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Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

ESAIC · 2023 · Europe

Source and licence

Authors
César Aldecoa, Gabriella Bettelli, Federico Bilotta et al.
Title
Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients
Journal
European Journal of Anaesthesiology, 2023
DOI
10.1097/EJA.0000000000001876
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC10763721

Licence statement of the original publication

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Meta-analyses

  • Recommendation 2.1Quality of the evidence Strength of recommendation We recommend evaluating the following preoperative risk factors for POD: (1) older age, (2) American Society of Anesthesiology Physical status score > 2, (3) Charlson Comorbidity Index >2 and (4) Mini Mental State Examination score lower than 25 points Moderate Strong

Adverse effects

  • Recommendation 3.1Quality of the evidence Strength of recommendation In patients undergoing surgery, we do not suggest the use of any drug as a prophylactic measure to reduce the incidence of POD. LowMei et al., 201860Yang et al., 201541Su et al., 201642Deiner et al., 201743Lee et al., 201844Kim et al., 201945Sun et al., 201946Xin et al., 202155Zhang et al., 202055Shi et al., 202047Li et al., 202048Hu et al., 202149Hong et al., 202150Li et al., 201751Subramaniam et al., 201935Turan et al., 202052Likhvantsev et al., 202153Van Norden et al., 202154Djaiani et al., 201657Azeem et al., 201858Momeni et al., 202159 Weak Recommendation 3.2 Quality of the evidence Strength of recommendation When dexmedetomidine is used intra-operatively or postoperatively with the aim to prevent POD, we recommend balancing the expected benefits against the most important side effects (bradycardia and hypotension). ModerateDjaiani et al., 201657Su et al., 201642Li et al., 201751Deiner et al., 201743Subramaniam et al. 201935Sun et al., 201946Xin et al., 202155Zhang et al., 202056Turan et al., 202052Shi et al., 202047Li et al., 202048Hu et al., 202149Hong et al., 202150Van Norden et al., 202152 Strong

PICO 11 (cardiac surgery: off-pump in cardiac surgery vs. on-pump in cardiac surgery)

  • Recommendation 3.3Quality of the evidence Strength of recommendation In patients undergoing surgery, we do not suggest any specific type of surgery or type of anaesthesia to reduce the incidence of POD. LowMei et al., 201860Avidan et al., 201787Brown et al., 202189Li et al., 202290Neuman et al., 202191Vlisides et al., 201993Li et al., 202194Shin et al., 201595Szwed et al., 202196 Weak

PICO 12 (biomarkers: abnormal value of a biomarker preoperatively, intra-operatively, or postoperatively vs. normal level of a biomarker)

  • Recommendation 3.4Quality of the evidence Strength of recommendation We do not suggest using biomarkers to identify patients at risk of POD. Low (References in the Supplement Table S9) Weak

PICO 13: Which nonpharmacological multicomponent or single interventions can be recommended to prevent POD?

  • Recommendation 4.1Quality of the evidence Strength of recommendation We recommend that preoperative anaesthesia consultation in older adults includes the screening for risk factors for POD and addresses patients’ needs to optimise their preoperative status. LowDalton and Zafirova, 2018116Lim and Lee, 2020117Carli and Baldini, 2021118Carli et al., 2021119 Strong
  • Recommendation 4.2Quality of the evidence Strength of recommendation We recommend that the results of the screening for POD risk factors are shared among the care team and the preventive strategies discussed and registered in the medical records. LowBerian et al., 2018123Oh and Park, 2019124Enomoto et al., 2021125Sockalingam et al., 2015126 Strong
  • Recommendation 4.3Quality of the evidence Strength of recommendation We recommend multicomponent nonpharmacological interventions in all patients at risk of POD. ModerateOlotu et al., 2022101Deeken et al., 202297Marcantonio et al., 2001100Vidan et al., 2005103Guo and Fan, 201698Partridge et al., 2017102Hempenius et al., 201399Wang et al., 201979 Strong

PICO 14: Is processed EEG monitoring during anaesthesia able to reduce POD?

