as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
Anaesthesia considerations and Implications during Oncologic and Non-Oncologi...Apollo Hospitals
Cancer has been the leading cause of mortality in both developed and developing countries. With the advancement in chemotherapeutic agents, the quality and lifespan of patients with advanced malignancies has improved. These patients often come to hospitals for various types of elective and emergency surgeries. The attending anaesthesiologist faces a daunting task while managing these patients as there can be gross physiological derangements in most of the organ systems. A careful and thorough preoperative assessment, optimisation of physiological milieu, vigilant intraoperative monitoring, anticipation of potential complications and postoperative pain control is essential for reducing perioperative mortality and morbidity in these patients.
Geriatric Oncology
1. Relationship between aging and cancer
2. Constructs of frailty and multimorbidity
3. Evidence for geriatric assessment in older adults living with cancer
Optimizing Therapeutic Strategies in Castration-Resistant Prostate Canceri3 Health
This activity will discuss emerging efficacy and safety data on novel therapies for nmCRPC and mCRPC, strategies to manage adverse events, and the role of imaging studies and PSA testing in evaluating treatment response.
Anaesthesia considerations and Implications during Oncologic and Non-Oncologi...Apollo Hospitals
Cancer has been the leading cause of mortality in both developed and developing countries. With the advancement in chemotherapeutic agents, the quality and lifespan of patients with advanced malignancies has improved. These patients often come to hospitals for various types of elective and emergency surgeries. The attending anaesthesiologist faces a daunting task while managing these patients as there can be gross physiological derangements in most of the organ systems. A careful and thorough preoperative assessment, optimisation of physiological milieu, vigilant intraoperative monitoring, anticipation of potential complications and postoperative pain control is essential for reducing perioperative mortality and morbidity in these patients.
Geriatric Oncology
1. Relationship between aging and cancer
2. Constructs of frailty and multimorbidity
3. Evidence for geriatric assessment in older adults living with cancer
Optimizing Therapeutic Strategies in Castration-Resistant Prostate Canceri3 Health
This activity will discuss emerging efficacy and safety data on novel therapies for nmCRPC and mCRPC, strategies to manage adverse events, and the role of imaging studies and PSA testing in evaluating treatment response.
Johns Hopkins Hospital doctors report that 40%-80% of chronic pain patient are misdiagnosed, and that MRIs and CTs miss pathology 56%-78% of the time, Therefore, during extensive chart reviews of current medical data will produce a classic case of GIGO-garbage in giving garbage out. The need for accurate diagnoses and testing is critical for AI to work.
How general internists can participate in the continuum of care for patients with cancer. (Talk given at Internal Medicine Grand Rounds, St. Elizabeth Hospital, General Santos City, 10 Feb 2021.)
ADDRESSING PHYSICIAN BURNOUT: IS IT THE ENVIRONMENT OR LACK OF RESILIENCY?Carescribr
Burnout has long been recognized as an occupational hazard for various people‐oriented professions, such as human services, education, and health care. These jobs require an ongoing and intense level of personal, emotional contact. If you speak to any physician they will likely confirm that although such relationships can be rewarding and engaging, they can also be quite stressful. One cultural aspect of these occupations is that they strive to be selfless and put others' needs first; they tend to work long hours and do whatever it takes to help others; to go the extra mile and to give one's all. This can put significant burden on physicians as work settings also tend to be high in demands and low in resources.
Where’s the evidence that screening for distress benefits cancer patients?James Coyne
“The case against screening for distress.” A presentation delivered as part of an invited debate with Alex Mitchell at the International Psycho Oncology Conference, Rotterdam, November 7, 2013
The Top Seven Analytics-Driven Approaches for Reducing Diagnostic Error and I...Health Catalyst
From a wrong diagnosis to a delayed one, diagnostic error is a growing concern in the industry. Diagnostic error consequences are severe—they are responsible for 17 percent of preventable deaths (according to a Harvard Medical Practice study) and account for the highest portion of total payments (32.5 percent), according to a 1986-2010 analysis of malpractice claims. Patient safety depends heavily on getting the diagnosis right the first time.
