Development of a Comprehensive Peri-anesthetic Bundle of Postoperative Delirium Interventions for Thoracic Patients: a Delphi Method Consensus Study

Development of a Comprehensive Peri-anesthetic Bundle of Postoperative Delirium Interventions for Thoracic Patients: a Delphi Method Consensus Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Development of a Comprehensive Peri-anesthetic Bundle of Postoperative Delirium Interventions for Thoracic Patients: a Delphi Method Consensus Study Rui Wang, Min Xu, Yali Wu, Jiarui Chen, Jing Yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8338925/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Postoperative delirium (POD) is a preventable complication that can prolong hospitalization and increase healthcare costs. Objective This study aimed to establish a streamlined, comprehensive peri-anesthetic bundle of interventions to prevent postoperative delirium in thoracic patients. Methods We assembled a multidisciplinary team of experts and conducted a Delphi method to develop bundle strategies. Our group initially formed the intervention questionnaire through a literature review. Plan to perform 2–3 rounds of expert consultations to finalize the prevention strategy. Results A panel consisting of twelve experts was convened. After two rounds of consultations, we developed an initial version of the peri-anesthetic bundle. The main contents comprise four programs: perioperative neurocognitive function assessment and cognitive function exercises, perioperative pain management with multimodal analgesia, intraoperative anesthesia management, and Anesthesia recovery period management. Conclusion We have established a bundle anesthesia program for thoracic patients using the Delphi method. Clinical trials have been conducted to confirm the scheme's effectiveness and to offer a new approach to preventing postoperative delirium. Bundle Interventions Delphi Technique Peri-anesthetic Postoperative Delirium Figures Figure 1 Figure 2 Introduction Postoperative delirium (POD) is a common and adverse postoperative complication, especially in the elderly and patients after major surgery. The incidence of this complication ranges from 4% to 53.3% [ 1 ] . Meanwhile, POD delays patient recovery, extends hospitalization, and increases medical costs [ 2 , 3 ] . The development of POD is associated with several factors, including both predisposing and precipitating elements. We can identify high-risk groups and plan subsequent management by evaluating predisposing factors, such as age, dementia, and other chronic diseases [ 1 ] . The precipitating factors are also the target points for interventions, offering greater opportunities to prevent POD occurrence and severity. Aiming at the improvability factors, nonpharmacological measures, such as the Hospital Elder Life Program (HELP) intervention, have achieved remarkable results [ 4 ] . Recently, there has been considerable attention on interventions in anesthesiology. The utilization of drugs, such as dexmedetomidine [ 5 ] and Methylprednisolone [ 6 ] , or anesthesia techniques, such as maintaining an appropriate depth of anesthesia [ 7 ] and paravertebral nerve block [ 8 ] , positively promotes the prevention of POD. However, there is insufficient evidence to support the inclusion of these approaches in clinical guidelines. Despite this, the potential benefits of these approaches warrant further investigation, and implementing a comprehensive, clustered anesthesia management may effectively reduce the risk of POD and prevent its occurrence. Regrettably, there has been no reported bundle program. The Delphi method's primary advantage is its ability to reach consensus in areas lacking clarity or evidence through continuous questionnaires or expert consultations, with constant feedback, thereby achieving consistent and reliable opinions [ 9 ] . Research indicates that patients undergoing thoracic surgery are at high risk of developing POD [ 10 , 11 ] . In light of this, the study aims to utilize the Delphi method to establish a multidisciplinary specialist team comprising anesthesiology, thoracic surgery, and geriatrics, thereby developing a comprehensive, multidisciplinary, and clustered POD intervention strategy. Methods Delphi is a democratic, structured method that utilizes anonymity, typically reaching a final consensus after 2–3 rounds [ 9 ] . The first round usually yields an open response that serves as the basis for constructing a second or subsequent round, and the second or subsequent round quantifies the early findings through rating or ranking fields [ 9 ] . The researchers integrated the expert opinions from each round and provided feedback to each specialist. Based on the preliminary research conducted by our group and the analysis of existing literature, the strategy should be achieved following two to three iterative rounds. Collaborator selection The selection criteria for the consulting experts included the following: (1) an MD degree; (2) a Senior professional title; (3) ≥ 15 years of working experience at large tertiary teaching hospitals; (4) a rich experience in the field of delirium; (5) a willingness to participate in several rounds of expert consultation. According to the above principles, we invite experts in anesthesiology, geriatrics, and thoracic surgery before January. 