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Jo Hoffman, BSN, RN, CCRN, CEN Theresa Posani, MS, RN, ACNS-BC, CCRN, CNE

Agenda Identify signs and symptoms of delirium in the

recovering patient Describe nursing interventions & medical treatments

appropriate for use with the patient with delirium in the PACU setting

Questions & Answer

Can you recognize delirium? CAM ICU Tool Use CAM ICU Video **

Changes in mental function Distinct categories:

Emergence delirium Delirium Postoperative cognitive dysfunction (POCD)

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What is emergence delirium? “Emergence  delirium  is  a  condition  that  can  affect  all  

segments of the postoperative population, but is seen most  often  in  pediatric  and  older  adult  patient”  (Hudek, 2009, 509).

Emergence delirium occurs in 10-15% of the geriatric population postoperatively.

Higher risk when undergoing: ophthalmological, otorhinolaryngological, breats, or abdominal surgery

Causes of Emergence Delirium Risk factors:

Patient’s  age Type of anesthesia Anxiety level Level of postoperative pain Preexisting medical conditions

Depression Drug dependence Organic brain disease (Lepouse et al., 2006; Hudek, 2009)

Other causes of Emergence delirium A rapid emergence from anesthesia without adequate

pain control Younger or advanced age No previous surgery Poor adaptability Large blood loss during surgery Postoperative pain Use of sevoflurane or isoflurance or a combination of

both Use of analgesics (Hudek, 2009, 510)

Medications causing . . . Most inhalation agents IV agents:

midazolam Remifentanil Propofol

Others: Atropine Ketamine Droperidol Barbiturates

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Physical causes . . . Urinary retention Hypoxia Severe hypercarbia Hypotension Hypoglycemia Increased intracranial

pressure Electrolyte imbalance

Sensory deprivation Sensory overload Pain Sepsis Embolism Alcohol withdrawal

Signs & Symptoms Emergence delirium:

Usually occurs within 15 to 30 minutes after surgery or in the elderly may be 8 to 24 hours later. (slower to metabolize anesthesia medications)

Excitement alternating with lethargy Restlessness and behavioral regression (verbally abusive

or infantile behavior)

Assessment of Agitation Richmond sedation-agitation-scale (SAS) Riker sedation-agitation-scale

Treatment of Emergence Delirium Basics:

Maintaining airway Breathing Circulation

Pulse oximetry Chemical restraint may be needed Vital sign monitoring Most cases resolve with only supportive care Debate over use of pharmaceuticals Calm & reassuring environment

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Effects of Emergence Delirium Morbidity

At risk for hurting themselves; i.e. self extubation, pulling out drains, etc.

Human resources Additional persons to hold them down Finances

Additional time in PACU Extra pharmaceuticals Repair of any physical damage Extra personnel to protect them

Delirium D = Mom Organic brain syndrome

Acute develops Fluctuating clinical course Disturbances

Attention Memory Orientation Perception Psychomotor Behavior Sleep

Key diagnostic feature: change in mental status; attention & reduced clarity of awareness of environment (Ouellette & Ouellette, 2010; Neufeld et al., 2013).

Neufeld et al. (2013) note that up to 50% of elderly patients experience delirium postoperatively and increase mortality, longer hospital stays, and cognitive & functional decline.

Delirium symptoms/signs Misinterpretations Illusions Hallucinations Inability to focus, sustain, & shift attention Disturbance in sleep-wake cycle & activity cycle Affective disturbances

Mood lability * delusions Anger * thought disorders Sadness * disorganized thinking euphoria

Delirium Causes General medical condition Substance-induced (medications or toxin exposure) Substance intoxication Substance withdrawal Multiple etiologies Any condition that interferes with neurotransmitter

function or supply of substrates for metabolism within the CNS.

Hepatic encephalopathy – drug or metabolic Melatonin is one mediator causing delirium Congestive heart failure (CHF) (Parente, Veiga, Silva, and Abelha,

2013) as an independent risk factor.

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Risk Factors Preoperative Age 70 or older History of delirium History of alcohol abuse Preoperative use of opioids Preoperative depression Malnutrition More than three medications added in 24-48 hours

before onset of delirium UTI and more.

