ISAKanyakumari - Anaesthesia Practice in Kanyakumari District

ANAESTHESIA PEARLS

COMPRESSION DEVICE
PLATELET TRANSFUSION
POSTOPERATIVE DELIRIUM

	A Cricoid Cartilage Compression Device
	Introduction:
	Cricoid pressure is a means of preventing passive regurgitation and aspiration of gastric contents during rapid sequence induction of anaesthesia. It involves the application of backward pressure on the cricoid cartilage with a force of between 30 and 40 N in order to occlude the upper oesophagus (although latterly it has been suggested that a force of 20–30 N might be more appropriate). Failure to secure the airway in this way may put the patient at risk of developing aspiration pneumonitis, bacterial pneumonia and or bronchial blockage.

	The current recommendations with regard to technique are that cricoid pressure should be applied to the cricoid cartilage using the originally proposed three-finger technique (thumb, index and long finger opposed in the midline). Until quite recently, cricoid pressure was viewed as pinching the upper oesophagus between the cricoid ring and the 6th cervical vertebrae, however, it is now understood that the cricoid ring actually compresses the postcricoid hypopharynx, the oesophagus being typically 1 cm distal to the former. The latter confusion does not invalidate the technique; on the contrary, it does still compress the conduit between the stomach and the pharynx and, moreover, the technique is not compromised by lateral movement of the cricoid cartilage relative to the body of the vertebrae.

	There has been a raft of contra-indicatory findings that cricoid pressure may not even prevent regurgitation, and may actually induce nausea and vomiting, promote aspiration by relaxing the lower oesophageal sphincter, impede airway management, prolong intubation time by obscuring the laryngeal view ; and possibly lead to cricoid cartilage fracture and/or oesophageal rupture by the application of excessive force. Despite this negativity, there still seems to be a wide body of acknowledged medical and legal approval for using this technique in order to reduce patient risk.
	Although ubiquitous, numerous studies have shown that knowledge and skills of cricoid pressure amongst anaesthetic and emergency department staff are still quite poor. The main deficiencies lie in the practitioners' method of application and understanding of the correct amount of force to apply. However, to which anatomical structure the force should be applied also remains an issue.

	New Device:
	With a view to circumventing this training need and so reduce patient risk, R. J. Taylor has developed a novel, plastic, recyclable, single-use, tactile feedback device that is cheap to manufacture (depending on quantity – a few pence), requires no power to operate or training to use and ensures the correct force is always consistently applied to the patient.
	The device, which is suitable for manufacture by injection moulding (or 3D printing additive manufacturing), is made of polyoxymethene (Acetal™) and comes as a single piece of moulded plastic.
	Figure 1 shows a schematic of the concept of operation of the tactile feedback instrument. The user grasps the central reinforced body of the device using the thumb, index and long finger opposed in the same configuration as he/she might use in the manual application of cricoid pressure. The lower concave section of the appliance is then placed over the cricoid cartilage and a downward force applied by the operator. At the point when 30 N of force is exerted (nominally 5 mm depression), the wedge on the left-hand side projects through and impinges the thumb or fingers (depending upon user orientation) above it (Fig. 2b). Further compression (typically another 1.8 mm depression) causes the pin on the right-hand side of the device to impact the proximal digit(s) (Fig. 2c). The latter occurs at a force of 35 N, informing the user that he/she is applying too much force. By careful regulation of the downward pressure applied, the operator may be confident that the force delivered to the cricoid cartilage never falls below 30 N nor exceeds 35 N. A set of push-fit foam pads (Fig. 3) are provided with the device to facilitate various applicator sizes covering a range of neck circumferences suitable for children, adolescents, average or large adults.
	Fig 1 : Schematic illustrating the concept of operation :

	Fig 2 : Operation of the device

	Fig 3 : Push-fit foam pads provide various sizes

	Authors Note : The details of this device were the subject of a patent application filed with the UK Intellectual Property Office in November 2012. It was our hope to attract the interest of a medical device manufacturer in the subsequent 12 months with a view to taking on a licence to manufacture the device on a commercial basis. Sadly, this did not happen and, due to the impending prospective financial burden of pursuing and maintaining the patent in this and other countries; we felt compelled to revoke the patent before its final ratification. We now find ourselves at a stasis with what we believe is a sound novel medical device, but unclear how its benefits can be passed on to others. In the spirit of true altruism, rather than waste this work, we prefer to share our knowledge and experiences of developing this device in the hope that someone may find the means to take it further.
	Source :
	A cricoid cartilage compression device for the accurate and reproducible application of cricoid pressure.
	Anaesthesia, Volume 70, Issue 1, pages 18–25, January 2015.
	Note : Author R. J. Taylor's permission was obtained to display images.