1, 2020. After outlining the study's purpose, procedures, ethical approval, and timelines to experts and receiving their agreement, we formed the Delphi expert panel. Scope Based on guideline recommendations, a multidisciplinary intervention strategy is an emerging trend comprising two significant components: (1) evaluation, diagnosis, and treatment of POD; and (2) an interdisciplinary approach to prevention, encompassing nursing, anesthesiology, and surgery. Delphi method expert consultation A permanent researcher reached out to the experts, distributed the questionnaires, and then retracted them, repeating this process until a consensus was achieved. We planned to screen protocols after the first round; if not, the screening would be repeated. If well-off, we will separate the strategies from universal and targeted protocols after the subsequent round. First round (dup: abstract ?) The questionnaire will be sent to every panelist, giving each item a necessity index. The statistics calculated the overall mean and the mean for each item. If the item's mean exceeds the average of all items, it proceeds to the second round. Any controversial protocols will only proceed to the next round if deemed indispensable. Should the need arise, the items under consideration will be assessed to ascertain whether their removal is warranted. Second round The second round of expert questionnaires will be sent out for evaluation of each item's significance. Statistics on the items' scores will be computed, yielding the mean. The objects whose mean scores exceed the overall average are considered universal interventions. In contrast, those that do not exceed are defined as targeted interventions. The final bundle intervention is accomplished. Statistical analysis There is no broad agreement as to what cutoff points determine consensus. Following extensive deliberation within our research collective, we agreed to establish the average as the standard. That signifies the item’s score would be chosen to retain or remove. Another researcher is responsible for the statistics, and the questionnaire team leader will verify the data. Results The panel comprises 12 experts from five teaching hospitals. Two rounds of expert consultations were conducted (Fig. 1 ). In the first round, the questionnaire was sent to eight experts via email, and six questionnaires were collected. The two experts did not respond in the initial round, so they were not included in the subsequent round. Following group deliberation, four additional experts were incorporated in the second round based on the results of the initial round. In the second round, ten experts similarly received the questionnaires and returned them to the research group. First round The questionnaire comprised nine significant sections after literature search analysis and group discussion, including"1. Perioperative neurocognitive function assessment and cognitive function exercise;2. Perioperative pain management with multi-modal analgesia;3. Intraoperative anesthesia management;4. Perioperative Sleep- Mood management;5. Nutritional status assessment and support;6. Anesthesia recovery period management;7. Intensive care unit interventions;8. Ward interventions;9. Interventions for enhanced recovery after surgery. " The sections mentioned above are considered the primary items, subdivided into 2 to 5 secondary items, resulting in 32 items. Among the secondary items, 47 are divided into third-level items. Furthermore, a few third-level items are classified into fourth-level items, comprising 15. This questionnaire, available in Addition Questionnaire 1, was sent to eight experts in February 2020, and 6 questionnaires were collected in June 2020. In the first round of expert opinions, the average index of all items was 3.24. After eliminating items with an average lower than 3.24, 9 primary items were retained, while 30 secondary, 32 third-level, and seven fourth-level items were kept. Additional Table 1 presents primary, secondary, and tertiary items, along with the results from the first round. Specific experts expressed reservations regarding the transfusion strategy. Consequently, the approach was revisited in the second round. Second round Following the initial expert consultations and group discussions, the second round will focus on anesthesia-related prevention. The primary item, "perioperative cognitive function assessment," remains due to its indispensability. Based on feasibility and clinical implementation, in the second round, there are four primary items: "perioperative cognitive function assessment,” "perioperative pain assessment,” "intraoperative anesthesia management,” and "anesthesia recovery period,” to be graded (0-100 points). To screen out general strategies (applicable to each patient) and targeted strategies (adjusted for the type of surgery, comorbid disease, and risk factors). The second-round questionnaire, available in Addition Questionnaire 2, was distributed to 10 experts in July 2020. In August 2020, 10 questionnaires were collected, and the importance scores for each item and the average of all items were calculated. The objects whose mean score exceeded the item mean (74.55) were defined as universal interventions. In contrast, those not exceeding the average weight score were described as targeted interventions. The final version of the " comprehensive peri-anesthetic bundle of postoperative delirium interventions " was generated. The