Delirium after fast-track hip and knee arthroplasty

ArticleinBJA British Journal of Anaesthesia 108(4):607-11 · January 2012with22 Reads
DOI: 10.1093/bja/aer493 · Source: PubMed
Abstract
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.
    • "In a pilot randomized clinical trial, use of gabapentin as an add-on agent of postoperative analgesia reduced the occurrence of postoperative delirium, possibly due to its opioidsparing effect [26]. In a prospective observational study of elderly patients undergoing total hip or knee arthroplasty, supplemental use of opioid-sparing drugs (gabapentin, paracetamol, and celecoxib) for postoperative analgesia was associated with a reduced incidence of delirium [27]. Neuraxial anesthesia and analgesia are used in patients undergoing lower abdominal or lower extremity surgery. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Delirium is a common complication in elderly patients after surgery and associated with increased morbidity and mortality. Studies suggest that deep anesthesia and intense pain are important precipitating factors of postoperative delirium. Neuraxial block is frequently used in combination with general anesthesia for patients undergoing major thoracic and abdominal surgery. Compared with general anesthesia alone and postoperative intravenous analgesia, combined epidural-general anesthesia and postoperative epidural analgesia decreases the requirement of general anesthetics during surgery and provided better pain relief after surgery. However, whether combined epidural-general anesthesia plus epidural analgesia is superior to general anesthesia plus intravenous analgesia in decreasing the incidence of postoperative delirium remains unknown. Methods/design This is a multicenter, open-label, randomized, parallel-controlled clinical trial. One thousand eight hundred elderly patients (age range 60–90 years) who are scheduled to undergo major thoracic or abdominal surgery are randomized to receive either general anesthesia plus postoperative intravenous analgesia or combined epidural-general anesthesia plus postoperative epidural analgesia. The primary outcome is the 7-day incidence of postoperative delirium. Secondary outcomes include the duration of postoperative delirium, the intensity of pain during the first three days after surgery, the 30-day incidences of postoperative non-delirium complications, the length of stay in hospital after surgery and 30-day all-cause mortality. Discussion Results of the present study will provide information to guide clinical practice in choosing appropriate anesthesia-analgesia method for elderly patients undergoing major thoracic and abdominal surgery. Trial registration The study is registered on ClinicalTrials.gov NCT01661907 and Chinese Clinical Trial Registry ChiCTR-TRC-12002371.
    Full-text · Article · Dec 2015
    • "A fast-track set-up reduces the duration of hospitalization. Krenk et al. showed that when the length of stay of patients who underwent hip and knee arthroplasty was reduced from 7 to 10 days, with a median of 3 days, no cases of postoperative delirium were observed in the analyzed population [103]. In a series of 225 patients over 60 years, no cases of postoperative delirium were observed, and the incidence of POCD was reduced by more than 50% at one week, postoperatively [104]. "
    [Show description] [Hide description] DESCRIPTION: The incidence of postoperative cognitive dysfunction (POCD) in orthopedic patients varies from 16% to 45%, although it can be as high as 72%. As a consequence, the hospitalization time of patients who developed POCD was longer, the outcome and quality of life were worsened, and prolonged medical and social assistance were necessary. In this review the short description of such biomarkers of brain damage as the S100B protein, NSE, GFAP, Tau protein, metalloproteinases, ubiquitin C terminal hydrolase, microtubule-associated protein, myelin basic protein, 𝛼-II spectrin breakdown products, and microRNA was made. The role of thromboembolic material in the development of cognitive decline was also discussed. Special attention was paid to optimization of surgical and anesthetic procedures in the prevention of postoperative cognitive decline.
    Full-text · Research · Jul 2015 · General Hospital Psychiatry
    • "b Includes only knee replacement patients from Refs. [24,43,52] and [59][60][61][62]. c Includes only general anesthesia patients from Refs. "
    [Show abstract] [Hide abstract] ABSTRACT: Delirium is common in older adults following total joint replacement (TJR) of the hip and knee. However, reports of the incidence of delirium vary widely, limiting their usefulness. The current meta-analysis therefore examined (1) the incidence of delirium in older patients who underwent TJR and (2) whether these rates vary according to the (a) joint (hip/knee replacement), (b) inclusion/exclusion of patients who underwent simultaneous bilateral surgery, (c) inclusion/exclusion of patients with preexisting cognitive impairments, (d) type of anesthesia (regional/general), (e) method/frequency of assessment, and (f) postoperative interval. Data from 24 studies (2,895 patients) that measured postsurgical delirium following TJR were analyzed. Mean weighted proportions were calculated using a random-effects model to assess the overall incidence of delirium and whether the rate varied according to the aforementioned variables. Overall, 17% of patients who underwent TJR developed delirium during hospital admission. Individual estimates varied from 0% to 82%, but this variability was not adequately explained by the variables that were examined. Delirium is relatively common following TJR; however, it remains unclear why individual estimates vary so widely. Health professionals working with these patients should remain alert to the presentation, diagnosis and management of delirium to optimize postsurgical outcomes. Copyright © 2015. Published by Elsevier Inc.
    Article · Feb 2015
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