Health systems know reducing diagnostic error to improve patient safety is a top priority, but knowing where to start is a challenge. Systems can start by implementing the top seven analytics-driven approaches for reducing diagnostic error:
Use KPA to Target Improvement Areas
Always Consider Delayed Diagnosis
Diagnose Earlier Using Data
Use the Choosing Wisely Initiative as a Guide
Understand Patient Populations Using Data
Collaborate with Improvement Teams
Include Patients and Their Families
Decision makers in the healthcare field like doctors, patients and policy makers need access to clinical evidence to address issues that have bearing on the health of the population and the treatment prescribed and thereby on the financials implications of the healthcare industry.
Improving Management of Non-Metastatic Castration-Resistant Prostate Cancer (...Carevive
NOT FOR CME - FOR REFERENCE ONLY
In 2018, there will be an estimated 164,690 new cases of prostate cancer (PC) in the U.S. and approximately 29,430 patients will die of the disease, making it the third-leading cause of cancer death in men (American Cancer Society [ACS], 2018). The majority of men with PC are treated with curative intent (i.e., with radical prostatectomy or radiation therapy) with good outcomes, but a fraction of men with locoregional PC will develop progressive disease. Men who have initial PSA/biochemical recurrence after curative treatment are a heterogeneous group of individuals with good overall prognosis, including a median metastasis-free survival (MFS) >8 years and a median overall survival (OS) of >23 years (Rozet et al., 2016).
Approximately 10%-20% of prostate cancer patients develop castration-resistant PC (CRPC) within approximately 5 years of follow-up. Decisions about clinical management (i.e., when to start treatment) are challenging because it is unclear which patients will have shorter versus longer survival, and metastatic disease is not always reliably detected with imaging (Rozet et al., 2016).
Multiple new targeted agents, including immunotherapy, second-generation hormone therapy, and androgen biosynthesis inhibitors have been recently approved. Two recently published studies (PROSPER and SPARTAN) have changed the standard of care for patients with nmCRPC.
Course 2 the need for a careful and thorough historyNelson Hendler
The medical literature reports that 40%-80% of chronic pain patients are misdiagnosed. Clearly, misdiagnosis leads to ordering the wrong tests, and thereby obtaining an incorrect diagnosis, or overlooking a diagnosis totally, which results in mistreatment. Many reports in the medical literature indicate the best way to get an accurate diagnosis, is to obtain a complete and thorough history. However, this is a time consuming process, and most physicians don’t spend the needed time with a patient. Therefore, a team of doctors from Johns Hopkins Hospital developed a 72 question test, with 2008 possible answers, available over the Internet. When a patient completes the questionnaire, diagnoses are returned within 5 minutes. These diagnoses have a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This is the highest level of accuracy of any expert system available. The efficacy of this approach is proven by outcome studies, which prove that this approach results in a far higher return to work rate and reduced use of medication and doctors visits, when compared to other techniques. This is similar to the techniques used by Johns Hopkins Hospital to reduce their workers compensation payments by 54%.
Unfortunately, some have interpreted Numbers Needed to Treat as indicating the proportion of patients on whom the treatment has had a causal effect. This interpretation is very rarely, if ever, necessarily correct. It is certainly inappropriate if based on a responder dichotomy. I shall illustrate the problem using simple causal models.
One also sometimes encounters the claim that the extent to which two distributions of outcomes overlap from a clinical trial indicates how many patients benefit. This is also false and can be traced to a similar causal confusion.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
1. C A M I L L A W O N G
Nov 2, 2019
Perioperative Risk Stratification, Prevention and Identification
DELIRIUM
2. I have NO relevant financial relationships with
any commercial interests.
Financial Disclosures
(over past 24 months)
I have received research grant funding from the Ministry of Health and Long Term Care of Ontario (MOHLTC) and
the Canadian Orthopedic Foundation for work related to perioperative geriatric models of care.