final result is presented in Additional Table 2. This round revealed that six experts favored the strict transfusion indication, with an average of 44.44. Following two rounds of expert consultation, the final peri-anesthetic bundle of postoperative delirium interventions was established and is shown in Fig. 2 . Discussion Preventing postoperative delirium is a multidisciplinary challenge. Postoperative non-pharmacological interventions, such as the HELP program, have demonstrated significant effectiveness and are included in guideline recommendations [ 12 ] . This suggests that multifaceted intervention programs are a viable approach for substantially reducing the risk of POD. Therefore, a bundle program comprising anaesthetic protocols may be a practical starting point when the impact of a single intervention is considered inadequate. After two rounds of multidisciplinary expert consultations using the Delphi method, we have developed anesthesia bundle strategies that include assessing cognitive function and implementing various preventions throughout the peri-anesthetic period. This bundle has been evaluated and confirmed as feasible and compliant within the parameters of a randomized controlled trial [ 13 ] . The scale should be selected for assessing cognitive function based on its clinical applicability. After the first round, expert opinions on the cognitive function assessment scale were scattered and inconsistent. Based on the latest guideline recommendations, the advantages of each scale, and the applicability of clinical studies, this strategy considers the Mini-Cognitive Assessment and the Montreal Cognitive Assessment for assessing cognitive function after several group discussions. For the evaluation of POD, the 3-minute diagnostic confusion assessment method scale was used, and the CAM-ICU scale was used to assess postoperative delirium during anesthesia resuscitation [ 14 , 15 ] . A clustered postoperative delirium prevention program should include anesthetic techniques with potential benefits, such as anesthesia monitoring and guided administration, blood pressure management, and a lung-protective ventilation strategy. Adjusting anesthesia drugs to maintain appropriate depth of anesthesia typically reduces drug dosages, and avoiding deep anesthesia can reduce burst suppression, which increases the risk of POD [ 14 , 16 ] . Active blood pressure control [ 17 ] and lung-protective ventilation strategy [ 18 ] are essential components that cannot be ignored [ 15 ] . There are numerous studies on the use of drugs during the perioperative period to prevent POD. Among these, only dexmedetomidine is recommended during or after surgery after assessing the benefits and risks [ 14 ] . Pain management is a key focus for preventing POD, particularly regional anesthesia. Regional anesthesia techniques can significantly reduce the risk of POD when used for pain management [ 8 , 19 , 20 ] . A thorough regional block technique like thoracic paravertebral block can provide a significant effect on pain control and minimize intraoperative stress response and opioid consumption [ 8 , 21 ] . Thus, regional anesthesia is a vital component of multimodal analgesia and should be integrated into comprehensive intervention strategies, as this research indicates. Maintain hemoglobin levels above 100 g/L in critically ill elderly patients at high risk of POD [ 22 ] . There is no clear guideline regarding when to perform blood transfusions. There is no clear guideline regarding when to perform blood transfusions. Research indicates that administering a blood transfusion post-surgery may elevate the likelihood of POD by 2.5 times [ 23 ] . A study involving 130 patients showed that both allogeneic transfusion and autologous blood were independent risk factors for POD in patients undergoing complex spinal surgery [ 24 ] . In this research, more than half of the experts preferred strict transfusion criteria and adhered to a stringent transfusion strategy after group discussion guided by the literature. High-quality evidence is still needed to clarify the relationship between blood transfusion and POD. In conclusion, the Delphi method led to the development of a comprehensive cluster anesthesia program that encompasses rational drug use, multimodal pain management, and meticulous anesthesia administration. This bundle program offers tailored approaches to prevent POD, thereby reducing potential risks and serving as a benchmark for comprehensive, interdisciplinary treatment plans that, in turn, accelerate patient recovery. Limitations Despite aggressive efforts to advance this study, the drawbacks of the Delphi method are difficult to avoid, such as low response rates and extended time consumption [ 9 ] . In the initial phase of the study, eight questionnaires were distributed, and six were returned within four months. Although the recovery rate was not optimal at 75%, the results from the first round remained informative. To ensure a comprehensive evaluation of all the interventions, the study team promptly made adjustments after the first round and incorporated additional panel members. This strategic shift was informed by the outcomes of the second round, which achieved a 100% response rate and was completed within a one-month timeframe. Abbreviations POD Postoperative delirium HELP the Hospital Elder Life Program CAM-ICU the Intensive Care