Postoperative delirium

A 64-year-old woman underwent coronary artery bypass surgery and was given intravenous haloperidol for agitation and to avoid postoperative delirium she developed torsade de pointes (15). 

Marcantonio ER, Juarez G, Goldman L, Mangione CM, Ludwig LE, Lind L, Katz N, Cook EF, Orav EJ, Lee TH. The relationship of postoperative delirium with psychoactive medications. JAMA 1994 272(19) 1518-22. 

Sevoflurane often causes postoperative delirium and agitation in children, and this may be severe. The effect of intravenous clonidine 2 pg/kg on the incidence and severity of postoperative agitation has been assessed in a double-blind, randomized, placebo-controlled trial in 40 boys who had anesthetic induction with sevoflurane after oral midazolam premedication (32). There was agitation in 16 of those who received placebo and two of those who received clonidine the agitation was severe in six of those given placebo and none of those given clonidine. 

Stanford BJ, Stanford SC. Postoperative delirium indicating an adverse drug interaction involving the selective serotonin reuptake inhibitor, Psychojharmacol (1999) 13,... 

A patient experienced postoperative delirium which lasted for nearly 2 days and included agitation, confusion, uncontrolled limb movements, abnormal ocular function, hypertension, pyrexia, brisk reflexes, ankle clonus and raised creatinine kinase. She had been taking paroxetine before surgery and during surgery she was given morphine and ondanset-... 

Pharmacological premedication is usually prescribed for patients with planned overnight hospital stay. Low-dose benzodiazepines provide anxiolysis, light sedation and anterograde amnesia. Especially at advanced age, benzodiazepines may elicit paradoxical reactions or predispose to postoperative delirium. Alternatives for oral premedication are clonidin or haloperidol. Ambulatory patients usually do not receive preoperative sedatives. 

Povidone-iodine (betadine) use in pleurodesis for malignant pleural effusions exhibits a good safety profile pi ]. However, adverse effects of postoperative delirium, hallucinations, transient cognitive impairment occurred following a single application of povidone-iodine to the sternal wound of a cardiac patient. Serum iodine was elevated threefold compared to preoperative levels suggesting caution in use of povidone-iodine [22 ]. 

Korevaar JC, van Munster BC, de Rooij SE (2005) Risk factors for delirium in acutely admitted elderly patients a prospective cohort study. BMC Geriatr 5 6 Kudoh A, Takase H, Takahira Y et al. (2004) Postoperative confusion increases in elderly longterm benzodiazepine users. Anesth Analg 99 (6) 1674-1678 McCusker J, Cole M, Dendukuri N et al. (2001) Delirium in older medical inpatients and subsequent cognitive and functional status a prospective study. Cmaj 165 (5) 575-583 McCusker J, Cole M, Dendukuri N et al. (2003) The course of delirium in older medical inpatients a prospective study. J Gen Intern Med 18 (9) 696-704 McShane R, Areosa Sastre A, Minakaran N (2006) Memantine for dementia. Cochrane Database Syst Rev 19 (2) CD003154... 

Postoperatively (recovery room) - 50 to 100 meg IM for the control of pain, tachypnea, and emergence delirium repeat dose in 1 to 2 hours as needed. 

Adverse effects include laryngospasm, which occurs generally when respiratory secretions or other irritants are present. Shivering and delirium may occur during recovery. Postoperative pain induces restlessness. Nausea and vomiting are uncommon. It can precipitate acute intermittent porphyria in susceptible individuals. 

Scopolamine Unknown mechanism in CNS Reduces vertigo, postoperative nausea Prevention of motion sickness and postoperative nausea and vomiting Transdermal patch used for motion sickness IM injection for postoperative use Toxicity Tachycardia, blurred vision, xerostomia, delirium Interactions With other antimuscarinics... 

Phencyclidine (PCP) was developed in late 1950 as an intravenous anesthetic agent. PCP produces anesthesia and analgesia with respiratory or cardiovascular depression. However, postoperatively, the drug produced psychotomimetic effects (e.g., delirium and hallucinations) and was subsequently withdrawn from the market. 

Delirium during emergence from sevoflurane anesthesia has often been documented. Four patients, an adult and three children aged 3-8 years, who were able to recount the experience, have been reported (599). They had full recall of postoperative events, were terrified, agitated, and distressed, and hence presented with acute organic mental state dysfunction which was short-lived. Two were disoriented and had paranoid ideation. They were not in any pain or were not distressed by pain if it was present. The authors hypothesized that misperception of environmental stimuli associated with sevoflurane s particular mode of action may have been the underlying cause of this phenomenon. Anxiolytic premedication and effective analgesia did not necessarily prevent the problem. 

Ketamine is a potent analgesic-anesthetic that is also effective intramuscularly. One particular property, production of cardiovascular stimulation, is of special advantage in elderly patients and those in shock (e.g., from bums). However, its propensity to precipitate hallucinations, delirium, disorientation, and other perceptual illusions postoperatively in about 12% of patients has led to its infrequent use in the United States. Ketamine s close structural analogy to the notorious and dangerous hallucinogen, phencyclidine (PCP, angel dust ), should be noted. This drug, which was first also introduced as an... 

Intramuscular hydroxyzine (100 mg q. 4 hours) is indicated for the acutely disturbed or hysterical patient the acute or chronic alcoholic with anxiety withdrawal symptoms or delirium tremens as pre- and postoperative and pre- and postpartum adjunctive medication to permit reduction in narcotic dosage, allay anxiety and control emesis and as an adjunctive therapy in asthma. 

Emergence from ketamine s anesthesia may be associated with psychological manifestations such as pleasant dream-like states, vivid imagery, hallucinations and emergence delirium, sometimes accompanied by confusion, excitement, and irrational behavior. The duration is ordinarily a few hours however, recurrences have been seen up to 24 hours postoperatively. No residual psychological... 

Unlike other parenteral anesthetics, ketamine increases cerebral blood flow and ICP with minimal alteration of cerebral metabolism. These effects can be attenuated by concurrent administration of thiopental and/or benzodiazepines along with hyperventilation. However, given that other anesthetics actually reduce ICP and cerebral metabohsm, ketamine is relatively contraindicated for patients with increased ICP or those at risk for cerebral ischemia. The effects of ketamine on seizure activity are mixed. Emergence dehrium characterized by hallucinations is a frequent comphcation of ketamine that can result in serious patient dissatisfaction and can complicate postoperative management. Delirium is most frequent in the first hour after emergence and appear to occur less frequently in children benzodiazepines reduce the incidence of emergence delirium. 

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