Sedation Depth During Spinal Anesthesia and the Development of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Repair

Sieber, Frederick E.; Zakriya, Khwaji J.; Gottschalk, Allan; Blute, Mary Rita; Lee, Ho-Chang; Rosenberg, Paul B.; Mears, Simon C.

doi:10.4065/mcp.2009.0469

Cited by 378 publications

(307 citation statements)

References 65 publications

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“…However, direct research comparison of 'regional' vs 'general' anaesthesia is a complex issue [80], and many questions remain unanswered, for example, such as whether general anaesthesia should involve intubation/mechanical ventilation, co-administration of peripheral nerve blockade and age-adjusted administration of inhalational/intravenous agents, or whether intrathecal/epidural anaesthesia should be administered after peripheral nerve blockade or sedation [81] or at lower doses [82].…”

Section: Intra-operative Managementmentioning

confidence: 99%

Emergency surgery: the big three – abdominal aortic aneurysm, laparotomy and hip fracture

2013

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SummaryNational reports recommended that peri-operative care should be improved for elderly patients undergoing emergency surgery. Postoperative mortality and morbidity rates remain high, and indicate that emergency ruptured aneurysm repair, laparotomy and hip fracture fixation are high-risk procedures undertaken on elderly patients with limited physiological reserve. National audits have reported variations in care quality, data that are increasingly being used to drive quality improvement through professional guidance. Given that the number of elderly patients presenting for emergency surgery is likely to rise as the population ages, this review summarises the evidence on which such guidance is based, and provides information about how anaesthetists might participate in audit and research aimed at improving local and national outcomes for these most vulnerable of patients. More recently, national audits have reported several-fold variations in the care of elderly emergency surgical patients in the UK [4][5][6], and importantly, these data are beginning to be used to drive quality improvement [11] through professional guidance [12][13][14] that advocates early, focused, multidisciplinary 70

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Section: Intra-operative Managementmentioning

confidence: 99%

Emergency surgery: the big three – abdominal aortic aneurysm, laparotomy and hip fracture

2013

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“…42 Rates of delirium were similar in those randomly assigned to nitrous oxide or to air oxygen supplementation (41.9% vs 43.8%, respectively; P = 0.78). Finally, a double-blind RCT 43 examined whether depth of sedation with propofol altered rates of delirium in elderly patients undergoing hip fracture repair under spinal anesthesia. A light level of sedation corresponded to a bispectral index (BIS) value of 80 or higher, while a deep level of sedation corresponded to a BIS value of approximately 50.…”

Section: Anesthetic Drug Choice and Depth Of Sedationmentioning

confidence: 99%

Postoperative delirium: risk factors and management: Continuing Professional Development

Chaput

Bryson

2012

Can J Anesth/J Can Anesth

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Purpose Postoperative delirium often remains undiagnosed and therefore untreated. The purpose of this continuing professional development module is to identify patients at high risk of developing delirium following noncardiac surgery and to provide tools to aid in the diagnosis of delirium at the bedside. Optimal prevention and treatment strategies are recommended. Principal findings Delirium is characterized by an acute onset and a fluctuating course, inattention, disorganized thinking and an altered level of consciousness, and occurs in up to 40% of patients in the perioperative period. The pathophysiology of delirium is multifactorial, but it is believed to be related to inflammation, altered neurotransmission, and stress in the patient who has had surgery. Acetylcholine and dopamine appear to play a significant role. There is an increased risk of a poor outcome in patients who develop delirium, including a longer hospital stay and death. Surgical and patient factors play a significant role in predicting who will subsequently develop delirium. Prevention is much more effective than treatment in the management of delirium. The most effective prevention strategies include proactive geriatric assessment and care of the patient on a geriatrics surgical ward as well as prophylactic low-dose antipsychotic agents. From an anesthetic perspective, evidence in some surgical populations would support the use of regional techniques and minimal sedation. If delirium develops, treatment with lowdose oral antipsychotics appears to be most effective.Conclusions Delirium is a serious condition that must be recognized early and treated promptly to minimize deleterious outcomes. In order to institute prevention strategies and treat the condition effectively when it occurs, the anesthesiologist must be vigilant in identifying patients at risk and in screening for this condition. Objectives of this Continuing Professional Development (CPD) module:After reading this module, the reader should be able to:1. Define delirium in the context of other cognitive changes following non-cardiac surgery. 2. Understand the incidence and adverse outcomes associated with delirium. 3. List predisposing and precipitating factors of postoperative delirium and identify the patient at risk. 4. Explain the underlying pathophysiologic mechanisms believed to be implicated in causing delirium. 5. Formulate an anesthetic plan that minimizes the risk of developing postoperative delirium. 6. Devise a management plan to treat postoperative delirium most effectively while minimizing the adverse effects of treatment.Like other Western nations, Canada's population is aging rapidly. Over the past 50 years, the proportion of Canadians over the age of 65 has risen from 7.7% to 13.7%. A Statistics Canada estimates that the proportion of seniors will double 123Can J Anesth/J Can Anesth (2012) 59:304-320 DOI 10.1007 yet again by 2036 and will represent 23-25% of Canada's population. B This rapid demographic shift will impact anesthesiologists and hospitals ...

