Sule AkinSule Akin, Pinar Ergenoglu, Perran Poyraz, Anis Aribogan, Pinar Ergenoglu, Perran Poyraz, Anis Aribogan

Baskent University School of MedicineAnesthesiology and Reanimation Department Adana - TURKEY

Acute and fluctuating change in mental status

Inattention

Altered levels of consciousness

Incidence in orthopedic patients: 5.1% - 61%

May be before or after surgery

To compare the effectiveness and tolerability of IV propofol vs midazolam infusions for postoperative agitation/delirium

Epidural infusions for postoperative analgesia

High-risk patients with CRF

Major hip or knee operations

82 high-risk CRF patients

(ASA III, BUN>40 mg/dl, Serum Cr > 2)

Postoperatively agitation/delirium

Sedation/orientation levels; RASS / CAM-ICU

Sessler et al. AJRCCM 2002; 166: 1338-1344Ely, et al. JAMA 2003; 289: 2983-2991

The Richmond Agitation and Sedation Scale: The RASSScore

Term Description

+4 Combative Overtly combative, violent, immediate danger to staff

+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive

+2 Agitated Frequent non-purposeful movent, fights ventilator

+1 Restless Anxious but movements not aggressive vigorous

0 Alert and calm

-1 Drowsy Not fully alert, but has sustained awakening(eye-opening/eye contact) to voice (10 seconds)

-2 Light sedation Briefly awakens with eye contact to voice (<10 seconds)

-3 Moderate sedation

Movement or eye opening to voice (but no eye contact)

-4 Deep sedation No response to voice, but movement or eye openingto physical stimulation

-5 Unarousable No response to voice or physical stimulation

VerbalStimulation

Physical Stimulation

If RASS is -4 or -5, then Stop na Reassess patient at later timeIf RASS is above -4 (-3 through +4) then Proceed to Step 2

Confusion Assessment Method in the ICU (CAM – ICU)

1. Acute onset of change in mentalstatus or a fluctuating course

AND2. Inattention

3. Disorganised thinking 4. Altered level of consciousness

DELIRIUM

OR

Combined lumbar spinal/epidural anesthesia for surgery

Epidurally administered drugs in postoperative period;

Loading dose: 0.25% Bupivacaine 25 mg

Continuous dose: 0.125% bupivacaine 2-4 ml/h

Meperidin with PCA 2mg/bolus, if needed

GROUP P (n=40) GROUP M (n=42)

PROPOFOL MIDAZOLAM

Loading dose: 1-2 mg/kg IV bolus

Loading dose: 0.05-0.2 mg/kg IV bolus

Continuous dose: 1-3 mg/kg/h IV infusion

Continuous dose: 0.05-0.3 mg/kg/h IV infusion

RASS TARGET = +1 and -1

Hemodynamic parameters (HR, SABP, DABP)

SpO2

Sedation/agitation scales

Adverse events

p <0.05 values statistically significant

Groups were demographically comparable (p>0.05)

Group P reached target RASS scores earlier than Group M (p<0.05)

Hemodynamic values were significantly higher in Group M (p<0.05)

Epidural bupivacaine consumption was significantly lower in Group P (p<0.05)

No treatment required adverse events was seen in Group P (p>0.05)

GROUP P(n=40)

GROUP M(n=42)

Sex(F: female M: male)

F:16 (40%)M:24 (60%)

F:17 (40%)M:25 (60%)

Age (years old) 5816 5617

BUN (mg/dl) 5610 5414

Cr (mg/dl) 5.52 52

Hip surgery 21 (52.5%) 22 (52%)

Knee surgery 19 (47.5%) 20 (48%)

RASS SCORES

TIME (min)

IV propofol infusion may be an effective and safe

approach adjunct to epidural analgesia

for possible postoperative agitation/delirium

treatment after major orthopedic surgeries

in high-risk patients with CRF

THANK YOUTHANK YOU