Do you:
1) Advise regional anesthesia instead of a GA?
2) Choose a specific anesthetic regime if a GA is required?
3) Manage the patient as if they were a neurosurgical case with tight control of ET CO2?
4) Carefully control hemodynamics and +/- consider transfusion more than you would otherwise?
5) Recommend that surgery not be undertaken for purely elective procedures?
Some other strategy for management?
The prevention of delirium is much more complex than just the choice of intra-operative anaesthetic. However, I generally advise regional anaesthesia instead of a GA.
The holistic approach also requires nutritional support (e.g. thiamine), assessment for and correction of metabolic derangements (e.g. hyponatraemia), avoidance of withdrawal symptoms (e.g. from alcohol or analgesics etc.) and prevention of urinary retention and constipation.
Delirium is a common but often undiagnosed complication in the elderly following a major operation. Initial treatment of delirium should be with environmental and supportive measures which can be instituted as preventative in patients with multiple risk factors. Subsequently, pharmacologic treatment is implemented.
I always recommend spinal anesthesia in preference to general anesthesia for surgeries of the lower half of the body where it is appropriate. I have often combined spinal analgesia with general anesthesia to optimize control of the stress mechanism. I am not, however, a fan of the "surgical home" idea, because most of the time this approach entails multiple blocks, any of which can fail, so the approach isn't reliable. In addition, there is the problem of LAST (toxicity) and nerve damage, which is minimal in the case of spinal analgesia.
Except it's on emergency. If the surgery is amenable to regional it will be the best option
2 I recommend specific anesthetic regime for general anaesthesia with specific hemodynamic and etco2 care
Target absolute stability in cardiac output and arterial pressure, and optimize analgesia with locoregional approach
I prefer GA with good control of ETCO2...
For Lower extremities I prefer central neuraxial block with minimal sedation...
Perfect metabolic, fluid, cardiovasc, pain control with regional/ local anaesthesia (if feasible) and constant gentle verbal communication during procedure with minimal/no sedation. Early mobilisation and family involvement to minimize disorientation.
Early communication post op at first hint of delirium so it is Ix'd & Rx'd as an emergency with any detected aberrations corrected. immed.
I will prefer regional anesthesia with good control of hemodynamic.
For patients known to have delirium, avoid general anesthesia as much as possible and proceed with regional anesthesia or central neuraxial block. Mimimim use of narcotics, midazolam or other benzodiazipams, and keeping inhalational agents on minimum MAC can avoide postoperative delirium along with use of EEG
I use EEG and spectrogram monitoring to avoid overdoses and burst suppression. "It raises several important points regarding the potential for cerebral monitoring to identify patients who may be at risk for significant postoperative neurologic complications, including delirium and postoperative cognitive dysfunction" https://pubs.asahq.org/anesthesiology/article-abstract/134/2/351/114648/Burst-suppression-and-Postoperative-Delirium?redirectedFrom=fulltext
1Regional anaesthesia can be given with added TIVA or sedation
2 In GA patient should be given balanced anaesthesia with analgesia amnesia and relaxation
3 EtCo2 monitoring is must but tight hyperventilation not given
4 drugs causing delirium should be avoided or if in case required should be given with caution
5 pt with high risk delirium has high probability of post operative delirium do patient should be examined and evaluate about risk benefit of surgery
6 Haloperidol can be given in post operative period if required
Regional whenever indicated and possible;
if generall, give them a slug of dexmedetomidine, keep them normocarbic and warm and titrate anesthesia sedation level with a BIS monitor and shoot for around 50; make sure their bladder is empty and I prefer propofol if possible; otherwise SEVO.
Thanks for the interest in this question and the multiple responses. Believe this remains one of the most important ‘open’ questions in clinical anesthesia.
Lots of hand wringing by anaesthetists but good general medical care peri-op would seem far more impt. eg. if you don't pick EtOh withdrawal doesn't matter how good the anaersthetic is
There is a multitude of strictly pathophysiology- related factors to look after as ascribed above by others. Part of it is abolishment of fear. This so called "soft " science is underestimated in the society, but then we need to decide what life is about. I often find patients requiring general anesthesia, because the anticipation is there. I choose individually and/or in combination.
