You are called by the bedside nurse that your patient arrived on the floor from the post-anesthesia care unit (PACU). The nurse tells you that the patient was delirious and agitated after anesthesia, pulled out their IVs, and was sedated by the PACU team. They are somnolent now, but awaken to voice. Their family is at the bedside, very concerned about what happened and would like to speak to you.
The patient experienced PACU delirium, a sub-form of postoperative delirium occurring in the initial phases of recovery from anesthesia and surgery that takes place in the PACU, rather than in the intensive care unit or on the floor. While it can happen to anyone, it’s more common in older patients, with incidences reported between 15 percent and 45 percent. As with all delirium in any phase of care, it can be unnerving to patients and their families, and they are likely to have many questions for their care team. It’s important for hospitalists, physicians whose primary professional focus is the general medical care of hospitalized patients, to be aware of this form of postoperative delirium to help better care for patients undergoing surgery, as it is not always easy to identify.
How should hospitalists counsel a patient and their family after delirium in the PACU?
When discussing delirium with the patient and their family, it is helpful to first reassure them that this behavior is not something the patient does purposefully, nor is it something to be ashamed about. Oftentimes, patients can remember bits and pieces of the episodes and feel ashamed, depressed, or anxious about how they behaved. Some patients even experience post-traumatic stress disorder (PTSD) from delirium. All patients should be supported through the processing of delirium and reassured that it is not their fault.
Next, I would recommend explaining to the patient how common PACU delirium is. The intention is not to normalize the occurrence, but to reassure the patient that they are not alone in this experience. It is also helpful to discuss the risk factors for delirium in general and in the PACU specifically. You can explain that age, preexisting cognitive impairment, frailty, infection, and certain types of surgery all increase a patient’s risk. If the patient was not aware of any preexisting cognitive impairment, be prepared to counsel them and their family about that possibility, and let them know that cognitive impairment may occur in up to one-sixth of older patients. Now is not the time to perform cognitive testing, but if a patient or family is concerned about cognitive decline prior to the hospital admission, referral to a geriatrician or cognitive neuropsychologist is warranted.
Finally, you should explain to the patient and their family that many studies have shown patients who experience PACU delirium are at an increased risk of experiencing delirium subsequently throughout their hospital stay. Their family can help by being present in the hospital, bringing in any sensory aids (e.g., eyeglasses or hearing aids), continuing to reorient the patient, exercising the brain by playing games and remembering past events, and by notifying the care team if they notice any acute or fluctuating changes in the patient’s attention or thought processing. Reassure the family that you will implement best practices to help reduce the risk of additional episodes of delirium.
How should hospitalists optimize the patient’s postoperative care?
There are multiple evidence-based steps that hospitalists can take to reduce delirium. While these have not been specifically studied to reduce the risk of subsequent hospital delirium after PACU delirium, it is reasonable to extrapolate from the current evidence. If your health care system has a bundled care plan in place to prevent delirium, such as the Hospital Elder Life Plan (HELP), you should use it. HELP is an evidence-based, multidisciplinary, and multipronged bundle shown to reduce the incidence of delirium in hospitalized patients. If your hospital provides a geriatric consult service, I recommend consulting with them to aid in the care of the patient.
Geriatric anesthesiologists and geriatricians can both be important resources for the physician, patient, and family. Discuss with your anesthesia department if a geriatric anesthesiologist or anesthesiologist champion of perioperative brain health can perform the post-anesthesia care visit and counsel the patient and their family.
Even if your hospital doesn’t have a delirium prevention bundle care plan or a geriatric consult service, you can initiate the following evidence-based aspects of the HELP program:
Perform daily delirium screenings yourself. The American Society of Anesthesiologists (ASA) Perioperative Brain Health Initiative website provides links to commonly and easily administered delirium and cognitive testing, as well as information, tools, and resources to improve brain health management and provide optimum perioperative care. Additionally, ASA is launching a new webinar on PACU delirium that will be available to both members and non-members on the website starting in mid-June.
Avoid ordering medications that may cause or lead to delirium and review the patient’s medications daily to be sure that potentially inappropriate medications are discontinued, such as benzodiazepines, anticholinergics, and antipsychotics. Unfortunately, many patients who experience agitated delirium during emergence or in the PACU receive sedatives. Typically, this may include small doses of propofol, dexmedetomidine, or less ideally, benzodiazepines or antipsychotics. You should familiarize yourself with the American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults.
Orient the patient during all visits and request the nurses do so as well. Display all the names of the patient’s care team and schedule for the day in their hospital room. Families can help with cognitive stimulation activities during the day, and you can help enhance their sleep by requesting that nighttime care is bundled to limit interruptions during sleep.
Be sure that physical and occupational therapy evaluation orders are active for early mobilization. Stay on top of the patient’s fluid balance, constipation, nutritional status, and pain management.
With more than 46 million Americans over the age of 65, postoperative delirium is a major public health issue in this vulnerable population, and PACU delirium is an important element of this. s we recognize Alzheimer’s & Brain Awareness Month in June, I want to raise awareness about this sub-form of postoperative delirium to ensure that education and processes are provided to both health care professionals and patients to protect and preserve the brain function of every patient undergoing surgery.
Elizabeth Mahanna-Gabrielli is an anesthesiologist.