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Delirium can occur after any major operation but is particularly common after hip fracture repair and cardiovascular surgery, where the incidence is 30–60%. Postoperative delirium has been associated with higher rates of major postoperative cardiac and pulmonary complications, poor functional recovery, increased length of hospital stay, increased risk of subsequent dementia and functional decline, and increased mortality. The American Geriatrics Society recommends screening preoperative patients for these delirium risk factors: age greater than 65 years, chronic cognitive impairment or dementia, severe illness, poor vision or hearing, and the presence of infection. Patients with any of these risk factors should be enrolled in a multicomponent, nonpharmacologic delirium prevention program after surgery, which includes interventions such as reorientation, sleep hygiene, bowel and bladder care, mobilization and physical therapy, and the elimination of unnecessary medications. Moderate-quality evidence supports the use of these nonpharmacologic interventions.
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Only a minority of patients with postoperative delirium will have a single, reversible etiology for their condition (see Delirium, Chapter 4). Evaluation of delirious patients should exclude electrolyte derangements, occult UTI, and adverse effects from psychotropic medications such as opioids, sedatives, anticholinergic agents, and antispasmodics. Conservative management includes reassuring and reorienting the patient; eliminating unneeded medications, intravenous lines, and urinary catheters; and keeping the patient active during the day while allowing uninterrupted sleep at night. Use of multimodal postoperative analgesic strategies can reduce or avoid the need for opioids. When agitation jeopardizes patient or provider safety, neuroleptic agents given at the lowest effective dose for the shortest duration needed are preferred over the use of benzodiazepines or physical restraints (Table 25–1). While clinically apparent delirium usually resolves over several days, some patients suffer from subtle postoperative cognitive dysfunction that can last for weeks or months after surgery. Patients who experience postoperative delirium are more likely to have subsequent postoperative cognitive dysfunction.
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Stroke complicates less than 1% of all surgical procedures but may occur in 1–6% of patients undergoing cardiac or carotid artery surgery. Most of the strokes in cardiac surgery patients are embolic in origin, and about half occur within the first postoperative day. A retrospective analysis found that patients who had previously suffered a stroke had an 18% risk of MI, recurrent stroke, or cardiac death if they underwent noncardiac surgery within 3 months of the stroke. This risk declined over time and reached its nadir 9 months after the stroke, suggesting a benefit to delaying elective surgery.
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Symptomatic carotid artery stenosis is associated with a high risk of stroke in patients undergoing cardiac surgery. In general, patients with independent indications for correction of carotid stenosis should have the procedure done prior to elective surgery. In contrast, most studies suggest that asymptomatic carotid bruits and asymptomatic carotid stenosis are associated with little or no increased risk of stroke in surgical patients. A cohort study found that preoperatively diagnosed patent foramen ovale (PFO) was associated with increased risk of postoperative stroke. Additional research is needed ...