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SATISFY
SURGICAL OUTCOMES SURVEYS
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AFTER SURGERY
FOR IRB USE ONLY
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BCD%%%%%%%%ECD%
Delirium - Incidence
–  Up to 80% of the sickest ICU populations.
–  40%-50% elderly after major surgery.
Rudolph JL. Circulation 2009;119(2):229-36.
Robinson TN. Annals of surgery 2009;249(1):173-8.
Robinson TN. American journal of surgery 2008;196(5):670-4.
Pathophysiology%
•  Neurotransmitter imbalance
•  Inflammation
•  Impaired oxidative metabolism
•  Availability of large neutral amino acids
Girard TD. Critical care 2008;12 Suppl 3:S3.
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Precipitating factors %
Pain
Infection
Withdrawal
Sodium, hydrogen, glucose, oxygen, CO
2
Temperature, BP
Benzodiazepines, drugs
Stroke, seizures
Endocrine
Vaquero et al. Sem in Liver Dis. 2003;32:59-69
%
Medications cause delirium
Different drugs implicated in different studies
Benzodiazepines (e.g., lorazepam) - dose-related?
Corticosteroids
Morphine
Maybe propofol and fentanyl
Anticholinergics
Dubois ICM 2001;27:1297-1304,
Marcantonio. JAMA, 1994;272:1518-1522,
Gadreau J of Clin Onc. 23(27):6712-6718
Pandharipande et al. Anesth;104(1):21-26,2006
Does it matter?
Increased ICU LOS 8 vs. 5 days
Increased Hosp. LOS 21 vs. 11 days
Increased time on vent 9 vs. 4 days
Higher costs $22 000 vs. $13 000
3 fold increased risk of death
Possible long term cognitive impairment
Ely ICM 2001;27,1892-1900,
Ely JAMA 2004;291:1753-1762,
Lim SM, CCM 2004;32:2254-2259,
Milbrandt E, CCM 2004;32:955-962,
Jackson Neuropsychology Review 2004;14:87-98
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Management:
treat causes & reduce risks
%
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Correct metabolic disturbance & hypoxia
Frequent reorientation of patient
Goal directed sedation/analgesia &/or daily wakeup.
Stop sedation daily
Spontaneous breathing trial daily
Early mobilisation
Attention to optimising sleep patterns
Inouye. NEJM 1999;340(9):669
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Hudetz JA, Patterson KM, Iqbal Z, Gandhi SD,
Byrne AJ, Hudetz AG, Warltier DC, Pagel PS.
Ketamine attenuates delirium after cardiac surgery
with cardiopulmonary bypass. J Cardiothorac Vasc
Anesth. 2009 Oct;23(5):651-7.
(1/29 vs. 10/29. Δ (ARR) = 31%)
[95% CI, 8.4% to 51.2%]
Ketamine & Delirium
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PTSD Checklist – Specific (PCL-S)
Mini Int’l Neuropsych Interview (MINI)
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0
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120
Number of patients
PCL-S score
Non-aware
Aware
PTSD symptoms
No PTSD symptoms
PCL-S DSM-IV
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Significant variables P-value
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Perceived threat to life at time of surgery 0.002
Past PTSD-complex symptoms 0.003
Poor perceived social support 0.006
Intraoperative awareness 0.014
Prior mental health treatment 0.017
Nonsignificant factors
Cardiac surgery 0.09 ICU care 0.40
Age 0.21 Gender 0.49
Previously described
for other PTSD triggers
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