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354 R.A. Marottoli et al.
Antibiotic Usual dose Dose for CrCl 10–50 ml/min Dose for CrCl <10 ml/min
Cefazolin 1–2
g q8 h 1–2 g q12 h 1–2 g q24–48 h
Cefuroxime 0.75–1.50
g q8 h 0.75–1.50 g q12 h 0.75–1.50 g q24 h
Ceftazidime 2
g q8 h 2 g q12–24 h 2 g q24–48 h
Cefotaxime 2
g q8 h 2 g q12–24 h 2 g q24 h
Penicillin G 0.5–4.0
million units q4 h 75% of dose 20–50% of dose
Ampicillin 1–2
g q6 h 1–2 g q6–12 h 1–2 g q12–24 h
Pipercillin tazobactam 3.375–4.5
g q6–8 h 2.25 g q6 h 2.25 g q8 h
Piperacillin 3–4
g q4–6 h 3–4 g q6–8 h 3–4 g q 8 h
Ticarcillin clavulanate 3.1
g q4 h 3.1 g q8–12 h 2 g q12 h
Aztreonam 2
g q8 h 50–75% of dose 25% of dose
Ertapenem 1
g q24 h 0.5 g q24 h 0.5 g q24 h
Imipenem cilastatin 0.5
g q6 h 0.25 g q6–12 h 0.125–0.25 g q12 h
Metronidazole 7.5
mg/kg q6 h 7.5 mg/kg q6 h 50% of dose
Vancomycin 1
g q12 h 1 g q 24–96 h 1 g q4–7 days
Gentamicin 1.7
mg/kg q8 h 1.7 mg/kg q12–24 h 1.7 mg/kg q48 h
Amikacin 7.5
mg/kg q12 h 7.5 mg/kg q24 h 7.5 mg/kg q48 h
Amphotericin B 0.4–1
mg/kg q24 h 0.4–1 mg/kg q24 h 0.4–1 mg/kg q24 h
Fluconazole 100–400
mg q24 h 50% of dose 50% of dose
Ciprofloxacin (IV) 400 mg q12 h 400 mg q12–24 h 400 mg q18–24 h
Source: Data from [
84]
CrCl creatinine clearance
T
a b l e 27.8 Selected antibiotics requiring
dose adjustment in the presence of severe
hepatic dysfunction
Nafcillin
Cefoperazone
Clindamycin
Erythromycin
Ketoconazole
Rifampin
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Ta b l e 27.7 Selected antibiotics requiring dose adjustment during renal insufficiency
increases in incidence from 2.8/1,000 in patients <35 years
old to 7.7/1,000 in patients ³55 years old [86, 93]. Therefore,
liver function tests must be performed frequently prior to and
during the course of antituberculous therapy. Antibiotics that
require dose adjustments in patients with hepatic dysfunction
include cefoperazone, clindamycin, erythromycin, isoniazid,
ketoconazole, nafcillin, and rifampin (Table 27.8).
b-Lactam antibiotics (penicillins, cephalosporins,
cephamycins, carbapenems, and monobactams) have varying
characteristics of absorption, peak concentration, bioavailability, and metabolism. These topics are described in detail
in standard texts and are not covered here. In general, bioavailability is relatively poor after oral administration, which
has implications for the switch from intravenous to oral preparations, and pharmacokinetics are similar after intramuscular or intravenous administration [83].
Cephalosporins are relatively safe drugs to use in older
persons. Dosages for certain cephalosporins need adjustment
for renal insufficiency (Table 27.7). The broad spectrum of
activity of ceftriaxone together with its convenient oncedaily dosing make it an ideal drug for empiric use in a variety
of clinical infections in the older adults [94, 95]. In addition,
it has both renal and biliary excretion and as a result needs
little adjustment for renal insufficiency. A lesser known side
effect of ceftriaxone is the formation of biliary sludge with
prolonged use [96].
Cefoperazone, a third-generation cephalosporin still in use
especially for the treatment of intra-abdominal infections, has
primarily biliary excretion and needs no adjustment for renal
insufficiency; however, it can cause elevation of the prothrombin time [97]. This side effect is particularly important
in the surgical patient. There are three proposed mechanisms
of cephalosporin-associated hypoprothrombinemia, two of
which involve the N-methylthiotetrazole (NMTT) moiety.
