Postoperatives Komplikationsmanagement nach Wirbelsäuleneingriffen: das postoperative Delir

Zusammenfassung

Das postoperative Delir nach wirbelsäulenchirurgischen Eingriffen stellt eine häufige und schwerwiegende Komplikation dar. Die genaue Kenntnis von Risikofaktoren - wie z.B. ein vorangegangenes Delir, kognitive Einschränkungen, Einnahme delirogener Medikamente und Alkoholismus – hilft, Risikopatienten präoperativ zu identifizieren. Präventionsstrategien schließen nehmen der Prähabilitation (in erster Linie Verbesserung des Ernährungszustandes), das Ab- bzw. Umsetzen delirogener Medikamente, die strenge Indikationsstellung zu größeren operativen Eingriffen und das perioperative Blutungsmanagement ein. Standardisierte Tests erleichtern die postoperative Detektion eines Delirs. Bei der Behandlung steht die nicht-medikamentöse Therapie im Vordergrund. Sie schließt insbesondere die Kontinuierliche (Re)-Orientierung, Reizabschirmung, Homöostase, Schlafhygiene, rasche Mobilisierung und adäquate Therapie von Schmerzen und Infekten ein. Ist eine medikamentöse Therapie zusätzlich notwendig, empfiehlt sich Melperon oder Pipamperon für das hyperaktive Delir und Haloperidol bei starken Halluzinationen.

Abstract

Postoperative delirium after spine surgery is a common and serious complication. Accurate knowledge of risk factors-such as previous delirium, cognitive impairment, use of delirogenic medications, and alcoholism-helps identify at-risk patients preoperatively. Prevention strategies include taking prehabilitation (primarily improving nutritional status), discontinuing or reversing delirogenic medications, strict indication for major surgical procedures, and perioperative bleeding management. Standardized tests facilitate postoperative detection of delirium. Treatment focuses on non-drug therapy. In particular, it includes continuous (re)-orientation, stimulus shielding, homeostasis, sleep hygiene, rapid mobilization, and adequate therapy for pain and infections. If drug therapy is additionally necessary, melperone or pipamperone is recommended for hyperactive delirium and haloperidol for severe hallucinations.

Schlüsselwörter

postoperative Delir - Postoperatives Komplikationsmanagement - Prävention - Risikofaktoren

Keywords

Postoperative complication management - postoperative delirium

• Literatur

• 1 Inouye SK. Delirium in older persons. N Engl J Med 2006; 354: 1157-1165
• 2 Wu X, Sun W, Tan M. Incidence and Risk Factors for Postoperative Delirium in Patients Undergoing Spine Surgery: A Systematic Review and Meta-Analysis. Biomed Res Int 2019; 2019: 2139834
• 3 Vlisides P, Avidan M. Recent Advances in Preventing and Managing Postoperative Delirium. F1000Research 2019; 8
• 4 Vasunilashorn SM, Ngo L, Inouye SK. et al. Cytokines and Postoperative Delirium in Older Patients Undergoing Major Elective Surgery. J Gerontol A Biol Sci Med Sci 2015; 70: 1289-1295
• 5 Van Dellen E, Van Der Kooi AW, Numan T. et al. Decreased functional connectivity and disturbed directionality of information flow in the electroencephalography of intensive care unit patients with delirium after cardiac surgery. Anesthesiology 2014; 121: 328-335
• 6 Zhu C, Wang B, Yin J. et al. Risk factors for postoperative delirium after spinal surgery: a systematic review and meta-analysis. Aging Clin Exp Res 2020; 32: 1417-1434
• 7 Baek W, Kim YM, Lee H. Risk Factors of Postoperative Delirium in Older Adult Spine Surgery Patients: A Meta-Analysis. AORN J 2020; 112: 650-661
• 8 Thomas C, Kreisel SH, Oster P. et al. Diagnosing Delirium in Older Hospitalized Adults with Dementia: Adapting the Confusion Assessment Method to International Classification of Diseases, Tenth Revision, Diagnostic Criteria. J Am Geriatr Soc 2012; 60: 1471-1477
• 9 Lütz A, Radtke FM, Franck M. et al. The Nursing Delirium Screening Scale (NU-DESC). Anasthesiol Intensivmed Notfallmed Schmerzther 2008; 43: 98-102
• 10 Dai YT, Lou MF, Yip PK. et al. Risk Factors and Incidence of Postoperative Delirium in Elderly Chinese Patients. Gerontology 2000; 46: 28-35
• 11 Litaker D, Locala J, Franco K. et al. Preoperative risk factors for postoperative delirium. Gen Hosp Psychiatry 2001; 23: 84-89
• 12 Wong CK, Van Munster BC, Hatseras A. et al. Head-to-head comparison of 14 prediction models for postoperative delirium in elderly non-ICU patients: an external validation study. BMJ Open 2022; 12
• 13 Hornor MA, Ma M, Zhou L. et al. Enhancing the American College of Surgeons NSQIP Surgical Risk Calculator to Predict Geriatric Outcomes. J Am Coll Surg 2020; 230: 88-100.e1
• 14 Saripella A, Wasef S, Nagappa M. et al. Effects of comprehensive geriatric care models on postoperative outcomes in geriatric surgical patients: a systematic review and meta-analysis. BMC Anesthesiol 2021; 21
• 15 Sun Y, Jiang M, Ji Y. et al. Impact of postoperative dexmedetomidine infusion on incidence of delirium in elderly patients undergoing major elective noncardiac surgery: a randomized clinical trial. Drug Des Devel Ther 2019; 13: 2911-2922
• 16 Deiner S, Luo X, Lin HM. et al. Intraoperative infusion of dexmedetomidine for prevention of postoperative delirium and cognitive dysfunction in elderly patients undergoing major elective noncardiac surgery: A randomized clinical trial. JAMA Surg 2017; 152: e171505
• 17 Theusinger OM, Kind SL, Seifert B. et al. Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland. Blood Transfus 2014; 12: 195
• 18 Fan Y-X, Liu F-F, Jia M. et al. Comparison of restrictive and liberal transfusion strategy on postoperative delirium in aged patients following total hip replacement: A preliminary study. Arch Gerontol Geriatr 2014; 59: 181-185
• 19 Blandfort S, Gregersen M, Borris LC. et al. Blood transfusion strategy and risk of postoperative delirium in nursing homes residents with hip fracture. A post hoc analysis based on the TRIFE randomized controlled trial. Aging Clin Exp Res 2017; 29: 459-466
• 20 Maschke M. S1-Leitlinie: Delir und Verwirrtheitszustände inklusive Alkoholentzugsdelir. DGNeurologie 2021; 4: 92-103
• 21 Duning T, Ilting-Reuke K, Beckhuis M. et al. Postoperative delirium – Treatment and prevention. Curr Opin Anaesthesiol 2021; 34: 27-32