Episode #48 Brain Safety Part 2: Now and Beyond

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show.  We will be returning to our discussion on perioperative brain health and safety and continuing to review our featured article from the October 2020 APSF Newsletter, “Brain Safety: The Next Frontier for Our Specialty” by Kamdar and colleagues.

Before we dive into today’s episode, we’d like to recognize Preferred Physicians Medical Risk Retention Group, a major corporate supporter of APSF. Preferred Physicians Medical Risk Retention Group has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Preferred Physicians Medical Risk Retention Group – we wouldn’t be able to do all that we do without you!”

Let’s continue the conversation from last week. If you have not already listened to Episode #47, I encourage you to go check it out first. To follow along with us online, head over to APSF.org and click on the Newsletter heading. Fourth one down is Newsletter Archives. Then click on October 2020. Then, scroll down looking at the left hand column until you come to our featured article. The October 2020 APSF newsletter had a special theme of “What then and What now” and included a review of the Top 10 most impactful anesthesia patient safety articles with a recent update. We left off last week by discussing what we know about the development of postoperative delirium. The pathophysiology of this complication appears to be multifaceted and related to neurotransmitter imbalance, inflammation, stress response, cellular metabolism, pre-existing neurologic vulnerability, and changes in network neurobiology.

This is an important concern for patients and physicians alike and it may not be something that we see immediately in the PACU. The symptoms may wax and wane as well. Have you taken care of a patient with postoperative delirium? Did your patient have risk factors for developing this such as baseline cognitive decline, dementia, poor vision, poor hearing, severe illness and underlying infection. The preoperative evaluation may include cognitive screening with tools such as the Mental Status Exam or the Mini-Cog and if you are not already doing this in your pre-anesthesia clinic, it may be something to consider going forward.

Last week, I mentioned that there are several tools to help make the diagnosis for postoperative delirium that include the Confusion Assessment Method (CAM), the Confusion Assessment Method modified for the ICU (CAM-ICU), Nursing Delirium Screening Scale, and the Delirium Symptom Interview. The confusion assessment method is widely used for diagnosis of delirium and can be used for medical and surgical patients including geriatric patients. The CAM-ICU or Confusion Assessment Method modified for the ICU tool is a newer version that has been modified to be used for critically ill patients in the ICU. The CAM tool includes 9 questions and takes about 5 minutes to complete. The answers to the questions help to identify the following features:

Feature 1: Acute Onset or Fluctuating Course

Feature 2: Inattention

Feature 3: Disorganized thinking

Feature 4: Altered level of consciousness

The diagnosis of delirium requires the presence of feature 1 and 2 as well as either feature 3 or feature 4. I will include a link to the CAM tool in the show notes as well. The CAM-ICU tool includes 2 steps. Step 1 is the Richmond Agitation Sedation Scale from +4 to -5. For patients with a RASS score of greater than or equal to -3 it is appropriate to move to Step 2 which is the CAM-ICU tool. The CAM-ICU tool involves an assessment of the 4 features that I mentioned with the CAM tool. I will include a link to the CAM-ICU tool in the show notes as well.

Last week, we also talked about what can be done to prevent postoperative delirium. The anesthesia plan for patients at high risk for postoperative delirium may involve minimizing use of or avoidance of high-risk medications such as benzodiazepines, anticholinergic medications, higher dose corticosteroids, and meperidine as well as decreasing polypharmacy when possible.

Now, let’s return to our featured article. The article highlights new areas for research going forward and a call to action since to quote the authors, “our engagement in best perioperative practices for neurocognitive health is critical.” This is a vital area of engagement for anesthesia professionals especially since many anesthesia medications target the brain in order to produce sedation and general anesthesia. Starting with knowledge gained from basic science models, it is possible to measure neuroinflammatory signals for delirium in humans. In addition, network neuroscience approaches provide vital information about the brain and different levels of consciousness as well as the transition between different levels of consciousness. So far, research has revealed neurophysiologic signatures that are associated with delirium and this is an exciting start which may provide further information about cognitive dysfunction during the postoperative time period and in other settings as well. This is also an important time to include research into implementation barriers for interventions that may be beneficial for improving perioperative brain health.

What can we do for our patients today and going forward to optimize brain health? Currently, there are several interventions that target multiple modifiable risk factors that show promise including cognitive orientation, social support, sleep protocols, early mobilization, and education for health care staff. Table 1 in the articles offers several interventions that may be useful during the postoperative time period. Let’s go through them now.