The most plausible mechanism is NMTT inhibition of vitamin K epoxide reductase in the liver. Patients at increased
risk for this adverse event include those with low vitamin K
stores, specifically patients who are malnourished with low
albumin concentrations and poor food intake. The elderly and
patients with liver or renal dysfunction are examples of populations at potential risk. The manufacturer therefore recommends concomitant use of vitamin K once a week during
cefoperazone administration, although epidemiologic studies
suggest that bleeding complications with antibiotics in general may have more to do with other risk factors than the
specific antibiotic [98–101]. It should also be noted that
cefoperazone causes a mild disulfiram-like reaction when
given within 72 h of alcohol ingestion.
Carbapenems (imipenem cilastatin, meropenem, and ertapenem) are a widely used class of drugs especially in the postoperative patient because of their broad spectrum of activity.
Their pharmacokinetics are similar to that of cephalosporins,
and they require dose adjustment for renal insufficiency
35527 Drug Usage in Surgical Patients: Preventing Medication-Related Problems
https://t.me/med1917
because they are excreted renally. The cilastatin component of
imipenem cilastatin has no antibacterial activity, but is used to
inhibit renal tubular metabolism of imipenem, thereby increasing the urinary concentration of the active drug. Major adverse
effects of the carbapenems, especially imipenem cilastatin,
are related to the CNS, including seizures, somnolence, and
confusion [102]. This is more likely to occur in the elderly
with a history of a CNS lesion, prior seizure disorder, or renal
failure.
Aztreonam is a monobactam that has only aerobic gramnegative bacterial coverage. Its pharmacokinetics are similar
to that of the cephalosporins. It is frequently used in patients
with renal insufficiency as a substitute for aminoglycosides,
although it too needs dose adjustment in such patients. Its
use in combination with b-lactam antibiotics for synergy (as
with aminoglycosides for enterococcal or pseudomonal
infections), however, has not been validated. It lacks crossreactivity with other b-lactam antibiotics and can be used
safely in patients with severe allergy to penicillin or cephalosporins [103, 104].
The fluorinated quinolones have gained wide usage during the past few decades. Compared with the older quinolones (norfloxacin and ciprofloxacin), the third- and
fourth-generation quinolones (ofloxacin, levofloxacin, and
moxifloxacin) have a broad spectrum of aerobic grampositive and gram-negative bacterial activity along with the
same excellent pharmacokinetic profile. The gram-positive
coverage, especially in vitro activity against Streptococcus
pneumoniae, of the earlier quinolones (ciprofloxacin) is not
as good as that of the new generation of quinolones. In addition, they are active against intracellular organisms such as
Legionella, Mycoplasma, Chlamydia, and Mycobacteria.
They are well absorbed orally, with a high degree of bioavailability that makes them especially useful drugs in the
transition from intravenous to oral dosing. They also have
excellent tissue penetration. Care should be taken with the
oral administration of these drugs to ensure that they are
administered 2 h before or after antacids, sucralfate, or other
multivalent metallic cations as their absorption can be
severely impaired [105, 106]. Renally eliminated fluoroquinolones (ofloxacin and levofloxacin) need to be dose-adjusted
when the creatinine clearance is <50 ml/min.
Along with the increased usage of this class of antibiotics,
there have been reports of specific side effects when prescribing these drugs in older adults. Certain quinolones can
cause QT interval prolongation. They should be avoided in
patients with known prolongation of the QT interval, patients
with uncorrected hypokalemia or hypomagnesemia, and
patients receiving Class I or Class II antiarrhythmic drugs
[107]. Elderly patients on corticosteroids, especially in the
setting of chronic renal insufficiency, are also at risk for
Achilles tendon rupture [108]. An important and welldocumented drug interaction of quinolones with warfarin
is particularly noteworthy in the postsurgical patient. The
prothrombin time (PT) and INR need to be closely monitored
to prevent bleeding complications [109, 110].