I have received a speaker honorarium from the Ontario Association of General Surgeons for a presentation on
perioperative geriatrics.
11. “The risk calculators are meant to serve as
decision aids. Numbers, whether taken in
isolation or as an index, are NOT a substitute
for clinical evaluation and clinical judgment.”
JAMA Intern Med. 2019
13. using processed EEG to help deliver the
optimal depth of anaesthesia MAY reduce
delirium incidence: RR 0.71 (95% CI 0.59 to
0.85), NNTB=17 (95% CI 11 to 34)
Cochrane Database of Systematic Reviews 2018,
Issue 5. Art. No.: CD011283.
14. PLoS One. 2019 Aug 16;14(8):e0218088.
D E X M E D E T O M I D I N E
may reduce postoperative delirium
RR = 0.61, 95% CI 0.34–0.76, P = 0.001
15. Ann Intern Med. 2019;171:474-484.
“There is limited evidence that second-generation antipsychotics may lower the
incidence of delirium in postoperative patients, but more research is needed.”
17. “Why is it acceptable care if the physical therapist doesn’t come every day but
not acceptable care if antibiotics are not given daily? Or acceptable to miss
meals all day waiting for procedures that are often cancelled? Why do the
alarms go off in the patient’s room if it is the nurse who should be notified? For
debilitated patients, why can’t testing and procedures be done in the afternoon,
so the mornings and evenings can be used for physical therapy, optimizing
nutrition, self-care, rest, and time with family?
Why does medical treatment trump recovery?”
JAMA. 2019;321(13):1253-1254.
22. Feature 1
Acute onset or fluctuations in mental status
Feature 2
Inattention
Feature 3
Disorganized thinking
Feature 4
Altered Level of
Consciousness
Confusion Assessment Method (CAM)
and
and either
or
DELIRIUM JAMA. 2010;304:779-786.
+LR = 9.6
-LR = 0.16
30. 10. If it is delirium, call it delirium.
9. Ask the family "Is this a change?"
8. Test for inattention.
7. Antipsychotics treat the provider rather than serve the best interest of the patient.
6. Ask WHY are they delirious?
5. Risk calculators may inform but do not replace clinical judgement.
4. Make friends with the anesthesiologists.
3. Make friends with the allied health team.
2. Empower the family.
Top 10
Tips
33. C A M I L L A W O N G
@camilla_wong
Thank you.
34. Cochrane Database Syst Rev. 2018 Jan 31;1:CD012485.
Comprehensive Geriatric Assessment may reduce delirium
Editor's Notes
Delirium, defined as an acute disorder of attention and cognition, is a common, life-threatening, and often preventable clinical syndrome in older persons. Often occurring after acute illness, surgery, or hospitalization, the development of delirium initiates a cascade of events culminating in loss of independence, increased morbidity and mortality, institutionalization, and high health care costs.
Postoperative cognitive dysfunction is a separate condition that refers to a decline in cognitive function following surgery as measured by neuropsychological testing. There has been significant recent work to redefine this condition to align with geriatric research.
Medical associations such as the UK’s National Institute for Health and Care Excellence, the European Society of Anaesthesiology, and the American Geriatrics Society offer evidence-based guidelines for postoperative delirium management
A delirium prediction model is a statistical model that either stratified individuals for their level of delirium risk, or assigned a risk score to an individual based on the number and/or weighted value of predetermined
modifiable and non-modifiable risk factors of delirium present. BMJ Open 2018;8:e019223.
variable definitions for the risk factors
assessment of outcome variable, delirium, was largely non-systematic and once daily
some include precipitating factors, which if collected after onset of delirium would exaggerate model performance
not all have external validation, and those that did were often narrow validation studies
The prevalence of postoperative delirium (POD) in elderly patients after noncardiac surgery is approximately 13% to 50%
A systematic review showed that incident hospital delirium persisted at hospital discharge in 45% of cases and 1 month later in 33% of cases
Ideally, prospectively derived, independently externally validated, easy to use, and have good psychometric properties
Systematic review of twenty-three delirium prediction models were identified, 14 were externally validated and 3 were internally validated. The following populations were represented: 11 medical, 3 medical/surgical and 13 surgical. The assessment of delirium was often nonsystematic, resulting in varied incidence. Fourteen models were externally validated with an area under the receiver operating curve range from 0.52 to 0.94. Limitations in design, data collection methods and model metric reporting statistics were identified.
