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The Role of Intravenous Agents in Delirium

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Total Intravenous Anesthesia and Target Controlled Infusions

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Abstract

Delirium is a symptom complex resulting from brain dysfunction and is a frequent complication in the perioperative setting. Classification into three subtypes is common: the rare hyperactive, the hypoactive, and the mixed forms of delirium. Delirium is an outcome relevant complication, as it is associated with an increased length of hospital stay, higher mortality rate, as well as an impaired long-term cognitive trajectory.

From the pathophysiological perspective, anesthesia is not—or at least not the only—cause of delirium, but rather a precipitating risk factor.

Identifying individual predisposing factors and avoiding precipitating risk factors are essential for an effective delirium prevention. The careful consideration of factors linked to general anesthesia is critical to prevent delirium and decrease anesthesia-associated risk factors.

Evidence shows that the depth of anesthesia is linked to the incidence of postoperative delirium and that too deep anesthesia (burst suppression) is a risk factor for postoperative delirium and postoperative cognitive dysfunction.

Target-controlled infusions (TCI) coupled with neuromonitoring can help to prevent inadequate depth of anesthesia linked to toxic effects of the substances, hemodynamic instability, and neuroinflammation. Anticholinergic effects known to increase the risk of postoperative delirium and postoperative cognitive dysfunction can be minimized by reduced opioid dosages if used in a TCI approach as pain is not really measurable during anesthesia, and opioid over- and underdosing play an important role to avoid postoperative delirium. Alpha-2 agonists and in particular patient groups such as in patients with intracranial hypertension ketamine might exert neuroprotective effects, and both are promising substances for a symptom-orientated counteraction of delirium. Used as an adjuvant, both ketamine and alpha-2 agonists reduce propofol and opioid requirements.

There are several substances used in the TCI setting to better predict hypnotic and sedative states.

In summary, this chapter provides an overview about postoperative delirium and focuses on intravenous agents and their role as risk factors or preventive agents.

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Authors and Affiliations

  1. Department of Anesthesiology and Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany

    Claudia Spies MD, Susanne Koch MD, Alissa Wolf MD, Rudolf Mörgeli MD & Björn Weiss MD

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  1. Claudia Spies MD
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  2. Susanne Koch MD
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  3. Alissa Wolf MD
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  4. Rudolf Mörgeli MD
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  5. Björn Weiss MD
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Correspondence to Claudia Spies MD .

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Editors and Affiliations

  1. Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

    Anthony R. Absalom

  2. Department of Anesthesia, Harvard Medical School, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA

    Keira P. Mason

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Spies, C., Koch, S., Wolf, A., Mörgeli, R., Weiss, B. (2017). The Role of Intravenous Agents in Delirium. In: Absalom, A., Mason, K. (eds) Total Intravenous Anesthesia and Target Controlled Infusions. Springer, Cham. https://doi.org/10.1007/978-3-319-47609-4_40

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