	A Clinical Practice Guideline of AAB
	Platelet Transfusion: A Clinical Practice Guideline of AABB
	(American Association of Blood Banks)
	Platelet transfusions are administered to prevent or treat bleeding in patients with quantitative or qualitative platelet disorders. The AABB (formerly, the American Association of Blood Banks) developed this guideline on appropriate use of platelet transfusion in adult patients.

	Recommendation 1:
	The AABB recommends that platelets should be transfused prophylactically to reduce the risk for spontaneous bleeding in hospitalized adult patients with therapy-induced hypoproliferative thrombocytopenia. The AABB recommends transfusing hospitalized adult patients with a platelet count of 10 × 109 cells/L or less to reduce the risk for spontaneous bleeding. The AABB recommends transfusing up to a single apheresis unit or equivalent. Greater doses are not more effective, and lower doses equal to one half of a standard apheresis unit are equally effective (Grade: strong recommendation; moderate-quality evidence).
	Recommendation 2:
	The AABB suggests prophylactic platelet transfusion for patients having elective central venous catheter placement with a platelet count less than 20 × 109 cells/L (Grade: weak recommendation; low-quality evidence).
	Recommendation 3:
	The AABB suggests prophylactic platelet transfusion for patients having elective diagnostic lumbar puncture with a platelet count less than 50 × 109 cells/L (Grade: weak recommendation; very low-quality evidence).
	Recommendation 4:
	The AABB suggests prophylactic platelet transfusion for patients having major elective non neuraxial surgery with a platelet count less than 50 × 109 cells/L (Grade: weak recommendation; very low-quality evidence).
	Recommendation 5:
	The AABB recommends against routine prophylactic platelet transfusion for patients who are nonthrombocytopenic and have cardiac surgery with cardiopulmonary bypass (CPB). The AABB suggests platelet transfusion for patients having CPB who exhibit perioperative bleeding with thrombocytopenia and/or evidence of platelet dysfunction (Grade: weak recommendation; very low-quality evidence).
	Recommendation 6:
	The AABB cannot recommend for or against platelet transfusion for patients receiving antiplatelet therapy who have intracranial hemorrhage (traumatic or spontaneous) (Grade: uncertain recommendation; very low-quality evidence).

	Source :
	Platelet Transfusion: A Clinical Practice Guideline From the AABB.
	Ann Intern Med. Published online 11 November 2014 doi:10.7326/M14-1589.

Postoperative Delirium Guideline

Postoperative Delirium Guideline for Older Adults

The American Geriatrics Society (AGS) has released a new practice guideline for preventing and treating postoperative delirium in patients aged 65 years or older.

Delirium is among the most common post-operative complications for older adults undergoing surgery. It is upsetting for patients and families, and can be harmful if not recognized and treated. Studies have shown that delirium can be prevented in up to 40% of cases in some hospitalized older adult populations. Surgical and related medical specialists, together with the multi-disciplinary members of their teams, can play an integral role in prevention.

The recommendations in the best practices article range from what to do before, during, and after surgery to what not to do to prevent and treat delirium in postoperative patients.

They include :

	Clinicians should perform a preoperative and postoperative assessment of delirium risk factors, including age older than 65 years, poor vision or hearing, severe illness, and presence of infection or chronic cognitive decline or dementia.
	Healthcare professionals should be trained in the recognition and documentation of delirium signs and symptoms.
	Anesthesiologists "may use processed electroencephalographic monitors of anesthetic depth during sedation or general anesthesia," with the reasoning that administering fewer or lower doses will reduce postoperative delirium compared with deeper sedation.
	Prescribers should avoid medications that may induce postoperative delirium, including anticholinergics, corticosteroids, meperidine, and hypnotics. The use of five or more medications increases the risk for delirium.
	Clinicians should consider providing regional anesthesia during and after surgery for pain control.
	Hospitals and healthcare systems should implement formal educational programs and refresher sessions and should develop multicomponent interventions to be delivered by multidisciplinary teams.
	Prescribers should not prescribe antipsychotics or benzodiazepines to older patients who are not a threat for personal harm or harm to others and should not prescribe benzodiazepines as first-line treatment for such a patient.
	Prescribers should use the lowest effective dose of benzodiazepines and antipsychotics for the shortest duration and only after behavioral interventions have failed.

