Should surgery be delayed in a patient with acute delirium?

Surgery Should Generally Be Delayed in Patients with Acute Delirium

Surgery should be delayed in patients with acute delirium until the delirium is resolved or adequately managed, as proceeding with surgery during active delirium increases morbidity and mortality risks. 1

Understanding Delirium and Surgical Risk

Delirium is a neuropsychiatric syndrome characterized by acute and fluctuating impairment in attention, memory, perception, and consciousness. It significantly impacts surgical outcomes:

• Patients with delirium have increased length of stay, higher morbidity and mortality (30-day mortality of 7-10%), and increased healthcare costs 2
• Delirium affects up to 50% of hospitalized surgical patients 1
• It is associated with poor cognitive and functional recovery beyond the immediate postoperative period 3

Risk Assessment for Existing Delirium

When evaluating a patient with acute delirium before surgery, consider:

• Severity of delirium: Assess using validated tools like 4AT or Confusion Assessment Method (CAM) 1
• Underlying cause: Identify and address reversible causes (infection, electrolyte abnormalities, medication effects) 3
• Urgency of surgery: Balance surgical necessity against delirium-related risks 1

Decision Algorithm for Surgery Timing

1. Emergency life-threatening conditions:

   • Proceed with surgery despite delirium
   • Implement perioperative delirium management strategies
   • Document decision-making clearly in medical notes 1

2. Urgent but non-immediate surgery:

   • Delay for 24-48 hours if possible to treat delirium
   • Involve multidisciplinary team (anesthesia, geriatrics, psychiatry)
   • Reassess delirium status every 12 hours 1

3. Elective surgery:

   • Delay until delirium resolves
   • Implement delirium treatment protocol
   • Reschedule when patient returns to baseline cognitive function 1

Delirium Management Before Proceeding with Surgery

If surgery must proceed or while waiting for delirium to resolve:

1. Non-pharmacological interventions:

   • Early mobilization
   • Orientation strategies (clocks, calendars)
   • Ensure cognitive aids (glasses, hearing aids) are available
   • Promote normal sleep-wake cycles
   • Encourage family presence 1

2. Pharmacological management:

   • Avoid benzodiazepines except in withdrawal delirium 4
   • Low-dose antipsychotics may be considered for severe symptoms 5
   • Minimize use of medications that can worsen delirium 4

3. Treat underlying causes:

   • Correct metabolic/electrolyte abnormalities
   • Treat infections
   • Review and adjust medications 6

Risk Factors That Should Prompt Extra Caution

Patients with these factors have significantly higher risk of poor outcomes if surgery proceeds during active delirium:

• Age >65 years (OR 2.67 for ages 65-85, OR 6.24 for >85 years) 1
• Preexisting cognitive impairment (OR 3.99) 1
• History of previous delirium (OR 3.9) 1
• Elevated C-reactive protein levels (OR 3.56 for >10 mg/dL) 1
• ASA status 4 (OR 2.43) 1
• Low BMI <18.5 (OR 2.25) 1

Pitfalls to Avoid

• Misattribution: Don't assume delirium is "normal" for elderly patients; it always represents pathology
• Underdetection: Hypoactive delirium is often missed but carries similar risks 7
• Medication errors: Avoid sedatives that can worsen delirium 4
• Inadequate monitoring: If surgery proceeds, implement twice-daily delirium screening postoperatively 1
• Poor communication: Ensure all team members are aware of delirium status and management plan 1

When Surgery Cannot Be Delayed

If surgery must proceed despite active delirium:

• Document clear rationale for proceeding
• Implement all possible delirium prevention strategies
• Consider regional anesthesia techniques when appropriate
• Minimize sedation during procedures
• Ensure close postoperative monitoring for worsening delirium 2