Anesthesia Alert: Make Post-op Delirium Prevention a Priority

If you asked your colleagues to define postoperative delirium and the symptoms to look out for, do you think they could answer you with confidence? Believe it or not, the condition is widely misdiagnosed because its symptoms can present in a variety of ways. What makes it so tricky to diagnose is there are several types of delirium:

• Hyperactive delirium. The most easily recognized and common form with symptoms including hostile behavior, such as climbing out of bed and pulling on oxygen tubes and IV lines.
• Hypoactive delirium. The hardest form of delirium to diagnose because the patient is acting withdrawn and lethargic. 
• Mixed delirium. This form is displayed as a constant vacillation between hyperactive and hypoactive delirium.

There is no definitive answer as to what causes post-op delirium, but older patients are most at risk because of a loss of physiological reserves combined with cognitive impairments. There are also many clinical factors that can contribute to delirium such as an infection, a large volume of blood loss during surgery or even a long procedure. Cancer patients who undergo robotic surgery are also at increased risk for developing the disorder.

Patients who receive general anesthesia experience slightly more cognitive impairment than those receiving regional anesthesia. The thought process is that general anesthesia renders the patient unconscious and decreases some of the body’s physiological responses, thus rendering an inability to regulate blood pressure and heart rate, which combine to decrease the amount of blood flow to the brain. 

Although our colleagues were already aware of post-op delirium, many did not connect it to a surgical event. We decided education was key to give information to staff, patients and their families about the potential causes of the disorder and how to manage it.

We had purple postoperative delirium bracelets made and handed them out to the staff. They are a great visual reminder to watch out for the condition when patients arrive in the PACU. We also developed brochures to give to patients and their families about the disorder, which can sometimes occur a few days after discharge.

There are no absolutes in the medication regimen for the treatment or prevention of delirium. Many studies have failed to provide support for specific and effective actions. Pain control is very important and should always be attended to, however, as it helps keep older at-risk patients oriented to their surroundings.

To at least reduce the likelihood of post-op delirium in at-risk patients, utilize the patients’ visual and hearing aids whenever possible. A lack of mobility can make someone more likely to develop delirium, so advocate for the appropriate removal of tethers such as IVs, oxygen tubes and urinary catheters. Keep patients hydrated as well because dehydration increases the risk of delirium.

It’s helpful to utilize the Confusion Assessment Method (CAM), which is a standardized evidence-based tool that helps clinicians identify and recognize delirium quickly and accurately. The CAM includes four features found to have the greatest ability to distinguish delirium from other types of cognitive impairment: acute onset and fluctuating course; inattention; cognitive disturbances; and altered level of consciousness. Before initiating the CAM assessment, note patient and environmental risk factors such as age and medical risks such as an existing infection.

If a patient has at least three risk factors, initiate the CAM assessment. Patients with less than three risk factors should still be monitored closely for any changes in their cognitive status. CAM assessments should take place whenever a discrepancy is observed in a patient’s condition. Patients who are identified as at-risk should have closer monitoring for changes in cognition and status.

When all prevention strategies fail, you can still help patients who experience delirium. Provide stimulation and address the patient’s immediate clinical needs if they are in the midst of hypoactive delirium. Make patients experiencing hyperactive delirium feel safe in their surroundings by removing distractions that are causing agitation. Patients’ family members often need support as well when their loved ones become aggressive or hyperactive toward them.