Postoperative delirium is a potentially dangerous and costly condition that can afflict patients after being anesthetized. However, instances of POD can be lowered through use of one piece of technology, according to Joseph Tobin, MD, emeritus professor and former chairman of the department of anesthesiology at Wake Forest University School of Medicine in Winston-Salem, N.C.
During a webinar hosted by Becker's Healthcare and Medtronic on Nov. 11, Dr. Tobin discussed:
- POD and postoperative cognitive dysfunction
- The effect on patients and hospitals
- A possible solution to reduce instances of POD and POCD
POD is defined as an acute change in cognition characterized by:
- Inattention
- Altered level of consciousness and/or disorganized thinking
- Possibly hallucinations
POCD is similar but lasts longer — up to one month post discharge. These conditions can be caused by anesthesia use, "but it has now been recognized that they are more than just anesthesia related," Dr. Tobin said. Aging, electrolyte abnormalities, and surgical inflammatory factors caused by the trauma of surgery also are linked to the instance of POD.
Risk factors for developing POD include:
- Preexisting cognitive impairment
- Advanced age
- Poor physical function
The length of surgery and type of surgery can also affect the likelihood of POD. Dr. Tobin said he is most concerned with the aging population and the growing risk of POD. "We have an aging population, and the aging population is responsible for an increasing percentage of surgical and anesthetic management, and therefore the epidemiologic manifestation of POD … [is] exacerbated with our aging population."
POD has several negative effects on patients, healthcare workers, and the hospitals that treat them, including:
- Symptoms extending as long as a month post discharge
- Increased length of stay
- Patient falls due to lack of coordination
- Employee injuries from treating uncooperative and uncoordinated patients
- Increasing Medicare penalties for readmissions
- Higher rates of discharge to nursing homes, leading to increased costs
Reduce the risk
"There are programs that can provide interventional help in order to help reduce the risk of postoperative delirium," Dr. Tobin said.
Examples include:
- Orientation like clocks and calendars
- Increased exposure to natural sunlight
- Early mobilization
- Fluid and electrolyte management
Perhaps the most important thing anesthesiologists can do to prevent POD is administer the right amount of anesthesia. Too much can lead to POD, whereas too little can lead to awareness during surgery. "What we have found is by monitoring the depth of anesthesia in randomized trials, we can reduce the rate of postoperative delirium," Dr. Tobin said.
A Bispectral Index™ device, the BIS™ system made by Medtronic, monitors anesthesia depth. The system evaluates the patient's EEG while he or she is anesthetized and displays a value from one to 100 to show how deep the patient is under anesthesia.
"If an anesthesiology team can decide [a] patient would do better in a certain BIS™ range, then as we titrate the anesthetic to that level, we really do believe we can give the patient the smoothest perioperative course and reduce the risk of postoperative delirium," Dr. Tobin said.
He cited four studies that linked the use of a BIS™ monitor to decreased instances of POD, as anesthesiologists tend to be "heavy-handed with [their] anesthetic technique" when no monitor is available.
"There are multiple studies which now suggest that the ability to both monitor and provide an appropriate reference range will be beneficial to reduce postoperative delirium," he said.
Not only can the monitor improve patient outcomes, it can provide an economic advantage. According to Dr. Tobin, the cost of one case of POD could be $2,500 or more with just one day increased length of stay, while the cost of monitoring a patient with the BISTM system costs roughly $500. "We see the economic opportunity that may be in front of us," he said.
Raise awareness, give support
Dr. Tobin encouraged making POD a focus during grand rounds to raise awareness among surgical and anesthesia staff. "Once surgeons are aware that this is a problem, they will allow or cooperate with the anesthesia team to formulate a plan, which would reduce the use of anesthetics and use a BIS™ guided anesthesia administration to reduce POD," he said.
Senior leadership also needs to commit to providing support and resources to purchase and implement the BIS™ monitors.
With support from senior leaders, anesthetists, and other clinicians, use of a BIS™ monitor can lead to improved patient outcomes, benefit healthcare workers, and reduce costs by reducing the incidence of POD.
Watch the presentation on YouTube here.
Download a copy of the presentation here.