Delirium after fast-track hip and knee arthroplasty

Section of Surgical Pathophysiology, 4074, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark.
BJA British Journal of Anaesthesia (Impact Factor: 4.85). 01/2012; 108(4):607-11. DOI: 10.1093/bja/aer493
Source: PubMed


Postoperative delirium (PD) is a serious complication after major surgery in elderly patients. PD is well defined and characterized by reduced attention and disorientation. Multimodal optimization of perioperative care (the fast-track methodology) enhances recovery, and reduces hospital stay and medical morbidity. No data on PD are available in fast-track surgery. The aim of this study was to evaluate the incidence of PD after fast-track hip (THA) and knee arthroplasty (TKA) with anticipated length of stay (LOS) of <3 days.
In a prospective multicentre study to evaluate postoperative cognitive dysfunction, we included 225 non-demented patients with a mean age of 70 yr undergoing either THA or TKA in a fast-track set-up. Anaesthesia and postoperative pain management were standardized with limited opioid use. Nursing staff were trained to look for symptoms of PD which was assessed during interaction with healthcare professionals. Patients were invited for a clinical follow-up 1-2 weeks after surgery.
Clinical follow-up was performed in 220 patients at a mean of 12.0 days after surgery while five patients were followed up by telephone. The mean LOS was 2.6 days (range 1-8 days). Twenty-two patients received general anaesthesia, and the rest had spinal anaesthesia. No patients developed PD (95% confidence interval 0.0-1.6%).
A fast-track set-up with multimodal opioid-sparing analgesia was associated with lack of PD after elective THA and TKA in elderly patients.

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    • "It has been found in several clinical trials that fast-track surgery (FTS) not only facilitates the physical rehabilitation of the patients with colorectal malignancies, but also prevents upregulation of proinflammatory cytokines including IL-6, with reduced stress response and inflammation [13, 14]. Moreover, Krenk et al. have shown that delirium was not observed in fast-track hip and knee arthroplasty in elderly patients [15]. However, there is little data on whether FTS can prevent or protect elderly patients with colorectal carcinoma from developing delirium after colorectal surgery. "
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    ABSTRACT: This study aims to investigate the role of fast-track surgery in preventing the development of postoperative delirium and other complications in elderly patients with colorectal carcinoma. A total of 240 elderly patients with colorectal carcinoma (aged ≥70 years) undergoing open colorectal surgery was randomly assigned into two groups, in which the patients were managed perioperatively either with traditional or fast-track approaches. The length of hospital stay (LOS) and time to pass flatus were compared. The incidence of postoperative delirium and other complications were evaluated. Serum interleukin-6 (IL-6) levels were determined before and after surgery. The LOS was significantly shorter in the fast-track surgery (FTS) group than that in the traditional group. The recovery of bowel movement (as indicated by the time to pass flatus) was faster in the FTS group. The postoperative complications including pulmonary infection, urinary infection and heart failure were significantly less frequent in the FTS group. Notably, the incidence of postoperative delirium was significantly lower in patients with the fast track therapy (4/117, 3.4 %) than with the traditional therapy (15/116, 12.9 %; p = 0.008). The serum IL-6 levels on postoperative days 1, 2, and 3 in patients with the fast-track therapy were significantly lower than those with the traditional therapy (p < 0.001). Compared to traditional perioperative management, fast-track surgery decreases the LOS, facilitates the recovery of bowel movement, and reduces occurrence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. The lower incidence of delirium is at least partly attributable to the reduced systemic inflammatory response mediated by IL-6.
    Full-text · Article · Dec 2013 · Langenbeck s Archives of Surgery
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    • "This could explain the decline in outliers after the introduction of the rapid recovery protocol. However, postoperative delirium still occurred after the introduction of the rapid recovery protocol, although lack of postoperative delirium has been described in fast track THA and total knee artoplasty as well (Krenk et al. 2012). A possible reason for this occurrence could be the use of tramadol and piritramide in our standardized protocol for pain medication, both of which are opioids. "
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    ABSTRACT: Background and purpose Rapid recovery protocols after total hip arthroplasty (THA) have been introduced worldwide in the last few years and they have reduced the length of hospital stay. We show the results of the introduction of a rapid recovery protocol for primary THA for unselected patients in our large teaching hospital. Patients and methods In a retrospective cohort study, we included all 1,180 patients who underwent a primary THA between July 1, 2008 and June 30, 2012. These patients were divided into 3 groups: patients operated before, during, and after the introduction of the rapid recovery protocol. There were no exclusion criteria. All complications, re-admissions, and reoperations were registered and analyzed. Results The mean length of hospital stay decreased from 4.6 to 2.9 nights after the introduction of the rapid recovery protocol. There were no statistically significant differences in the rate of complications, re-admissions, or reoperations between the 3 groups. Interpretation In a large teaching hospital, the length of hospital stay decreased after introduction of our protocol for rapid recovery after THA in unselected patients, without any increase in complications, re-admissions, or reoperation rate.
    Full-text · Article · Sep 2013 · Acta Orthopaedica
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    Preview · Article · Jul 2012 · BJA British Journal of Anaesthesia
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