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Delirium—acute fluctuating disturbance of consciousness accompanied by alteration of cognition.

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Postoperative delirium in elderly undergoing elective surgery: 11%.

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Postoperative delirium more common in vascular surgery and long-lasting oral surgery.

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One in 10 Americans consumes excess alcohol and is at risk for withdrawal. The risk for delirium is doubled in this population.

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Preoperative: age >70, preexisting cognitive impairment, alcohol abuse, narcotics and drug use, previous history of delirium.

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Peroperative: significant blood loss, pain, hypoxia; anesthetic agents—ketamine, opioids, benzodiazepines, metoclopramide, anticholinergics, droperidol; possible influence of intraoperative embolization (e.g., joint replacement).

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Postoperative: major surgery, perioperative hypoxia.

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Acute cerebral dysfunction in relation to neurotransmitter disturbance, particularly anticholinergic, melatonin, norepinephrine, and lymphokines.

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Confusion Assessment Method (CAM) in ICU and Intensive Care Delirium Screening Checklist (ICDSC) can be used to detect delirium in patients. However, mechanical ventilation and/or sedation make utilization of these screening tools challenging. In addition, medications for sedation might induce or treat symptoms of delirium.

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Confusion Assessment Method
Feature 1: acute onset or fluctuating change in baseline mental status in the past 24 h as evidenced by sedation scale, Glasgow coma scale, or other delirium assessment?Yes or no
Feature 2: inattention testYes or no
Feature 3: altered level of consciousness—if RASS is other than alert and calmYes or no
Feature 4: disorganized thinkingYes or no
Feature 1 plus 2 and either 3 or 4 = CAM–ICU positive
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The Intensive Care Delirium Screening Checklist
1 point for each positive finding; score ≥4 indicates delirium
  • Altered level of consciousness
  • Inattention
  • Disorientation
  • Hallucination, delusion, or psychosis
  • Psychomotor agitation or retardation
  • Inappropriate speech or mood
  • Sleep/wake cycle disturbance
  • Symptom fluctuation
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Nonpharmacologic treatment might benefit patients preoperatively and postoperatively.

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  • Daily orientation—increase exposure to daylight, clocks in rooms
  • Reduce sleep deprivation
  • Decrease unnecessary sedatives or antipsychotics
  • Avoid use of restraints
  • Encourage early mobilization; physical therapy and occupational therapy
  • Early family contact

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  • After ensuring adequate ventilation and perfusion, treat any underlying acid base disturbances or electrolyte abnormalities. Physostigmine (0.5–2 mg IV) may reverse postoperative delirium due to anticholinergics
  • For patients with history of substance abuse, detoxification is beneficial prior to surgery
  • For prevention of the effects of stress on the hypothalamic–pituitary–adrenal axis (HPA axis), morphine 15 μg/kg/h is initiated prior to induction of anesthesia
  • For patients with known alcohol use disorder, treatment is symptom-based during perioperative state:
    • Benzodiazepines for agitation and seizures
    • Clonidine or dexmedetomidine for autonomic symptoms
    • Neuroleptics (haloperidol or risperidone) for hallucinations
    • Premedication:
      • Long-acting benzodiazepine before the surgery or short-acting benzodiazepine on the morning of surgery
      • After induction of anesthesia, clonidine 0.5 μg/kg/h, haloperidol up to 3.5 mg per day, ketamine 0.5 mg/kg
    • Prevention of Wernicke encephalopathy:
      • Thiamine 200 mg per day ...

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