Risperidone and Post-op Delirium

Puja Trivedi, DO

Anesthesiology. 2012 May;116(5):987-97.

Early Treatment with Risperidone for Subsyndromal Delirium after On-pump Cardiac Surgery in the Elderly: A Randomized Trial.

Hakim SM, Othman AI, Naoum DO.

Sources estimate that up to 80% of post cardiac surgery patients experience post operative delirium which has a known association with prolonged ICU stays, ICU readmissions, unnecessary examinations and neurology consults, patient and family frustration and dissatisfaction and as recently noted in the Journal of Thoracic Surgery, increased incidence of strokes. It is for this reason Hakim et al decided to study the effect of early diagnosis and treatment of post operative delirium. The aim of this randomized, parallel-arm trial was to study the effect of treating subsyndromal delirium with risperidone on the incidence of clinical delirium in elderly patients who underwent on-pump cardiac surgery. One hundred one patients aged 65 yr or older who experienced subsyndromal delirium after on-pump cardiac surgery were randomized using a computer-generated list to receive 0.5 mg risperidone or placebo every 12 h by mouth. Patients were assessed at 8 h by a blinded observer using the Intensive Care Delirium Screening Checklist, and those scoring more than 3 were evaluated by a blinded psychiatrist to confirm delirium. Patients in either group who experienced delirium were treated according to the same algorithm. Initially, risperidone was administered and if symptoms were not controlled, haloperidol was administered. Seven (13.7%) patients in the risperidone group experienced delirium versus 17 (34%) in the placebo group (P = 0.031). Due to small patient size, the fact that there is no definitive diagnosis of subsyndromal delirium or accepted diagnostic exam, no consensus on the role of risperidone as a first line agent to treat delirium, cross over obscurity since patients in the placebo portion were given risperidone and/or haldol, as well as the potential side effects; risperidone for the treatment for subsyndromal delirium needs to be further studied before it can be adopted into mainstay practice.

Fast-Tracking and Modified Aldrete Score

Vimmi Kang, DO

New Criteria for Fast-Tracking After Outpatient Anesthesia: A Comparison with the Modified Aldrete’s Scoring System

Paul F. White, PhD, MD, FANZCA and Dajun Song, MD, PhD

A & A May 1999 vol. 88 no. 51069-1072

The modified Aldrete’s scoring system is commonly used for determining when patients can be safely discharged from the PACU to either the postsurgical ward or to the second stage (Phase II) recovery area. Recently, these discharge criteria have also been used in the OR to determine the fast-track eligibility of outpatients undergoing ambulatory surgery. The modified Aldrete’s scoring system is a highly acceptable criteria for discharging patients from the PACU. However, this scoring system was not designed to assess the patient’s ability to bypass the PACU after major ambulatory procedures under general anesthesia. So a new criteria was compared to the modified Aldrete scoring system to see which one was more structured to fit fast tracking after outpatient anesthesia.

Recovery data from 216 consenting female outpatients undergoing either laparoscopic tubal ligation or cholecystectomy procedures at the University of Texas Southwestern Medical Center at Dallas from January 1997 through July 1998 were analyzed. General anesthetics were either maintained by inhaled anesthetics (desflurane, sevoflurane) or Propofol. Early recovery status was evaluated at 1-min intervals after termination of the anesthetics using both the modified Aldrete scoring system  and the new fast-track scoring system. Patients were considered fast-track–eligible if they achieved a score of 10 using the modified Aldrete scoring system or a score of ≥12 (with no score <1 in any individual category) using the new scoring system.

In conclusion, The results from this data evaluation demonstrated that 22%–29% of outpatients judged fast-track–eligible using the modified Aldrete scoring system subsequently required IV analgesics and antiemetics. Although these patients were fully oriented and had stable vital signs, they would have added to the workload of the Phase II nursing staff and may have necessitated the use of more extensive monitoring in the step-down unit. So, the new fast-track scoring system seems to offer advantages over the modified Aldrete’s scoring system in evaluating the suitability of outpatients for bypassing the PACU after undergoing ambulatory surgery with general anesthesia.

Can you bypass PACU for Outpatient Knee Surgery?

Cameron Cartier, DO

Article Review

PACU Bypass after Outpatient Knee Surgery Is Associated with Fewer Unplanned Hospital Admissions but More Phase II Nursing Interventions

Anesthesiology:

October 2002 - Volume 97 - Issue 4 - pp 981-988

This prospective study was designed to compare post-operative complications of patients who bypassed PACU with those who went to PACU following outpatient knee surgery.  The patients receiving the outpatient knee surgery were evaluated based upon a new criteria to separate whether or not the patients would bypass the PACU.   Eighty-seven percent of the patients bypassed the PACU.  These patients required more nursing interventions in the step-down unit, but required less hospitalizations secondary to anesthetic complications.  This article shows that hospital based criteria may be considered in specific patient populations in order to help decrease the amount of recovery time needed for patients to help save the hospital time, money, and staff.

Complications PACU, Dr. Kang

Vimmi Kang, DO

Summary of “Complications Occuring in the Postanesthesia Care Unit: A Survey”

Hines R., Barash P., Watrous, G and Theresa O’Connor. “Complications Occuring in the Postanesthesia Care Unit: A Survey” Anesth Analg 1992;74:503-9.

            The main objectives of the article was to identify the complications that occurred in PACU, the incidence of those complications in PACU and intraoperative, and determine the variables associated with a greater risk of developing PACU complications.  This was a prospective study looking at 18,473 patients in a PACU setting at a university teaching hospital.

            The study showed the incidence of intraoperative events only to be 5.1%, Postoperative events to be 23.7%, and the combined intraoperative and postoperative events to be 26.7%.

            The incidence of events were analyzed and found to have complications mostly associated with nausea and vomiting (9.8%), need for upper airway support (6.9%) and hypotension requiring treatment (2.7%).

            The study also examined the variables associated with greater risk of developing complications. These variable were determined to be ASA II status, duration of anesthesia (2-4hr), anesthetic technique (general anesthesia associated with higher complication rates versus regional or monitored anesthetic), emergency procedures, and certain types of surgical procedures (orthopedic or abdominal).

            Temperature was also found to prolong stay in PACU. A temperature less than 35 degrees Celsius resulted in average stay of 152 minutes versus 116 minutes in patients with a temperature greater than 36 degrees Celsius. 

            ICU patients were excluded from this study and participation was at the discretion of the attending anesthesiologist.

            An important point to be made prior to concluding is that the article found ASA II to be more of a risk factor than ASA III or IV, which could be related to the fact that most of the patients were ASA II to begin with and most of the patients that were ASA III or IV were directly taken to ICU and thus excluded from the study.

Complications Occurring in the Postanesthesia Care Unit

http://www.anesthesia-analgesia.org/content/74/4/503.full.pdf+html