demonstrates the frequency of variable use in the 14 externally validated delirium prediction models
variable definitions for the risk factors
assessment of outcome variable, delirium, was largely non-systematic and once daily
some include precipitating factors, which if collected after onset of delirium would exaggerate model performance
not all have external validation, and those that did were often narrow validation studies
Another approach is to identify prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery from cohort studies. That is what was done with this systematic review.
The risk calculators are meant to serve as decision aids. Numbers, whether taken in isolation or as an index, are NOT a substitute for clinical evaluation and clinical judgment.
The American Geriatric Society, the European Society of Anesthesiologists, and the UK’s National Institute for Health and Care Excellence all recommend that intraoperative electroencephalogram monitoring should be considered to prevent excessive anesthetic administration to patients at high risk of postoperative delirium.
Anaesthesia administration guided by the indices from a processed EEG (bispectral index) probably reduces the risk of POD within seven days after surgery with risk ratio (RR) of 0.71 (95%CI 0.59 to 0.85; number needed to treat for an additional beneficial outcome: (NNTB) of 17, 95% CI 11 to 34; 2197 participants; 3 RCTs; moderate quality of evidence).
STRIDE and ENGAGES trial since this review. Contradicting results.
One of the most important baseline patient-related factors contributing to adverse postoperative cognitive outcomes is preexisting cognitive impairment. Therefore, the depth of anesthesia may simply be a marker for patient’s baseline brain vulnerability to the effects of anesthetics. The differentiation between direct effects of anesthetic effects on the brain versus patients’ baseline vulnerability is critical to understanding the relationship between delirium and the role of the use of processed electroencephalogram-guided anesthesia.
Two trials underway:
ENGAGES-Canada Trial
Balanced Anesthesia Trial (primary outcome of mortality was just reported in the Lancet in Oct 2019)
Dexmedetomidine for the prevention of postoperative delirium in elderly patients undergoing noncardiac surgery: A meta-analysis of randomized controlled trials. PLoS One. 2019 Aug 16;14(8):e0218088.
Dexmedetomidine, a highly selective alpha-2 adrenoreceptor agonist, has the positive sedation, anti-anxiety, and analgesic effects
A total of 6 RCTs with 2102 participants were included. Compared with PLACEBO, dexmedetomidine significantly reduced the prevalence of POD (RR = 0.61, 95% CI 0.34–0.76, P = 0.001, I2 = 66%), and the risk of tachycardia (RR = 0.48, 95% CI 0.30–0.76, P = 0.002, I2 = 0%), hypertension (RR = 0.59, 95% CI 0.44–0.79, P < 0.001, I2 = 20%), stroke (RR = 0.22, 95% CI 0.06–0.76, P = 0.02, I2 = 0%), and hypoxaemia (RR = 0.50, 95% CI 0.32–0.78, P = 0.002, I2 = 0%) in elderly patients who underwent noncardiac surgery. However, dexmedetomidine accelerated the occurrence of bradycardia (RR = 1.36, 95% CI 1.11–1.67, P = 0.003, I2 = 0%). Furthermore, no significant differences were observed in the incidence of hypotension, myocardial infarction, and all-cause mortality between the dexmedetomidine and placebo groups.
moderate heterogeneity among the included trials, including in variables such as intervention time (intraoperative, intraoperative plus postoperative, and postoperative), type of surgery, sedative dose and rate of dexmedetomidine infusion, and patient characteristics
In a systematic review published in September 2019 in the Annals of Internal Medicine.
2 cardiac surgery (risperidone)
1 ortho join replacement (olanzapine) – in those that developed delirium, longer and more severe.
