delirium recognition in the pacu: recognition and ... · electrolyte imbalance sensory deprivation...
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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