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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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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 × 3–5 days
- Nicotine ...