I. Postoperative Delirium Risk Factors

Risk Factors for Postoperative Delirium
	Age greater than 65 y
	Cognitive impairment
	Severe illness or comorbidity burden
	Hearing or vision impairment
	Current hip fracture
	Presence of infection
	Inadequately controlled pain
	Depression
	Alcohol use
	Sleep deprivation or disturbance
	Renal insufficiency
	Anemia
	Hypoxia or hypercarbia
	Poor nutrition
	Dehydration
	Electrolyte abnormalities (hyper- or hyponatremia)
	Poor functional status
	Immobilization or limited mobility
	Polypharmacy and use of psychotropic medications (benzodiazepines, anticholinergics, antihistamines, antipsychotics)
	Risk of urinary retention or constipation
	Presence of urinary catheter
	Aortic procedures

II. Delirium Diagnosis

Symptoms Associated with Delirium
	Change in level of arousal: drowsiness or decreased arousalor increased arousal with hypervigilance
	Delayed awakening from anesthesia
	Abrupt change in cognitive function (worsening confusion over hours or days), including problems with attention, difficulty concentrating, new memory problems, new disorientation
	Difficulty tracking conversations and following instructions
	Thinking and speech that is more disorganized, difficult to follow, slow, or rapid
	Quick-changing emotions, easy irritability, tearfulness, uncharacteristic refusals to engage with postoperative care
	Expression of new paranoid thoughts or delusions (ie, fixed false beliefs)
	New perceptual disturbances (eg, illusions, hallucinations)
	Motor changes such as slowed or decreased movements, purposeless fidgeting or restlessness, new difficulties in maintaining posture such as sitting or standing
	Sleep/wake cycle changes such as sleeping during the day and/or awake and active at night
	Decreased appetite
	New incontinence of urine or stool
	Fluctuating symptoms and/or level of arousal over the course of minutes to hours

III. Delirium Screening

Common Diagnostic Systems for Delirium
Diagnostic and Statistical Manual, 5th Edition, must meet all A – E	Confusion Assessment Method Algorithm, must meet I, II, and either III or IV
A. Disturbance in attention (ie, reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment). B. The disturbance develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day. C. An additional disturbance in cognition (eg, memory deficit, disorientation, language, visuospatial ability, or perception). D. The disturbances in criteria A and C are not better explained by a pre-existing, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma. E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (ie, due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.	I. Acute change and fluctuating course a. Evidence of an acute change in mental status from the patient's mental status prior to hospitalization, and b. Evidence that abnormal behavior fluctuates during the day (ie, tends to come and go or increase and decrease in severity). II. Inattention Evidence of difficulty focusing attention, eg, being easily distractible, or having difficulty keeping track of what is being said. III. Disorganized thinking Evidence that thinking is disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. IV. Altered level of consciousness Any evidence of any mental state other than a normal level of alertness. (Altered states include vigilant or hyperalert, lethargic, drowsy or easily aroused, stuporous or difficult to arouse, coma or unarousable.)

Validated Delirium Screening Instruments

General delirium screening instruments

Confusion Assessment Method (CAM) - short form

Delirium Symptom Interview (DSI)

Nursing Delirium Screening Scale (NuDESC)

Intensive care unit screening instruments

Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)

Intensive Care Delirium Screening Checklist (ICDSC)

CAM is used by many as a screening tool (short form) and as a diagnostic instrument (long form plus the algorithm). Increased reliability is demonstrated when used by trained evaluators using cognitive screening tests rather than as a screening tool informed only by routine patient care.

IV. Intraoperative Measures to Prevent Delirium

The anesthesia practitioner may use processed electroencephalographic monitors of anesthetic depth during intravenous sedation or general anesthesia of older patients to reduce postoperative delirium.

V. Medications as Risk Factors for Postoperative Delirium

Commonly Used Medications Used in the Perioperative Setting That May Induce Postoperative Delirium
Drug class or drug	Examples
Drugs with anticholinergic properties	Tricyclic antidepressants: amitriptyline, doxepin, imipramine Antihistamines: cyproheptadine, diphenhydramine, hydroxyzine Antimuscarinics: oxybutynin, tolterodine Antispasmodics: hyoscyamine, scopolamine First-generation antipsychotics: chlorpromazine, thioridazine H2-receptor antagonists: cimetidine, ranitidine Skeletal muscle relaxants: cyclobenzaprine, tizanidine Antiemetics: promethazine Olanzapine Paroxetine
Corticosteroids	Methylprednisolone Prednisone
Meperidine	Meperidine
Sedative hypnotics	Benzodiazepines: alprazolam, diazepam, lorazepam, midazolam Sedative-hypnotics: zolpidem, zaleplon
Polypharmacy	Starting ≥5 new medications increases risk of delirium

VI. Pharmacologic Prevention of Postoperative Delirium

	A health care professional trained in regional anesthetic injection may consider providing regional anesthetic at the time of surgery and postoperatively to improve pain control and prevent delirium in older adults.
	Optimize postoperative pain control, preferably with nonopioid pain medications, to minimize pain in older adults to prevent delirium.
	There is insufficient evidence to recommend for or against the use of antipsychotic medications prophylactically in older surgical patients to prevent delirium.
	In older adults not currently taking cholinesterase inhibitors, the prescribing practitioner should not newly prescribe cholinesterase inhibitors perioperatively to older adults to prevent or treat delirium.

