Langenbecks Arch Surg (2015) 400:513–516 DOI 10.1007/s00423-015-1297-8
ORIGINAL ARTICLE
Delirium in fast-track colonic surgery Sorel Kurbegovic & Jens Andersen & Lene Krenk & Henrik Kehlet
Received: 13 November 2014 / Accepted: 3 March 2015 / Published online: 13 March 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Background Postoperative delirium (PD) is a common but serious problem after major surgery with a multifactorial pathogenesis including age, pain, opioid use, sleep disturbances and the surgical stress response. These factors have been minimised by the Bfast-track methodology^ previously demonstrated to enhance recovery and reduce morbidity. Methods Clinical symptoms of PD were routinely collected three times daily from preoperatively until discharge in a welldefined enhanced recovery program after colonic surgery in 247 consecutive patients. Results Total median length of hospital stay was 3 days. Seven patients (2.8 %) developed clinical signs of PD most within the first 72 postoperative hours and only 1 patient with PD extending to 120 h postoperatively. Only 1 PD patient required treatment with serenase. PD patients were older (83 vs. 73 years) and had longer median stay (6 vs. 3 days). No difference in development of PD between open and laparoscopic operation could be demonstrated. Among the 7 patients with PD, 3 of these patients had later surgical complications. One patient had a subsequent strangulated small intestine, another an anastomotic leakage complicated by a bleeding gastric ulcer and death on day 12 and 1 with fever, abdominal pain and suspected but disproven anastomotic Sorel Kurbegovic and Jens Andersen contributed equally to this work. S. Kurbegovic : L. Krenk : H. Kehlet (*) Section of Surgical Pathophysiology, Rigshospitalet Copenhagen University, 4074, Blegdamsvej 9, 2100 Copenhagen, Denmark e-mail: [email protected] S. Kurbegovic : L. Krenk : H. Kehlet The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark J. Andersen Department of Surgical Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
leakage (stay 21, 12 and 22 days, respectively). The remaining 4 PD patients stayed 4, 4, 5 and 6 days with an uncomplicated course. Conclusions These data support that an enhanced postoperative recovery program may decrease the risk and duration of PD after colonic surgery. Keywords Postoperative delirium . Colonic surgery . Fast-track surgery . Enhanced recovery program
Introduction Postoperative delirium (PD) and more subtle early and late postoperative cognitive dysfunction (POCD) are welldocumented undesirable sequelae in major surgery, especially in elderly patients [1]. Although the topic has received major attention in the last decade, a summary of previous studies on strategies for perioperative interventions to decrease delirium has largely been inconclusive [2, 3]. However, there is agreement that several non-modifiable factors may contribute to PD and POCD such as high age, limited preoperative cognitive function and chronic pain [1]. When it comes to modifiable factors, the type of anaesthesia may not be important [1–3]. Others have hypothesised that PD and POCD is a multifactorial problem influenced by acute postoperative pain, opioid use, sleep disturbances and the inflammatory responses [4], all of which are potentially modifiable and interrelated in the postoperative phase. At the same time, several efforts have been made to enhance postoperative recovery according to the Bfast-track methodology,^ which include patient information and involvement in the early recovery phase, optimised opioidsparing multimodal analgesia, optimised fluid management, early mobilisation and oral feeding all of which have been
514
shown to be successful to enhance recovery and decrease postoperative morbidity across surgical procedures [5, 6]. Unfortunately, few studies have focused on the risk of PD and POCD in a fast-track surgical setting, but the first study in colorectal surgery has shown a low incidence of PD [7] and the same positive findings were found within the setting of fast-track hip and knee arthroplasty [8, 9]. The aim of the present retrospective analysis of prospectively collected data from a well-established fast-track colorectal unit [10] was therefore to assess the incidence and severity of PD in a large consecutive cohort in fast-track colonic surgery.