  • Recommendation 5.1Quality of the evidence Strength of recommendation We suggest Index-based EEG monitoring depth of anaesthesia guidance to decrease the risk of POD. LowChan et al., 2013129Radtke et al., 2013130Whitlock et al., 2014131Zhou et al., 2018132Wildes et al., 2019133Tang et al., 2020134Evered et al., 202122Wang et al., 2022135 Weak

PICO 15: Does multiparameter intraoperative EEG monitoring, focusing on burst suppression activity and including the density spectral array, improve guiding depth of anaesthesia and decrease the risk of POD?

  • Recommendation 5.2Quality of the evidence Strength of recommendation We suggest multiparameter, intraoperative EEG monitoring (burst suppression, density spectral array, DSA) during anaesthesia to decrease the risk of POD. LowSoehle et al., 2015140Fritz et al., 2016141Fritz et al., 2018142Pedemonte et al., 2020143Fritz et al., 2020144Cooter Wright et al., 2022145Acker et al., 2021146Koch et al., 2021147Tanabe et al., 2020148Gutierrez et al., 2019149 Weak

PICO 16: Should antipsychotics be used for the treatment of POD?

  • Recommendation 6.1Quality of the Evidence Strength of recommendation We suggest using low-dose haloperidol for the treatment of POD if nonpharmacological measures fail.We advise a short-term, symptom-oriented therapy. The application should be bolus-wise and with the lowest dose possible. Use antipsychotic drugs with caution or not at all for people with preexisting neurologic conditions, such as Parkinson's disease or Lewy bodies dementia. Very lowRCT: Fukata et al., 2017 204/SR: Shen et al., 2018207 Weak

PICO 17: Should benzodiazepines be used for the treatment of POD?

  • Recommendation 6.2Quality of the evidence Strength of recommendation The use of benzodiazepines for the treatment of delirium in postoperative patients is not suggested. The evidence for the benefits of benzodiazepine therapy for treating POD symptoms or the underlying causes is very low to nonexistent.This recommendation is not to be confused with delirium in the context of alcohol withdrawal, where benzodiazepines are recommended symptom orientated as the first-line medication (in a bolus-titrated dosage, lowest as possible). Very lowYapici et al., 2011215 Weak

PICO 18: Should alpha-2 agonists be used for the treatment of POD?

  • Recommendation 6.3Quality of the evidence Strength of recommendation We suggest using dexmedetomidine for the treatment of postoperative delirium in cardiac surgery. Very lowRCT: Yapici et al., 2011215/SR: Pieri et al., 2019216 (based on Yapici 2011)RCT: Shokri and Ali, 201961 Weak

