Kim Macfarlane

Clinical Nurse Specialist, Critical Care

Lisa Ying

Post-operative delirium in orthopedic surgery:

incidence, risk factors, and mitigation

Disclosure

• The authors have none to declare

•Dareena Malli

•Christine Donald

•Susann Camus

•Parm Panesar

•Pawan Sindhar

Acknowledgements

•Delirium is an ACUTE BRAIN FAILURE

• Patients who become delirious are unable to think clearly and can’t make sense of what is going on around him

• Commonly, they have hallucinations that are particularly frightening

•Delirium significantly increases morbidity and mortality and as such is a MEDICAL EMERGENCY requiring the same expert attention and intervention as any other acute organ failure

What is delirium?

• The incidence of delirium is high amongst hospitalized older adults being about 50% in the general population, and 60% in the orthopedic population

• However, in 40% of cases, delirium is preventable

• The biggest misunderstandings about delirium are that it is inevitable and inconsequential

• As a hospital-acquired condition, it far exceeds the rates of other care-sensitive adverse events such as SSIs, UTIs and pneumonia

• Delirium causes significant patient/family suffering, increases morbidity and mortality, and financially burdens the healthcare system

What are the consequences of delirium?

•Many patients never return to their pre-hospital mental or functional status:

• Some will develop posttraumatic stress disorder, which is characterized by re-experiencing the traumatic event via flashbacks or nightmares

•Mortality at 1 year may be as high as 20%

•The length of stay rises by 60%

•The rate of nursing home placement increases 5 fold

What are the consequences of delirium?

•A study of delirium risk factors, incidence and mitigation factors in a Surrey Memorial Hospital’s Orthopedic Unit:

• Estimate baseline delirium risk factor prevalence

• Estimate incidence of postoperative delirium

•Audit nursing assessments and interventions for delirium

Aims of our study

Methods

• Literature review to explore common causes, risk factors, assessments and interventions for delirium

• Patients (n=24) scheduled for orthopedic surgery were assessed for delirium between June and August of 2015

• Collected medical, functional, and social information from medical records completed upon admission

• Noted nursing delirium assessments and interventions on patient chart audits

• Patients individually evaluated postoperatively through Confusion Assessment Method, and review of 24-hour nursing record

•Sample Size: n=24

•Incidence of Delirium: 12.5% determined by positive Confusion Assessment Method (CAM) scores

What were the key finding ?

ASA levels of orthopedic patients undergoing surgery

0

2

4

6

8

10

12

14

16

1 2 3

Nu

mb

er

of

pati

en

ts

ASA level

Predisposing risk factors

0 10 20 30 40 50 60 70 80 90 100

Age > 65

Gender (male)

Dementia

Depression

Bipolar

Anxiety

Stress

Aggression

Hypertension

GERD

Hyperlipidemia

Hypothyroidism

Arthritis

Gout

Headaches

Renal insufficiency

Nephrectomy

Anemia

BMI > 30 kg/m^2

Myocardial infarction

Cerebral Vascular Accident (Stroke)

Peripheral Vascular Disease

Pacemaker

Diabetes Mellitus

Brain tumour

Deep Vein Thrombosis

Obstructive sleep apnea

Visual impairment

Hearing impairment

Proportion of patients (%)

Pre

dis

po

sin

g f

acto

rs

Delirious patients

Control patients

All patients

Precipitating risk factors

0 20 40 60 80 100

Polypharmacy (>5 drugs)

General anaesthesia

Spinal anaesthesia

Infection

Sleep disturbances

Alcohol or drug withdrawal

Nutritional deficiencies

Electrolyte Imbalances

Hypotension or shock

Immobility

Nursing home

Language barrier

Physical restraints

Proportion of Patients (%)

Pre

cip

itati

ng

facto

rs Delirious

patients

Control patients

Drug therapy

0 20 40 60 80 100 120

Amitryptiline

Dilaudid

Dimenhydrinate

Fentanyl

Meperidine

Propofol

Stemetil

Proportion of patients treated (%)

Dru

g n

am

e

Delirious patients

Control patients

All patients

0

1

2

3

4

5

6

7

8

9

10

28-Jul 29-Jul 30-Jul 31-Jul

Pain

scale

(0

-10)

Date

Patient A

Patient B

Patient C

Patient D

Other patients

Spikes in pain management over 4 days

Mitigating Factors Enhancing Factors Reorienting patients Administration of delirium culprit

medications (e.g. meperidine, dimenhydrinate)

Alcohol withdrawal protocol initiated when needed

Inadequate pain management

Encouraging visits from family and friends

Movement of patients within wards/rooms

Checking for mood and psychosocial well-being of patients

Medical and nursing interventions during sleeping periods

Ensuring patient nutrition and adequate fluid intake

Use of physical restraint on patients

Keeping track of bowel movements

Early ambulation

Looking for and treating infections

Alarm call bell within reach

Factors affecting delirium development

•Substantial reduction in the use of Dimenhydrinate

•Redesign of nursing flowsheet to support CAM assessments

•Review of pain management practices

•Second study with 60 patients using the same methodology completed

What have we improved on?