If a treatable underlying cause for early postoperative delirium is not identified, non-pharmacological interventions are indicated. Calm reassurance and orientation may be helpful for the surgical patient. Reassurance to the patient that they are safe is often beneficial. Reorientation to time, place, and situation should be repeated as needed. Limiting unnecessary stimulation including noise from loud talking and monitor alarms may also help. Restoration of sensory input by returning glasses or hearing aids, if applicable, should also be attempted. Although not formally studied in the early postoperative setting, simple non-pharmacological interventions shortened both the duration and severity of delirium in hospitalized medical patients.[28] The risk–benefit ratio favors these benign interventions for delirium in the PACU not caused by a reversible underlying cause in a patient who is not so agitated as to pose a danger to self or staff.
If pharmacological treatment of early postoperative delirium is needed, physostigmine 0.5 mg to 2 mg IV (not faster than 1 mg per minute) is efficacious in reversing CNS anticholinergic effects. Physostigmine can cause bradycardia and asystole, particularly with too rapid injection. Caution is needed in patients with reactive airway disease because of the risk of bronchospasm. Rigidity and tremors can be exacerbated in patients with Parkinson’s disease. Haloperidol 1–2 mg IV may be considered. Side effects include sedation, tardive dyskinesia, priapism, malignant neuroleptic syndrome, dry mouth, and QT prolongation. Haloperidol is also contraindicated in Parkinson’s disease. The pharmacological treatment of early postoperative delirium should be reserved for only the most severe cases.
Postoperative delirium management: Delirium in the surgical patient that presents after the early postoperative period requires special management. Therapeutic goals are to decrease the duration and/or severity of the delirium while ensuring patient safety. Non-pharmacological interventions in medical patients with delirium including reorientation, reassurance, cognitive stimulation, sleep hygiene, improvement of hearing or visual impairment, and correction of dehydration have been demonstrated to be both efficacious and cost-effective.[29] Guidelines for the treatment of delirium in medical patients include sleep promotion by noise and lighting regulation, avoidance of unnecessary polypharmacy, hydration with associated electrolyte correction, and prophylaxis for alcohol withdrawal for at-risk patients.[30]
Towards this aim, the American Geriatrics Society issued Clinical Practice Guidelines for Postoperative Delirium in November 2014.[31] While limited to the older adult patient, this represents the first attempt by a medical organization to offer guidelines for postoperative delirium specifically. Although the aim was to construct evidence-based recommendations, the quality of evidence underlying nearly all the recommendations was low. The recommendation for institutions to establish interdisciplinary (physician, nurses, ancillary staff) teams to deliver multicomponent non-pharmacological interventions was deemed to be supported by moderate evidence. Despite a paucity of evidence, the panel did agree upon several strong recommendations. These included formal education for staff to recognize and treat delirium in the postoperative patient, medical evaluation of the delirious patient, opioid-sparing multimodal analgesia, and the avoidance of the routine use of cholinesterase inhibitors to treat or prevent delirium. The routine use of benzodiazepines was strongly discouraged, except to treat benzodiazipine or alcohol withdrawal syndrome.[31]
References
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