Cognitive disorders in perioperative and intensive care

Authors: J. Kletečka 1,2;  K. Soumar 2;  Beneš J. 1–3
Authors‘ workplace: Klinika anesteziologie, resuscitace a intenzivní medicíny, Lékařská fakulta v Plzni, Univerzita Karlova 1;  Klinika anesteziologie, resuscitace a intenzivní medicíny, Fakultní nemocnice v Plzni 2;  Biomedicínské centrum, Lékařská fakulta v Plzni, Univerzita Karlova 3
Published in: Anest. intenziv. Med., 28, 2017, č. 5, s. 297-304
Category: Intensive Care Medicine - Review Article


Surgery and critical illness represent significant interventions into the integrity of the organism, which can lead to the development of a cognitive disorder. The most common symptoms include confusion and disorders of perception, attention and memory. Several syndromes are distinguished according to the time of their manifestation. Their pathophysiology has not yet been sufficiently clarified. Emergence delirium is a disorder of rapid onset immediately after general anesthesia, occurring more commonly in children, and it is likely associated with the use of inhalational agents. It is transient, partially preventable, nevertheless connected with a risk of major postoperative complications. The intensive care unit and postoperative delirium is usually associated with a longer hospital stay and increased morbidity and mortality. Screening is essential for its diagnosis, as well as a search and treatment of possible causes. No specific medication influencing significantly the delirium duration and course is currently available. Integration of care bundles including delirium management markedly improves patients’ outcome. Cognitive disorders are a part of long-term consequences of surgery and critical condition. The occurrence and importance of these conditions is still significantly underestimated although their impact on the quality of daily living of patients is fundamental.

cognitive disorders – delirium – postoperative cognitive dysfunction


1. Salluh JI, Wang H, Schneider EB, Nagaraja N, Yenokyan G, Damluji A, Serafim RB, Stevens RD. Outcome of delirium in critically ill patients: systematic review and meta-analysis. BMJ. 2015;350:h2538.

2. Silverstein JH, Timberger M, Reich DL, Uysal S. Central nervous system dysfunction after noncardiac surgery and anesthesia in the elderly. Anesthesiology. 2007;106:622–628.

3. Pai. Delayed emergence and emergence delirium in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 25, 2017.)

4. Card E, Pandharipande P, Tomes C, Lee C, Wood J, Nelson D, Graves A, Shintani A, Ely EW, Hughes C. Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit. Br J Anaesth. 2015;115:411–417.

5. Mixa V. Emergentní delirium po použití sevofluranu u dětí. Anest intenziv Med. 2013;24:385–390.

6. Sharma PT, Sieber FE, Zakriya KJ, Pauldine RW, Gerold KB, Hang J and Smith TH. Recovery room delirium predicts postoperative delirium after hip-fracture repair. Anesth Analg. 2005;101:1215–1220.

7. Lepousé C, Lautner CA, Liu L, Gomis P, Leon A. Emergence delirium in adults in the post-anaesthesia care unit. Br J Anaesth. 2006;96:747–753.

8. Hudetz AG. General Anesthesia and Human Brain Connectivity. Brain Connect. 2012;2:291–302.

9. Choi SH, Lee H, Chung TS, Park KM, Jung YC, Kim SI, Kim JJ. Neural network functional connectivity during and after an episode of delirium. Am J Psychiatry. 2012;169:498–507.

10. Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anestesiology. 2004;100:1138–1145.

11. Mason KP. Paediatric emergence delirium: a comprehensive review and interpretation of the literature. Br J Anaesth. 2017;118:335–343.

12. Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A, Cherubini A, Jones C, Kehlet H, MacLullich A, Radtke F, Riese F, Slooter AJ, Veyckemans F, Kramer S, Neuner B, Weiss B, Spies CD. European Society of Anaesthesiology evidence-based and consensus-based guidelines on postoperative delirium. Eur J Anaesthesiol. 2017;34:192–214.

13. Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306.

14. Černý V, Gabrhelík T, Herold I, Mach D, Matějovič M, Stibor B. Doporučený postup analgezie a sedace dospělých pacientů v intenzivní péči. Anest intenziv Med. 2014;25:392–396.

15. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

16. European Delirium Association. The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer. BMC Med. 2014;12:141.

17. Meagher DJ, Morandi A, Inouye SK, Ely W, Adamis D, Maclullich AJ, Rudolph JL, Neufeld K, Leonard M, Bellelli G, Davis D, Teodorczuk A, Kreisel S, Thomas C, Hasemann W, Timmons S, O‘Regan N, Grover S, Jabbar F, Cullen W, Dunne C, Kamholz B, Van Munster BC, De Rooij SE, De Jonghe J, Trzepacz PT. Concordance between DSM-IV and DSM-5 criteria for delirium diagnosis in a pooled database of 768 prospectively evaluated patients using the delirium rating scale-revised-98. BMC Med. 2014;12:164.

18. Peterson JF, Pun BT, Dittus RS, Thomason JW, Jackson JC, Shintani AK, Ely EW. Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc. 2006;54:479–484.

19. Jones SF1, Pisani MA. ICU delirium: an update. Curr Opin Crit Care. 2012 A19. pr;18:146–151.

20. Káňová M, Burda M, Povová J, Neiser J. Delirium u kriticky nemocných – prospektivní studie. Cesk Slov Neurol N. 2015;78/111: 662–667.

21. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, Inouye SK, Bernard GR, Dittus RS. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291:1753–1762.

22. Wolters AE, Slooter AJ, van der Kooi AW, van Dijk D. Cognitive impairment after intensive care unit admission: a systematic review. Intensive Care Med. 2013;39:376–386.

23. Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit. Crit Care. 2008;12 Suppl 3:S3.

24. Hughes CG, Morandi A, Girard TD, Riedel B, Thompson JL, Shintani AK, Pun BT, Ely EW, Pandharipande PP. Association between endothelial dysfunction and acute brain dysfunction during critical illness. Anesthesiology. 2013;118:631–639.

25. Hughes CG, Patel MB, Pandharipande PP. Pathophysiology of acute brain dysfunction: what‘s the cause of all this confusion? Curr Opin Crit Care. 2012;18:518–526.

26. Zaal IJ, Devlin JW, Peelen LM, Slooter AJ. A systematic review of risk factors for delirium in the ICU. Crit Care Med. 2015;43:40–47.

27. Mitášová A, Bednařík J, Košťálová M, Michalčáková R, Ježková M, Kašpárek T, Skutilová S, Straževská E, Šályová P, Šikolová V, Šrámková L. Standardizace české verze The Confusion Assessment Method for the Intensive Care Unit (CAM‑ICUcz). Cesk Slov Neurol N. 2010;73/106: 258–266.

28. ICU Delirium and Cognitive Imapirment Study Group. Terminology and Mnemonics. [online] [cit. 26.2.2017] Dostupné z

29. Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care. 2009;13:R77-10.1186/cc7892.

30. Martinez FE, Anstey M, Ford A, Roberts B, Hardie M, Palmer R, Choo L, Hillman D, Hensley M, Kelty E, Murray K, Singh B, Wibrow B. Prophylactic Melatonin for Delirium in Intensive Care (Pro-MEDIC): study protocol for a randomised controlled trial. Trials. 2017;18:4.

31. Adrienne M. Rouiller, PharmD. Antibiotics and Mental Status Changes. Medscape Critical Care [online] [cit. 26.2.2017] Dostupné z

32. Davidson JE, Aslakson RA, Long AC, Puntillo KA, Kross EK, Hart J, Cox CE, Wunsch H, Wickline MA, Nunnally ME, Netzer G, Kentish-Barnes N, Sprung CL, Hartog CS, Coombs M, Gerritsen RT, Hopkins RO, Franck LS, Skrobik Y, Kon AA, Scruth EA, Harvey MA, Lewis-Newby M, White DB, Swoboda SM, Cooke CR, Levy MM, Azoulay E, Curtis JR. Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU. Crit Care Med. 2017;45:103–128.

33. Peitz, G. J., Balas, M. C., Olsen, K. M., Pun, B. T., & Ely, E. W. Top 10 Myths Regarding Sedation and Delirium in the ICU. Critical Care Medicíně. 41:46–S56.

34. Ely EW. The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families. Crit Care Med. 2017;45:321–330.

35. Barnes-Daly MA, Phillips G, Ely EW. Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients. Crit Care Med. 2017;45:171–178.

