People after anesthesia sometimes show strange symptoms for weeks: some go crazy, others rave, have a mood swing. This “delirium” primarily affects children and continues to be a mystery to doctors.
In retrospect, I can guess what it must be like when everything in your head falls apart and you look death in the eye. Madness, panic, terror. Now I also know that it usually passes – at least in children. That what happens to some people after surgery is called “delirium”. And that we urgently need to educate people in this area: hospital employees, but also ourselves.
“Ordinary” surgery
My son had a fractured skull. He was put down, intubated and operated on. He looked calm. Just that bandaged and swollen head. “We’ll wake him up tomorrow morning,” the doctors said after four days in the intensive care unit. On the way to the room, the chief physician took me aside and said: “When he wakes up, it won’t look like in a series, he’ll open his eyes and everything will be fine. Be prepared for transient psychotic disorders ». I don’t remember if I asked what that exactly meant.
I sat down next to my son. His hands were immobilized. «That he would not struggle,» explained the doctor. The child began to regain consciousness, narrowed his eyes. He was seven at the time. He has never been to a hospital before. Strangers in coats stood in front of him, staring down at him. He looked at his body, tubes everywhere. He wanted to check with his hand what was on his head. I stopped him, stroked him and said: “You had a car accident, your head was injured, you are in the hospital and you slept four days ago”.
His body tensed and the first sentence was, “I want to be human!”. And then: “I want to go home to my mother!”. He stuck his lower lip aggressively. “Let me go!”.
They all looked as if they were shocked. I hugged my son and said: “I am here, there is nothing to be afraid of, everything will be fine”. Suddenly he jerked his head and shouted: “Watch out, something’s coming from behind, watch out, it’s about to hit, it’s a tornado!”
Someone else
It was as if his soul was stuck at the time of the accident, as if it had yet to catch up with him. She was crazy. The doctor thought it was “like he was in rehab”. After his skull fractured, it was opened by surgeons, and the top of his face reassembled in a seven-hour operation, a tremendous amount of medication flowed through the tiny organism. Anesthesiologists call such deep anesthesia “burst supression” – I know it because I asked pediatricians and scientists. The few who know a little bit about delirium – and research into it has only begun recently – believe that the drugs used to suppress consciousness do not do well for the brain.
My son was getting excited. He screamed. And then he became apathetic. Then deep sadness followed. And again that’s something he saw coming from behind – he was breaking up and screaming. I sang lullabies to him, which normally calmed him down. I did not leave him one step. His anger with an aggressively protruding chin kept recurring. After 10 hours, I started to be afraid of him.
Doctors and nurses were helpless. Eventually they gave him a sedative. Today I know that benzodiazepines can cause delirium – as can 70 other causes. American doctors came up with the acronym for them: I WATCH DEATH. Each of the letters represents a potential factor that could trigger delirium: I like Infection (e.g. meningitis or pneumonia), T for Trauma (head injury), D for Deficiency, deficiency (vitamins or proteins) up to H – Heavy Metals, i.e. heavy metals (arsenic, lead, mercury).
The next day, my son stopped screaming. He lay in bed and stared at nothingness with a completely blank expression on his face. He didn’t react to any of my jokes. It was this stillness on the second day that made me begin to doubt. Does he have brain damage? Will he stay like this forever? Meanwhile, around the third day, he came back to us – like many children who awake after surgery and fall into a state of confusion, madness or apathy for a day or two.
Speech without words
A few days after the accident, I was reading the book “Speech Without Words” by therapist Peter Levine. He writes that trauma is a mental trauma caused by paralyzing terror and a sense of helplessness and loss. In order to overcome it, a person needs a guide who will treat him as an equal. In 2012, when the described incident occurred, there was no literature on acute transient psychotic disorders. I managed to google it as a kind of psychosis and dropped the subject.
I came back to it only when my father, after the surgery, fell into anxiety and insomnia that lasted for weeks. He fought, hyperventilated, fell over and injured his head. Then I started looking for answers. Scientists such as Claudia Spies – professor of anesthesiology at Berlin’s Charité hospital who studies the phenomenon of delirium – believe that 30 to 80 percent of them suffer from delirium. patients after surgery or treatment in the ICU. “It is the most common, serious and least known of organ dysfunction,” says Spies.
