emergence delirium jane bolton cn paru rah. postoperative neurobehavioral disturbances 3 distinct...

Emergence DeliriumJane Bolton

CN PARU RAH

Postoperative Neurobehavioral Disturbances

3 distinct forms :• emergence delirium• postoperative delirium• postoperative cognitive decline

Emergence deliriumDefinition

Altered state of consciousness & agitation during emergence from anaesthesia• Usually lasts 15 – 30 mins, no interval• Poorly understood• Lack of studies• Affects about 5-20 % of patient population

Recognition

RECOGNITION of CONDITION

• extremely important• allows for appropriate treatment• hastens response time• hastens treatment time• improves outcome

Risk Factors

Non modifiable :• age• cognitive impairment• dementia• depression• comorbid disease• type of surgery• genetic factors

Risk Factors

Modifiable :• infection & inflammation• metabolic disturbances• medication• pain & discomfort• sleep disruption

Causes

Physiological• hypoxemia, hypercarbia, hyponatremia, hypoglycemia• head injury, dementia, sepsis, alcohol withdrawal, airway

obstruction• full bladder, pain, hypothermia, sensory overload or

deprivation

Causes

Pharmacological :• Ketamine• Droperidol• Benzodiazepines• Opioids• Atropine• Scopolamine • Inhalation agents eg sevoflurane, desflurane

Signs and symptoms

• excitement alternating with sedation• excitement and disorientation• inappropriate behaviour and language• violence and threatening behaviour• unresponsive to commands• disinhibited behaviour

Treatment

Patient and staff safety top priority

Treat possible cause with :• oxygen• F & E replacement• analgesia• warming• IDC• sedation

Violent Patient Protocol

Protocol is located in PARU

• calm patient• assistance : anaesthetist, code black• safety top priority• TC to coordinate response team• chemical sedation: IV Haloperidol 1mg-10mgs• physical restraint if threatening

Treatment

Code Black if uncontrollable & dangerous

Medications :• Haloperidol 1 mg per ml up to 10 mgs• Olanzapine IV or wafer for longer effect

Literature suggests midazolam if above drugs are ineffective but in practice this can exacerbate situation

Treatment

• calming reassurance• quiet orientation to time and place• do not yell at patient • do not try and reason or argue • reduce number of people at scene• explain procedures to patient• gentle physical restraint as a last resort