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Postoperative delirium after intracranial neurosurgery: A prospective cohort study from a developing nation

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Abstract

Introduction

Post-operative delirium (POD) is a major complication after anesthesia and surgery with an incidence varying from 5 to 50%. The incidence of POD after intracranial surgery is likely to be higher due to the pre-existing brain pathology and direct handling of the brain during neurosurgery. The primary objective of this study was to assess the incidence of POD after intracranial neurosurgery and our secondary objective was to identify the potential risk factors for its occurrence.

Materials and methods

This prospective observational study was conducted after the institutional ethics committee approval between october 2020 and march 2021. We included patients of either gender aged ≥ 18 years and undergoing elective intracranial neurosurgery. Exclusion criteria included patients aged below 18 years, undergoing emergency neurosurgery, patients with impaired consciousness and patients with psychiatric comorbidities or those taking psychotropic medications. We planned to exclude patients from analysis who were transferred to intensive care unit (ICU) or if they were not extubated after surgery. Our study outcome was development of POD as assessed by confusion assessment method (CAM).

Results

The overall incidence of POD during the three postoperative days was 19.2% (n=60/313). The incidence of POD on days 1, 2, and 3 were 19.2% (n=60/313), 17.2% (n=50/291), and 16.3% (n=39/239). Preoperative delirium and hyperactive Emergence Delirium were found to be the significant predictors of POD.

Conclusion

Every one in five patients undergoing intracranial neurosurgery is vulnerable for the development of POD within first three days after surgery. The incidence of occurrence of POD is time-sensitive and is decremental.

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Data Availability

Data is readily available. Can be provided if within the limits of the local ethics committee rules and regulations.

Abbreviations

ASA:

American society of anesthesiologist

CAM:

Confusion assessment method

ED:

Emergence delirium

GLMM:

Generalized linear mixed effect models

MAC:

Minimum alveolar concentration

NRS:

Numerical rating scale

PACU:

Post-anesthesia care unit

POD:

Post-operative delirium

PONV:

Postoperative nausea vomiting

RSAS:

Riker’s sedation agitation score

VAS:

Visual analogue score

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Author information

Authors and Affiliations

  1. Department of Neuroanaesthesia and Neurocritical care, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560 029, India

    Dhritiman Chakrabarti, Suparna Bharadwaj, V. S. Akash, Archisha Wadhwa, Sriganesh Kamath & Kadarapura Nanjundaiah Gopalakrishna

  2. Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560 029, India

    Subhas Konar

Authors
  1. Dhritiman Chakrabarti
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  2. Suparna Bharadwaj
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  3. V. S. Akash
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  4. Archisha Wadhwa
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  5. Subhas Konar
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  6. Sriganesh Kamath
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  7. Kadarapura Nanjundaiah Gopalakrishna
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Contributions

Dhritiman Chakrabarty (DC) contributed to research design, data interpretation, statistical analysis and manuscript writing. Suparna Bharadwaj (SB) contributed to research design, data interpretation and manuscript writing. Akash VS (AKS) contributed to data collection. Archisha Wadhwa (AW) contributed to data collection. Subhas Konar (SK) contributed to research design and data interpretation. Sriganesh Kamath (SGK) contributed to research design, data interpretation and manuscript writing. Kadarapura Nanjundaiah Gopalakrishna (KNG) contributed to research design, data interpretation and manuscript writing. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Kadarapura Nanjundaiah Gopalakrishna.

Ethics declarations

Ethical approval

IEC approval taken in this study involving human participants.

Informed consent

Informed consent obtained from all the individual participants in this study.

Conflict of interest

Authors declare that they have no conflicts of interest.

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Appendices

Annexure A

Confusion Assessment Method (CAM)

Diagnosis of Delirium by CAM requires presence of both features A and B

  A. Acute onset and fluctuating course

Is there an evidence of an acute change in mental status from baseline?

Does the abnormal behavior

• come and go?

• fluctuate during the day?

• Increase/decrease in severity

  B. Inattention

Does the patient:

• Have difficulty focusing attention

• Become easily distracted

• Have difficulty keeping track of what is said?

And the presence of either feature C or D

  C. Disorganized thinking

Is the patient’s thinking

• disorganized

• incoherent

For example, does the patient have

• Rambling speech/irrelevant conversation

• Unpredictable switching of subjects

• Unclear or illogical flow of ideas

  D. Altered level of consciousness

Overall what is the patient’s level of consciousness:

• Alert (normal)

• Vigilant (hyper-alert)

• Lethargic (drowsy but easily roused)

• Stuporous (difficult to rouse)

• Comatose (unarousable)

Annexure B

Riker’s sedation agitation score

7

Agitated, Dangerous, agitation

Pulling at ET tube, trying to remove catheters, climbing over bed rail, striking at staff, thrashing side-to-side.

6

Very agitated

Does not calm, despite frequent verbal reminding of limits; requires physical restraints, biting ET tube.

5

Agitated

Anxious or mildly agitated, attempting to sit up, calms down to verbal instructions.

4

Non-agitated, Calm and cooperative

Calm, awakens easily, follows commands

3

Sedated

Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again, follows simple commands

2

Very sedated

Arouses to physical stimuli but does not communicate or follow commands , may move spontaneously

1

Unarousable

Minimal or no response to noxious stimuli, does not communicate or follow commands

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Chakrabarti, D., Bharadwaj, S., Akash, V.S. et al. Postoperative delirium after intracranial neurosurgery: A prospective cohort study from a developing nation. Acta Neurochir 165, 1473–1482 (2023). https://doi.org/10.1007/s00701-023-05610-w

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  • DOI: https://doi.org/10.1007/s00701-023-05610-w

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