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“…126,127 Ancelin found that ''Adding sedation to peridural anaesthesia led to a decline in verbal secondary memory,'' 128 and Sieber et al found that lighter sedation during spine surgery led to less delirium. 129 Again, there are empirical and neuropathological reasons to suspect a link between delirium, deep sedation, poor neurological outcome, and POCD 101 -109 . .…”

Section: Regional Versus General Anesthesiamentioning

confidence: 99%

“…and there is evidence that patients with the apolipoprotein epsilon 4 allele experience postoperative delirium at more than twice the rate of patients without apolipoprotein epsilon, adding a genetic link to account for some of the variability. 130 If the association between POCD and deep sedation had been discovered before the association between POCD and general anesthesia, perhaps we would have come more readily to the hypothesis that lighter anesthesia 119 -122 and deeper sedation 128,129 occupy an equivalent middle ground (approximately BIS [45][46][47][48][49][50][51][52][53][54][55] when it comes to increasing the risk of POCD relative to both lighter sedation (approximately BIS ≥60) and deeper anesthesia (approximately BIS [35][36][37][38][39][40][41][42][43][44][45]. 131 …”

Section: Regional Versus General Anesthesiamentioning

confidence: 99%

Developmental Disability in the Young and Postoperative Cognitive Dysfunction in the Elderly After Anesthesia and Surgery: Do Data Justify Changing Clinical Practice?

Cottrell

Hartung

2012

Mount Sinai J Medicine

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The assumption that anesthesia has no serious, long‐term, adverse central nervous system consequences may be true for most patients between 6 months and 60 years of age. However, for patients younger than 6 months or older than 60 years, that status quo assumption is under challenge from a growing body of evidence. Fetuses and newborns appear to be at risk because systems that would enable them to fully recover from the effects of more than 2 hours of anesthesia are still in development. In distinction, the elderly appear to be at risk because systems that once enabled them to fully recover have ever‐diminishing capacity. Even for those between the age of 6 months and 60 years, full recovery may require replacing apoptosed neurons and pruning overabundant dendritic spines … perhaps leaving patients not quite the same person that they were before they were anesthetized. Mt Sinai J Med 79:75–94, 2012. © 2012 Mount Sinai School of Medicine

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Sedation Depth During Spinal Anesthesia and the Development of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Repair

Cited by 378 publications

References 65 publications

Emergency surgery: the big three – abdominal aortic aneurysm, laparotomy and hip fracture

Emergency surgery: the big three – abdominal aortic aneurysm, laparotomy and hip fracture

Postoperative delirium: risk factors and management: Continuing Professional Development

Developmental Disability in the Young and Postoperative Cognitive Dysfunction in the Elderly After Anesthesia and Surgery: Do Data Justify Changing Clinical Practice?

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