1. Daily visitor orientation with an orientation board that includes the names of the care team members and a schedule for the day.
2. Therapeutic activities including cognitive stimulation 3 times daily
3. Early mobilization with ambulation or active range of motion exercise 3 times daily.
4. Vision protocol with visual aids and adaptive equipment.
5. Hearing protocol with portable amplifying devices and special communication techniques.
6. Oral volume repletion with feeding and drinking assistance and encouragement.
7. Sleep enhancement with nonpharmacologic sleep protocol.

Other program interventions may include:

1. Geriatric nursing assessment with nursing assessment and intervention for cognitive and functional impairment
2. Interdisciplinary rounds with twice-weekly rounds to discuss patients and set goals for care.
3. Provider education with formal didactic sessions and one-on-one interactions
4. Community linkages with referrals and communication with community agencies to optimize patients’ transition to home.
5. Geriatrician consultation with targeted consultation referred by program staff
6. Interdisciplinary consultation which provides as needed consultation when requested by staff.

Implementation of these interventions requires support from quality improvement, implementation science, and quality control from engineering science to be used consistently in clinical practice…and to be effective to support brain health and prevent and treat postoperative delirium.

The authors provide practical guidance for building a clinical practice that focuses on perioperative brain health for healthcare professionals.

1^st: It is important to measure cognitive function before surgery to provide a baseline assessment for each patient and as a component of population data for longitudinal studies. This is where the Mini-Cog tool can be used to provide this vital information. Is this a part of your pre-anesthesia clinic testing already?

2^nd: It is important to perform regular delirium testing for patients after surgery especially geriatric and high risk patients. In addition, healthcare providers performing the assessments need to be trained on these assessment tools and regularly scheduled education sessions about using these tools effectively in clinical practice needs to be maintained.

3^rd: It is important to simplify medications, minimize sedation when possible, and identify vision and hearing deficits as soon as possible during the postoperative period. These simple steps will go a long way to improve patient-centered care especially for our elderly patients.

4^th: This appears to be a time to shift the focus of research on postoperative delirium interventions from very specific outcomes measures to implementation science measurements. For example, performance improvement tools such as control charts can be used as well as process measurements aimed at measuring diagnostic, monitoring, and therapeutic change. This will allow for the study of the impact of some of the interventions that we talked about on the show today until we have a reliable and valid diagnostic biomarker or more specific interventions to study.

We have learned a lot about how to make anesthesia safer for patients over the past 35 years especially in the areas of preventing cardiovascular collapse, hypoxemia, drug errors, and human errors. There is a new call to action and a new frontier when it comes to perioperative brain health and anesthesia patient safety to help prevent delirium and cognitive dysfunction following surgery and anesthesia. There is challenging work to be done in this area to better understand the pathophysiology as well as to help bridge the gap between prevention and treatment for postoperative delirium and to standardize the workflow to optimize perioperative brain health.

Now before we wrap up our special two-part series, I reached out to Kamdar and asked him what he hopes to see going forward. Let’s take a listen to what he had to say.

[Kamdar] This patient safety topic requires a multi-faceted approach to solve. I hope to see even more resources placed to investigate the scientific hypothesis that we’ve outlined such as network neurobiology, inflammation, neurotransmitter imbalance, and neurologic vulnerability. However, I do hope that we won’t wait for a single scientific hypothesis to prevail before we attempt methods to protect patients against postoperative delirium. There is still much work to do from an implementation science perspective to have teams measure cognitive baselines and declines in the perioperative period. We need to design multidimensional interventions and acclimate out hospital culture to measure cognitive performance and implement multifaceted interventions. This topic challenges not only our scientific aptitude but our change management and implementations aptitude as well. I hope to see these move in parallel as we advance the way we protect the neurocognition of patients undergoing surgery in the future.

[Bechtel] Thank you so much to Kamdar for his contributions to the show today. We are so excited to see what this next frontier for anesthesia patient safety and perioperative brain health looks like going forward.

If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Plus, you can find us on twitter and Instagram!  See the show notes for more details and we can’t wait for you to tag us in a patient safety related tweet or like our next post on Instagram!! Follow along with us for anesthesia patient safety pictures and stories!!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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