Perioperative Risk Factors Greater intraopertive blood loss than typical for the

procedure Postporcedure blood transfusions Postprocedure hematocrit less than 30% Severe postprocedure pain (especially use of

Meperidine)

Recognition of delirium “Early  recognition  &  treatment  is  essential  to  reduce  

the duration and severity of delirium & negative outcomes”  (Ouellette & Ouelette, 2010, 43).

Most common complication: hip surgery – 16 to 62% of the older patient population.

Use the CAM tool.

Use of the CAM tool Discuss the use of the confusion assessment method

(CAM) tool in the PACU area. (Waszynski, 2012) 1. Acute onset 2A. Inattention 2B. If present or abnormal 3. Disorganized thinking 4. Altered level of consiousness 5. Disorientation 6. Memory impairment 7. Perceptual disturbances 8A. Psychomotor agitation 8B. Psychomotor retardation 9. Altered sleep-wake cycle

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The CAM Diagnostic Algorithm Feature 1: Acute onset of fluctuating course Feature 2: Inattention Feature 3: Disorganized thinking Feature 4: Altered level of consciousness

The diagnosis of delirium by CAM requires the

presence of features 1 & 2 and either 3 or 4. (Inouye et al., 1990).

Another tool used is the Nursing Delirium Symptom Checklist (NuDESC) (Neufeld et al., 2013).

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Nursing Interventions Recognition Correct imbalances: fluid, electrolytes Remove precipitating factors: overstimulation Encourage family visits Reorient patient Medications:

Haloperidol Benzodiazepine

Why control delirium? Neufeld et al. (2013) note post discharge morbidity,

institutionalization, and mortality. May not be recognized for up to days after surgery

Common occurrence after anesthesia Natural history of postoperatively after surgery

Surgery types with delirium Cardiac surgery

Shad & Hamilton, 2013 Smulter, Lingehall, Gustafson, Olofsson, & Engstrom, 2013 Martin & Arora, 2013

Lumbar spine surgery Fineberg, nandyala, Marquez-Lara, Oglesby, Patel, and Singh, 2013

Hip & knee Nandi, Harvey, Saillant, Kazakin, Talmo, & Bono, 2013 Krenk, Rasmussen, Hanse, Bogo, Soballe, and Kehlet, 2012

Postoperative Parkh and Chung, 1995

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Postoperative cognitive dysfunction (POCD) “Long-term deterioration of cognition after surgery

and anesthesia, POCD is characterized by mild changes in personality, emotional instability after anesthesia and surgery or some loss of cognitive poweres (such as short-term memory lapses, difficulty concentrating, or reduced visual-motor  speed)”  (Ouellette & Ouellette, 2010, 44).

Causes of POCD Unknown and unclear Cerebrovascular disease Cerebral hypoperfusion Genetic susceptibility Alteration in neurotransmitter function Neurohumoral stress Central nervous system inflammatory phenomenon Anticholinergic agents Regional anesthesia may reduce incidence of POCD early

after surgery according to Ouellette & Ouellette (2010).

More causes of POCD . . . Pain Epidurals may actually decrease incidence of POCD Sustained high levels of cortisol Major surgery

At risk for POCD 10-60% of POCD in the older patients 25% cognitive dysfunction a week after anesthesia POCD is usually reversible but may take up to one year

Increased risk with older patients, multiple surgeries

during same admission, and postoperative infections.

Polypharmacy increases risk, alcohol & sedative hypnotic withdrawal, anxiety, & depression.

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Preventing POCD Medication reconciliation before surgery Medical problem evaluation Detect sensory perceptual deficits Education before surgery to reduce anxiety Correct imbalances before surgery Adjust drugs for age, weight, comorbidities Ambulate older adults as soon as possible Allow family members & care givers to be with patient

Drugs to avoid Known to alter cognitive behavior

Diazepam Flurazepam Reserpine Hydroclorothiazide Beta-adrenergic blockers (propranolol) Aspirin Metoclopramide

What next? Ettema, et al. (2013) noted that further research is

needed on delirium recognition and treatment in the postoperative cardiac surgery patient population especially in regards to preoperative interventions to reducing postoperative delirium. (Ouellettte & Ouellette, 2010).