Patients and methods Patients Elderly patients (range 60–94 years) undergoing elective colonic surgery at Copenhagen University Hvidovre Hospital from January 7, 2010 to December 27, 2012 were extracted from a prospective database. A total number of 259 consecutive patients was registered but 12 cases were excluded due to incorrect social security number (n=8) or inadequate record (n=4), leaving a total of 247 patients eligible for analysis. The fast-track methodology Perioperative management followed the principles of fasttrack colonic surgery described in detail before [10, 11]. In summary, the program included detailed preoperative patient information about the care principles, no bowel preparation except for a 240-ml natriumducosate enema (klyx®; Ferring, Copenhagen, Denmark) in the evening and morning before surgery. The patients were operated during combined general anaesthesia (no premedication, remifentanil 1 μg/kg/h, propofol 3 mg/kg/h, cisatracium 0.15 mg/kg, ondansetron 4 mg and i.v. ketorolac 30 mg) and thoracic epidural analgesia (bupivacaine 0.25 % 4 ml/h and morphine 0.2 mg/h), using transverse or curved incisions or a laparoscopic approach. A nasogastric tube was removed at the end of operation, drains were not used routinely and urinary bladder and epidural catheters were removed 24 and 48 h postoperatively, respectively. Oral analgesia consisted of paracetamol 1 g/6-hourly and ibuprofen 600 mg/8-hourly and only opioids on request. Free solid food intake was initiated from the day of surgery, and mobilisation initiated on the day of surgery following a welldefined nursing care program [10]. Fluid management secured no fluid overload and discharge was planned on the third postoperative day (72 h postoperatively) [11]. Discharge criteria were normalisation of gastrointestinal function with normal fluid and food intake, sufficient pain relief on oral
Langenbecks Arch Surg (2015) 400:513–516
analgesics and patient acceptance. All patients were seen in the outpatient clinics 30 days postoperatively. Mental function was assessed by the nurses based upon the confusion assessment method (CAM) [12] with an algorithm including four features: (1) acute onset and fluctuating course, (2) inattention, (3) disorganized thinking and (4) altered level of consciousness. The diagnosis of PD requires the presence of features 1 and 2 and either 3 or 4. The nursing staff routinely evaluated the patients three times daily (each nursing shift) starting on the day before surgery (baseline) up to the fourth postoperative day (POD 4) or discharge day using a standardised care plan including cognitive evaluation. To ensure consistency and accuracy and to eliminate bias among nursing staff, these have been instructed to note and specify any onset compared to baseline. All patient records were screened for patients meeting the CAM criteria for PD. Data processing was done by IBM® SPSS® statistic 22 and presented as absolute or relative numbers and with median or mean values where appropriate. Continuous data were compared with Mann-Whitney test and Fisher’s test when comparing PD and type of surgery. P < 0.05 was considered significant.
Results Seven patients (2.8 %) of the 247 patients fulfilled the CAM criterions [12] for PD. Five patients fulfilled features 1, 2 and 3. Two patients fulfilled features 1, 2, 3 and 4. Patient demographics in patients with or without postoperative PD are shown in Table 1. Median (range) postoperative LOS in the total group was 3 (2–45) days. The PD patients were older and with a longer postoperative stay but otherwise did not differ Table 1
Patient characteristics. Values are median (range) [mean] Overall (n=247)
Age Gender Male Female LOS (days) Surgical procedure Right hemicolectomy Sigmoid resection Hartmann reversal Left hemicolectomy Surgical technique Laparoscopic Open surgery
+ Delirium ÷ Delirium P value (n=7) (n=240)
73 (60–94) 80 (79–93) 73 (60–94)
ORIGINAL ARTICLE
Delirium in fast-track colonic surgery Sorel Kurbegovic & Jens Andersen & Lene Krenk & Henrik Kehlet
Received: 13 November 2014 / Accepted: 3 March 2015 / Published online: 13 March 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Background Postoperative delirium (PD) is a common but serious problem after major surgery with a multifactorial pathogenesis including age, pain, opioid use, sleep disturbances and the surgical stress response. These factors have been minimised by the Bfast-track methodology^ previously demonstrated to enhance recovery and reduce morbidity. Methods Clinical symptoms of PD were routinely collected three times daily from preoperatively until discharge in a welldefined enhanced recovery program after colonic surgery in 247 consecutive patients. Results Total median length of hospital stay was 3 days. Seven patients (2.8 %) developed clinical signs of PD most within the first 72 postoperative hours and only 1 patient with PD extending to 120 h postoperatively. Only 1 PD patient required treatment with serenase. PD patients were older (83 vs. 73 years) and had longer median stay (6 vs. 3 days). No difference in development of PD between open and laparoscopic operation could be demonstrated. Among the 7 patients with PD, 3 of these patients had later surgical complications. One patient had a subsequent strangulated small intestine, another an anastomotic leakage complicated by a bleeding gastric ulcer and death on day 12 and 1 with fever, abdominal pain and suspected but disproven anastomotic Sorel Kurbegovic and Jens Andersen contributed equally to this work. S. Kurbegovic : L. Krenk : H. Kehlet (*) Section of Surgical Pathophysiology, Rigshospitalet Copenhagen University, 4074, Blegdamsvej 9, 2100 Copenhagen, Denmark e-mail: [email protected] S. Kurbegovic : L. Krenk : H. Kehlet The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark J. Andersen Department of Surgical Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
leakage (stay 21, 12 and 22 days, respectively). The remaining 4 PD patients stayed 4, 4, 5 and 6 days with an uncomplicated course. Conclusions These data support that an enhanced postoperative recovery program may decrease the risk and duration of PD after colonic surgery. Keywords Postoperative delirium . Colonic surgery . Fast-track surgery . Enhanced recovery program
Introduction Postoperative delirium (PD) and more subtle early and late postoperative cognitive dysfunction (POCD) are welldocumented undesirable sequelae in major surgery, especially in elderly patients [1]. Although the topic has received major attention in the last decade, a summary of previous studies on strategies for perioperative interventions to decrease delirium has largely been inconclusive [2, 3]. However, there is agreement that several non-modifiable factors may contribute to PD and POCD such as high age, limited preoperative cognitive function and chronic pain [1]. When it comes to modifiable factors, the type of anaesthesia may not be important [1–3]. Others have hypothesised that PD and POCD is a multifactorial problem influenced by acute postoperative pain, opioid use, sleep disturbances and the inflammatory responses [4], all of which are potentially modifiable and interrelated in the postoperative phase. At the same time, several efforts have been made to enhance postoperative recovery according to the Bfast-track methodology,^ which include patient information and involvement in the early recovery phase, optimised opioidsparing multimodal analgesia, optimised fluid management, early mobilisation and oral feeding all of which have been
514
shown to be successful to enhance recovery and decrease postoperative morbidity across surgical procedures [5, 6]. Unfortunately, few studies have focused on the risk of PD and POCD in a fast-track surgical setting, but the first study in colorectal surgery has shown a low incidence of PD [7] and the same positive findings were found within the setting of fast-track hip and knee arthroplasty [8, 9]. The aim of the present retrospective analysis of prospectively collected data from a well-established fast-track colorectal unit [10] was therefore to assess the incidence and severity of PD in a large consecutive cohort in fast-track colonic surgery.
