A Adverse cognitive impairment
Impairments in cognitive functioning from disturbances in the brain’s physiology can easily occur in the surgical patient. Neurologic impairment can be devastating in postanesthesia patients in terms of quality of life and activities of daily living. Cognitive functioning is a broad construct that includes a number of categories, including attention span, concentration, judgment, memory, orientation, perception, psychomotor ability, reaction time, and social adaptability. The prevalence of adverse neurologic impairment in surgical patients often results from organic brain disorders; the most common incidences are confusion, delirium, awareness, and (infrequently) coma.
2. Postoperative cognitive dysfunction
a) Postoperative cognitive dysfunction (POCD) is characterized by persistent and long-term deterioration of cognitive performance after anesthesia and surgery.
b) POCD is often associated with cardiac and orthopedic surgery, but it can also accompany other surgical procedures. Cognitive dysfunction in both cardiac and noncardiac surgery has largely focused on older adults, who might have a greater vulnerability to neurologic deterioration as a consequence of the aging process.
c) POCD is difficult to diagnose because it requires sophisticated neurophysiologic testing, including preoperative baseline tests.
d) Patient risk factors include age, lower levels of education, and history of stroke even without residual deficit.
3. Confusion
a) The term confusion is used to describe the general affect and behaviors of patients; however, it is not specific and appears to have a great deal in common with delirium.
b) Confusion (a form of transient cognitive dysfunction) after anesthesia relates to disorders of orientation and is usually a relatively short-lived transient cognitive dysfunction.
4. Postoperative delirium
a) Delirium (or acute mental confusion) is transient, often abrupt and fluctuating, typically reversible, and related to increased risk of postoperative adverse reactions (i.e., pulmonary edema, myocardial infarction, respiratory failure, pneumonia, and death), increased length of hospital stay, increased health care cost, and poor functional and cognitive recovery. The onset occurs in hours to days after anesthesia and surgery.
b) Key symptoms include anxiety, incoherent or disorganized thinking and perceiving, reduced ability to sustain and shift attention to new external stimuli, and agitated behavior. There is sensory misperception; a disordered stream of thought; and difficulty in shifting, focusing, and sustaining attention to both external and internal stimuli. Irrelevant stimuli can easily distract the delirious individual.
c) The cause of postoperative delirium is multifactorial. Virtually any drug with central nervous system effects has been implicated, including narcotics (especially meperidine), benzodiazepines, and drugs that possess anticholinergic properties (except glycopyrrolate). Common are perceptual disturbances that result in misinterpretations, illusions, and hallucinations. Disturbances of sleep–wakefulness and psychomotor activity are present.
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