Unit Declarations Ethics approval and consent to participate This study is part of the project " Establishment and Validation of a Comprehensive Peri-anesthetic Bundle of Postoperative Delirium Interventions for Thoracic Patients. " Ethical approval was requested and granted by the Biomedical Ethics Committee of West China Hospital, Sichuan University (approval 2019/920). Following thorough communication with prospective experts regarding the study's objectives, methodology, and ethical approval, and upon securing their consent, a Delphi expert panel for this research was established. Consent for publication: Not applicable Funding: This study was supported by the Natural Science Foundation of Sichuan (2024NSFSC0559) and the Sichuan Science and Technology Program (2023ZYD0168). Author Contribution YJ designed and supervised the entire study, as well as revised the manuscript. WR developed the questionnaire, contacted experts, and drafted the manuscript. XM verified the data and drafted the manuscript. WYL and CJR collaborated on conducting the literature searches, organizing, and analyzing the data. Acknowledgement We would like to express our sincere gratitude to the group of 12 experts from the following institutions: West China Hospital of Sichuan University, Sichuan Academy of Medical Sciences-Sichuan Provincial People’s Hospital, Sichuan Cancer Hospital, the First Affiliated Hospital of Guangzhou Medical University, and the Affiliated Hospital of Zunyi Medical University. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A, et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium [J]. Eur J Anaesthesiol. 2017;34(4):192–214. Hughes CG, Boncyk CS, Culley DJ, Fleisher LA, Leung JM, Mcdonagh DL, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention [J]. Anesth Analg. 2020;130(6):1572–90. Meyer M, Gotz J, Parik L, Renkawitz T, Grifka J, Maderbacher G, et al. Postoperative delirium is a risk factor for complications and poor outcome after total hip and knee arthroplasty [J]. Acta Orthop. 2021;92(6):695–700. Inouye Sk BSJ, Pa C, Leo-Summers L, Acampora D. Holford Tr, Cooney Lm Jr. A multicomponent intervention to prevent delirium in hospitalized older patients [J]. N Engl J Med. 1999;340:669–76. Shin HJ, Woo Nam S, Kim H, Yim S, Han SH, Hwang JW, et al. Postoperative Delirium after Dexmedetomidine versus Propofol Sedation in Healthy Older Adults Undergoing Orthopedic Lower Limb Surgery with Spinal Anesthesia: A Randomized Controlled Trial [J]. Anesthesiology. 2023;138(2):164–71. Xiang XB, Chen H, Wu YL, Wang K, Yue X, Cheng XQ. The Effect of Preoperative Methylprednisolone on Postoperative Delirium in Older Patients Undergoing Gastrointestinal Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial [J]. J Gerontol Biol Sci Med Sci. 2022;77(3):517–23. Evered LA, Chan MTV, Han R, Chu MHM, Cheng BP, Scott DA, et al. Anaesthetic depth and delirium after major surgery: a randomised clinical trial [J]. Br J Anaesth. 2021;127(5):704–12. Wei W, Zheng X, Gu Y, Fu W, Tang C, Yao Y. Effect of general anesthesia with thoracic paravertebral block on postoperative delirium in elderly patients undergoing thoracoscopic lobectomy: a randomized-controlled trial [J]. BMC Anesthesiol. 2022;22(1):1. Hsu C-C, a S, Brian A. The Delphi Technique: Making Sense of Consensus [J]. Practical Assessment, Research, and Evaluation, 2007, 12: Article 10. Takeuchi M, Takeuchi H, Fujisawa D, Miyajima K, Yoshimura K, Hashiguchi S, et al. Incidence and risk factors of postoperative delirium in patients with esophageal cancer [J]. Ann Surg Oncol. 2012;19(12):3963–70. Dezube AR, Bravo-Iniguez CE, Yelamanchili N, De Leon LE, Tarascio J, Jaklitsch MT, et al. Risk factors for delirium after esophagectomy [J]. J Surg Oncol. 2020;121(4):645–53. Wang YY, Yue JR, Xie DM, Carter P, Li QL, Gartaganis SL, et al. Effect of the Tailored, Family-Involved Hospital Elder Life Program on Postoperative Delirium and Function in Older Adults: A Randomized Clinical Trial [J]. JAMA Intern Med. 2020;180(1):17–25. Xu M, Wu Y, Wang R, Luo C, Chen J, Yang J. The Efficacy of a Multidisciplinary Perianesthetic Management Bundle for Alleviating Delirium After Thoracic Surgery: A Randomized Clinical Trial [J]. J Cardiothorac Vasc Anesth; 2025. Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Aceto P, Audisio R, et al. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients [J]. Eur J Anaesthesiol. 2024;41(2):81–108. Branch CG, S A. Expert consensus on prevention and treatment of postoperative delirium in elderly patients in China [J]. International Journal of Anesthesiology and Resuscitation, 2023, 44: No.1. Wildes TS, Mickle AM, Ben Abdallah A, Maybrier HR, Oberhaus J, Budelier TP, et al. Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial [J]. JAMA. 2019;321(5):473–83. Xu X, Hu X, Wu Y, Li Y, Zhang Y, Zhang M, et al. Effects of different BP management strategies on postoperative delirium in elderly patients undergoing hip replacement: A single center randomized controlled trial [J]. J Clin Anesth. 2020;62:109730. Wang J, Zhu L, Li Y, Yin C, Hou Z, Wang Q. The Potential Role of Lung-Protective Ventilation in Preventing Postoperative Delirium in Elderly Patients Undergoing Prone Spinal Surgery: A Preliminary Study [J]. Med Sci Monit. 