Patients and methods Patients Elderly patients (range 60–94 years) undergoing elective colonic surgery at Copenhagen University Hvidovre Hospital from January 7, 2010 to December 27, 2012 were extracted from a prospective database. A total number of 259 consecutive patients was registered but 12 cases were excluded due to incorrect social security number (n=8) or inadequate record (n=4), leaving a total of 247 patients eligible for analysis. The fast-track methodology Perioperative management followed the principles of fasttrack colonic surgery described in detail before [10, 11]. In summary, the program included detailed preoperative patient information about the care principles, no bowel preparation except for a 240-ml natriumducosate enema (klyx®; Ferring, Copenhagen, Denmark) in the evening and morning before surgery. The patients were operated during combined general anaesthesia (no premedication, remifentanil 1 μg/kg/h, propofol 3 mg/kg/h, cisatracium 0.15 mg/kg, ondansetron 4 mg and i.v. ketorolac 30 mg) and thoracic epidural analgesia (bupivacaine 0.25 % 4 ml/h and morphine 0.2 mg/h), using transverse or curved incisions or a laparoscopic approach. A nasogastric tube was removed at the end of operation, drains were not used routinely and urinary bladder and epidural catheters were removed 24 and 48 h postoperatively, respectively. Oral analgesia consisted of paracetamol 1 g/6-hourly and ibuprofen 600 mg/8-hourly and only opioids on request. Free solid food intake was initiated from the day of surgery, and mobilisation initiated on the day of surgery following a welldefined nursing care program [10]. Fluid management secured no fluid overload and discharge was planned on the third postoperative day (72 h postoperatively) [11]. Discharge criteria were normalisation of gastrointestinal function with normal fluid and food intake, sufficient pain relief on oral
Langenbecks Arch Surg (2015) 400:513–516
analgesics and patient acceptance. All patients were seen in the outpatient clinics 30 days postoperatively. Mental function was assessed by the nurses based upon the confusion assessment method (CAM) [12] with an algorithm including four features: (1) acute onset and fluctuating course, (2) inattention, (3) disorganized thinking and (4) altered level of consciousness. The diagnosis of PD requires the presence of features 1 and 2 and either 3 or 4. The nursing staff routinely evaluated the patients three times daily (each nursing shift) starting on the day before surgery (baseline) up to the fourth postoperative day (POD 4) or discharge day using a standardised care plan including cognitive evaluation. To ensure consistency and accuracy and to eliminate bias among nursing staff, these have been instructed to note and specify any onset compared to baseline. All patient records were screened for patients meeting the CAM criteria for PD. Data processing was done by IBM® SPSS® statistic 22 and presented as absolute or relative numbers and with median or mean values where appropriate. Continuous data were compared with Mann-Whitney test and Fisher’s test when comparing PD and type of surgery. P < 0.05 was considered significant.
Results Seven patients (2.8 %) of the 247 patients fulfilled the CAM criterions [12] for PD. Five patients fulfilled features 1, 2 and 3. Two patients fulfilled features 1, 2, 3 and 4. Patient demographics in patients with or without postoperative PD are shown in Table 1. Median (range) postoperative LOS in the total group was 3 (2–45) days. The PD patients were older and with a longer postoperative stay but otherwise did not differ Table 1
Patient characteristics. Values are median (range) [mean] Overall (n=247)
Age Gender Male Female LOS (days) Surgical procedure Right hemicolectomy Sigmoid resection Hartmann reversal Left hemicolectomy Surgical technique Laparoscopic Open surgery
+ Delirium ÷ Delirium P value (n=7) (n=240)
73 (60–94) 80 (79–93) 73 (60–94)
