Postoperative Delirium after elective and emergency surgery: analysis and checking of risk factors. A study protocol

BACKGROUND: Delirum is common in hospitalized elderly patients and may be associated with increased morbidity, length of stay and patient care costs. Delirium (acute confusional state) is defined as an acute disorder of attention and cognition. In elderly patients, delirium is often an early indicator of patho-physiological disturbances. Despite landmark studies dating back to the 1940s, the pathogenesis of Delirium remains poorly understood. Early investigators noted that Delirium was characterized by global cortical dysfunction that was associated predominantly with specific electroencephalographic changes. It's important to understand the risk factors and incidence of Delirium. Some of the risk factors are already identified in literature and can be summarized in the word "VINDICATE" which stands for: Vascular, Infections, Nutrition, Drugs, Injury, Cardiac, Autoimmune, Tumors, Endocrine. Aims of this study are: to re-evaluate the above mentioned clinical risk factors, adding some others selected from literature, and to test, as risk factors, a pattern of some genes associated to cognitive dysfunction and inflammation possibly related to postoperative Delirium. DESIGN: All patients admitted to our Emergency Unit who are meet our inclusion/exclusion criteria will be recruited. The arising of postoperative Delirium will select incidentally two groups (Delirium/non Delirium) and the forward analysis of correlate risk factors will be performed. As in a typical observational case/control study we will consider all the exposure factors to which our population are submitted towards the outcome (presence of Delirium). Our exposures are the following: ASA, Pain (SVS; VAS), Blood gas analysis (pH; Hb; pO2; pCO2), Residence pharmacological therapy (BDZ; hypnotics; narcotic drugs; alcohol; nitrous derivates), Body temperature, Arterial pressure, Heart frequency, Breath frequency, Na, K, Creatinin, Glicemia, Albumin, Hct, White blood cells, Glasgow Coma Scale (GCS), Cognitive state (SPMSQ), Functional state (ADL and IADL), Psychological Distress (HADS), Cumulative Illness Rating Scale (CIRS), Hypotension (classified in: light; moderate and severe and duration), Blood loss (classified in: < 2 lt and > 2 lt), Blood transfusions (< 2 lt and > 2 lt), Quantity of red cells and plasma transfusions, Visual VAS / SVS (timing: I-II-III post-operative day), Red cells and Plasma transfusions, Blood count evaluation and Saturation (O(2)%), Postoperative analgesia (Emilia-Romagna protocol), Presence of malignant tumoral disease, APACHE Score II. Moreover the presence of some relevant genetic polymorphisms will be studied in different genes such as IL-6, IL-10, TNF-alpha, and IL-1 cluster

Medical Evidence Influence on Inpatients and Nurses Pain Ratings Agreement

Biased pain evaluation due to automated heuristics driven by symptom uncertainty may undermine pain treatment; medical evidence moderators are thought to play a role in such circumstances. We explored, in this cross-sectional survey, the effect of such moderators (e.g., nurse awareness of patients' pain experience and treatment) on the agreement between n = 862 inpatients' self-reported pain and n = 115 nurses' pain ratings using a numerical rating scale. We assessed the mean of absolute difference, agreement (κ-statistics), and correlation (Spearman rank) of inpatients and nurses' pain ratings and analyzed congruence categories' (CCs: underestimation, congruence, and overestimation) proportions and dependence upon pain categories for each medical evidence moderator (χ2 analysis). Pain ratings agreement and correlation were limited; the CCs proportions were further modulated by the studied moderators. Medical evidence promoted in nurses overestimation of low and underestimation of high inpatients' self-reported pain. Knowledge of the negative influence of automated heuristics driven by symptoms uncertainty and medical-evidence moderators on pain evaluation may render pain assessment more accurate

Postoperative Cognitive Dysfunction: Toward the Alzheimer's Disease Pathomechanism Hypothesis

