Routine management of postoperative delirium outside the ICU: Results of an international survey among anaesthesiologists.

BACKGROUND: Postoperative delirium (POD) is a severe brain dysfunction. Although data indicate a high relevance, no survey has investigated the routine practice to monitor delirium outside the ICU setting after surgery. Prior to publishing of the new European Society of Anaesthesiology (ESA) guidelines on POD, an international survey was conducted to assess current practice. METHODS: European Society of Anaesthesiology-endorsed online survey; Trial Registration: NCT-identifier: 02513537. RESULTS: In total, 566 respondents from 62 countries accessed, and 564 (99.6%) completed the survey (completion rate). Overall, 385 (68%) of the respondents reported that delirium is either "very relevant" or "relevant" for their daily clinical practice. In all, 38 (7%) of the respondents routinely monitor for delirium in >50% of all patients. Asked on the monitoring time point, more than half (n = 308, 55%) indicated to screen before or at recovery room discharge, 235 (42%) up to the first postoperative day, 143 (25%) up to 3 days, and 77 (14%) up to 5 postoperative days. Although there is a lack of long-term monitoring, nearly all respondents (n = 530, 94%) reported to treat delirium. Availability of EEG/EMG-based monitoring to assess the depth of anaesthesia was high in the study group (n = 547, 97%) and was used by more than one-third of the respondents to reduce risk of burst suppression (n = 189, 34%). CONCLUSION: Although delirium is perceived as a relevant condition among anaesthesiologists, there is a high demand for implementing monitoring strategies after publishing of the POD Guideline. The survey shows that tools necessary for POD Guideline implementation are available in the centres represented by the respondents.

Emergence delirium in children is not related to intraoperative burst suppression - prospective, observational electrography study.

BACKGROUND: Emergence-delirium is the most frequent brain dysfunction in children recovering from general anaesthesia, though the pathophysiological background remains unclear. The presented study analysed an association between emergence delirium and intraoperative Burst Suppression activity in the electroencephalogram, a period of very deep hypnosis during general anaesthesia. METHODS: In this prospective, observational cohort study at the Charité - university hospital in Berlin / Germany children aged 0.5 to 8 years, undergoing planned surgery, were included between September 2015 and February 2017. Intraoperative bi-frontal electroencephalograms were recorded. Occurrence and duration of Burst Suppression periods were visually analysed. Emergence delirium was assessed using the Pediatric Assessment of Emergence Delirium Score. RESULTS: From 97 children being analysed within this study, 40 children developed emergence delirium, and 57 children did not. Overall 52% of the children displayed intraoperative Burst Suppression periods; however, occurrence and duration of Burst Suppression (Emergence delirium group 55% / 261 + 462 s vs. Non-emergence delirium group 49% / 318 + 531 s) did not differ significantly between both groups. CONCLUSIONS: Our data reveal no correlation between the occurrence and duration of intraoperative Burst Suppression activity and the incidence of emergence delirium. Burst Suppression occurrence is frequent; however, it does not seem to have an unfavourable impact on cerebral function at emergence from general anaesthesia in children. TRAIL REGISTRATION: NCT02481999, June 25, 2015.

Emergence delirium in children is related to epileptiform discharges during anaesthesia induction: An observational study.

BACKGROUND: Epileptiform discharges frequently occur in children during induction of anaesthesia. However, studies analysing the impact of epileptiform discharges on postoperative emergence delirium in children are still scarce. The aim of this study is to correlate the incidence of epileptiform activity during anaesthesia induction with the occurrence of emergence delirium during stay in the recovery room. OBJECTIVES: Prospective, observational cohort study in children 0.5 to 8 years old undergoing planned surgery. Bifrontal electroencephalogram electrodes were placed before induction of anaesthesia. Visual electroencephalogram analysis was performed from start of anaesthetic agent administration until intubation with regard to epileptiform patterns: rhythmic polyspikes; periodic epileptiform discharges; delta with spikes; and suppression with spikes. Emergence delirium was assessed during stay in the recovery room using the Pediatric Assessment of Emergence Delirium Score. DESIGN: Prospective, observational cohort study. SETTING: University hospital - Germany/Berlin. Children were included between September 2015 and February 2017. PATIENTS: A total of 62 Children, aged 0.5 to 8 years old undergoing planned surgery were included. MAIN OUTCOME MEASURES: Primary outcome was emergence delirium. Secondary outcomes, peri-operative Electroencephalography (EEG) data analysis. The presented study analysed an association between emergence delirium and the occurrence of epileptiform discharges during anaesthesia induction. RESULTS: A total of 43.5% of the children developed emergence delirium and 56.5% did not. Epileptiform discharges were observed more often in children developing emergence delirium (63%) compared with children not developing emergence delirium (43%). But only the occurrence of interictal spike events - such as rhythmic polyspikes; periodic epileptiform discharges and delta with spikes - were significantly related to emergence delirium (emergence delirium-group 48% vs. nonemergence delirium-group 14%, OR = 5.6 [95% CI: 1.7 to 18.7]; P = 0.004). CONCLUSION: Emergence delirium in children is significantly related to interictal spike events occurring during induction of anaesthesia. CLINICAL TRIAL: NCT02481999.