References Ettema, R. G. A., Van Koeven, H., Peelen, L.M., Kalkman, C. J.,

and Schuurmans, M. J. (2013). Preadmission interventions to prevent postoperative complications in older cardiac surgery patients: A systematic review of the literature. International Journal of Nursing Studies; G Model; 1-10.

Fineberg, S. J., nandyala, S. V., Marquez-Lara, A., Oglesby, M., patel, A. A., and Singh, K. (2013). Incidence and risk factors for postoperative delirium after lumbar spine surgery. SPINE; 38(20); 1790-1796.

Hudek, K., (2009). Emergence delirium: A nursing perspective. AORN Journal; 89(3); 509-520.

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References 2 . . . Inouye, S. K., van Dyck, C., Alessi, C., Balkin, S., Siegal, A., &

Horwitz, R. (1990). Clarifying confusion: The confusion assessment method. Annuals of Internal Medicine; 113(12); 941-948.

Krenk, L., Rasmussen, L. S., Hansen, T. B., Bogo, S., Soballe, K., and Kehlet, H. (2012). Delirium after fast-track hip and knee arthroplasty. British Journal of Anaesthesia; 108(4); 607-611.

Lepouse, C., lautner, C. A., Liu, L., Gomis, P., and Leon, A. (2006). Emergence delirium in adults in the post-anesthesia care unit. British Journal of Anaesthesia; 96(6); 747-753.

Martin, B. and Arora, R. C. (2013). Delirium and cardiac surgery: Progress and more questions. Critical Care; 17; 140-141.

Reference 3 . . . Nandi, S., Harvey, W. F., Saillant, J., Kazakin, A., Talmo, C., and

Bono, J. (2013). Pharmacologic risk factors for post-operative delirium in total joint arthroplasty patients: A case-control study. The Journal of Arthroplasty; 1-4. Doi: dx.doi.org/10.1016/j.arth.2013.06.004

Neufeld, K. J., Leoutsakos, J. S., Sieber, F. E., Wanamaker, B. L., Chambers, J. J. G., Rao, V., Schretlen, D.J., and Needham, D. M. (2013). Outcomes of early delirium diagnosis after general anesthesia in the elderly. Neuroscience in Anesthesiology and Perioperative Medicine; 11; 1-8.

Neufeld, K. J., Leoutsakos, J. S., Sieber, F. E., Joshi, D., Wanamaker, B.L., Rios-Robles, J., and Needham, D. M. (2013). Evaluation of two delirium screening tools for detecting post-operative delirium in the elderly. British Journal of Anaesthesia; 111(4); 612-618.

Reference 4 . . . Ouellette, R. G. and Ouellette, SM. (2010). Understanding

postoperative cognitive dysfunction and delirium. OR Nurse; July; 40-46.

Parente, D., Veiga, L. C., Silva, H., and Abelha, F. (2013). Congestive heart failure as a determinant of postoperative delirium. Rev Port Crdiol; 32(4); 665-671.

Parikh, S. S. and Chung, F. (1995). Postoperative delirium in the elderly. Anesthesia Anal; 80; 1223-1232.

Reference 5 . . . Shah, N. and Hamilton, M. (2013). Clinical review: can we

predict which patients are at risk of complications following surgery? Critical Care; 17; 226-234.

Smulter, N., Lingehall, H. C., Gustafson, Y., Olofsson, B., and Engstrom, K. G. (2013). Delirium after cardiac surgery: Incidence and risk factors. Interactive CardioVascular and Thoracic Surgery; 1-7. Doi: 10.10993/icvts/ivt323

Waszynski, C. M. (2012). The confusion assessment method (CAM). Try this. Best Practices in Nursing Care to Older Adults; 13. Retrieved from www.hartfordign.org

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Questions How do you see yourself using the CAM tool in your

recovering patients? Have your recognized delirium in your recovering

patients? Are there medications you use to treat delirium in

recovery? Do you recognize patients at high risk for delirium in

recovery?

Question & Answer Time