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Association between postoperative delirium in the postanaesthesia care unit and subsequent ward delirium: A
Yotam Weiss1, Shiri Zarour, Daniel Hikry
1From the Division of Anaesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel (YW, SZ, DH, TT, MI, AZ, OG, BC, IM), Department of Peri-Operative Medicine, University College London Hospitals NHS Trust, London, UK (SZ) and Outcomes Research Consortium, Houston, Texas, USA (BC).
Insights
Postoperative delirium diagnosed in the post-anaesthesia care unit (PACU-POD) is a significant early indicator of subsequent delirium on the ward (ward-POD) and other adverse outcomes. Routine PACU screening can improve patient risk stratification and facilitate timely interventions.
Area of Science:
- Geriatric Medicine
- Anesthesiology
- Surgical Outcomes Research
Background:
- The aging surgical patient population necessitates effective postoperative delirium (POD) screening.
- The post-anaesthesia care unit (PACU) is a critical period for early POD detection, but the significance of PACU-diagnosed POD (PACU-POD) is not well understood.
Purpose of the Study:
- To investigate the association between PACU-POD and the development of ward-POD.
- To determine if PACU-POD predicts other adverse postoperative outcomes.
Main Methods:
- Retrospective cohort study of 3,781 patients aged 70+ undergoing elective noncardiac, noncranial surgery.
- Postoperative delirium assessed using the 4AT and CHART-DEL review.
- Primary outcome: ward-POD. Secondary outcomes: falls, ICU admission, discharge disposition, 30-day mortality.
Main Results:
- PACU-POD occurred in 9.1% of patients and was associated with older age, frailty, cognitive impairment, and high-risk surgeries.
- Patients with PACU-POD had a significantly higher incidence of ward-POD (24.6% vs. 4.3%).
- PACU-POD independently predicted ward-POD (aOR 4.4), in-hospital falls (aOR 2.3), and 30-day mortality (aOR 4.4), along with prolonged PACU and hospital stays.
Conclusions:
- PACU-POD serves as a robust early marker for increased risk of ward-POD and other postoperative complications.
- Implementing routine PACU screening can enhance early diagnosis, risk stratification, and targeted interventions for POD.
- Further research is warranted to evaluate the impact of early interventions initiated during PACU stay on POD trajectory and outcomes.
Background:
The ageing surgical population underscores the need for routine postoperative delirium (POD) screening, particularly in the immediate postoperative period. The postanaesthesia care unit (PACU) presents a critical window for early detection and intervention, yet the clinical significance of PACU-diagnosed POD (PACU-POD) remains underexplored.
Objectives:
To examine whether PACU-POD is associated with subsequent ward-POD and other adverse postoperative outcomes.
Design:
Retrospective cohort study.
Setting:
Tertiary academic hospital, single-centre, conducted between 2020 and 2022.
Patients:
Three thousand seven hundred and eighty-one patients aged at least 70 years who underwent elective noncardiac, noncranial surgery under general anaesthesia. POD was assessed using the 4AT and supplemented by CHART-DEL review.
Main Outcome Measures:
Primary outcome: ward-POD. Secondary outcomes: in-hospital falls, unplanned ICU admission, nonhome discharge and 30-day mortality. Exploratory outcomes: PACU and hospital length of stay.
Results:
PACU-POD was diagnosed in 9.1% of patients (341/3781), who were more likely to be older, 77.1 (73.7 to 82.7) vs. 75.7 (72.9 to 80.6) years; frailer (52 vs. 40%); cognitively impaired (36 vs. 18%); and undergoing high-risk (52 vs. 27%); prolonged surgeries, 196 (133 to 275) vs. 142 (95 to 204) minutes (all P < 0.001). Ward-POD occurred in 6.2% of patients (234/3781) and was significantly more common among those with PACU-POD (24.6 vs. 4.3%, P < 0.001). PACU-POD was independently associated with ward-POD [adjusted odds ratio (aOR) 4.4; 95% confidence interval (CI), 3.2 to 6.3], in-hospital falls (aOR 2.3; 95% CI, 1.2 to 4.4) and 30-day mortality (aOR 4.4; 95% CI, 1.5 to 13.0), as well as prolonged PACU, 185 [144 to 265] vs. 150 [115 to 210] minutes, P < 0.001, and hospital stays, 6 [3 to 10] vs. 3 [2 to 6] days, P = 0.01.
Conclusion:
PACU-POD is a strong early marker of increased risk for ward-POD and other postoperative complications. Routine PACU screening enables early diagnosis, risk stratification and targeted interventions. Future studies should evaluate whether early intervention starting during the PACU stay can improve the trajectory of POD and related complications.
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