2020;26:e926526. Lim EJ, Koh WU, Kim H, Kim HJ, Shon HC, Kim JW. Regional Nerve Block Decreases the Incidence of Postoperative Delirium in Elderly Hip Fracture [J]. J Clin Med, 2021, 10(16). Li YW, Li HJ, Li HJ, Zhao BJ, Guo XY, Feng Y, et al. Delirium in Older Patients after Combined Epidural-General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial [J]. Anesthesiology. 2021;135(2):218–32. Li T, Li J, Yuan L, Wu J, Jiang C, Daniels J, et al. Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial [J]. JAMA. 2022;327(1):50–8. Geriatric Anesthesiology Group C S O A. Multidisciplinary expert consensus on perioperative brain health in elderly patients in China [J]. Chin Med J. 2019;99(29):2252–69. Lee SS, Kim JH, Lee JJ, Kwon YS, Seo EM. The Impact of Blood Transfusion in Developing Postoperative Delirium in Patients with Hip Fracture Surgery [J]. J Clin Med, 2023, 12(14). Elsamadicy AA, Adil SM, Charalambous L, Drysdale N, Koo AB, Lee M, et al. Independent Association Between Type of Intraoperative Blood Transfusion and Postoperative Delirium After Complex Spinal Fusion for Adult Deformity Correction [J]. Spine (Phila Pa 1976). 2020;45(4):268–74. Additional Declarations No competing interests reported. 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Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePostoperative delirium (POD) is a common and adverse postoperative complication, especially in the elderly and patients after major surgery. The incidence of this complication ranges from 4% to 53.3% \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Meanwhile, POD delays patient recovery, extends hospitalization, and increases medical costs \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe development of POD is associated with several factors, including both predisposing and precipitating elements. We can identify high-risk groups and plan subsequent management by evaluating predisposing factors, such as age, dementia, and other chronic diseases\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The precipitating factors are also the target points for interventions, offering greater opportunities to prevent POD occurrence and severity. Aiming at the improvability factors, nonpharmacological measures, such as the Hospital Elder Life Program (HELP) intervention, have achieved remarkable results\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRecently, there has been considerable attention on interventions in anesthesiology. The utilization of drugs, such as dexmedetomidine\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e and Methylprednisolone\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, or anesthesia techniques, such as maintaining an appropriate depth of anesthesia\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e and paravertebral nerve block\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e, positively promotes the prevention of POD. However, there is insufficient evidence to support the inclusion of these approaches in clinical guidelines. Despite this, the potential benefits of these approaches warrant further investigation, and implementing a comprehensive, clustered anesthesia management may effectively reduce the risk of POD and prevent its occurrence. Regrettably, there has been no reported bundle program.\u003c/p\u003e \u003cp\u003eThe Delphi method's primary advantage is its ability to reach consensus in areas lacking clarity or evidence through continuous questionnaires or expert consultations, with constant feedback, thereby achieving consistent and reliable opinions\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Research indicates that patients undergoing thoracic surgery are at high risk of developing POD\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. In light of this, the study aims to utilize the Delphi method to establish a multidisciplinary specialist team comprising anesthesiology, thoracic surgery, and geriatrics, thereby developing a comprehensive, multidisciplinary, and clustered POD intervention strategy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eDelphi is a democratic, structured method that utilizes anonymity, typically reaching a final consensus after 2\u0026ndash;3 rounds\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. The first round usually yields an open response that serves as the basis for constructing a second or subsequent round, and the second or subsequent round quantifies the early findings through rating or ranking fields\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. The researchers integrated the expert opinions from each round and provided feedback to each specialist. Based on the preliminary research conducted by our group and the analysis of existing literature, the strategy should be achieved following two to three iterative rounds.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCollaborator selection\u003c/h2\u003e \u003cp\u003eThe selection criteria for the consulting experts included the following: (1) an MD degree; (2) a Senior professional title; (3)\u0026thinsp;\u0026ge;\u0026thinsp;15 years of working experience at large tertiary teaching hospitals; (4) a rich experience in the field of delirium; (5) a willingness to participate in several rounds of expert consultation.\u003c/p\u003e \u003cp\u003eAccording to the above principles, we invite experts in anesthesiology, geriatrics, and thoracic surgery before January. 1, 2020. After outlining the study's purpose, procedures, ethical approval, and timelines to experts and receiving their agreement, we formed the Delphi expert panel.