Evidence-based strategies to reduce the incidence of postoperative delirium: a narrative review

Delirium is one of the most commonly occurring postoperative complications in older adults. It occurs due to the vulnerability of cerebral functioning to pathophysiological stressors. Identification of those at increased risk of developing delirium early in the surgical pathway provides an opportunity for modification of predisposing and precipitating risk factors and effective shared decision-making. No single delirium prediction tool is used widely in surgical settings. Multi-component interventions to prevent delirium involve structured risk factor modification supported by geriatrician input; these are clinically efficacious and cost effective. Barriers to the widespread implementation of such complex interventions exist, resulting in an ‘implementation gap’. There is a lack of evidence for pharmacological prophylaxis for the prevention of delirium. Current evidence suggests that avoidance of peri-operative benzodiazepines, careful titration of anaesthetic depth guided by processed electroencephalogram monitoring and treatment of pain are the most effective strategies to minimise the risk of delirium. Addressing postoperative delirium requires a collaborative, whole pathway approach, beginning with the early identification of those patients who are at risk. The research agenda should continue to examine the potential for pharmacological prophylaxis to prevent delirium while also addressing how successful models of delirium prevention can be translated from one setting to another, underpinned by implementation science methodology.     

Geriatric Comanagement of Older Vascular Surgery Inpatients Reduces Hospital-Acquired Geriatric Syndromes

ObjectiveThis study evaluates the impact of a novel model of care called Geriatric Comanagement of Older Vascular surgery inpatients on clinical outcomes.Design, Setting, and ParticipantsA pre-post study of geriatric comanagement, comparing prospectively recruited preintervention (February–October 2019) and prospectively recruited postintervention (January–December 2020) cohorts. Consecutively admitted vascular surgery patients age ≥65 years at a tertiary academic hospital in Concord and with an expected length of stay (LOS) greater than 2 days were recruited.InterventionA comanagement model where a geriatrician was embedded within the vascular surgery team and delivered proactive comprehensive geriatric assessment based interventions.MethodsPrimary outcomes of incidence of hospital-acquired geriatric syndromes, delirium, and LOS were compared between groups using univariable and multivariable logistic regression analyses. Prespecified subgroup analysis was performed by frailty status.ResultsThere were 150 patients in the preintervention group and 152 patients in the postintervention group. The postintervention group were more frail [66 (43.4%) vs 45 (30.0%)], urgently admitted [72 (47.4%) vs 56 (37.3%)], and nonoperatively managed [52 (34.2%) vs 33 (22.0%)]. These differences were attributed to the coronavirus disease 2019 pandemic during the postintervention phase. The postintervention group had fewer hospital-acquired geriatric syndromes [74 (48.7%) vs 97 (64.7%); P = .005] and reduced incident delirium [5 (3.3%) vs 15 (10.0%); P = .02], in unadjusted and adjusted analyses. Cardiac [8 (5.3%) vs 30 (20.0%); P < .001] and infective complications [4 (2.6%) vs 12 (8.0%); P = .04] were also fewer. LOS was unchanged. Frail patients in the postintervention group experienced significantly fewer geriatric syndromes including delirium.Conclusions and ImplicationsThis is the first prospective study of inpatient geriatric comanagement for older vascular surgery patients. Reductions in hospital-acquired geriatric syndromes including delirium, and cardiac and infective complications were observed after implementing geriatric comanagement. These benefits were also demonstrated in the frail subgroup.     

eCASH理念结合早期活动在ICU机械通气患者的应用研究

目的探讨eCASH理念结合早期活动在ICU机械通气患者中的应用效果。方法将96例ICU机械通气患者按入院时间分为对照组和观察组各48例,对照组给予常规镇痛镇静及护理,观察组实施基于eCASH理念的舒适化浅镇静管理结合早期活动。结果观察组谵妄发生率和ICU获得性衰弱发生率显著低于对照组,MRC肌力评分显著高于对照组,机械通气时间和ICU住院天数显著短于对照组(P0.05,P0.01)。结论 eCASH理念结合早期活动应用于ICU机械通气患者,可降低患者谵妄和ICU获得性衰弱,缩短机械通气和ICU入住时间,促进患者康复。     

加深麻醉对改善 MECT 后谵妄的作用

目的: 将不同麻醉深度下进行无抽搐电休克治疗( MECT) 后的谵妄发生率进行对比研究，探讨加深 麻醉对改善 MECT 后谵妄的作用。方法: 将 2017－09～ 2018－12 期间，在内蒙古精神卫生中心接受 MECT 治疗并 符合入组标准的 116 例精神分裂症病人随机分为 A、B 两组，在治疗中分别给予1．2mg /kg 和1．6mg /kg 的丙泊酚 进行麻醉，对治疗后谵妄发生率进行对比分析。结果: B 组谵妄发生率明显低于 A 组( P＜0．05) 。结论: 适当增 加麻醉深度在同等条件下可以有效降低 MECT 治疗后谵妄的发生。