Martin Franck

Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction

BACKGROUND Postoperative delirium in elderly patients is a frequent complication and associated with poor outcome. The aim of this parallel group study was to determine whether monitoring depth of anaesthesia influences the incidence of postoperative delirium. METHODS Patients who were planned for surgery in general anaesthesia expected to last at least 60 min and who were older than 60 yr were included between March 2009 and May 2010. A total of 1277 patients of a consecutive sample were randomized (n=638 open, n=639 blinded) and the data of 1155 patients were analysed (n=575 open, n=580 blinded). In one group, the anaesthesiologists were allowed to use the bispectral index (BIS) data to guide anaesthesia, while in the other group, BIS monitoring was blinded. Cognitive function was evaluated at baseline, 1 week, and 3 months after operation. RESULTS Delirium incidence was lower in patients guided with BIS. Postoperative delirium was detected in 95 patients (16.7%) in the intervention group compared with 124 patients (21.4%) in the control group (P=0.036). In a multivariate analysis, the percentage of episodes of deep anaesthesia (BIS values <20) were independently predictive for postoperative delirium (P=0.006; odds ratio 1.027). BIS monitoring did not alter the incidence of postoperative cognitive dysfunction (7th day P=0.062; 90th day P=0.372). CONCLUSIONS Intraoperative neuromonitoring is associated with a lower incidence of delirium, possibly by reducing extreme low BIS values. Therefore, in high-risk surgical patients, this may give the anaesthesiologist a possibility to influence one precipitating factor in the complex genesis of delirium. Clinical trial registration ISRCTN Register: 36437985. http://www.controlled-trials.com/ISRCTN36437985/.

Changes in sedation management in German intensive care units between 2002 and 2006: a national follow-up survey.

BackgroundThe aim of this study, conducted in 2006, was to find out whether changes in sedation management in German intensive care units took place in comparison with our survey from 2002.MethodsWe conducted a follow-up survey with a descriptive and comparative cross-sectional multi-center design. A postal survey was sent between January and May 2006, up to four times, to the same 269 hospitals that participated in our first survey in 2002. The same questionnaire as in 2002 was used with a few additional questions.ResultsTwo hundred fourteen (82%) hospitals replied. Sixty-seven percent of the hospitals carried out changes in sedation management since the 2002 survey. Reasons for changes were published literature (46%), national guidelines (29%), and scientific lectures (32%). Sedation protocols (8% versus 52%) and a sedation scale (21% versus 46%) were used significantly more frequently. During sedation periods of up to 24 hours, significantly less midazolam was used (46% versus 35%). In comparison to 2002, sufentanil and epidural analgesia were used much more frequently in all phases of sedation, and fentanyl more rarely. For periods of greater than 72 hours, remifentanil was used more often. A daily sedation break was introduced by 34% of the hospitals, and a pain scale by 21%.ConclusionThe increased implementation of protocols and scoring systems for the measurement of sedation depth and analgesia, a daily sedation break, and the use of more short-acting analgesics and sedatives account for more patient-oriented analgesia and sedation in 2006 compared with 2002.

Duration of fluid fasting and choice of analgesic are modifiable factors for early postoperative delirium.

Background and objective Most therapeutic options for postoperative delirium are only symptom oriented; therefore, the best approach remains prevention. The aim of this study was to identify predisposing and precipitating factors for early postoperative delirium. Methods A total of 1002 patients were screened for delirium in an observational, cohort study. Nine hundred and ten patients were observed in the recovery room and 862 patients on the first postoperative day in the ward at the Charité – Universitaetsmedizin, Berlin. Delirium was measured with the nursing delirium screening scale. Risk factors were analysed in a multivariate analysis. Results Delirium was seen in 11.0% of the patients in the recovery room and in 4.2% of the patients on the ward. Delirium in the recovery room was associated with delirium on the ward (McNemars test P = <0.001). Apart from age and site of surgery, we found the duration of preoperative fluid fasting to be a modifiable precipitating factor for delirium in the recovery room (odds ratio 2.69, 95% confidence interval 1.4–5.2) and on the ward (odds ratio 10.57, 95% confidence interval 1.4–78.6) and the choice of intraoperative opioid for delirium on the ward (odds ratio 2.27, 95% confidence interval 1.0–5.1). Conclusion Duration of preoperative fluid fasting and the choice of intraoperative analgesic are risk factors for postoperative delirium, and their modification provides a promising approach to reduce the incidence of postoperative delirium.

