Research| Volume 36, ISSUE 1, P41-46, February 2021

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The Relationship of Postoperative Delirium and Unplanned Perioperative Hypothermia in Surgical Patients

Published:October 13, 2020DOI:



      The purpose of this study was to investigate associations between postoperative delirium (POD) and unplanned perioperative hypothermia (UPH) among adults undergoing noncardiac surgery.


      A retrospective, exploratory design was used.


      A retrospective, exploratory study was conducted using electronic medical record data abstracted from a purposive convenience sample of adult patients undergoing noncardiac surgery from January 2014 to June 2017.


      The analyzed data set included 22,548 surgeries, of which 9% experienced POD. Logistic regression indicated that American Society of Anesthesiologists (ASA) class was the strongest predictor of POD (χ2 = 1,207.11, df = 4, inclusive of all ASA class terms). A significant relationship between UPH and POD (χ2 = 54.94, df = 4, inclusive of all UPH terms) and a complex relationship among UPH, patient age, ASA class, and POD were also found.


      Results support a relationship between UPH and POD. Notably, there is also a complex relationship in the noncardiac surgery population among UPH, age, ASA class, and POD. Preliminary understanding of this relationship is based on the pathophysiological response to surgical stress. Further research is indicated.


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        • American Association of Critical Care Nurses
        AACN Practice Alert: Delirium Assessment and Management.
        2016 (Available at:)
        • Devlin J.W.
        • Skrobik Y.
        • Gélinas C.
        • et al.
        Clinical Practice Guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.
        Crit Care Med. 2018; 46: e825-e873
        • Card E.
        • Pandharipande P.
        • Tomes C.
        • et al.
        Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit.
        Br J Anaesth. 2015; 115: 411-417
        • Rengel K.F.
        • Pandharipande P.P.
        • Hughes C.G.
        Postoperative delirium.
        Presse Med. 2018; 47: e53-e64
        • Evered L.
        • Silbert B.
        • Knopman D.S.
        • et al.
        Nomenclature Consensus Working Group. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery-20181.
        J Alzheimers Dis. 2018; 66: 1-10
        • Shim J.J.
        • Leung J.M.
        An update on delirium in the postoperative setting: Prevention, diagnosis and management.
        Best Pract Res Clin Anaesthesiol. 2012; 26: 327-343
        • Theuerkauf N.
        • Guenther U.
        • Putensen C.
        Postoperative delirium in the PACU and intensive care unit.
        Trends Anaesth Crit Care. 2012; 2: 148-155
        • Colon E.
        • Bittner E.A.
        • Kussman B.
        • McCann M.E.
        • Soriano S.
        • Borsook D.
        Anesthesia, brain changes, and behavior: Insights from neural systems biology.
        Prog Neurobiol. 2017; 153: 121-160
        • Salazar F.
        • Doñate M.
        • Boget T.
        • et al.
        Intraoperative warming and post-operative cognitive dysfunction after total knee replacement.
        Acta Anaesthesiol Scand. 2011; 55: 216-222
        • Cunningham C.
        • Maclullich A.M.
        At the extreme end of the psychoneuroimmunological spectrum: Delirium as a maladaptive sickness behaviour response.
        Brain Behav Immun. 2013; 28: 1-13
        • Guo Y.
        • Zhang Y.
        • Jia P.
        • et al.
        Preoperative serum metabolites are associated with postoperative delirium in elderly hip-fracture patients.
        J Gerontol A Biol Sci Med Sci. 2017; 72: 1689-1696
        • Maldonado J.R.
        Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure.
        Int J Geriatr Psychiatry. 2018; 33: 1428-1457
        • Oh S.T.
        • Park J.Y.
        Postoperative delirium.
        Korean J Anesthesiol. 2019; 72: 4-12
        • DeCrane S.K.
        • Sands L.
        • Ashland M.
        • et al.
        Factors associated with recovery from early postoperative delirium.
        J Perianesth Nurs. 2011; 26: 231-241
        • Brooks P.
        • Spillane J.J.
        • Dick K.
        • Stuart-Shor E.
        Developing a strategy to identify and treat older patients with postoperative delirium.
        AORN J. 2014; 99: 257-276
        • Lee C.
        • Lee C.H.
        • Lee G.
        • Lee M.
        • Hwang J.
        The effect of the timing and dose of dexmedetomidine on postoperative delirium in elderly patients after laparoscopic major non-cardiac surgery: A double blind randomized controlled study.
        J Clin Anesth. 2018; 47: 27-32
        • Liu Y.
        • Li X.J.
        • Liang Y.
        • Kang Y.
        Pharmacological prevention of postoperative delirium: A systematic review and meta-analysis of randomized controlled trials.
        Evid Based Complement Alternat Med. 2019; 2019: 9607129
        • Wang L.H.
        • Xu D.J.
        • Wei X.J.
        • Chang H.T.
        • Xu G.H.
        Electrolyte disorders and aging: Risk factors for delirium in patients undergoing orthopedic surgeries.
        BMC Psychiatry. 2016; 16: 418
        • Kiekkas P.
        • Fligou F.
        • Igoumenidis M.
        • et al.
        Inadvertent hypothermia and mortality in critically ill adults: Systematic review and meta-analysis.
        Aust Crit Care. 2018; 31: 12-22
        • Sessler D.I.
        Perioperative thermoregulation and heat balance.
        Lancet. 2016; 387: 2655-2664
        • Sun Z.
        • Honar H.
        • Sessler D.I.
        • et al.
        Intraoperative core temperature patterns, transfusion requirement, and hospital duration in patients warmed with forced air.
        Anesthesiology. 2015; 122: 276-285
        • Hooper V.D.
        • Chard R.
        • Clifford T.
        • et al.
        ASPAN's evidence-based clinical practice guideline for the promotion of perioperative normothermia: Second edition.
        J Perianesth Nurs. 2010; 25: 346-365
      1. Association of periOperative Registered Nurses (AORN). 2020 Guidelines for Perioperative Practice. Denver, CO: AORN; 2020.

