People can dream during an operation

After anesthesia : Waking up becomes a nightmare

“My father was hallucinating, thrashing around and frantically trying to rip the tubes out of his body. The nursing staff had to tie him to the bed, ”says Florian Riese. When his 76-year-old father woke up from anesthesia after a thyroid operation, he was no longer himself.

Around 15 million patients are operated on in Germany every year, and every fifth person suffers from delirium afterwards. However, most people are unfamiliar with this form of cognitive disorder, and it often goes undetected. Delirium is a very confused state: "You can imagine waking up from a nightmare and not knowing where you are and what is happening - only worse," says Claudia Spies from the Clinic for Anaesthesiology at the Berlin Charité.

The Leopoldina Symposium “Postoperative Cognitive Disorder” recently took place here. Riese also reported on his experiences there as a speaker. Even he, as a doctor, was overwhelmed with the situation. “My father was in normal shape for his age. We expected a two or three day stay in the clinic, ”he recalls. Then everything turned out differently: pneumonia, tracheal cannula, nasogastric tube, pressure ulcer. "Two months in the clinic, then in the rehab hospital, mentally and physically impaired," says Riese. No unusual course.

Delirium can cause long-term damage

Delirium can have serious consequences, explains Finn Radtke, senior physician at the Charité: “Anyone who is affected has a three times higher risk of dying within six months of being discharged. In addition, long-term damage remains and the risk of needing care doubles. ”Therefore, comprehensive monitoring of the cognitive condition before, during and after the operation is important. Because delirium is not always as noticeable as with Riesen's father. Other symptoms are drowsiness, disinterest and apathy, but above all impaired attention and awareness of the environment and poor memory. It is important to recognize this and interpret it correctly.

“There are checklists for this, which are ticked off during the anesthesia and afterwards in the recovery room,” explains Spies. Doctors and nurses compare the patient's cognitive abilities before and after an operation in order to identify alarm signals. Some questionnaires are so simple that both inexperienced staff and family members can tick them off.

This is not enough in intensive care units, where specialists should do extensive tests. They have to determine the patient's state of mind with the help of scales and test the logical thinking ability and attention with the help of various questions and tasks. For example, you will slowly spell the word PINEAPPLE TREE. Every time A, the patient should squeeze the tester's hand. If the result of the test indicates delirium, they sound the alarm.

Stress increases the risk of delirium

There is a reason for the stricter monitoring in intensive care units: up to 80 percent of ventilated patients there suffer from delirium, compared with around 25 percent in a normal ward. The exact causes are unclear. Experts suspect a connection between previous illnesses, stress, inflammation and the age of the patient. The surgical stress in combination with certain medications probably leads to the fact that cognitive disorders are temporarily or permanently intensified after the procedure.

It is therefore important to reduce the stress for the patient. "As soon as the body is under stress - be it through inflammation, infection or surgery - the blood-brain barrier becomes more permeable," explains Spies. The brain can prevent this itself by activating the parasympathetic nervous system. Because this nerve promotes the resting state of the body. "However, older patients swallow many drugs that partially inhibit the parasympathetic nervous system and thus prevent it from blocking the process."

Since even dehydration causes stress, the sobering phase should be shortened before the procedure. The correct amount of painkillers during the operation and the measurement of brain waves, which allow the correct depth of anesthesia to be maintained, also reduce stress. Such measures may prevent waking up from anesthesia feeling like being out of a nightmare.

Familiar voices and faces help calm the patient down

Especially in the waking up phase, it is important that relatives and friends are there: The familiar voices and faces calm the patient. "After a bad dream, it is also beneficial to have someone around you to find your way back to reality," says Spies. "In addition, apparently mundane things like glasses and hearing aids help the patient a lot with orientation."

An autoimmune disease could also cause delirium, triggered by immunoglobulin A antibodies (IgA), suspect experts such as the neurologist Harald Prüß from the Charité. IgA is usually found in blood and tissue fluids. If stress causes a weakened blood-brain barrier, the antibodies could get into the brain. There they attack NMDA receptors that every nerve cell has.

So that information can be passed on from nerve cell to nerve cell, they need messenger substances such as glutamate at their connection points. However, it is not enough that the substance is released; it must also be able to dock on the next nerve cell at the NMDA receptors. These receptors usually act as a channel through which ions can migrate inside the cell. If they are blocked by antibodies, this could damage memory, comprehension or information processing, the researchers reported during the symposium.

"Doctors and nurses have to explain what is happening"

In the laboratory, you can determine an increased IgA level in the brain water and then reduce it again with the help of a blood wash. Immunotherapy is also possible. The first attempts have already been made. However, there is still a need for further research, says Spies.

For the experts, however, it was not just about investigating the cause, which is important for the development of suitable drugs and therapies. Their aim is also a comprehensive and regulated monitoring of the patients. In addition, communication in everyday clinical practice, especially with relatives, should be improved. “The doctors and nurses have to explain what happens,” says Florian Riese. His father has now recovered, but he is still feeling the consequences. Although Riese is a doctor himself, he felt he was left alone: ​​“For laypeople, explanations would be helpful. In this way they can deal with the situation better and thereby give the patient the necessary support. "

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