VII. Nonpharmacologic Prevention and Treatment of Postoperative Delirium

Behavioral and Nonpharmacologic Strategies for Prevention of Delirium
	Sensory enhancement (ensuring glasses, hearing aids, or listening amplifiers)
	Mobility enhancement (ambulating at least twice per day if possible)
	Cognitive orientation and therapeutic activities (tailored to the individual)
	Pain control with scheduled acetaminophen if appropriate
	Cognitive stimulation (if possible, tailored to the individual's interests and mental status)
	Simple communication standards and approaches to prevent the escalation of behaviors
	Nutritional and fluid repletion enhancement
	Sleep enhancement (daytime sleep hygiene, relaxation, nonpharmacologic sleep protocol, and nighttime routine)
	Medication review and appropriate medication management
	Daily rounding by an interdisciplinary team to reinforce the interventions

VIII. Medical Evaluation of Postoperative Delirium

Precipitating Factors for Postoperative Delirium and Recommended Evaluation
Precipitant	Evaluation considerations
Environmental factors
Inadequately controlled pain	Physical examination Prednisone
Sleep disturbance	Review of medical records, including nursing notes
Use of physical restraints
Use of bladder catheterization
Poor vision and/or hearing
Infection
Urosepsis	Physical examination
Pneumonia	Urinalysis and white blood cell count
Line sepsis	Chest radiograph
Bacteremia	Blood, sputum, and urine cultures
Surgical site infection	Imaging of surgical site if indicated
Delirium-inducing medications	Medication reconciliation
Metabolic derangement
Hypoxia	Vital signs, including pulse oximetry
Acidosis	Laboratory evaluation, including:
Electrolyte derangement	Electrolytes, creatinine, blood urea nitrogen
Hypoglycemia	Blood gas analysis
Dehydration	Serum glucose
Acute blood loss anemia	Serum hematocrit
Hypotension/shock
Substance withdrawal
Alcohol	Physical examination
Benzodiazepines	Social history
Illicit drugs	Preadmission medication reconciliation

IX. Pharmacologic Treatment of Postoperative Delirium

	The prescribing practitioner may use antipsychotics at the lowest effective dose for the shortest possible duration to treat patients who are severely agitated or distressed, and are threatening substantial harm to self and/or others. In all cases, treatment with antipsychotics should be used only if behavioral interventions have failed or are not possible, and ongoing use should be evaluated daily with in-person examination of patients.
	The prescribing practitioner should not prescribe antipsychotic or benzodiazepine medications for the treatment of older adults with postoperative delirium who are not agitated and threatening substantial harm to self or others.
	The prescribing practitioner should not use benzodiazepines as a first-line treatment of the agitated postoperative delirious patient who is threatening substantial harm to self and/or others to treat postoperative delirium except when benzodiazepines are specifically indicated (including, but not limited to, treatment of alcohol or benzodiazepine withdrawal). Treatment with benzodiazepines should be at the lowest effective dose for the shortest possible duration, and should be used only if behavioral measures have failed or are not possible and ongoing use should be evaluated daily with in-person examination of the patient.

Conclusion:

The panel members conclude, "Successful postoperative management of delirium for older adults requires knowledge of approaches for screening, diagnosis, risk factor assessment, and nonpharmacologic and pharmacologic interventions aimed to prevent and treat delirium. The recommendation statements within provide a framework to allow hospital systems and health care professionals to implement actionable, evidence-based measures to address the highly morbid problem of delirium in perioperative patients."

Source :

Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society.

J Am Coll Surg. (2014), doi: 10.1016/ j.jamcollsurg.2014.10.019

Ref :

American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults

AGS Clinical Practice Guideline for Postoperative Delirium in Older Adults

Delirium Guideline Evidence Table

American Geriatrics Society Abstracted Clinical Practice Guideline for Postoperative Delirium in Older Adults

Related Content :

Journal Article: Postoperative Delirium in Older Adults: Best Practice Statement. J Am Coll Surg. (2014), doi: 10.1016/ j.jamcollsurg.2014.10.019

Patient Resources: Tips for Managing Delirium in Older Adults

Ask the Experts: Prevention and Treatment of Post-Operative Delirium

ISA KANYAKUMARI

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