The aim of this review is to identify an evidence-based perioperative management for patients affected by Alzheimer's disease (AD) that are scheduled to undergo surgery. This will minimize the negative effects of anesthesia and postoperative sedation and correct those perioperative variables possibly responsible for a decline in cognitive status and a worsening of AD. We here gather evidence on the importance of correct preoperative assessment regarding cognitive and functional status and the presence of preoperative delirium. The potential role of anesthesia, surgery, and postoperative analgosedation as risk factors for development of delirium are herein outlined. Finally, pain assessment instruments, as well as principles of management strategies for postoperative delirium in subjects with AD, are suggested

Development, validation and psychometric properties of a diagnostic/prognostic tool for breakthrough pain in mixed chronic-pain patients

Background/Objective Breakthrough pain (BTP) shows variable prevalence in different clinical contexts of cancer and non-cancer patients. BTP diagnostic tools with demonstrated reliability, validation and prognostic capability are lacking. We report the development, psychometric and validation properties of a diagnostic/prognostic tool, the IQ-BTP, for BTP recognition, its likelihood and clinical features among chronic-pain (CP) patients. Methods. Patients n\u2005=\u2005120 consecutive mixed cancer/non-cancer CP in/outpatients. Development, psychometric analyses and formal validation included: Face/Content validity (by \u2018experts\u2019 opinion and assessing the relationship between the IQ-BTP classes and criteria derived from BTP operational-case-definition); Construct validity, by Principle Component Analysis (PCA); and the strength of Spearman correlation between IQ-BTP classes and the Brief Pain Inventory (BPI) items; Reliability, by Cronbach's alpha statistics. Associations with clinical/demographic moderators were assessed applying \u3c72 analysis. Results Potential-BTP was found in 36.7% of patients (38.4% of non-cancer and 32.4% of cancer patients). Among these the likelihood for BTP diagnosis was \u2018high\u2019 in 25%, \u2018intermediate\u2019 in 41% and, \u2018low\u2019 34% of patients. Analyses showed significant differences between IQ-BTP classes and between the latter BPI pain-item scores. Correlation between IQ-BTP classes and BPI items was moderate. PCA and scree test identified 3 components accounting for 62.3% of the variance. Cronbach's alpha was 0.71. Conclusions The IQ-BTP showed satisfactory psychometric and validation properties. With adequate feasibility it enabled the allocating of cancer/non-cancer CP patients in three prognostic classes. Results are sufficient to warrant a subsequent impact study of the IQ-BTP as prognostic model and screening tool for BTP in both CP populations

Pain control in the continuity of care

As cancer is earlier diagnosed and its treatments improve, palliative care is increasingly playinga vital role in the oncology population. The concept and the timing of application of palliativecare have evolved in the last decades. The WHO pain ladder and the greater understanding ofappropriate multimodal pain control treatments have dramatically improved the managementof cancer pain. Integration of palliative care, which appears crucial for a proper management ofpatients, can be defined as the provision of palliative care both during curative cancer treatmentand after curative treatment has ceased. Clinical assistance should be delivered by specialisedphysicians in different fields, psychologists and nurses, and should include all aspects of advancedcancercare, from diagnosis to the treatment of symptoms. A further aspect of integration ofpalliative care concerns the role of the continuity of care in acute or emergency contexts bothfor out- and inpatients. Further improvements in the management of cancer pain are needed.First, the WHO ladder should be modified with further steps, like those of interventional paincontrol procedures and techniques, with the aim of being effective also for the small proportion ofnonresponsive patients. Second, more research is needed to find out which interventions aimingto improve continuity of care of cancer patients are beneficial to improve patient, providerand process of care outcomes and to identify which outcomes are the most sensitive to change.Of crucial importance would be the development of a standardised instrument to measure thecontinuity of care in cancer patients.This article is a brief overview on the management of cancer pain, from the pharmacologicaltreatments reported by WHO ladder, to the need for integration and continuity of care