36. Valerie J Page, MBBCh, E Wesley Ely, MD, Prof, Simon Gates, PhD, Prof, Xiao Bei Zhao, RN, Timothy Alce, PhD, Ayumi Shintani, PhD, Jim Jackson, PsyD, Gavin D Perkins, MD, Prof, and Daniel F McAuley, MD, Prof. Efficacy of Intravenous Haloperidol on the duration of Delirium and Coma in Critically Ill Patients (Hope-ICU): a Randomised, Placebo-Controlled Trial. Lancet Respir Med. 2013;1:515–523.

37. van Eijk MM, Roes KC, Honing ML, Kuiper MA, Karakus A, van der Jagt M, Spronk PE, van Gool WA, van der Mast RC, Kesecioglu J, Slooter AJ. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial. Lancet. 2010;376:1829–1837.

38. Cole JB, Moore JC, Dolan BJ, O’Brien-Lambert A, Fryza BJ, Miner JR, Martel ML. A Prospective Observational Study of Patients Receiving Intravenous and Intramuscular Olanzapine in the Emergency Department. Ann Emerg Med. 2017;69:327–336.e2.

39. Savage GH. Insanity following the use of anaesthetics in operations. British Medical Journal. 1887;2:1199–1200.

40. Bedford PD. Adverse cerebral effects of anaesthesia on old people. Lancet. 1955;269:259–263.

41. Moller JT, Cluitmans P, Rasmussen LS, Houx P, Rasmussen H, Canet J, Rabbitt P, Jolles J, Larsen K, Hanning CD, Langeron O, Johnson T, Lauven PM, Kristensen PA, Biedler A, van Beem H, Fraidakis O, Silverstein JH, Beneken JE, Gravenstein JS. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet. 1998;351:857–861.

42. Monk TG, Weldon BC, Garvan CW, Dede DE, van der Aa MT, Heilman KM, Gravenstein JS. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology. 2008;108:18–30.

43. Grigore AM, Murray CF, Ramakrishna H, Djaiani G. A core review of temperature regimens and neuroprotection during cardiopulmonary bypass: does rewarming rate matter? Anesth Analg. 2009;109:1741–51.

44. Foo I, Griffiths WH,Griffiths R and Plaat F. Postoperative Cognitive Dysfunction: Fact or Fiction? AAGBI Core Topics in Anaesthesia. 2015;114–126.

45. Bilotta F, Gelb AW, Stazi E, Titi L, Paoloni FP, Rosa G. Pharmacological perioperative brain neuroprotection: a qualitative review of randomized clinical trials. Br J Anaesth. 2013;110 Suppl 1:i113–120.

46. Rasmussen LS, Johnson T, Kuipers HM, Kristensen D, Siersma VD, Vila P, Jolles J, Papaioannou A, Abildstrom H, Silverstein JH, Bonal JA, Raeder J, Nielsen IK, Korttila K, Munoz L, Dodds C, Hanning CD, Moller JT; ISPOCD2 (International Study of Postoperative Cognitive Dysfunction) Investigators. Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients. Acta Anaesthesiol Scand. 2003;47:260–266.

47. Chan MTV, Cheng BCP, Lee TMC, Gin T and the CODA Trial Group. BIS-guided Anesthesia Decreases Postoperative Delirium and Cognitive Decline. J Neurosurg Anesthesiol. 2013;25:33–42.

48. Morandi A, Pandharipande PP, Jackson JC, Bellelli G, Trabucchi M, Ely EW. Understanding terminology of delirium and long-term cognitive impairment in critically ill patiens. Best Pract Res Clin Anaesthesiol. 2012;26:267–276.

49. Wilcox ME, Brummel NE, Archer K, Ely EW, Jackson JC, Hopkins RO. Cognitive dysfunction in ICU patients: risk factors, predictors, and rehabilitation interventions. Crit Care Med. 2013;41(9 Suppl 1):S81–98.

50. Jackson JC, Ely EW, Morey MC, Anderson VM, Denne LB, Clune J, Siebert CS, Archer KR, Torres R, Janz D, Schiro E, Jones J, Shintani AK, Levine B, Pun BT, Thompson J, Brummel NE, Hoenig H. Cognitive and physical rehabilitation of intensive care unit survivors: results of the RETURN randomized controlled pilot investigation. Crit Care Med. 2012;40:1088–1097.

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