Anästhesiol Intensivmed Notfallmed Schmerzther 2023; 58(09): 494-512
DOI: 10.1055/a-2065-3764
CME-Fortbildung
Topthema

Nicht pharmakologisches Management des postoperativen Delirs

Non-pharmacological Management of Postoperative Delirium
Elisa Weidner
,
Laura Hancke
,
Peter Nydahl
,
Claudia Spies
,
Alawi Lütz

Ein postoperatives Delir ist gerade bei älteren Patienten eine häufige Komplikation chirurgischer Eingriffe [1] [2]. Es erhöht Morbidität und Mortalität [1] [2] [3]. Strategien zum erfolgreichen Management des postoperativen Delirs sind nicht pharmakologische Multikomponentenmaßnahmen zur Risikoreduktion sowie Maßnahmen zur Früherkennung und Delir-Therapie. Dieser Beitrag soll Impulse für die praxisnahe Umsetzung des perioperativen nicht pharmakologischen Delir-Managements vermitteln.

Abstract

Postoperative delirium is common especially in the elderly and is associated with high rates of morbidity and mortality. Non-pharmacological multicomponent interventions are effective in reducing the incidence and to a degree the duration of postoperative delirium and are recommended in international guidelines on postoperative delirium as first line intervention for management of delirium. Non-pharmacological management of postoperative delirium consists of strategies for risk stratification, risk reduction by non-pharmacological bundle interventions, early recognition of delirium by screening protocols and immediate therapy of underlying causes of delirium and continuation of non-pharmacological bundles. Non-pharmacological bundle interventions address common perioperative risk factors. Bundles comprise strategies for oxygenation, mobilization, hydration and nutrition, sensory and cognitive stimulation, reorientation, modifications of environmental factors such as design aspects and noise reduction, adequate analgesia, management of agitation and anxiety, protecting circadian rhythms for example by adequate light exposure during daytime, family involvement and timely reduction of unnecessary catheters and anticholinergic drugs. The article aims at providing an overview of non-pharmacological management of postoperative delirium in the hospital.

Kernaussagen
  • Das postoperative Delir gewinnt im klinischen Alltag aufgrund des demografischen Wandels und der damit verbunden zunehmenden perioperativen Versorgung älterer Patienten mit erhöhtem Delir-Risiko an Relevanz.

  • Ein postoperatives Delir erhöht die Morbidität und Mortalität der betroffenen Patienten relevant. Die Therapie ist zeitkritisch, da ein prolongiertes Delir mit einem schlechteren Outcome assoziiert ist. Nicht pharmakologische Multikomponentenmaßnahmen können die Inzidenz und Dauer eines postoperativen Delirs effektiv reduzieren und werden in Leitlinien zum Management des postoperativen Delirs empfohlen.

  • Das nicht pharmakologische Management des postoperativen Delirs besteht aus einer Risikostratifizierung zur Identifikation vulnerabler Patienten, Risikoreduktion durch nicht pharmakologische Multikomponentenmaßnahmen, Früherkennung durch strukturiertes Messen von Sedierung, Agitation, Delir und Schmerz und frühzeitiger Identifikation und Therapie der delirauslösenden Ursache sowie Intensivierung nicht pharmakologischer Maßnahmen.

  • Nicht pharmakologische Multikomponentenmaßnahmen adressieren typische perioperative Risikofaktoren für ein Delir und vereinen Maßnahmen wie eine bedarfsorientierte Oxygenierung, Mobilisierung, Hydrierung und Ernährung, sensorische und kognitive Stimulierung, Reorientierung, Modifikation von Umgebungs- und Designfaktoren, ein effektives Schmerz-, Angst- und Agitationsmanagement, zirkadiane Rhythmisierung, Involvierung von Angehörigen und die kritische Indikationsstellung für einliegende Katheter und anticholinerge Medikamente.

  • Das nicht pharmakologische Management des postoperativen Delirs setzt eine interdisziplinäre Zusammenarbeit des perioperativen Behandlungsteams sowie Implementierungsstrategien in die klinische Praxis voraus.



Publication History

Article published online:
19 September 2023

© 2023. Thieme. All rights reserved.

