When an elderly loved one needs surgery, there are a host of worries and fears in the minds of friends, family, and caregivers. Advanced age predisposes people to many surgical complications, but one of the most common yet least recognized is post-operative delirium (POD). A 2015 review of scientific literature about POD defines delirium as “an acute decline in cognitive function and attention and represents acute brain failure” (1). Delirium can occur in any surgical patient, but is much more common in the elderly.  Not only do clinicians, particularly anesthesiologists, need to be more educated about preventing, detecting, and treating POD, but family members and caregivers also need to play a role in monitoring the patient to be sure that the symptoms of delirium are detected promptly. POD is of increasing relevance due to the aging population of the United States. Clinicians involved in outpatient care must be especially careful to assess a patient’s risk of developing POD in planning procedures, and should administer tests to evaluate the patient’s cognitive status before discharge.

Risk factors for POD can include age, invasiveness and length of the operation, pre-existing dementia, certain medications, and alcohol abuse. POD is a serious issue because it is associated with poor surgical outcomes, cognitive decline, development of dementia, increased length of hospital stay, and increased risk of morbidity and mortality. POD can also be an initial indicator of heart problems. The prompt detection of POD can help to allay these issues. It is vital that surgeons and anesthesiologists consider a patient’s risk factors for POD before, during, and after surgery.

But what should a family member, caregiver, or clinician be looking out for? POD typically manifests in the first day or two after the operation. There are three main types, which are associated with different sets of symptoms. Hyperactive delirium is associated with agitation and increased activity. Hypoactive delirium, the most common subtype, is associated with lethargy and decreased activity. The third type is mixed delirium, and patients can exhibit a blend of the characteristics of hyper- and hypoactive delirium. The most common symptoms of POD are fluctuations in consciousness, cognitive deficit, visual or auditory hallucinations, impaired motor skills, lethargy, agitation, trouble sleeping, poor concentration, trouble communicating, and severe mood swings. When a patient may be showing symptoms of POD, there are a variety of assessments which clinicians can use to measure their cognitive function. The two most commonly used for POD are the Confusion Assessment Method (CAM) and the Mini-Mental State Examination. Even if a patient’s delirium doesn’t meet clinical standards, it should still be monitored, and environmental measures to ameliorate it can be taken.

There are many ways that POD can be treated, as well as preventative measures that can be taken before surgery. Environmental treatments and preventative measures can include placing orienting materials such as a clock and a calendar in the patient’s room, keeping the room calm and quiet, ensuring that glasses and hearing aids are accessible, helping patients get up and moving as soon as possible after surgery, keeping track of nutrition, preventing dehydration, and having familiar faces around to make patients feel grounded. Anesthesiologists should carefully monitor the drugs administered, particularly sedatives and muscle relaxants, as well as oxygen levels and blood pressure. In some severe cases, POD can be treated with antipsychotic drugs such as haloperidol, though recent studies have indicated that it may not be as effective as previously thought (1).

Amid the many worries and concerns that beset the loved ones of a surgical patient, it is important to keep POD in mind, because often the family and friends of a patient are best situated to look for signs of POD. While clinicians should be sure to administer tests of cognitive function, the loved ones of the patient know them best and typically spend the most time with them. Clinicians and family members need to work together to ensure that POD is detected and treated as expeditiously as possible, and there are many simple and inexpensive strategies that can have a big impact.

Sources

[1] American Geriatrics Society Expert Panel. (2015). Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. Journal of the American College of Surgeons, 220(2): 136-48. doi: 10.1016/j.jamcollsurg.2014.10.019.

[2] Robinson, T.N., & Eiseman, B. (2008). Postoperative delirium in the elderly: diagnosis and management. Clinical Interventions in Aging, 3(2): 351-5.

[3] Vijayakumar, B., Elango, P., & Ganessan, R. (2014). Post-operative delirium in elderly patients. Indian Journal of Anaesthesia, 58(3): 251-6. doi: 10.4103/0019-5049.135026.

[4] Whitlock, E.L., Vannucci, A., Avidan, M.S. (2013). Postoperative Delirium. Minerva Anestesiologica, 77(4): 448-56.

