Surgical Critical Care: Delirium

Delirium

Definitions

  • Delirium (DSM-5 Characteristics):
    • Disturbance in Attention (Reduced Ability to Direct, Focus, Sustain & Shift Attention) & Awareness
    • Develops Over a Short Period of Time (Hours-Days), Represents a Change from Baseline & Tends to Fluctuate Throughout the Day
    • An Additional Disturbance in Cognition is Present (Memory, Disorientation, Language, Visuospatial Ability or Perception)
    • Caused by a Medical Condition, Intoxication, Substance Withdrawal or Medication Side Effect
    • Not Better Explained by Another Neurocognitive Disorder
  • Postoperative Delirium: Delirium that Presents in the Postoperative Period
    • Emergence Delirium: Delirium in the Operating Room Immediately After Extubation
  • ICU Delirium: Delirium that Presents During a Stay in the ICU
  • Sundowning: Behavioral Deterioration During the Evening Hours
    • Most Common with Preexisting Dementia

Common Associated Features

  • Psychomotor Behavioral Disturbances:
    • Hypoactivity
    • Hyperactivity with Increased Sympathetic Activity
    • Sleep Impairment
  • Variable Emotional Disturbances:
    • Fear
    • Depression
    • Euphoria
    • Perplexity

Incidence & Course

  • Incidence Varies Widely Between Studies
  • Emergence Delirium Most Commonly Resolves Shortly After Admission to PACU
  • Postoperative Delirium-Induced Persistent Cognitive Dysfunction Can Last as Long as 1 Year
    • Can Last Up to 5 Years if Underlying Dementia is Present

Risk Factors

  • Patient Factors:
    • Elderly
    • Dementia – The Most Important Risk Factor in Elderly Patients
    • Malnutrition
    • ETOH Abuse
    • Medical Comorbidities
    • Psych Meds
  • Type of Surgery
    • 35% After Vascular Surgery
    • 40-60% After Hip Replacement
  • Severe Illness:
    • Infection
    • Medications
    • Hypoxia
    • Electrolyte Abnormalities
    • Pain
    • Dehydration
  • ICU Factors:
    • Bladder Catheter Use
    • Sensory or Functional Impairment
    • Physical Restraints
    • Sleep Deprivation
    • Unfamiliar Environment

Complications

  • Increased Morbidity and Mortality
    • 1-Month Mortality After a Single-Day of Delirium: 14.5%
      • After ≥ 3-Days of Delirium: 39%
    • 6-Month Mortality Increased 3.2-Fold
    • 12-Month Mortality Increases 10% Per Day of Delirium
  • Increased Length of Stay
  • Increased Rate of Discharge to Skilled Nursing Facility
  • Increased Rate of Readmission
  • Increased Cost

Prevention/Treatment

  • Treat Underlying Medical Conditions
  • Appropriate Pain Control with Non-Opioid Medications
    • Avoid Opioids & Benzodiazepines
  • Frequent Reorientation
  • Allow Regular Visits from Family & Friends for Cognitive Stimulation
  • Support Physiologic Sleep Patterns
    • Avoid Unnecessary Night-Time Interruptions & Reduce Night-Time Noises
    • Avoid Excessive Day-Time Sleeping
    • Provide Clocks & Keep Lights-On with Windows Open During the Day
  • Avoid Physical Restraints
  • Early Mobilization with Physical Therapies
  • Ensure Vision & Hearing Aids are Accessible

Management of Agitation