The Assessment of Immediate Postoperative Delirium in Neurologically Intact Adult Patients Admitted to the Post-anesthesia Care Unit: A Cross-Sectional Study.

Background Immediate postoperative delirium (IPD) in the post-anesthesia care unit (PACU) can cause significant morbidity affecting everyday activities and length of stay with cost implications. This study was undertaken to find the proportion of IPD in PACU and its association with anesthesia and other perioperative factors. Methods After obtaining ethical approval and informed consent, this cross-sectional study was conducted in the PACU. A total of 600 consecutive adult patients (American Society of Anesthesiologists (ASA) 1-3) posted for surgery were approached between January and March 2019, of which 402 patients without neurological diseases and language and hearing discrepancies were studied. All patients had the intervention of surgery under anesthesia in a usual manner. Delirium was assessed preoperatively, postoperatively at 15 and 30 minutes, and before discharge from the PACU. IPD was assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) score, while sedation/agitation was assessed using the Richmond Agitation-Sedation Scale (RASS). The primary outcomes were the proportion of IPD, association with anesthesia, and perioperative risk factors. The secondary outcomes were the length of stay, delirium treatment, and mortality. Results Overall, the IPD proportion was 14.7%. A significant association was demonstrated with premedication with midazolam (odds ration (OR): 3.2; 95% confidence interval (CI): 1.42-7.35; P=0.003), general anesthesia (GA) (OR: 6.3; 95% CI: 2.23-17.8; P<0.001), duration of anesthesia (126 versus 95 minutes; P=0.001), laparoscopic mode of surgical access (OR: 3.4; 95% CI: 1.8-6.4; P<0.001), and postoperative RASS >/< 0 (OR: 10.6; 95% CI: 4.69-24.11; P<0.001) at 30 minutes and before discharge from the PACU. Multivariate analysis showed the strongest association of RASS at 30 minutes with IPD. Conclusion The proportion of IPD was found to be 14.7% in this study, and the chances of developing IPD are high if the patient is not awake and calm in the PACU, especially if midazolam is administered as premedication, followed by general anesthesia (GA) for a long duration.

Gastrointestinal Migration of a Pharyngeal Pack During Functional Endoscopic Sinus Surgery (FESS): A Case Report and Preventive Strategies.

The pharyngeal pack is routinely used in many nasopharyngeal surgeries to reduce the spillage of secretions into the trachea and esophagus. Here we report a case of migration of a pharyngeal pack into the stomach of a patient undergoing functional endoscopic sinus surgery and review risks of delayed recognition and the management of this complication. In this case report, we share our experience to reinforce and highlight the importance of proper documentation of pharyngeal pack insertion and removal to prevent easily avoidable morbidity and mortality. It also highlights the importance of an immediate esophago-gastro-duodenoscopy (OGD) to retrieve the migrated pharyngeal pack as soon as its migration to the gastrointestinal tract is suspected.

Airway and Anaesthetic Challenges in a Child With Bronchus Suis and Superimposed Double Aortic Arch: A case report.

Bronchus suis or tracheal bronchus is an accessory bronchus arising from the trachea above the carina. Double aortic arch is a congenital vascular anomaly with persistence of both left and right aortic arches beyond fetal life which can form a vascular ring compressing the major airways and may be symptomatic. We report the case of a 16-month-old girl who had recurrent episodes of respiratory distress requiring multiple hospitalisations and was diagnosed at the Sultan Qaboos University Hospital, Muscat, Oman in 2019 with a double aortic arch compressing upon a tracheal bronchus causing symptomatic emphysema of the right upper lobe. This report presents anaesthetic and airway challenges during the patient's lobectomy. A single lumen cuffed endotracheal tube was successfully used as a bronchial blocker to occlude the origin of the aberrant bronchus. The position of the tube was confirmed intraoperatively using fibreoptic bronchoscopy. Following her discharge, she continued to have recurrent episodes of respiratory distress and three months after her last appointment she succumbed to her illness. To the best of the authors' knowledge, this is the first such reported case in Oman.