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