Postudural Puncture Headache (PDPHA) is defined by the International Headache Society as any headache that develops within five days of dural puncture and is not better accounted for by another cause. Classic symptomatology includes a positional headache in the frontal or occipital locations that is worse when upright and relieved by supine positioning. However, there are reports of atypical PDPHA in a small minority of patients that is worsened when lying flat. Accompanying symptoms include neck stiffness and subjective auditory symptoms, visual disturbances, and nausea/vomiting. Most occur within 48 hours of dural puncture, but less than 25% of cases occur later than 3 days afterward. The pathophysiology is felt to be leakage of CSF through the dural puncture site, creating traction on brain structures and cranial nerves.

It is important to note that most postpartum headaches in obstetric patients (which is the population most commonly attributed with PDPHA) is not in fact due to PDPHA. Rather, tension headaches, followed by preeclampsia, are the leading causes of headaches in these patients. The incidence of PDPHA as established by the Serious Complication Repository (SCORE) project of the Society for Obstetric Anesthesia and Perinatology is roughly 1%; however this includes both spinal anesthetics and accidental dural puncture with epidural anesthesia. Young age and female gender have been identified as risk factors for developing PDPHA. Obesity does not increase the risk of developing a headache, and patients with a high BMI may have a lower incidence of PDPHA. Among parturients, cesarean delivery is protective when compared to vaginal delivery. It is theorized that bearing down during the second stage of labor exacerbates CSF leakage.

Once thought a benign complication of neuraxial anesthesia, most PDPHA resolve spontaneously within two weeks. However, several studies have shown that in a small subset of patients, headache persists for greater than six weeks.

While there is no standard method of preventing PDPHA, some anesthesia providers place prophylactic epidural blood patches after difficult epidural placements during which they suspect dural puncture. Studies on this technique have yielded mixed results. Another method which initially showed promise in studies has met with inconsistent results in practice: threading an intrathecal catheter through an epidural needle following known dural puncture. The thought is that the catheter, left in for greater than 24 hours, will staunch CSF leakage and stimulate a fibrotic response which will result in a smaller tear in the dura.

Despite the widespread use of intravenous caffeine in the treatment of PDPHA, only one study has shown a positive effect and no subsequent study has reproduced its results. The emergency medicine literature includes case series of sphenopalatine ganglion blocks using a cotton-tip swab dipped in lidocaine inserted through the nostril as being an effective technique, however this is not widely implemented. Epidural blood patch is the only effective treatment borne out in studies. Optimal volume of sterile blood injected into the epidural space is accepted as 20ml, or until patient complains of back pain. Serious complications are rare, including radicular pain, chronic adhesive arachnoiditis and epidural hematoma. Roughly 10% of patients will require a repeat blood patch.

It behooves anesthesia providers to familiarize themselves with the background and management of PDPHA, a leading cause of lawsuits despite being a fairly well-understood and treatable condition.

The preoperative anesthetic evaluation is a key component of anesthetic management. The American Society of Anesthesiologists establishes guidelines detailing that each patient requiring care by an anesthesia provider must be provided a detailed medical, anesthesia and drug history, a physical exam, appropriate diagnostic testing and data, assignment of an ASA physical status score, and formulation and discussion of an anesthetic plan. Taken together, this process allows for preoperative risk stratification and adequate preparation to provide safe anesthesia.

When and how the pre-anesthesia assessment occurs differs from practice to practice. One study found that an overwhelming majority of patients preferred to complete their preoperative evaluation via telephone. This obviously does not allow for a physical examination, which would need to be done on the day of surgery. While this modality (along with its even less rigorous cousin, completing the entire pre-anesthetic assessment upon meeting the patient immediately before surgery) may serve well to provide pertinent negatives in healthy individuals, the question remains what to do about concerning positive findings. There is rarely time to schedule a stress test for a patient admitting for occasional exertional chest pain the evening prior to or on the day of surgery, a complication which often necessitates cancellation of their procedure for workup and medical optimization. Other potential pitfalls include lack of preparation for a patient with a concerning airway examination, leaving the anesthesia provider to scramble at the last minute to locate equipment or additional personnel to safely manage the patient’s airway. One study attempted to have patients self-administer an airway questionnaire but found poor correlation with an airway assessment by an anesthesiologist.