The organ in question is the brain. In the case of infants, the incidence rate after ICU treatment is as high as 85%. People who are very small or very old seem to be the most susceptible, because a growing or aging brain shows some similarities from a medical point of view: it changes and is therefore very sensitive.
Where is it coming from?
Delirium is not only caused by heavy surgeries, sometimes tonsillectomy is enough. And it doesn’t matter, says pediatrician Jochen Meyburg, whether the baby had a head operated on or whatever. The risk factors are age, depth and duration of anesthesia, and infection. So delirium is not just a bizarre condition noticed by relatives and nurses when an over-aroused patient fights, tears an IV drip or, on the contrary, stares apathetic into the distance. According to the American researcher Wes Ely, you cannot wait for it to “pass by itself”. In more severe cases, medicine has to step in.
What exactly, I ask Claudia Spies, is going on in the brain? This organ is made up of cells and nerve connections through which electric waves travel. They are transferred from one nerve cell to another with the help of semiochemicals. The pulsing of electrical impulses is – you might say – the language of the brain. Pulsating is life, because when the waves stop vibrating, death occurs. From the EEG examination, Spies can read that during delirium on the way from the diencephalon to the frontal lobe, these flows seem to fall out of the tracks. Even in antiquity it must have been perceived similarly, because in Latin “De lira ire” means “to fall out of the furrow”.
One hypothesis is that delirium occurs when certain neurotransmitters, such as acetylcholine, do not function properly. Inflammatory processes in the body may contribute to this. Growth factors travel from the blood to the brain, activating phagocytes, which in turn destroy nerve cells. Either way, the thought process gets disrupted and the nerves try to connect things like crazy. There are hallucinations similar to nightmares or malignancies. “You lose your bearings,” explains Claudia Spies. Orientation in space, in time, in oneself. Scientists fear this could have lasting consequences. There is a growing body of research on the subject, for example, showing that a third of patients who were frequently anesthetized as children later have a reduced IQ – possibly due to scarring of the brain – and the link to possible delirium is not clear here. .
Co dalej?
The fact that so many children suffer from delirium has only recently been realized. A recent study in New York shows a link between untreated delirium and the death rate of critically ill children in hospital. In turn, pediatrician Jochen Meyburg, who has been observing cases of delirium at the University of Heidelberg clinic for years, did not notice any significant neurological changes in any of his young patients one year after the onset of the attack.
There is no pill for delirium. One can only try to either avoid it or control it by reducing the dose of anesthesia, getting less sleepy sleep, administering fewer sedatives, possibly by administering certain psychotropic medications, and by using rapid diagnosis tests such as CAPD. Thanks to this test, by asking eight questions, we can determine in a few minutes whether the infant or child is delirious. Is the baby nervous and rummaging about everything? Or maybe lethargic and withdrawn? Meyburg diagnoses delirium in three-quarters of infants in the pediatric ICU. The threat decreases with age but never completely disappears. “If a child has been sedated for two weeks, there is a very high risk of delirium on awakening,” says the pediatrician. And often nobody is prepared for them – neither the hospital staff nor the family.
Thanks to modern medicine, more and more people are experiencing accidents and illnesses, thanks to which in the past they would not only stand on the verge of death, but also exceed it. In this way, a person comes out of a state that he cannot cope with. Some doctors and nurses avoid warning patients of potential delirium – for fear of overwhelming relatives, and because even in the best-equipped hospitals, with their pressure to cut costs, they often lack the time and willingness to adequately treat traumatized people.
“Everything that gives the child a constant point of reference helps,” says Meyburg. That is, things that parents and medical staff often do instinctively: sticking to the set rhythm of the day and night, creating a homely environment thanks to cuddly toys, photos or a blanket with a familiar scent, calming music, warm light, staying with the child, reading to him, singing to him. , stroking, cheering him up, calming him down. You are not alone. It’s not a spaceship or a prison, it’s a hospital, with people who have time to pay attention to you.
Dr. Meyburg advises parents, patients, and relatives to raise the topic of delirium before treatment — with the doctor, with the patient and their family, to alleviate fear. Parents are helped by having a CAPD test taken three times a day, so they can see delirium retreats, and if they are at least informed that research is ongoing.
My child and my father were lucky. They feel good. The son doesn’t remember anything. Only trees outside the hospital window, green as in the grandparents’ garden he was driving to when he looked death in the eye.