title: Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit.
abstract: BACKGROUND
  Emergence from anaesthesia is often accompanied by signs of delirium, including fluctuating mental status and inattention. The evolution of these signs of delirium requires investigation since delirium in the post-anaesthesia care unit (PACU) may be associated with worse outcomes.
  
  
  METHODS
  Adult patients emerging from anaesthesia were assessed for agitated emergence in the operating room using the Richmond Agitation-Sedation Scale (RASS). The Confusion Assessment Method for the Intensive Care Unit was then used to evaluate delirium signs at PACU admission and during PACU stay at 30 min, 1 h, and discharge. Signs consistent with delirium were classified as hyperactive vs hypoactive based upon a positive CAM-ICU assessment and the concomitant RASS score. Multivariable logistic regression was utilized to assess potential risk factors for delirium during PACU stay including age, American Society of Anesthesiologists classification, and opioid and benzodiazepine exposure.
  
  
  RESULTS
  Among 400 patients enrolled, 19% had agitated emergence. Delirium signs were present at PACU admission, 30 min, 1 h, and PACU discharge in 124 (31%), 59 (15%), 32 (8%), and 15 (4%) patients, respectively. In patients with delirium signs, hypoactive signs were present in 56% at PACU admission and in 92% during PACU stay. Perioperative opioids were associated with delirium signs during PACU stay (P=0.02).
  
  
  CONCLUSIONS
  A significant proportion of patients develop delirium signs in the immediate postoperative period, primarily manifesting with a hypoactive subtype. These signs often persist to PACU discharge, suggesting the need for structured delirium monitoring in the PACU to identify patients potentially at risk for worse outcomes in the postoperative period.
authors.affiliation: Department of Anesthesiology, Perioperative Clinical Research Institute.
authors.forename: E
authors.initials: E
authors.lastname: Card
authors.affiliation: Department of Anesthesiology, Perioperative Clinical Research Institute, Department of Anesthesiology, Division of Critical Care Department of Perioperative Services, Department of Urologic Surgery Department of Biostatistics and Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center and the VA Tennessee Valley Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA.
authors.forename: P
authors.initials: P
authors.lastname: Pandharipande
authors.affiliation: Department of Perioperative Services.
authors.forename: C
authors.initials: C
authors.lastname: Tomes
authors.affiliation: Department of Perioperative Services.
authors.forename: C
authors.initials: C
authors.lastname: Lee
authors.affiliation: Department of Perioperative Services.
authors.forename: J
authors.initials: J
authors.lastname: Wood
authors.affiliation: Department of Anesthesiology, Perioperative Clinical Research Institute.
authors.forename: D
authors.initials: D
authors.lastname: Nelson
authors.affiliation: Department of Urologic Surgery.
authors.forename: A
authors.initials: A
authors.lastname: Graves
authors.affiliation: Department of Biostatistics and.
authors.forename: A
authors.initials: A
authors.lastname: Shintani
authors.affiliation: Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center and the VA Tennessee Valley Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA.
authors.forename: E W
authors.initials: EW
authors.lastname: Ely
authors.affiliation: Department of Anesthesiology, Division of Critical Care christopher.hughes@vanderbilt.edu.
authors.forename: C
authors.initials: C
authors.lastname: Hughes
mesh_terms: D000328:Adult; D000368:Aged; D000762:Anesthesia Recovery Period; D000768:Anesthesia, General; D003422:Critical Care; D003693:Delirium / Q000453:epidemiology*; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D055820:New Orleans / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology*; D011446:Prospective Studies; D011595:Psychomotor Agitation / Q000453:epidemiology; D012307:Risk Factors
keywords: anaesthesia; complications; delirium