With the current escalating problem of antibiotic resistance and the increase in the numbers of resistant grampositive infections (methicillin resistant Staphylococcus
aureus and vancomycin resistant enterococci), several new
antibiotics have been introduced in the past decade as an
alternative to vancomycin. Linezolid and quinupristin dalfopristin are two such antibiotics. Linezolid, a fluorinated
oxazolidinone active against gram-positive organisms, is a
nonselective inhibitor of monoamine oxidase (MAOI). In the
elderly patient with the potential for polypharmacy as discussed above, drug interactions need to be kept in mind when
using this antibiotic. Linezolid is on the list of drugs with
serotonergic activity that may cause serotonin syndrome – a
potentially preventable complex of symptoms that may be
fatal if not recognized early. The most common drug combinations associated with serotonin syndrome are MAOIs with
selective serotonin reuptake inhibitors (SSRIs). Since SSRIs
are frequently used for the treatment of depression, this is an
important drug interaction to keep in mind [111–113].
No discussion of antibiotic use is complete without mention of Clostridium difficile-associated diarrhea (CDAD) – a
challenge in the care of all hospitalized patients, particularly
older ones. Surgical patients comprise 55–75% of all patients
with CDAD [114]. Initial treatment regimens remain the
same in this population and include oral metronidazole
(cheap and effective) or oral vancomycin (expensive and
concern for antibiotic resistance); however, there is an
increased frequency of treatment failure and CDAD recurrence among elderly persons. Prolonged, tapering course of
antibiotics, treatment with anion exchange resins, oral lactobacillus, or nonpathogenic yeast such as Saccharomyces
boulardii and fecal transplants (enema with feces from
healthy donors) or combinations of the above may need to be
considered. None of these regimens has been proven superior to the others [115].
Summary
A number of factors can potentially influence the risk-benefit
equation for drug use in an older population, including agerelated physiologic changes in organ system function;
increased likelihood of comorbid diseases affecting organ
systems that are the intended site of drug action or are responsible for the metabolism or clearance of a drug; and increased
likelihood of multiple chronic medications, which may
increase the possibility of drug interactions. However, the
vast majority of drugs can be used safely and effectively in
older surgical patients if appropriate precautions are taken in
the selection, dosing, and timing of drugs and in the active
monitoring of effects and side effects.
356 R.A. Marottoli et al.
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4-quinolones in the aged. Rev Infect Dis 11(suppl 5):S1102–S1106
107. Stahlmann R, Lode H (2003) Fluoroquinolones in the elderly:
safety considerations. Drugs Aging 20(4):289–302
108. van der Linden PD, Sturkenboom MC, Herings RM et al (2003)
Increased risk of achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids.
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109. Holbrook AM, Pereira JA, Labiris R et al (2005) Systematic overview of warfarin and its drug and food interactions. Arch Intern
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110. Jones CB, Fugate SE (2002) Levofloxacin and warfarin interaction. Ann Pharmacother 36:1554–1557
111. Huang V, Gortney JS (2006) Risk of serotonin syndrome with concomitant administration of linezolid and serotonin agonists.
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linezolid and selective serotonin reuptake inhibitors: case report
involving sertraline and review of the literature. Pharmacotherapy
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drug interactions: a retrospective survey. Clin Infect Dis 43:180–187
114. Jobe BA, Grasley A, Deveney KE et al (1995) Clostridium difficile
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Chapter 28
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Invited Commentary
Donald D. Trunkey
Injury in the elderly is increasing, and we now see a bimodal
distribution of injury deaths. The first peak in death rates is
in the 16 to 24 age group, and the second is after the age of
60. This increase in the number of elderly patients is due in
no small part to the fact that they are more active, continue to
drive, and remain involved in some risk-taking sports, such
as skiing and driving motorcycles. One can ask, “When does
‘old age’ begin?” If one reviews the National Trauma Data
Bank maintained by the American College of Surgeons,
there appears to be an increase in deaths after the age of 45.
I wish to emphasize the variability in the physiologic changes
that occur in the aged. The most common comorbidities that
I see are cirrhosis, smoking, heart disease, and chronic
obstructive pulmonary disease.