1: Agree with the common considerations to look for correction of all correctable causes of Delirium, importance of Perfusion and oxygenation of BRAIN. 2:Hypo active delirium may be missed out as patient is inactive. 3: Keeping in Mind that imbalance of Acetyl Choline and Dopamine in Reticular Activating system as the Main component of DELRIUM, when Central neuraxial Blocks especially Spinal Anaesthesia is used use of NEOSTIGMINE makes less risk for Post operative Delirium.
Article Risk and safety concerns in anesthesiology practice: The pre...
One commonly missed risk factor for postoperative delirium is alcohol or other drug use. Abrupt discontinuation of any of the sedative class of drugs can resulting in postoperative delirium. In fact, even withdrawal from non sedating drugs can, in the fragile or elderly patient result in a complicated postoperative course. This is best identified during a perioperative assessment or when other stigmata of drug use is identified.
Chronic benzodiazepin use and alcohol are the most common offenders.
I agree with Douglas Gourlay a careful pre-anaesthesia assessment is required to detect substance misuse. However, some patients are not forthcoming with this information. Another cause of post-operative delirium is urinary retention. I was taught that I should always percuss the bladder if called to see an agitated patient. These days I do a quick Bladderscan or bedside ultrasound.
Article Midazolam-Induced Hyperactivity Treated with Flumazenil
It is also important to recognize that, somewhat paradoxically, benzodiazipines can also cause agitation. Benzodiazipine-induced agitation can be treated with flumazenil but this should be used with caution.
aprupt discontinuation alcohol or any other drug abuse may confuse with POD
in terms of preop assessment of at-risk population it can sometimes be inferred from the type of surgery. For example, I had a case of post op delerium in a pneumonectomy in the ICU. They would settle down with a bit of benzos but clearly a difficult course. The key that the attending didn't appreciate was the reason for the surgery and the associated "possible" comorbid risks. The surgery was for lung cancer due to smoking. Smokers often use alcohol.... Alcoholics are often treated (incorrectly) by well intended GP's who give benzos thinking "benzo's are better than booze." A quick talk with the wife made the situation clear....
This would have been avoided with a careful preop history. The myth is people always lie about their drug/alcohol use... Actually, people don't lie about what they think is normal. The most common reason we don't know is "we don't ask"
(sorry for the length of the post!)
I am preparing to publish a book called “50 Years Lost in Medical Advance” via Amazon no later than October 10th that describes the discovery of the mammalian stress mechanism and reviews its implications. It includes my report documenting how the combined benefits of fentanyl analgesia and hypercarbia optimize tissue oxygenation and surgical outcome. It also reviews what I call “The Great Medical Hoax of the 20th Century” that has disrupted medical progress since the introduction of the harmful Leake-Waters general anesthesia technique of paralysis and hyperventilation that is inherently harmful and incompatible with beneficial narcotic analgesia. Postoperative delirium and dementia are primarily caused by anesthetic mis-management due to hyperventilation that depletes carbon dioxide tissue reserves and decreases brain perfusion and oxygenation, plus inadequate analgesia to prevent harmful nociception during surgery.
@W. Alan C. Mutch,
Dear Prof. Mutch,
It depends on multiple factors.
The type of surgery, associated comorbidities, the place of potential postoperative care, need for prolonged postoperative ventilation and hospital stay and the patient' s preference.
Regional anaesthesia is preferable to GA provided surgery and consent allow so.
Adequate analgesia, maintaining adequate volume status, glycemic and electrolyte balance, avoid postoperative infection, avoidance of long term benzodiazepines, monitoring for withdrawal effects for the patients who were on alcohol and recreational drugs are all important.
If somehow end up giving a GA, perioperative care targeting the mentioned goals should be carried out. I would have a lengthy discussion with the patient and the relative about the risk of postoperative delirium. Psychiatric analysis by preop referral, preparation and postoperative plan will be laid down. I would try to avoid ketamineduring induction unless indicated. For analgesia, a multimodal regimen involving epidural or a nerve block with titrated systemic opiates will be utilized. Heamodynamics will be maintained. I would do an Arterial blood gas analysis to identify and correct electrolyte or acid base alteration before extubation ( depending on the duration of the surgery).