The value of an in-person visit to a dedicated pre-anesthesia assessment clinic rests in both expertise and time. The patient is able to be evaluated by a provider skilled at least in providing preoperative assessments (one model entails nurse practitioners who are trained to evaluate patients and discuss any unexpected findings with a supervising anesthesiologist) and is allowed enough time before the scheduled surgical date to identify any modifiable risk factors, confer with specialists, optimize regimens, and answer questions. Arguments that such clinic visits are costly and inconvenient are countered by positive results borne out in studies: well-designed pre-anesthesia clinics decrease surgical cancellations, reduce costs due to unnecessary tests, and are even associated with lower in-hospital mortality for patients admitted after surgery.

For ambulatory surgery in healthy patient populations, it may not be cost-effective or high-yield to send every patient to a pre-anesthesia clinic. In these cases, a phone interview should be conducted to screen for any potential red flags prior to surgery. For hospital-based surgeries and higher risk populations, an in-person pre-anesthesia evaluation is more likely to provide safer and more cost-effective anesthetic management.

References:

Blitz JD1, Kendale SM, Jain SK, Cuff GE, Kim JT, Rosenberg AD. Preoperative Evaluation Clinic Visit Is Associated with Decreased Risk of In-hospital Postoperative Mortality. Anesthesiology. 2016 Aug;125(2):280-94.

Payne E, Ragheb J, Jewell ES, Huang BP, Bailey AM, Fritsch LM, Engoren M. Are physician assistant and patient airway assessments reliable compared to anesthesiologist assessments in detecting difficult airways in general surgical patients? Perioperative Medicine20176:20

Prabhakar, A., Helander, E., Chopra, N. et al. Preoperative Assessment for Ambulatory Surgery. Curr Pain Headache Rep (2017) 21: 43.

As a central force in operative care, anesthesiologists are undeniably subject to the mandate of shift work, or designated periods of time in which a person is required to be working a high amount of consecutive hours for his or her employment. Anesthesiologists may take shifts in daytime or after-hours, as there is no time of day limit for surgery. However, different shift times also carry important implications for case volume, episode severity, and procedure type. In a recent article from the Journal of Medical Systems, researchers sought to utilize data from the National Anesthesia Clinical Outcomes Registry to characterize the nature of daytime shifts versus after-hours shifts^[1]. They found that in after-hour shifts, patients had increased odds of being in a non-operating room anesthesia environment, with decreased odds for more complex procedures. This result was in contrast to the widespread perception that after-hour procedures are more dangerous — presumably, physicians are more sleep-deprived, and thus are more susceptible to making medical error. Yet, the data shows the very opposite, that in fact, the centers sampled in the National Anesthesia Clinical Outcomes Registry are moving to counteract fatigue effects by scheduling less complex procedures on after-hours shifts.

In addition to simply scheduling less complex procedures for after-hours shifts, in recent years hospital administrators and researchers alike have proposed several potential methods to increase the safety and efficacy of procedures, particularly during after-hours shifts. One such method involves the use of Certified Registered Nurse Anesthetists, or highly specialized Registered Nurses who undergo rigorous training to be experts in the field of anesthesia. CRNAs often experience comparable schedules to anesthesiologists, with approximately 43% of sampled CRNAs reporting on-shift fatigue occurring “often”, or at least once each shift. In a piece for the American Association of Nurse Anesthetists, Domen, R et al reported on strategies that CRNAs implement to reduce the strain of fatigue on quality of work^[2]. For example, CRNAs listed specific fatigue prevention tactics, including strategic sleep, increased caffeine and food intake, and naps combined with bright light exposure, that were effective as mediators for reducing medical error. Scholars on the topic emphasize that while individual fatigue prevention techniques can prove impactful, it will take larger policy changes to effect change on an institutional level.