Other drugs
JAMA Intern Med. Published online October 21, 2019. doi:10.1001/jamainternmed.2019.4914
Sensory – glasses, hearing
Cognitive stimulation and orientation – default position for hospitalized, not antagonistic
Fluid and nutrition – n.p.o. with spine precautions, constipation, urinary retention
Mobility – one-point restraint (IV), two-point restraint (Foley).
Sleep – ear plugs, noise reduction, avoiding tests/meds at night, by the window
Medication review – avoiding anticholinergics (Gravol), sedatives (benzos, zopiclone)
Pain – multimodal pain strategies including fascia iliaca blocks, standing acetaminophen
Surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants) consistent, reproducible intervention for preventing
Delirium
Future directions: cognitive prehabilitation
The Tailored, Family-Involved Hospital Elder Life Program may be beneficial for older patients who undergo noncardiac surgical treatment as it appears to help in reducing postoperative delirium, maintaining physical and cognitive functions, and shortening the length of hospital stay.
There are no randomized controlled trials examining routine delirium screening in hospitalized patients. Risks of routine delirium screening include misdiagnosis, costs and risks of evaluation, and inappropriate treatment such as with antipsychotic medications. But if screening is done, it has to be done using a validated instrument by a trained clinician.
The word “confused” does not provide any clarification to the underlying problem. If it’s delirium, call it delirium.
Sensitivity: 94-100%
Specificity: 90-95%
+LR = 9.6
-LR = 0.16
The cornerstone of diagnosis is determining the patient’s baseline mental status and the acuity of any changes; with delirium, the changes typically occur over hours to days. This step is critical and requires obtaining the history from a knowledgeable informant. Neglecting the baseline mental status assessment is a leading reason for a missed diagnosis, since the acute change might otherwise be missed.
An acute change in mental status from baseline may distinguish delirium from other conditions. Furthermore, inattention, while common in delirium, tends to occur in later stages of dementia. For accurate differential diagnosis, knowledge of the patient’s baseline is essential to make the diagnosis. Alteration in the level of consciousness is another feature unique to delirium that is less common with dementia, depression, or psychosis.
Inattention is the sine qua non of delirium, with difficulties sustaining, focusing, or shifting attention.
It must be formally tested.
A systematic review of 9 low quality trials with 727 participants concluded antipsychotics did NOT reduce
delirium severity, resolve symptoms, or alter mortality:
Delirium duration Not reported in trials
Delirium severity SMD -1.08 (-2.55 to 0.39)
Delirium symptom resolution RR 0.95 (95% CI 0.30 to 2.98)
Mortality RR 1.29 (0.73 to 2.27)
Cochrane Database of Systematic Reviews 2018, Issue 6. Art. No.: CD005594
Medication, pain, infection, bleed, traumatic brain injury, PE, etc
Delirium is a symptom, not a diagnosis.
10 .If it is delirium, call it delirium. The word “confused” does not provide any clarification to the underlying problem.
9. Ask the family "Is this a change?” Then educate and empower the family.
8. Test for inattention. Formally.
7. Antipsychotics treat the provider rather than serve the best interest of the patient.
6. Ask why are they delirious? Delirium is a symptom, not a diagnosis. Precipitants are frequently iatrogenic.
5. Risk calculators may inform but do not replace clinical judgment. Allows for focusing prevention efforts.
4. Make friends with the anesthesiologists. They can, at their discretion use different monitoring systems, administer peripheral nerve blocks, use non-benzodiazepine based sedation strategies.
3. Make friends with the allied health team. Best evidence supports multicomponent prevention interventions.
2. Empower the family. Multicomponent prevention interventions may be even better when delivered by family.
1. An ounce of prevention is worth a pound of cure.
An evidence-based approach to perioperative delirium necessitates interdisciplinary and cross-specialty collaboration.
The intervention may make little or no difference for delirium rates (RR 0.75,95% CI 0.60 to 0.94, 3 trials, 705 participants, I² = 0%; low-certainty evidence).