Executive summary

  • Recommendation 3.1Quality of the evidence Strength of recommendation In patients undergoing surgery, we do not suggest the use of any drug as a prophylactic measure to reduce the incidence of POD. Low Weak
  • Recommendation 3.2Quality of the evidence Strength of recommendation When dexmedetomidine is used intra-operatively or postoperatively with the aim to prevent POD, we recommend balancing the expected benefits against the most important side effects (bradycardia and hypotension). Moderate Strong
  • Recommendation 3.3Quality of the evidence Strength of recommendation In patients undergoing surgery, we do not suggest any specific type of surgery or type of anaesthesia to reduce the incidence of POD. Low Weak
  • Recommendation 3.4Quality of the evidence Strength of recommendation We do not suggest using biomarkers to identify patients at risk of POD. Low Weak
  • Recommendation 4.1Quality of the evidence Strength of recommendation We recommend that preoperative anaesthesia consultation in older adults includes the screening for risk factors for POD and addresses patients’ needs to optimise their preoperative status. Low Strong
  • Recommendation 4.2Quality of the evidence Strength of recommendation We recommend that the results of the screening for POD risk factors are shared among the care team and the preventive strategies discussed and registered in the medical records. Low Strong
  • Recommendation 4.3Quality of the evidence Strength of recommendation We recommend multicomponent nonpharmacological interventions in all patients at risk of POD. Moderate Strong
  • Recommendation 5.1Quality of the evidence Strength of recommendation We suggest Index-based EEG-monitoring depth of anaesthesia guidance to decrease the risk of POD. Low Weak
  • Recommendation 5.2Quality of the evidence Strength of recommendation We suggest multiparameter, intraoperative EEG monitoring (burst suppression, density spectral array, DSA) during anaesthesia to decrease the risk of POD. Low Weak
  • Recommendation 6.1Quality of the evidence Strength of recommendation We suggest using low-dose haloperidol for the treatment of POD if nonpharmacological measures fail.We advise a short-term, symptom-oriented therapy. The application should be bolus-wise and with the lowest dose possible. Use antipsychotic drugs with caution or not at all for people with preexisting neurologic conditions, such as Parkinson's disease or Lewy bodies dementia. Very low Weak
  • Recommendation 6.2Quality of the evidence Strength of recommendation The use of benzodiazepines for the treatment of delirium in postoperative patients is not suggested. The evidence for the benefits of benzodiazepine therapy for treating POD symptoms or the underlying causes is very low to nonexistent.This recommendation is not to be confused with delirium in the context of alcohol withdrawal, where benzodiazepines are recommended symptom orientated as the first-line medication (in a bolus-titrated dose, lowest as possible). Very low Weak
  • Recommendation 6.3Quality of the evidence Strength of recommendation We suggest using dexmedetomidine for the treatment of POD in cardiac surgery. Very low Weak

Abstract

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients’ clinical and functional status.

Contents of the original publication

The section headings of the original.

  • Introduction
  • General methods
  • General approach for all working groups
  • Results and recommendations
  • Chapter 1: Basic Science
  • Chapter 2: Risk Factors
  • Chapter 3: Preventive Measures I: Effects of Drugs on POD prevention
  • PICO 1 (preventive use of dexmedetomidine preoperatively, intra-operatively or postoperatively vs. non-dexmedetomidine/placebo)
  • PICO 2 (preventive use of neuroleptics preoperatively, intra-operatively, or postoperatively vs. nonneuroleptics/placebo)
  • PICO 3 (preventive use of sleep medications preoperatively or postoperatively vs. no sleep medications/placebo)
  • PICO 4 (preventive use of cholinesterase inhibitors preoperatively or postoperatively vs. no use of cholinesterase inhibitors)
  • PICO 5 (other drugs: application of a drug to reduce POD vs. no application of any specific drug to reduce POD)
  • PICO 6 (anaesthetic drugs: intravenous anaesthetics vs. inhalation anaesthetics)
  • PICO 7 (anaesthetic drugs: ketamine intra-operatively or postoperatively vs. no ketamine)
  • PICO 8 (type of anaesthesia: regional anaesthesia vs. general anaesthesia)
  • PICO 9 (surgery: minimally invasive surgery [except laparoscopy] vs. more invasive surgery [except laparotomy])
  • PICO 10 (surgery: laparoscopy vs. laparotomy)
  • PICO 11 (cardiac surgery: off-pump in cardiac surgery vs. on-pump in cardiac surgery)
  • PICO 12 (biomarkers: abnormal value of a biomarker preoperatively, intra-operatively, or postoperatively vs. normal level of a biomarker)
  • Chapter 4: Preventive Measures II: Nonpharmacological Interventions
  • PICO 13: Which nonpharmacological multicomponent or single interventions can be recommended to prevent POD?
  • Chapter 5: Neuromonitoring
  • PICO 14: Is processed EEG monitoring during anaesthesia able to reduce POD?
  • PICO 15: Does multiparameter intraoperative EEG monitoring, focusing on burst suppression activity and including the density spectral array, improve guiding depth of anaesthesia and decrease the risk of POD?
  • Chapter 6: Pharmacological Treatment of POD and POD Outcomes
  • PICO 16: Should antipsychotics be used for the treatment of POD?
  • PICO 17: Should benzodiazepines be used for the treatment of POD?
  • PICO 18: Should alpha-2 agonists be used for the treatment of POD?
  • Discussion
  • Executive summary

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