        • Rajagopalan S.
        • Mascha E.
        • Na J.
        • Sessler D.I.
        The effects of mild perioperative hypothermia on blood loss and transfusion requirement.
        Anesthesiology. 2008; 108: 71-77
        • Kurz A.
        • Sessler D.I.
        • Lenhardt R.
        Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.
        N Engl J Med. 1996; 334: 1209-1215
        • Lenhardt R.
        Monitoring and thermal management.
        Best Pract Res Clin Anaesthesiol. 2003; 17: 551-568
        • Horn E.P.
        • Sessler D.I.
        • Standl T.
        • et al.
        Non-thermoregulatory shivering in patients recovering from isoflurane or desflurane anesthesia.
        Anesthesiology. 1998; 89: 878-886
        • Mangusan R.F.
        • Hooper V.
        • Denslow S.A.
        • Travis L.
        Outcomes associated with postoperative delirium after cardiac surgery.
        Am J Crit Care. 2015; 24: 156-163
        • Riker R.R.
        • Fraser G.L.
        The new practice guidelines for pain, agitation, and delirium.
        Am J Crit Care. 2013; 22: 153-157
        • Radtke F.M.
        • Franck M.
        • Schust S.
        • et al.
        A comparison of three scores to screen for delirium on the surgical ward.
        World J Surg. 2010; 34: 487-494
        • Gaudreau J.D.
        • Gagnon P.
        • Harel F.
        • Roy M.A.
        Impact on delirium detection of using a sensitive instrument integrated into clinical practice.
        Gen Hosp Psychiatry. 2005; 27: 194-199
        • Wong C.L.
        • Holroyd-Leduc J.
        • Simel D.L.
        • Straus S.E.
        Does this patient have delirium? Value of bedside instruments.
        JAMA. 2010; 304: 779-786
      2. 2018. Body Mass Index (BMI), Healthy Weight.
        (Available at:) (Accessed January 2, 2018)
        • Lindroth H.
        • Bratzke L.
        • Purvis S.
        • et al.
        Systematic review of prediction models for delirium in the older adult inpatient.
        BMJ Open. 2018; 8: e019223
        • Dasgupta M.
        • Brymer C.
        Prognosis of delirium in hospitalized elderly: Worse than we thought.
        Int J Geriatr Psychiatry. 2014; 29: 497-505
        • Finnerty C.C.
        • Mabvuure N.T.
        • Ali A.
        • Kozar R.A.
        • Herndon D.N.
        The surgically induced stress response.
        JPEN J Parenter Enteral Nutr. 2013; 37: 21S-29S
        • Liu X.
        • Yu Y.
        • Zhu S.
        Inflammatory markers in postoperative delirium (POD) and cognitive dysfunction (POCD): A meta-analysis of observational studies.
        PLoS One. 2018; 13: e0209284
        • Dobson G.P.
        Addressing the global burden of trauma in major surgery.
        Front Surg. 2015; 2: 43
      3. World Population. Asheville, North Carolina. 2019.
        (Available at:
        Date accessed: June 10, 2019

      Linked Article

      • Assessing Relationship of Postoperative Delirium and Unplanned Perioperative Hypothermia in Surgical Patients
        Journal of PeriAnesthesia NursingVol. 36Issue 6
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          With a great interest we read the recent article by Wagner et al1 assessing the relationship of postoperative delirium (POD) and unplanned perioperative hypothermia (UPH) in adult patients undergoing noncardiac surgery. They showed a significant relationship between UPH and POD. Furthermore, there are complex relationships among UPH, age, ASA physical status class and POD. Given that POD is significantly associated with increased lengths of ICU and hospital stay, costs, morbidity and mortality after noncardiac surgery,2 their findings have potential implications.
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