There have been many recent changes in the management
of shock and hemotherapy. One has to be careful in analyzing and applying some of these changes to the elderly. Data
from Iraq and Afghanistan have confirmed what Cannon
observed in World War I. It is important not to over-resuscitate the patient prior to surgical control of bleeding. The military studies show that minimal pre-hospital fluid should be
given, corroborating Cannon’s data in that keeping the blood
pressure above 85 mm/Hg is optimal. However, this may not
be applicable or should be modified in the case of elderly
patients who have arterial sclerosis or congestive heart failure. One of the more dramatic changes shown recently by
our military is in hemotherapy. During World War I, Cannon
used whole blood. The component therapy data from
Operation Enduring Freedom and Operation Iraqi Freedom
have been modified to reflect a 1:1:1 ratio of packed red
blood cells, fresh frozen plasma, and platelets and provide a
statistically better outcome when compared to the earlier
management of components. An even better outcome can be
achieved with whole blood, which most surgeons believe to
be the appropriate fluid to give for hypovolemic shock.
D.D. Trunkey (*)
Department of Surgery, Oregon Health and Science University,
Portland, OR 97239, USA
e-mail: trunkeyd@ohsu.edu
Another concept that is gaining credibility is the prevention
and treatment of compartment syndromes. Compartment syndromes can occur in the cranial vault, hemithoraces, abdomen,
pelvis, and the extremities. Neurosurgery has rightly pointed
out the ravages of compartment syndrome within the cranial
vault, and there has been aggressive management in the form
of evacuation of hematomas, and even craniectomy. These
problems are aggravated in the elderly because many of them
come into the emergency room after major injury and are on
Warfarin, Plavix, or aspirin. Although rapid reversal of these
compounds is desirable, it is fraught with difficulties, particularly if one uses vitamin K, fresh frozen plasma, or platelets.
These all take time to reverse. Some centers have used lowdose Factor VII with promising results, but there is the downside of increased thrombosis. Compartment syndromes,
including air and blood within either hemithorax can usually
be addressed once the patient arrives at the emergency department, but in some instances, can be relieved (tension) in the
pre-hospital care. The compartment syndromes that develop
in the abdomen and pelvis are partly preventable by prudent
limitation of over-resuscitation, but in some instances will
require leaving the abdomen open, packing the pelvis temporarily to gain hemostasis, and repeated damage control until
the abdomen can be closed either primarily or at a later date
after temporary closure with synthetic material.
A related issue is the triad of coagulopathy, hypothermia,
and acidosis, which is often a complication of resuscitation.
Oftentimes, this is preventable. Warming the patient should
start in the prehospital setting, and acidosis can be partially
ameliorated by use of balanced salt solutions. In the emergency room, this triad must be recognized early and aggressively addressed.
A particularly contentious issue in the elderly is futility of
care in the emergency room and the ICU. This includes both
quantitative and qualitative futility. Examples of quantitatively futile care would include full ventilatory support of a
patient with documented brain death or an instance where
there is no precedent for survival. Qualitative futility describes
the nature of function following survival of a devastating
insult. The descriptors of qualitative futility are dependent on
R.A. Rosenthal et al. (eds.), Principles and Practice of Geriatric Surgery,
DOI 10.1007/978-1-4419-6999-6_28, © Springer Science+Business Media, LLC 2011
359
360 D.D. Trunkey
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personal preferences and are value-laden. For geriatric
trauma patients, substantial erosion in the capability for independent living defines qualitative futility, with the range of
individual preferences defining the specifics of the loss of
function. For some elderly patients, becoming permanently
dependent on the assistance of others for management of
bodily function constitutes a qualitative futile outcome; while
for others, coma and a requirement for mechanical ventilation would be the threshold for qualitative futility. Futilities
are tough ethical issues that the surgeon and intensivist face
almost on a daily basis. Unfortunately, when we studied this
at our institution, our outcomes were mixed. Patients who
were discharged to nursing homes, skilled nursing facilities,
and rehabilitation centers had a higher death rate at 1 year
than those discharged to their homes. Furthermore, those
who had significant injury (ISS >15) were able to return
immediately to independent living status in only 25% of
instances. When discharged to secondary care institutions,
many did not return to independent living status.