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  • Literatur

  • 1 Aldecoa C, Bettelli G, Bilotta F. et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34: 192-214
  • 2 American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc 2015; 63: 142-150
  • 3 Müller DA, Markewitz PDA, Waydhas PDC. et al. S3-Leitlinie Analgesie, Sedierung und Delir-Management in der Intensivmedizin (DAS-Leitlinie). 2021 Accessed July 01, 2023 at: https://register.awmf.org/de/leitlinien/detail/001-012
  • 4 Jin Z, Hu J, Ma D. Postoperative delirium: perioperative assessment, risk reduction, and management. Br J Anaesth 2020; 125: 492-504
  • 5 Radtke FM, Franck M, MacGuill M. et al. Duration of fluid fasting and choice of analgesic are modifiable factors for early postoperative delirium. Eur J Anaesthesiol 2010; 27: 411-416
  • 6 Deeken F, Sánchez A, Rapp MA. et al. Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery. JAMA Surg 2022; 157: e216370
  • 7 Hshieh TT, Yue J, Oh E. et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med 2015; 175: 512-520
  • 8 Wang YY, Yue JR, Xie DM. et al. Effect of the Tailored, Family-Involved Hospital Elder Life Program on Postoperative Delirium and Function in Older Adults: A Randomized Clinical Trial. JAMA Intern Med 2020; 180: 17-25
  • 9 Pun BT, Balas MC, Barnes-Daly MA. et al. Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults. Crit Care Med 2019; 47: 3-14
  • 10 Schubert M, Ausserhofer D, Schaffert B. et al. Prävention des postoperativen Delirs. Anästhesiol Intensivmed Notfallmed Schmerzther 2023; 58: 482-493
  • 11 Maldonado JR. Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure. Int J Geriatr Psychiatr 2018; 33: 1428-1457
  • 12 Dixon M. Assessment and management of older patients with delirium in acute settings. Nursing Older People 2018; 30: 35-42
  • 13 Vasiljewa L, Müller A, Spies C. Pharmakologische Behandlung des postoperativen Delirs. Anästhesiol Intensivmed Notfallmed Schmerzther 2023; 58: 513-524
  • 14 Ahrens E, Tartler TM, Suleiman A. et al. Dose-dependent relationship between intra-procedural hypoxaemia or hypocapnia and postoperative delirium in older patients. Br J Anaesth 2023; 130: e298-e306
  • 15 Chu Z, Wu Y, Dai X. et al. The risk factors of postoperative delirium in general anesthesia patients with hip fracture. Medicine (Baltimore) 2021; 100: e26156
  • 16 Kupiec A, Adamik B, Forkasiewicz-Gardynik K. et al. Intra-operative hyperoxia and the risk of delirium in elderly patients after cardiac surgery. Ageing 2020; 12: 7006-7014
  • 17 Potharajaroen S, Tangwongchai S, Tayjasanant T. et al. Bright light and oxygen therapies decrease delirium risk in critically ill surgical patients by targeting sleep and acid-base disturbances. Psychiatr Res 2018; 261: 21-27
  • 18 National Institute for Health and Care Excellence (NICE). Delirium: prevention, diagnosis and management in hospital and long-term care. Guideline. 2023 Accessed July 10, 2023 at: https://www.nice.org.uk/guidance/cg103
  • 19 Nydahl P, Jeitziner MM, Vater V. et al. Early mobilisation for prevention and treatment of delirium in critically ill patients: Systematic review and meta-analysis. Intensive Crit Care Nurs 2023; 74: 103334
  • 20 Hodgson CL, Bailey M, Bellomo R. TEAM Study Investigators and the ANZICS Clinical Trials Group. et al. Early Active Mobilization during Mechanical Ventilation in the ICU. N Engl J Med 2022; 387: 1747-1758
  • 21 Patel BK, Wolfe KS, Patel SB. et al. Effect of early mobilisation on long-term cognitive impairment in critical illness in the USA: a randomised controlled trial. Lancet Respir Med 2023; 11: 563-572
  • 22 Malenbaum S, Keefe FJ, de C Williams AC. et al. Pain in its environmental context: Implications for designing environments to enhance pain control. Pain 2008; 134: 241-244
  • 23 Maurice-Szamburski A, Auquier P, Viarre-Oreal V. et al. Effect of Sedative Premedication on Patient Experience After General Anesthesia. JAMA 2015; 313: 916