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eScope\u003c/h3\u003e\n\u003cp\u003e Based on guideline recommendations, a multidisciplinary intervention strategy is an emerging trend comprising two significant components: (1) evaluation, diagnosis, and treatment of POD; and (2) an interdisciplinary approach to prevention, encompassing nursing, anesthesiology, and surgery.\u003c/p\u003e\n\u003ch3\u003eDelphi method expert consultation\u003c/h3\u003e\n\u003cp\u003eA permanent researcher reached out to the experts, distributed the questionnaires, and then retracted them, repeating this process until a consensus was achieved. We planned to screen protocols after the first round; if not, the screening would be repeated. If well-off, we will separate the strategies from universal and targeted protocols after the subsequent round.\u003c/p\u003e\n\u003ch3\u003eFirst round (dup: abstract ?)\u003c/h3\u003e\n\u003cp\u003eThe questionnaire will be sent to every panelist, giving each item a necessity index. The statistics calculated the overall mean and the mean for each item. If the item's mean exceeds the average of all items, it proceeds to the second round.\u003c/p\u003e \u003cp\u003eAny controversial protocols will only proceed to the next round if deemed indispensable. Should the need arise, the items under consideration will be assessed to ascertain whether their removal is warranted.\u003c/p\u003e\n\u003ch3\u003eSecond round\u003c/h3\u003e\n\u003cp\u003eThe second round of expert questionnaires will be sent out for evaluation of each item's significance. Statistics on the items' scores will be computed, yielding the mean. The objects whose mean scores exceed the overall average are considered universal interventions. In contrast, those that do not exceed are defined as targeted interventions. The final bundle intervention is accomplished.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThere is no broad agreement as to what cutoff points determine consensus. Following extensive deliberation within our research collective, we agreed to establish the average as the standard. That signifies the item\u0026rsquo;s score would be chosen to retain or remove. Another researcher is responsible for the statistics, and the questionnaire team leader will verify the data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe panel comprises 12 experts from five teaching hospitals.\u003c/p\u003e \u003cp\u003eTwo rounds of expert consultations were conducted (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the first round, the questionnaire was sent to eight experts via email, and six questionnaires were collected. The two experts did not respond in the initial round, so they were not included in the subsequent round. Following group deliberation, four additional experts were incorporated in the second round based on the results of the initial round. In the second round, ten experts similarly received the questionnaires and returned them to the research group.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eFirst round\u003c/h3\u003e\n\u003cp\u003eThe questionnaire comprised nine significant sections after literature search analysis and group discussion, including\"1. Perioperative neurocognitive function assessment and cognitive function exercise;2. Perioperative pain management with multi-modal analgesia;3. Intraoperative anesthesia management;4. Perioperative Sleep- Mood management;5. Nutritional status assessment and support;6. Anesthesia recovery period management;7. Intensive care unit interventions;8. Ward interventions;9. Interventions for enhanced recovery after surgery. \" The sections mentioned above are considered the primary items, subdivided into 2 to 5 secondary items, resulting in 32 items. Among the secondary items, 47 are divided into third-level items. Furthermore, a few third-level items are classified into fourth-level items, comprising 15.\u003c/p\u003e \u003cp\u003eThis questionnaire, available in Addition Questionnaire 1, was sent to eight experts in February 2020, and 6 questionnaires were collected in June 2020. In the first round of expert opinions, the average index of all items was 3.24. After eliminating items with an average lower than 3.24, 9 primary items were retained, while 30 secondary, 32 third-level, and seven fourth-level items were kept. Additional Table\u0026nbsp;1 presents primary, secondary, and tertiary items, along with the results from the first round.\u003c/p\u003e \u003cp\u003eSpecific experts expressed reservations regarding the transfusion strategy. Consequently, the approach was revisited in the second round.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSecond round\u003c/h2\u003e \u003cp\u003eFollowing the initial expert consultations and group discussions, the second round will focus on anesthesia-related prevention. The primary item, \"perioperative cognitive function assessment,\" remains due to its indispensability.\u003c/p\u003e \u003cp\u003eBased on feasibility and clinical implementation, in the second round, there are four primary items: \"perioperative cognitive function assessment,\u0026rdquo; \"perioperative pain assessment,\u0026rdquo; \"intraoperative anesthesia management,\u0026rdquo; and \"anesthesia recovery period,\u0026rdquo; to be graded (0-100 points). To screen out general strategies (applicable to each patient) and targeted strategies (adjusted for the type of surgery, comorbid disease, and risk factors).