The elderly represent a heterogeneous group in the physiologic changes that occur during latter years. Comorbid factors described above also influence the elderly patient’s
response to injury and surgery. There are no simple rules in
preventing futility, but the surgeon has to be aggressive in
making decisions, working with the families, and trying to
do what is best for the patient.
Chapter 29
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Common Perioperative Complications in Older Patients
Sandhya A. Lagoo-Deenadayalan, Mark A. Newell, and Walter E. Pofahl
Introduction
As one of the fastest growing segments of the population,
elderly patients account for an increasing percentage of operations in most practices. On the basis of the 2006 National
Hospital Discharge Survey, patients aged 65 and older
accounted for 35% of all procedures [1]. Elderly patients
have a higher rate of postoperative complications. Two large
studies found complication rates of 20–50% in patients aged
80 years and older [2, 3]. In contrast, younger patients had
complication rates approximately half of that in the elderly
patients. Table 29.1 outlines the relative frequency of specific complications in elderly patients undergoing a variety
of noncardiac surgical procedures.
Elderly patients are similar to other patients in terms of
the “typical” postoperative complications that can occur with
an operation such as bleeding, infection, or technical errors.
However, elderly patients are at risk for a group of unique
complications owing to the physiologic changes of aging and
the stress of the perioperative period. The underlying mechanisms for recognition, treatment, and prevention of these
complications are the focus of this chapter.
There are some general principles for identifying, preventing, and treating postoperative complications in elderly
patients. First and foremost, many postoperative complications in elderly patients have “atypical” presentations, making the recognition of postoperative complications difficult
in this age group. For example, infectious complications do
not necessarily present with fever and leukocytosis; delirium
can be the sole clinical manifestation of an infectious
complication.
The second principle is to actively search for and avoid
complications. Every surgeon caring for elderly patients has
W.E. Pofahl (*)
Department of Surgery, Brody School of Medicine, East Carolina
University, Pitt County Memorial Hospital, Greenville, NC, USA
e-mail: pofahlw@ecu.edu
had a case where a single, seemingly minor, postoperative
complication spiraled into something more significant. This
is because although elderly patients tolerate most elective
operations, they have limited physiologic reserves to tolerate
the increased physiologic stress of postoperative complications. After emergency operations, much of physiologic
reserve is spent maintaining homeostasis, leaving even less
reserve for complications. Therefore, it is imperative to avoid
preventable complications such as those that result from a
poor choice of medications.
The third principle is to perform an adequate preoperative
risk assessment including functional status and cognitive
assessment. In the elective setting, there is adequate time to
fully evaluate the elderly patient for occult comorbidities and
determine functional and cognitive status. Unfortunately, the
same time is usually not available in the case of urgent or
emergency operations. However, this information can often
be obtained from caregivers and family. This has a direct
impact on expected postoperative course, especially after
emergency operations, and can help set expectations and
goals of therapy.
Age-Related Complications
Delirium
Delirium is a relatively frequent complication following surgery in elderly patients. Table 29.2 outlines the rates of postoperative delirium for selected common procedures. The
reported rates of postoperative delirium range from 15 to
>50%. [4] The rate varies from <5% following cataract surgery to as high as 60% after hip replacement [5]. Elderly
patients who develop delirium have longer postoperative
hospital stays, are more likely to be discharged to a nursing
home, less likely to regain full function, and have higher
death rates at 30 days, 6 months, and 1 year [5–8].
