (40 %) shows urgent need for optimization. A re-evaluation involving all relevant caretakers could probably improve the implementation of guidelines in intensive care and perioperative medicine.
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Affiliation(s)
- T Saller
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Nußbaumstraße 20, 80336, München, Deutschland.
| | - V V Dossow
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Nußbaumstraße 20, 80336, München, Deutschland
| | - K Hofmann-Kiefer
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Nußbaumstraße 20, 80336, München, Deutschland
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