  • 24 Seemann M, Zech N, Graf B. et al. Das Prämedikationsgespräch – Anregungen zu einer patientenfreundlichen Gestaltung. Anästhesiol Intensivmed Notfallmed Schmerzther 2015; 50: 142-146
  • 25 Zem AJ, Nowicka-Sauer K, Jarmoszewicz K. et al. Measures of preoperative anxiety. Anesthesiol Intensive Ther 2019; 51: 64-69
  • 26 Saravana-Bawan B, Warkentin LM, Rucker D. et al. Incidence and predictors of postoperative delirium in the older acute care surgery population: a prospective study. Can J Surg 2019; 62: 33-38
  • 27 Adams AMN, Chamberlain D, Grønkjær M. et al. Nonpharmacological interventions for agitation in the adult intensive care unit: A systematic review. Aust Crit Care 2023; 36: 385-400
  • 28 Knauert MP, Ayas NT, Bosma KJ. et al. Causes, consequences, and treatments of sleep and circadian disruption in the ICU: An official American thoracic society research statement. Am J Respir Crit Care Med 2023; 207: e49-e68
  • 29 Schmidt S, Hancke L, Spies C. et al. Lichttherapie zur Delirprävention bei Intensivpatienten: Was sagt die Evidenz?. Anästhesiol Intensivmed Notfallmed Schmerzther 2022; 57: 27−40
  • 30 Shigeta H, Yasui A, Nimura Y. et al. Postoperative delirium and melatonin levels in elderly patients. Am J Surg 2001; 182: 11754849
  • 31 van Gool WA, van de Beek D, Eikelenboom P. Systemic infection and delirium: when cytocines and acetylcholine collide. Lancet 2010; 375 (9716): 773-775
  • 32 Brainard GC, Hanifin JP, Greeson JM. et al. Action spectrum for melatonin regulation in humans: evidence for a novel circadian photoreceptor. J Neurosci 2001; 21: 6763155
  • 33 Jaiswal S, Garcia S, Owens R. Sound and Light Levels Are Similarly Disruptive in ICU and non-ICU Wards. J Hospital Med 2017; 12: 798-804
  • 34 Dessap AM, Roche-Campo F, Launay JM. et al. Delirium and Circadian Rhythm of Melatonin During Weaning From Mechanical Ventilation: An Ancillary Study of a Weaning Trial. Chest 2015; 148: 1231-1241
  • 35 Hashemighouchani H, Cupka J, Lipori J. et al. The impact of environmental risk factors on delirium and benefits of noise and light modifications: a scoping review. F1000 Research 2020; 9: 1183
  • 36 Taguchi T, Yano M, Kido Y. Influence of bright light therapy on postoperative patients: A pilot study. Intensive Crit Care Nurs 2007; 23: 289-297
  • 37 Luetz A, Uhrlau H, Piazena H. et al. Modification of ICU environment is associated with reduced incidence of delirium – Results from the VITALITY study. Authorea 2019;
  • 38 Aurell J, Elmqvist D. Sleep in the surgical intensive care unit: continuous polygraphic recording of sleep in nine patients receiving postoperative care. Br Med J Clin Res Ed 1985; 290: 1029-1061
  • 39 Su X, Wang DX. Improve postoperative sleep: What can we do?. Curr Op Anaesthesiol 2018; 31: 83-88
  • 40 Drouot X, Cabello B, Ortho MP. et al. Sleep in the intensive care unit. Sleep Med Rev 2008; 12: 18502155-18502155
  • 41 Meissner HH, Riemer A, Santiago SM. et al. Failure of physician documentation of sleep complaints in hospitalized patients. West J Med 1998; 169: 1305196-1305196
  • 42 He E, Dong Y, Jia H. et al. Relationship of sleep disturbance and postoperative delirium: a systematic review and meta-analysis. Gland Surg 2022; 11: 1192-1203
  • 43 Schmidt S, Hancke L, Haussmann R. et al. [Chronobiological interventions for prevention and treatment of delirium in critically ill patients]. Nervenarzt 2022; 93: 901-911
  • 44 Luetz A, Grunow JJ, Mörgeli R. et al. Innovative ICU Solutions to Prevent and Reduce Delirium and Post Intensive Care Unit Syndrome. Semin Respir Crit Care Med 2019; 40: 673-686
  • 45 Kotfis K, van Diem-Zaal I, Roberson SW. et al. The future of intensive care: delirium should no longer be an issue. Crit Care 2022; 26: 200
  • 46 Yürek F, Marschall U, Gaedigk U. et al. Qualitätsvertrag zur Prävention des postoperativen Delirs. Anästhesiol Intensivmed Notfallmed Schmerzther 2023; 58: 525-539