R.A. Rosenthal et al. (eds.), Principles and Practice of Geriatric Surgery,
DOI 10.1007/978-1-4419-6999-6_29, © Springer Science+Business Media, LLC 2011
361
362 S.A. Lagoo-Deenadayalan et al.
Age
<80 (n
= 568,263) ³80 (n = 26,648)
Morbidity % Complication
³1 complication
12.1 20.0
Respiratory complications
Pneumonia 2.3 5.6
>48
h on ventilator 2.1 3.5
Required reintubation 1.6 2.8
Pulmonary embolism 0.2 0.4
Urinary tract complications
Urinary tract infection 2.2 5.6
Acute renal failure 0.4 0.6
Progressive renal failure 0.4 1.0
Cardiac complications
Myocardial infarction 0.4 1.0
Pulmonary edema 0.6 1.0
Cardiac arrest 0.9 2.1
Wound complications
Deep wound infection 1.4 1.3
Superficial wound infection 1.9 1.7
Wound dehiscence 0.9 0.9
Nervous system complications
Cerebrovascular accident 0.3 0.7
Coma
> 24 h 0.3 0.3
Peripheral nerve injury 0.3 0.3
Other complications
Systemic sepsis 1.2 2.0
Bleeding requiring >4 units
blood
1.0 1.5
Prolonged ileus 1.2 1.7
Deep-vein thrombosis 0.4 0.6
Graft or prosthesis failure 0.5 0.4
Source: Reprinted from Hamel et
al. [2], with permission from Wiley
Blackwell
T
a b l e 29.2 Rates of delirium following selected procedures
Procedure Rate (%)
Cardiac surgery
a
48
Aortic surgery
b
30–50
Vascular bypass
b
29
Cataract surgery
c
<5
Hip surgery (elective)
b
4–15
Hip surgery (emergency)
b
19–44
Colorectal surgery
d
38
a
Data from Rudolph JL et al (2009) Circulation
b
Data from Dasgupta and Dumbrell [12]
c
Data from Milstein A et al (2002) Int Psychogeriatr
d
Data from Beaussier M et al (2006) Reg Anesth Pain Med
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Ta b l e 29.1 Postoperative complications in elderly patients
postoperative complication rates [9], higher probability of
discharge to nursing home [6], poorer functional outcome
[7, 10], and higher death rates at 6 [6] and 12 months [7]. This
results in a greater financial burden of care for these patients.
Robinson documented an average cost of hospitalization of
$50,100 in patients who developed postoperative delirium [6].
In contrast, the average cost of hospitalization in patients who
did not develop delirium was $31,600. Two studies of patients
undergoing nonorthopedic operations documented a doubling
of length of stay in patients with postoperative delirium when
compared to patients who do not develop delirium [6, 9].
The development of delirium is also associated with
higher rates of overall postoperative complications [9]. This
is not unexpected as delirium is often the initial sign of a
postoperative complication. However, a large study of
patients who developed delirium after surgical treatment of
hip fracture did not show an increased length of stay or
increased postoperative complication rate when compared to
patients who did not develop postoperative delirium [7].
There are also conflicting data on increased rates of discharge to nursing homes in patients who developed postoperative delirium. Robinson et al. [6] showed a significantly
higher rate (33%) of postdischarge institutionalization in
patients who developed delirium as compared to patients
who did not (1%) following nonorthopedic procedures. In
contrast, Edelstein et al. [7] did not find a significant increase
in the rate of discharge to a skilled nursing facility for patients
who developed delirium after hip fracture repair.
There is general agreement, however, that postoperative
delirium is associated with worse functional recovery, as
demonstrated by decline in basic activities of daily living at
1 [10] and 12 months [7] after treatment of hip fracture, and
with a higher risk of death in the 6–12 months following
operation [6, 7].
Impact on Outcome
The development of postoperative delirium has a deleterious
effect on postoperative outcomes. Specifically, postoperative
delirium is associated with longer length of stay [6, 9], higher
Etiology, Risk Factors, and Precipitating Factors
The underlying mechanisms of delirium are uncertain.
However, it appears to represent an imbalance between central
nervous system cholinergic and dopaminergic activity. The
predominant theory is that underactivity of cholinergic system
coupled with excessive dopaminergic activity can lead to
delirium. This is supported by precipitation of delirium through
use of anticholinergic or dopaminergic medications [11].
Delirium is the end result of a complex interaction between
risk factors and precipitating events. Furthermore, in similar
situations, similar patients may not necessarily develop
delirium. A key component in preventing postoperative
delirium is recognition of at-risk patients. The preoperative
evaluation should include a detailed cataloging of the
common risk factors noted in Table 29.3. The risk factor
with the strongest association with development of postoperative delirium is preoperative cognitive impairment [12].
