What is it like to "let yourself go" on the hospital bed after surgery?

Audit expert: Yin Tielun

Deputy Chief Physician, Department of Neurology, Airport Branch, Peking University Third Hospital

Some time ago, a teacher who was under general anesthesia for gastroscopy became a hot topic. It is understood that the teacher, Mr. Peng, went to the hospital for gastroscopy because of stomach pain. Because the general anesthesia had not worn off, he had hallucinations and unconsciously taught mathematics knowledge. This phenomenon resonated with many netizens, who left messages to tell their own or their family and friends' "post-anesthesia stories", but some people said that they slept through the whole process and did not have these "socially dead" behaviors.

This symptom, which usually occurs after surgery, is called postoperative delirium. So what are its causes and common manifestations?

Source: Online video screenshot

How does postoperative delirium occur?

Postoperative delirium, also known as "sunset syndrome" or "ICU syndrome", is an acute and short-term brain dysfunction that usually occurs within 3 to 5 days after the end of a surgical operation and lasts for a short time, usually a few hours to a few days. Its occurrence is often accompanied by a poor prognosis for the patient. When patients develop symptoms of delirium after surgery, they need to strictly monitor changes in vital signs and keep their airways open. Once any abnormal situation occurs, they need to report to the doctor in time and receive symptomatic treatment under the doctor's guidance.

Hallucinations (diagram)

Source: pexels

The occurrence of delirium is the result of the combined action of multiple factors. According to the underlying condition and individual causes of delirium, it can be roughly divided into three categories:

(1) Susceptible factors (preoperatively): patients over 65 years old; patients with serious diseases; patients with a history of stroke; patients with water and electrolyte imbalance before surgery; patients with alcoholism; patients who have taken large amounts of drugs or psychotropic drugs before admission.

(2) Predisposing factors (postoperatively): stroke or pathological disease process of the central nervous system; metabolic, electrolyte, endocrine imbalance or fever; infection, pain, trauma, inadequate perfusion, hypoxia or cardiopulmonary insufficiency; withdrawal from drugs or use of large amounts of drugs (psychotropic or antibiotic drugs); physical restraint.

(3) Promoting factors: including the new ICU environment and significant changes in the living environment.

In addition, studies have shown that patients undergoing major surgery (such as abdominal surgery, heart surgery) are more likely to develop delirium. Elderly patients, especially those with neurological or psychiatric complications before surgery, are also more likely to develop delirium.

Understanding these factors will help identify high-risk groups for postoperative delirium so that appropriate preventive measures can be taken.

Symptoms of postoperative delirium

Postoperative delirium is typically characterized by an acute onset that is usually present at night or manifests itself more prominently at night (hence the term "sundowning"). Delirium can be divided into three types based on its clinical presentation: high-activity, low-activity, and mixed.

Dental surgery source: pexels

Studies have shown that the most common type of delirium is the low-activity type, accounting for about 50%, which is often manifested by expressionless face, drowsiness, decreased alertness, psychomotor retardation, decreased speech, etc. It is easily misdiagnosed as depression. Because it is difficult to detect, it has the worst prognosis. High-activity delirium accounts for about 25%, and is often manifested by extreme sensitivity to the surrounding environment, hallucinations, auditory hallucinations, emotional tension, fear, and increased awakening threshold. Because this type is the easiest to detect, treatment is more timely. Mixed delirium accounts for about 25%, and is manifested by the alternation of the above two situations.

How to prevent and treat postoperative delirium?

Postoperative delirium is a relatively common and harmful disease. Its prevention and treatment are far more important than treatment. It is very important to eradicate potential risk factors and intervene early.

The patient's vital signs and mental state should be closely observed after the operation, especially at night. More attention should be paid to whether the patient shows symptoms such as irritability, nonsense, excessive excitement, hallucinations, delusions, or being too quiet and drowsy.

Delirium is closely related to hypoxemia. We need to pay close attention to the patient's blood oxygen saturation. If the blood oxygen saturation is lower than 85%, it should attract the doctor's attention and give the patient oxygen in time. Pain is also a risk factor that may lead to delirium. After surgery, we should chat with the patient more or do something else to distract the patient, which will help relieve pain.

If the patient is in severe pain, he or she can consult with the attending physician, take analgesics under the doctor's guidance, and keep the indoor temperature and humidity appropriate. Sleep dysfunction may also lead to delirium, so do not make noise when the patient is sleeping.

Consensus of the American Society for the Advancement of Recovery and Perioperative Quality on the Prevention of Postoperative Delirium

Source: China Medical Channel

The purpose of delirium treatment is to relieve symptoms and prevent further aggravation of delirium. In clinical practice, symptomatic and supportive treatment is often used. Drug treatment is still controversial. Although drug treatment is not necessary, if symptoms that make patients feel painful or endanger their safety occur, drug treatment should be considered. It is necessary to avoid various stimuli for patients, add bed guards or protective restraints, turn over regularly, pat the back, keep the environment clean and tidy, create a familiar environment, and ensure that patients get enough sleep. When the condition permits, try to let the patient be accompanied by family members to increase verbal and emotional communication.

In short, even if postoperative delirium occurs, there is no need to be overly nervous, because more than 80% of patients' symptoms will disappear on their own. More care, more patience, more love, and high-quality companionship from relatives and friends while the doctor is treating the patient are also the best "medicine" for the patient.