Wednesday, August 9, 2017

Confused Much?

Well as I have been writing of my own trip down surgical lane, I have been relentless about the use of General Anesthesia and how there is a move to have more surgeries done with local to have better recovery and less costs and risks. 

I can only speak of my limited experience and in turn how panicked I was prior to Surgery.  I get now why I was under and in my case it was wise as it turned out to be more complex than originally planned.  I was, however, und er for longer than necessary and I was not given the 30 minutes transition time needed post surgery as they needed to hustle me out.   I was fortunate that I hired a Nurse experienced with this as she was quite aware of my mental and physical state when she came in to get me and in turn take me home.  She was only scheduled to stay with me an hour post surgery but due to their delays she was with me less than 30 minutes. However, I am going to believe that if I was not capable she would have found arrangements that I not be alone. But again this is all hindsight and again I was functioning.   But again that is why the 30 minutes is valuable to ascertain the state of the patient and their ability.  As in most cases it is a friend or family member who may not realize the reality and demands of the situation.     It was only after I vomited it all out of my system did I actually feel well.  And that was about 2 hours of me being home alone.   I should never been given an anti nausea patch which I removed it immediately as I wanted that toxic shit out of my system immediately.   Now having a Nurse would have been useful but a Maid more so to assist in the whole cleaning up and getting me comfortable after projectile vomiting in my shower.  That was a risk and I could have fallen but again I knew what was happening and stood with a cane to make sure I did not slip and had the cane for support to step out and up after showering with all my clothes on.  (I had actually changed in lounge wear but all of that had to be removed after the incident and in turn washed with the towels, shower curtain, etc)   But much of that could have been avoided with less time under and some transition where vomiting was actually encouraged under observation.

But this is not about Patients this is about a revolving door and getting people in and out and the rest of it - you are on your own.  

So when I read this and went:  Really?

Confusion after surgery linked to later dementia in older people, study finds

By Tara Bahrampour The Washington Post  July 28 2106

Older patients who become disoriented or confused after surgery are more than three times more likely to develop dementia later, a new study has found.

The report, published Friday by the British Journal of Anaesthesia, assesses the effects of postoperative delirium (POD) on people 65 and older who were cognitively normal before their operations. Of 1,152 such patients, 9.5 percent met criteria for mild cognitive impairment or dementia a median of nine months after surgery.

The frequency of being diagnosed with MCI or dementia after surgery was much higher — 33.3 percent — among those who had experienced postoperative delirium, compared with 9 percent among those who had not.

While earlier studies have shown a relationship between POD and dementia, this is the first to look entirely at subjects who showed no cognitive decline in pre-surgery assessments, said David Warner, an anesthesiologist at Mayo Clinic in Rochester, Minn., and the study’s senior author.

Delirium is defined by an acute state of confusion, inattention, disorganized thinking and a fluctuating mental state. Older patients are more likely than younger ones to develop it after surgery, as are people with lower education levels and those who undergo vascular procedures.

Further study is needed to determine whether delirium contributes to later cognitive decline or is an indicator of some underlying factor that made people more likely to develop dementia, Warner said.

“Either it’s a marker,” he said, “or maybe there’s something about developing delirium that increases your risk for dementia. If it is the latter, then you really ought to do something” to reduce the incidence of delirium.

That could include using different techniques for anesthesia or postoperative pain management.

Most of the patients in the study underwent general anesthesia, and while there was no indication that this put them at higher risk, it could be worth studying whether using regional anesthesia techniques, such as spinal epidurals, reduced the incidence of delirium, Warner said.

Pain-control techniques could also be adjusted. “We’ve used opioids for pain control traditionally after surgery almost exclusively,” he said. “Now, partly because of the opioid epidemic, we are looking more at multimodal techniques.”

Adjustments to the postoperative environment could also reduce delirium. Earlier studies have recommended the use of clocks, calendars and similar materials to help reorient a patient after surgery. The presence of family members and minimization of staff changes and nighttime disruptions, and providing access to glasses and hearing aids can also help.

Older people are not the only ones who may suffer deleterious cognitive effects after surgery — studies have shown that exposing babies to general anesthesia may negatively affect their future cognitive development, Warner said.

“This is just another sign that we really need to pay attention to brain health at the time of surgery,” he said.

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