Observational clinical study on organ dysfunction associated with dosing of antibiotics in a Pediatric Intensive Care Unit.

BACKGROUND: Medication errors are of concern especially in pediatric patients. This study investigates impact of dosing errors of antibiotics on outcome in critically ill pediatric patients. METHODS: Retrospective study including all consecutive patients admitted to one university pediatric intensive care unit (PICU) in 2010 with length of PICU stay >24 hrs, age <18 years and antibiotic therapy. Antibiotic dosages were evaluated for compliance with recommended dosing individually adapted for bodyweight, age and organ function. Primary endpoint was organ dysfunction defined as occurrence of liver injury (LI) or acute kidney injury (AKI) after initiation of antibiotic therapy. AKI was defined as reduced estimated glomerular filtration below 50 mL/min or renal replacement therapy. LI was defined as more than two-fold elevation of liver enzymes. Additionally, duration of PICU stay, ventilation and all-cause PICU mortality were investigated. RESULTS: Altogether 305 patients were evaluated with 2577 patient PICU days and 4021 antibiotic dosages. Overall 38.6% of dosages were incorrect according to recommendations and were applied in 130 patients (low-adherence-group). 175 children received antibiotic dosing according to recommendations (high-adherence-group). Patients in the low-adherence-group showed a 7-fold increase in adjusted risk to develop new-onset organ dysfunction (95% CI: 2.1-26.4), needed longer median PICU treatment (7 versus 3 days, P<0.001) and prolonged duration of mechanical ventilation (8 versus 2 days, P<0.001). In subgroup analyses, organ dysfunction and PICU mortality were associated with non-adherence to recommendations. CONCLUSIONS: Adherence to a bodyweight- and age-adapted dosage-protocol is associated with less organ dysfunction and a more favorable clinical outcome in pediatric patients.

[Drama in the Recovery Unit: Paediatric Emergence Delirium]. / Drama im Aufwachraum: pädiatrisches Emergence-Delir.

The upcoming and ongoing debate on neurotoxicity of anesthetics at a young age put a new spotlight on the emergence delirium of children (paedED). The European Society for Anesthesiology published a consensus guideline on prevention and therapy in 2017 which can be a useful guidance in daily clinical practice. Patient data management systems with their clear documentation concerning pain/therapy of pain and paedED will be valuable tools in order to assess the real incidence of paedED. Differentiating between pain/agitation and paedED migth not always be easy. Age-adapted scores should always be applied. Main focus in the prevention of paedED is the reduction of anxiety. The way this is achieved by the dedicated pediatric anesthesia teams caring for children, e.g. by oral midazolam, clowns, music, smartphone induction, does not matter. Using α2-agonists in the perioperative phase and applying propofol seems to be effective. A quiet supportive environment for recovery adds to a relaxed, stress-free awakening. For the future detecting paedED on normal wards becomes an important issue. This may be achieved by structured interviews or questionnaires assessing postoperative negative behavioural changes at the same time.

European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium.

The purpose of this guideline is to present evidence-based and consensus-based recommendations for the prevention and treatment of postoperative delirium. The cornerstones of the guideline are the preoperative identification and handling of patients at risk, adequate intraoperative care, postoperative detection of delirium and management of delirious patients. The scope of this guideline is not to cover ICU delirium. Considering that many medical disciplines are involved in the treatment of surgical patients, a team-based approach should be implemented into daily practice. This guideline is aimed to promote knowledge and education in the preoperative, intraoperative and postoperative setting not only among anaesthesiologists but also among all other healthcare professionals involved in the care of surgical patients.

[Web-based for preanesthesia evaluation record: a structured, evidence-based patient interview to assess the anesthesiological risk profile]. / Webbasierte Anästhesieanamnese - Patienteninterview zur Erfassung des anästhesiologischen Risikoprofils.