\u003c/p\u003e \u003cp\u003eThe second-round questionnaire, available in Addition Questionnaire 2, was distributed to 10 experts in July 2020. In August 2020, 10 questionnaires were collected, and the importance scores for each item and the average of all items were calculated. The objects whose mean score exceeded the item mean (74.55) were defined as universal interventions. In contrast, those not exceeding the average weight score were described as targeted interventions. The final version of the \" comprehensive peri-anesthetic bundle of postoperative delirium interventions \" was generated. The final result is presented in Additional Table\u0026nbsp;2.\u003c/p\u003e \u003cp\u003eThis round revealed that six experts favored the strict transfusion indication, with an average of 44.44.\u003c/p\u003e \u003cp\u003eFollowing two rounds of expert consultation, the final peri-anesthetic bundle of postoperative delirium interventions was established and is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePreventing postoperative delirium is a multidisciplinary challenge. Postoperative non-pharmacological interventions, such as the HELP program, have demonstrated significant effectiveness and are included in guideline recommendations\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. This suggests that multifaceted intervention programs are a viable approach for substantially reducing the risk of POD. Therefore, a bundle program comprising anaesthetic protocols may be a practical starting point when the impact of a single intervention is considered inadequate. After two rounds of multidisciplinary expert consultations using the Delphi method, we have developed anesthesia bundle strategies that include assessing cognitive function and implementing various preventions throughout the peri-anesthetic period. This bundle has been evaluated and confirmed as feasible and compliant within the parameters of a randomized controlled trial\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe scale should be selected for assessing cognitive function based on its clinical applicability. After the first round, expert opinions on the cognitive function assessment scale were scattered and inconsistent. Based on the latest guideline recommendations, the advantages of each scale, and the applicability of clinical studies, this strategy considers the Mini-Cognitive Assessment and the Montreal Cognitive Assessment for assessing cognitive function after several group discussions. For the evaluation of POD, the 3-minute diagnostic confusion assessment method scale was used, and the CAM-ICU scale was used to assess postoperative delirium during anesthesia resuscitation\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA clustered postoperative delirium prevention program should include anesthetic techniques with potential benefits, such as anesthesia monitoring and guided administration, blood pressure management, and a lung-protective ventilation strategy. Adjusting anesthesia drugs to maintain appropriate depth of anesthesia typically reduces drug dosages, and avoiding deep anesthesia can reduce burst suppression, which increases the risk of POD\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Active blood pressure control\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e and lung-protective ventilation strategy\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e are essential components that cannot be ignored\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. There are numerous studies on the use of drugs during the perioperative period to prevent POD. Among these, only dexmedetomidine is recommended during or after surgery after assessing the benefits and risks\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePain management is a key focus for preventing POD, particularly regional anesthesia. Regional anesthesia techniques can significantly reduce the risk of POD when used for pain management\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. A thorough regional block technique like thoracic paravertebral block can provide a significant effect on pain control and minimize intraoperative stress response and opioid consumption\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Thus, regional anesthesia is a vital component of multimodal analgesia and should be integrated into comprehensive intervention strategies, as this research indicates.\u003c/p\u003e \u003cp\u003eMaintain hemoglobin levels above 100 g/L in critically ill elderly patients at high risk of POD\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. There is no clear guideline regarding when to perform blood transfusions. There is no clear guideline regarding when to perform blood transfusions. Research indicates that administering a blood transfusion post-surgery may elevate the likelihood of POD by 2.5 times \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. A study involving 130 patients showed that both allogeneic transfusion and autologous blood were independent risk factors for POD in patients undergoing complex spinal surgery \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. In this research, more than half of the experts preferred strict transfusion criteria and adhered to a stringent transfusion strategy after group discussion guided by the literature. High-quality evidence is still needed to clarify the relationship between blood transfusion and POD.