36329 Common Perioperative Complications in Older Patients
Risk factors Precipitating factors
Advanced age Infection
Underlying cognitive impairment Medications
Functional impairment Hypoxemia
Coexisting medical comorbidities Dehydration
Psychotropic medications Sensory deprivation
Alcohol abuse Electrolyte abnormalities
Sensory impairment Unfamiliar environment
Immobility Surgery
Neurologic events
Sleep deprivation/disruption
Use of physical restraints
Malnutrition
Use of a bladder catheter
T
a b l e 29.4 Etiology of acute confusion in surgical
patients
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Ta b l e 29.3 Risk factors for and precipitating factors of delirium
Unfortunately, this and many of the other risk factors cannot
be modified in the preoperative setting prior to elective operation. However, reduction in the severity of individual risk
factors, such as visual and hearing impairment and immobility, has been shown to reduce the incidence of delirium [
13].
In addition to risk factors noted in the table, the presence of
preoperative pain is a risk factor for postoperative delirium
[14]. This is a factor that can be mitigated prior to operation
using an appropriate clinical strategy. Specifically, use of
oral instead of intravenous analgesia is associated with lower
rates of postoperative delirium in elderly patients.
During the perioperative period, the most important strategy to prevent delirium is to actively monitor, treat, and avoid
the precipitating factors. Each precipitating factor is a marker
for a risk factor, has the potential to increase the severity of
risk factors, or can lead to development of complications for
which delirium may be a sign. Use of physical restraints and
bladder catheters both lead to immobilization. In addition,
indwelling bladder catheters predispose to urinary tract
infection, which can precipitate delirium. Factors that alter
sensorium, such as sleep deprivation or disruption, medications, or neurologic events, can also precipitate delirium. It
should be noted that neurologic events are an unusual, but
often sought, cause of postoperative delirium.
Diagnosis
Delirium is distinguished from dementia by its acute onset
and fluctuating course. Other components include inattention
with the inability to focus, disorganized thinking, and altered
level of consciousness. Although most clinicians are familiar
with the agitated or hyperactive state of delirium, the condition can also present as somnolence. This can lead to misdiagnosis and attribution to other causes. The Confusion
Assessment Method as proposed by Inouye [15] is a validated
method to diagnose delirium. It requires the presence of
acute onset with a fluctuating course and inattention. Either
disorganized thinking or altered level of consciousness must
I
M
C
O
N
F
U
S
E
D
also be present to confirm the diagnosis. The
Infection
Metabolic
Cognitive, sensory
Oxygenation
Nutrition, swallowing
Function, pharmacy, Foley catheter
Unfamiliar environment
Stress, pain
Electrolytes/fluids
Dysfunction lung, liver, kidney, brain
presence or
absence of each component is obtained by history or testing.
Acute onset and fluctuating course are confirmed by direct
observation or in the case of patients presenting with delirium through history from family and/or care providers.
Inattention can be tested using simple tests such as counting
backward (by threes or sevens) or naming months in reverse
order. Disorganized thinking is noted on interviewing the
patient. The patient will have rambling speech and/or illogical flow of ideas. He or she may switch between
subjects of
conversation unpredictably. Altered level of consciousness is
defined as reduced clarity of surroundings – either lethargy/
somnolence or hyperactivity/mania.
Evaluation and Treatment
Initial evaluation of patients with postoperative delirium is
focused on assessing etiology and stabilizing the patient.
Review of the preoperative history, including functional
assessment and medications, is critical. The presence of
risk factors as outlined should be determined. Possible precipitating factors should also be sought. A mnemonic for
etiologies of acute confusion in surgical patients is shown in
Table 29.4.
In those instances when postoperative delirium occurs,
treatment is directed at identifying the underlying cause,
providing supportive care and controlling symptoms
(Fig. 29.1). Delirium is often a manifestation of other postoperative complications such as occult infection, anastomotic
leak, hypoxia, hypovolemia, or electrolyte imbalance. A thorough investigation is indicated to evaluate and treat these
possible etiologies. Unfortunately, a single, specific etiology
is not identified in a significant number of cases. Supportive
care includes many of the strategies used to prevent delirium
and also includes measures to ensure airway protection,
maintain adequate oxygenation, maintain fluid and electrolyte balance, and provide nutritional support. If possible,
physical restraints should be avoided. Control of the patient’s
symptoms includes the prevention strategies previously
discussed. Pharmacologic intervention should be reserved
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