At present, providers at an Anesthesia Preoperative Evaluation Clinic (APEC) may have difficulties in gaining access to relevant clinical information, including external medical records, surgical dictations etc. This common occurence makes obtaining an informed consent by the patient after a complete pre-anesthetic assessment difficult. This form of patient information is subject to wide interindividual variations and, thus, represents a challenge for quality assurance. Insufficient or not completed pre-anesthetic assessments can lead to an untimely termination of an elective procedure.A web-based pre-anesthetic evaluation record moves the time point of the first contact to well before the day of admission. The current pre-anesthesia evaluation record is replaced by a structured interview in the form of a complex of questions in a specific hierarchy taking guidelines, standard operating procedures (SOP) and evidence-based medicine (EBM) into consideration. The answers to the complex of questions are then classified according to agreed criteria and possible scoring systems of relevant classifications. The endpoints result in procedural recommendations not only for the informing anesthesiologist but also for the patient. The standardized risk criteria can be used as core process indicators to check the process quality of the anesthesiological risk evaluation. Short-notice cancellations of elective operations due to incomplete premedication procedures will then be avoided with the help of such structured and evidence-based patient interviews with detailed assessment of the anesthesiological risk profile.The web-based anesthesia evaluation record (WAR) corresponds with the recommendations of the DGAI to carry out the staged information in analogy to the staged information of Weissauer. The basic practice is not changed by WACH. By means of WACH, the time point of the first contact with anesthesia is moved forward and occurs within a different framework. WACH has potential advantages for both patient and anesthesiologist, not least due to a higher patient safety.

Clinical practice in the management of postoperative delirium by Chinese anesthesiologists: a cross-sectional survey designed by the European Society of Anaesthesiology.

OBJECTIVE: In this survey, we assessed the current clinical management of postoperative delirium (POD) among Chinese anesthesiologists, after publishing the European POD guideline. METHODS: We administered an electronic survey, designed according to the European POD guideline. The survey was completed using mobile devices. RESULTS: In total, 1,514 respondents from China participated in the survey. Overall, 74.4% of participants reported that delirium is very important. More than 95% of participants stated that they routinely assessed POD. In total, 61.4% screened for POD using clinical observation and 37.6% used a delirium screening tool. Although the depth of anesthesia (a POD risk factor) was monitored, electroencephalogram monitoring was unavailable to 30.6% of respondents. Regarding treatment, only 24.1% of respondents used a standard algorithm; 58.5% used individualized treatment. CONCLUSION: Our survey showed that there are high awareness levels among Chinese anesthesiologists regarding the importance of POD. However, routine assessment and monitoring of all patients, including perioperative anesthesia depth monitoring, and a treatment algorithm need to be implemented on a larger scale. According to the results, efforts should be made to improve the knowledge of POD among Chinese anesthesiologists.

Frequency, predictive factors and therapy of emergence delirium: data from a large observational clinical trial in a broad spectrum of postoperative pediatric patients.

BACKGROUND: Emergence delirium (ED) is an important postanesthetic complication in children. Although it has been thoroughly studied, data on frequency, predictive factors, and therapy of this phenomenon are inconclusive. In this study, we seek to obtain a better understanding of the frequency of ED and different therapeutic approaches, making use of the large amount of patients in our university hospital. METHODS: After approval by the local ethics committee, patients aged zero to 13 years, who were treated in the post anesthesia care of our hospital, were investigated in this observational study. ED was diagnosed on basis of a clinical evaluation as well as with the Pediatric Anesthesia Emergence Delirium (PAED) Scale. RESULTS: In 86 of 821 patients a PAED-Score≥10 and therefore an ED was detected (10.5%). Based on clinical assessment by the PACU staff only 5.7% experienced an ED. Age

Incidence of epileptiform discharges in children during induction of anaesthesia using Propofol versus Sevoflurane.

OBJECTIVE: In pediatric patients, anaesthesia induction is often performed with intravenous Propofol or Sevoflurane inhalation. Although epileptiform discharges have been observed during inductions with Sevoflurane, their occurrence has not been investigated for i.v. Propofol inductions. The aim of this study is to compare the incidence of epileptiform discharges in children during anaesthesia induction using Propofol versus Sevoflurane. METHODS: Prospective, observational cohort study in children aged 0.5-8 years undergoing elective surgery. Children were anaesthetized with either Propofol or Sevoflurane. Bi-frontal electroencephalograms electrodes were placed before start of anaesthesia. Visual electroencephalogram analysis was performed from start of anesthetic agent administration until Intubation with regard to identify epileptiform patterns, i.e. delta with spikes; rhythmic polyspikes; periodic, epileptiform discharges; or suppression with spikes. RESULTS: 39 children were anaesthetized with Propofol, and 18 children with Sevoflurane. Epileptiform discharges were seen in 36% of the children in the Propofol group, versus 67% in the Sevoflurane group (p = 0.03). Incidence of the distinct types of epileptiform discharge differed for periodic, epileptiform discharges (Sevoflurane group 39% vs. Propofol group 3%; p < 0.001). Higher concentration of Remifentanil (≥0.15 µg/kg/min) was associated with less frequent epileptiform discharges (Exp 5.8; CI 95% 1.6/21.2; p = 0.008). CONCLUSIONS: Propofol i.v. induction of anaesthesia in children triggers epileptiform discharges, whereas to a lesser extent than Sevoflurane does. SIGNIFICANCE: Presuming that epileptiform discharges have an impact on postoperative brain function, it is advisable to use Propofol rather than Sevoflurane and higher level of Remifentanil for anaesthesia induction in children.