Certain hospitals are experimenting with change. For example, a hospital in Germany has piloted a flexible scheduling program, in which physicians select 13-hour shifts with a mandated break, and self-schedule procedures around these timeslots^[3]. While the apex of efficiency is yet to be decided, it is clear that the topic of shift work will remain an engaging discussion in the anesthesia community for years to come.

^[1] https://www.ncbi.nlm.nih.gov/pubmed/28776233

^[2] https://www.ncbi.nlm.nih.gov/pubmed/26016171

^[3] https://www.ncbi.nlm.nih.gov/pubmed/19739361

Pain management is a crucial component of surgical recovery for any patient, but there are unique concerns and challenges that comes with managing pain in pediatric patients. While the inherent vulnerability of children is deeply felt by clinicians and families alike, postoperative pain is nevertheless undertreated in this population. A major driver of this issue is that many common procedures require little time in the hospital, leaving most of the recovery to happen at home. Neglected postoperative pain creates short-term issues of sleep disruption, stress, and delayed recovery but can also lead to serious long-term consequences, or even disability.[1]

A central barrier to effectively managing pain following a procedure is reliably assessing a young patient’s pain level. [2] This task most often falls to parents and other caregivers, and is deceptively difficult. Research reveals two major challenges in pain reporting: a child’s ability to identify and name their pain, and the reliability of measurement instruments to consistently guide a clinical response. Opioids are unsurprisingly a central tool for effectively treating pain in children. For acute pain in particular, they are a powerful option that can provide uniquely immediate relief. However, there are known risks and side effects associated with opioid use that merit heightened caution when opiods are being used by children. Understanding a child’s experience of pain is key to responding with the appropriate balance of analgesics, and this can place an immense amount of pressure on caregivers at home.

Self-reporting is the clinically preferred way to assess pain in children.[3] However, this approach to pain measurement can be difficult among children for reasons that any parent could probably guess—a child may be afraid that sharing about their pain will cause them to return to the hospital, for example, or their social environment might cause them to overstate or understate their pain level. Commonly used instruments take various forms of visual and verbal rating scales, but the evidence is mixed on which tools are the most rigorous and widely applicable across the many developmental stages of childhood.

What if there was a way to solicit a child’s experience of pain through a familiar, less clinical and engaging instrument? This is where the recently developed Panda pain management mobile app is poised to make a difference.  The Panda app seeks to improve pediatric postoperative pain management through an engaging and easy-to-use platform. Parents or other caregivers use the app’s walkthrough design to assess and record important aspects of their child’s pain. Then, the app guides them in making decisions about when and how to administer pain medication, tracking when medication is administered to keep families on schedule for future dosages. Users receive medication alerts directly from their phone, much like the many apps families already use to schedule and track their commitments and routines.

Panda was developed by researchers at the University of British Columbia and has already seen promising results in the controlled setting of in-hospital use. Parents piloting the app with the guidance of clinical staff reported that the app was easy to use and could see themselves using it in the home setting.[4] The app is currently being evaluated for in-home use.

Providing families with an easy-to-navigate tool to not just identify pain in children following surgery, but also connect those pain measurements to a medication schedule, could be an important step in better addressing this neglected area of pain management. Pain management is a complex aspect of clinical care for patients regardless of age, and the special concerns of pediatric patients demand innovation beyond merely adapting adult guidelines for younger patients. There are exciting possibilities for the use of smartphone apps like Panda in better describing and alleviating pain in children. Tools that fit neatly into a familiar routine, like a smartphone app, may reduce some of the stress parents face in managing complex pain without clinical support.

[1] Porter FL, Grunau RE, Anand KJ: Long-term effects of pain in infants. J Dev Behav Pediatr 1999; 20:253–61Porter, FL Grunau, RE Anand, KJ

[2] Chou, Roger, et al. “Management of Postoperative Pain: a clinical practice guideline from the American pain society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council.” The Journal of Pain 17.2 (2016): 131-157.

[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983412/

[4] https://www.researchgate.net/publication/316853501_Feasibility_of_Panda_a_Smartphone_Application_Designed_to_Support_Pediatric_Postoperative_Pain_Management_at_Home