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INTRODUCTION

Postoperative delirium is defined as a fluctuating state of confusion marked by impaired cognition, attention, and/or awareness. It occurs with acute onset typically in the first 1–2 days following surgery and is most commonly encountered in older adults. Incidence ranges from 5% to 50%, with the highest percentages observed following cardiothoracic, major vascular, and emergent orthopedic surgeries.1,2 Postoperative outcomes are dramatically altered once a patient has delirium, rendering them higher risk for prolonged hospitalization, increased mortality, cognitive and functional decline, and increased rates of institutionalization. To minimize adverse outcomes, a three-pronged approach is recommended: 1) early delirium risk assessment, 2) aggressive preventative measures, and 3) prompt diagnosis and treatment (See Figure 41-1).2,3

FIGURE 41-1

Approach to postoperative delirium

TABLE 41-1Features of Postoperative Delirium
TABLE 41-2Confusion Assessment Method (Cam)

RISK ASSESSMENT AND REDUCTION STRATEGIES

Preoperative delirium risk assessment is outlined in Chapter 31 (Geriatrics) and should be performed in all adults over 65 years old undergoing surgery. Risk factors are either related to patient features or to the specific procedure and hospitalization1 (see Chapter 31, Table 31-3). Up to 40% of cases may be prevented through conservative measures, so emphasis on risk mitigation preoperatively (patient/family education, reduction of EtOH intake and deliriogenic meds) and prevention strategies during and after the surgery are key. A coordinated inpatient program of delirium precautions may include frequent reorienting conversation, minimizing tethers, limiting sleep interruptions, adequate pain control, avoidance of deliriogenic medications, and attention to urinary retention and bowel regularity.2,3 Comprehensive risk reduction strategies are outlined in Chapter 31, Table 31-3. While a number of pharmacologic strategies have been studied to prevent postoperative delirium, repeated efforts have been unsuccessful showing efficacy of antipsychotics or cholinesterase inhibitors.2,4 A recent meta-analysis, however, did report that melatonin, and to a lesser degree, ramelteon, were associated with a decreased incidence of postoperative delirium in certain surgeries.5 There is growing evidence that dexmedetomidine may reduce incidence and shorten duration of delirium following cardiac and ...

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