Independent risk factors for postoperative pain in need of intervention early after awakening from general anaesthesia

Despite advances in postoperative pain management, the proportion of patients with moderate to severe postoperative pain is still ranging 20–80%. In this retrospective study, we investigated 1736 patients to determine the incidence of postoperative pain in need of intervention (PPINI)defined as numeric rating scale >4 at rest in the post anaesthesia care unit early after awakening from general anaesthesia, and to identify possible risk factors. The proportion of patients with PPINI was 28.5%. On multivariate analysis, younger age (OR = 1.300 [1.007–1.678], p = 0.044), female gender (OR = 1.494 [1.138–1.962], p = 0.004), obesity (OR = 1.683 [1.226–2.310], p = 0.001), use of nitrous oxide (OR = 1.621 [1.110–2.366], p = 0.012), longer duration of surgery (OR = 1.165 [1.050–1.292], p = 0.004), location of surgery (musculoskeletal OR = 2.026 [1.326–3.095], p = 0.001; intraabdominal OR = 1.869 [1.148–3.043], p = 0.012), and ASA‐PS I–II (OR = 1.519 [1.131–2.039], P = 0.005) were identified as independent risk factors for PPINI. Patients with PPINI experienced significantly more PONV (10.3% vs. 6.2%, p = 0.003), more psychomotor agitation (5.5% vs. 2.7%, p = 0.004), needed more application of opioid in PACU (62.8% vs. 24.2%, p < 0.001), stayed significantly longer in PACU (89.6 min [70–120] vs. 80 min [60–100], p < 0.001), had a longer median length of hospital stay (6.6 days [4.0–8.8] vs. 6.0 days [3.2–7.8]], p < 0.001), and longer postoperative stay (5.0 days [3.0–6.5] vs. 4.1 days [2.5–5.8], p < 0.001]). Patients with PPINI required more piritramid (8.0 mg [5.0–12.0] vs. 5.0 mg [3.0–7.8], p < 0.001) in PACU than patients without. The identification of patients at high risk for immediate postoperative pain in need of intervention would enable the formation of effective postoperative pain management programs.

A Comparison of Three Scores to Screen for Delirium on the Surgical Ward

BackgroundPostoperative delirium is associated with adverse outcome. The aim of this study was to find a valid and easy-to-use tool to screen for postoperative delirium on the surgical ward.MethodsData were collected from 88 patients who underwent elective surgery. Delirium screening was performed daily until the sixth postoperative day using the Confusion Assessment Method (CAM), the Nursing Delirium Screening Scale (Nu-DESC), and the Delirium Detection Score (DDS), and the DSM-IV criteria as the gold standard.ResultsSeventeen of 88 patients (19%) developed delirium on at least one of the postoperative days according to the gold standard. The DDS scored positive for 40 (45%) patients, the CAM for 15 (17%), and the Nu-DESC for 28 (32%) patients. Sensitivity and specificity were 0.71 and 0.87 for the DDS, 0.75 and 1.00 for the CAM, and 0.98 and 0.92 for the Nu-DESC. The interrater reliability was 0.83 for the Nu-DESC, 0.77 for the DDS, and 1.00 for the CAM.ConclusionsAll scores showed high specificity but differed in their sensitivity. The Nu-DESC proved to be the most sensitive test for screening for a postoperative delirium on the surgical ward followed by the CAM and DDS when compared to the gold standard.

[The Intensive Care Delirium Screening Checklist (ICDSC)--translation and validation of intensive care delirium checklist in accordance with guidelines].

BACKGROUND Although Delirium is the most common psychiatric disease in ICU settings, it is recognized late or not at all in up to 84 % of all cases. METHODS Translation of the ICDSC, in accordance with ISPOR guidelines and validation by conducting a screening of 68 ICU patients. RESULTS The translation process was authorized by the original author. The final German translation of the ICDSC showed a sensitivity and specificity of 89 % and 57 % respectively. CONCLUSION The ICDSC is suitable for delirium screening by nurses even on ventilated patients. Besides a high sensitivity another advantage is the possibility to screen for a subsyndromal delirium.

