The assessment of postoperative delirium at the Port of Spain General Hospital

Objective: To determine the incidence of post-operative delirium at the Port of Spain General Hospital, Trinidad and Tobago. Design and Methodology: Post-operative delirium (POD) is a relatively common occurrence particularly in the elderly (>65 yr.), after prolonged surgery and after major orthopaedic surgery. It is linked to longer hospitalization and a more prolonged recovery to full functional status. This study aimed to establish the incidence of POD at the Port of Spain General Hospital during the period September 2017 to March 2018. After obtaining consent, patients were screened using the 4 'A's Test questionnaire pre- and postoperatively. Post-operative testing was done on days 0, 1 and 2 between the hours of 18:00 and 22:00. Results: Sixty-one (61) patients were recruited. A total of 42 underwent surgery and were screened using the 4AT questionnaire. Eighteen (42.8%) displayed cognitive impairment post-operatively, with 9 (21.4%) having delirium according to the 4AT score. Delirium occurred more frequently after general anaesthesia (26.7%) compared to regional anaesthesia (8.4%). Vasopressor use was associated with a higher risk of POD (66.6%). There was an association between gynaecological malignancy and POD (3/9, 33.3%). Conclusion: The incidence of POD in elderly patients at a tertiary level hospital in Trinidad was 21.4%. At risk patients were those who underwent general anaesthesia, those who received vasopressors and those with gynaecological malignancy. We recommend that the 4AT tool be modified for our population to more accurately detect delirium.

Epidemiology and management trends of patients with severe sepsis and septic shock in Trinidadian Intensive Care Units: A prospective multicenter trial

Objectives: To investigate the epidemiology, management and predictors of mortality in severe sepsis. Design and Methodology: Prospective observational study in 4 Trinidadian Intensive Care Units (ICU) over a one year period August 2017-August 2018. Physiologic and treatment data was collected on admission to ICU and patients were followed up until ICU discharge and then at 28 days to determine mortality. Results: 163 patients fit the criteria for severe sepsis and were enrolled. Twenty-eight day and ICU mortality rate were 42% (68) and 34 % (56) respectively. Case distribution by the various hospitals were San Fernando General Hospital 62% (101), Port of Spain General Hospital 16% (26), Eric Williams Medical Sciences Complex 12.3% (20) and Sangre Grande Hospital 9.8% (16). The most common source of sepsis was pulmonary (54%) followed by abdominal (17%) and urological sepsis (14%). Acute Kidney Injury (AKI) was present in 71% (115) patients and 43% (46) of patients with stage 2 and above AKI received Renal Replacement Therapy (RRT) in the ICU. In the regression model, the only factors that were found to predict both 28 day and ICU mortality were stage 2 AKI [OR 6.2 (95% CI 1.7- 23.1, p = .007)], stage 3 AKI [OR 7.2 (95% CI, 2.1-24.0, p=.001)] , mean arterial pressure of < 60mmHg in the first 24 hours [OR 10.8 (95% CI 1.7-68.1, p= .001)], presence of either moderate-severe Acute Respiratory Distress Syndrome [OR 4.1 (95% CI 1.8 ­ 9.2, p = .002)] and Acute Physiology, Age, Chronic Health Evaluation (APACHE) II score [OR 1.08 (95% CI, 1.0-1.2, p=.039)]. Conclusion: Severe sepsis is associated with a high hospital mortality rate and this sepsis burden varies according to region. Limited access to RRT remains a problem in certain centers.