Die Nursing Delirium Screening Scale (Nu–DESC) – Richtlinienkonforme Übersetzung für den deutschsprachigen Raum

BACKGROUND Both in the recovery room as well as in the intensive care unit post-operative delirium is the most common psychiatric disease. The post-operative delirium is stated in literature to occur in 15 % to 50 % of patients, whereby up to 80 % of patients requiring intensive care with artificial respiration develop a delirium. The delirium correlates with the length of hospital stay and leads to a tripple rate of the six-month-mortality. Nu-DESC, developed by Gaudreau et al. is a measuring instrument for the clinical diagnostics of deliriums which is quickly operable, care-based and which can thus be easily integrated in everyday routine. The aim of this study was the translation of Nu-DESC from English as basis for the use in clinical research and routine. MATERIALS AND METHODS The translation process was conducted in accordance with the internationally acknowledged guidelines of Translation and Cultural Adaptation of Patient Reported Outcomes Measures - Principles of Good Practice (PGP). An interim German version was developed from 3 independently devised translations, a back-translation of which was then conducted by a registered state-approved translator. The back-translation was then presented to the author of the original for evaluation. RESULTS The back-translation of the German translation was authorised by the author of the original. On the basis of the cognitive debriefing results which were consistently very good to good, the translation process could be finalised and the final German version of Nu-DESC could be passed by the expert team. An evaluation of the German Nu-DESC regarding its practicability showed significant differences between doctors and nursing staff. CONCLUSION The German version of Nu-DESC provides an instrument for evaluating the delirium in the area of clinical routine and research.

Documentation of Post-operative Nausea and Vomiting in Routine Clinical Practice:

This study investigated the quality of documentation of post-operative nausea and vomiting (PONV) by comparing incidences collected by a research team with those reported routinely by nursing personnel. A total of 560 patients passing through an interdisciplinary recovery room were included in the study. The overall recorded incidence of PONV over 24 h was 30.7%, which was in agreement with the predicted value of 32% calculated using incidences from published randomized controlled trials. Out of the total number of 86 cases of PONV in the recovery room only 36 (42%) were detected by nursing staff. Similarly, out of the total number of 129 cases of PONV on the ward over 24 h, only 37 (29%) were recognized by nursing staff during routine care. In conclusion, PONV in routine clinical care is likely to be under-reported. To use PONV as a valid quality measure, patients need to be actively asked about nausea and vomiting at frequent intervals in a standardized fashion. A considerable proportion of patients experience PONV after discharge from the recovery room, so the assessment of PONV should cover at least 24 h post-operatively

Einhaltung der Behandlungsrichtlinien für postoperative Übelkeit und Erbrechen

BACKGROUND In order to reduce the incidence of postoperative nausea and vomiting (PONV) a standard operating procedure (SOP) was developed in our department. This consists basically in the administration of one antiemetic intervention for moderate risk (2 risk factors), two interventions for high risk (3-4 risk factors) and no prophylaxis in patients who have no or only one risk factor. The aim of this study was to find out whether PONV prophylaxis according to our SOP was followed and led to a lower incidence of PONV. METHOD AND PATIENTS A total of 2,729 patients were examined in a prospective observational study with post-ad hoc analysis in our department. Inclusion criteria were age over 14 years after general anesthesia and postoperative care in the recovery room. This group was examined in relation to compliance with the SOP. RESULTS A total of 725 (26.6%), 1050 (38.5%) and 954 (35.0%) patients were grouped according to risk classification into groups with low, medium and high risks, respectively. An SOP compliant regime occurred in 668 patients (92.1%) of the low risk groups, in 373 patients (35.6%) of the moderate risk group and 177 patients (18.6%) of patients at high risk for PONV. In the high risk group 565 patients (59.2%) received at least one antiemetic medication. Patients with PONV were on average cared for 12 min longer in the recovery room (p=0.048). CONCLUSION Patients with medium and high risk have a lower incidence of PONV than expected per risk calculation by complying with the SOP. However, the recommended risk-adapted approach was inadequately implemented. Considering this there is room for improvement. Moreover taking into account these implementation issues a general PONV prophylaxis may be beneficial.

Remifentanil Reduces the Incidence of Post-Operative Delirium

A secondary exploratory analysis of data from an observational study was used to study the influence of the opioid used for intraoperative anaesthesia on the incidence of post-operative delirium. Patients who had been admitted to the recovery room following elective general anaesthesia were divided into those who had received fentanyl or remifentanil. For unbiased patient analysis, matched pairs were built with respect to gender, age, physical status, anaesthetic type and surgery duration. In 752 patients, the overall incidence of delirium was 9.9% in the recovery room and 3.8% on the first post-operative day. Compared with the remifentanil group, the fentanyl group had a significantly higher incidence of delirium in the recovery room (12.2% versus 7.7%) and on the first post-operative day (5.8% versus 1.9%). Delirium in the recovery room and on the first post-operative day were both associated with a significantly prolonged post-operative hospital stay. The choice of intraoperative opioid influences the incidence of post-operative delirium. Remifentanil was associated with a lower incidence of post-operative delirium in the early post-operative period.