\u003c/p\u003e \u003cp\u003eIn conclusion, the Delphi method led to the development of a comprehensive cluster anesthesia program that encompasses rational drug use, multimodal pain management, and meticulous anesthesia administration. This bundle program offers tailored approaches to prevent POD, thereby reducing potential risks and serving as a benchmark for comprehensive, interdisciplinary treatment plans that, in turn, accelerate patient recovery.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eDespite aggressive efforts to advance this study, the drawbacks of the Delphi method are difficult to avoid, such as low response rates and extended time consumption \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. In the initial phase of the study, eight questionnaires were distributed, and six were returned within four months. Although the recovery rate was not optimal at 75%, the results from the first round remained informative. To ensure a comprehensive evaluation of all the interventions, the study team promptly made adjustments after the first round and incorporated additional panel members. This strategic shift was informed by the outcomes of the second round, which achieved a 100% response rate and was completed within a one-month timeframe.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostoperative delirium\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHELP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ethe Hospital Elder Life Program\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAM-ICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ethe Intensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThis study is part of the project \" Establishment and Validation of a Comprehensive Peri-anesthetic Bundle of Postoperative Delirium Interventions for Thoracic Patients. \" Ethical approval was requested and granted by the Biomedical Ethics Committee of West China Hospital, Sichuan University (approval 2019/920). Following thorough communication with prospective experts regarding the study's objectives, methodology, and ethical approval, and upon securing their consent, a Delphi expert panel for this research was established.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis study was supported by the Natural Science Foundation of Sichuan (2024NSFSC0559) and the Sichuan Science and Technology Program (2023ZYD0168).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYJ designed and supervised the entire study, as well as revised the manuscript. WR developed the questionnaire, contacted experts, and drafted the manuscript. XM verified the data and drafted the manuscript. WYL and CJR collaborated on conducting the literature searches, organizing, and analyzing the data.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to express our sincere gratitude to the group of 12 experts from the following institutions: West China Hospital of Sichuan University, Sichuan Academy of Medical Sciences-Sichuan Provincial People\u0026rsquo;s Hospital, Sichuan Cancer Hospital, the First Affiliated Hospital of Guangzhou Medical University, and the Affiliated Hospital of Zunyi Medical University.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A, et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium [J]. Eur J Anaesthesiol. 2017;34(4):192\u0026ndash;214.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHughes CG, Boncyk CS, Culley DJ, Fleisher LA, Leung JM, Mcdonagh DL, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention [J]. Anesth Analg. 2020;130(6):1572\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer M, Gotz J, Parik L, Renkawitz T, Grifka J, Maderbacher G, et al. Postoperative delirium is a risk factor for complications and poor outcome after total hip and knee arthroplasty [J]. Acta Orthop. 2021;92(6):695\u0026ndash;700.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInouye Sk BSJ, Pa C, Leo-Summers L, Acampora D. 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J Cardiothorac Vasc Anesth; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAldecoa C, Bettelli G, Bilotta F, Sanders RD, Aceto P, Audisio R, et al. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients [J]. Eur J Anaesthesiol. 2024;41(2):81\u0026ndash;108.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBranch CG, S A. Expert consensus on prevention and treatment of postoperative delirium in elderly patients in China [J]. International Journal of Anesthesiology and Resuscitation, 2023, 44: No.1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWildes TS, Mickle AM, Ben Abdallah A, Maybrier HR, Oberhaus J, Budelier TP, et al. Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial [J]. JAMA. 2019;321(5):473\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu X, Hu X, Wu Y, Li Y, Zhang Y, Zhang M, et al. Effects of different BP management strategies on postoperative delirium in elderly patients undergoing hip replacement: A single center randomized controlled trial [J]. J Clin Anesth. 2020;62:109730.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang J, Zhu L, Li Y, Yin C, Hou Z, Wang Q. The Potential Role of Lung-Protective Ventilation in Preventing Postoperative Delirium in Elderly Patients Undergoing Prone Spinal Surgery: A Preliminary Study [J]. Med Sci Monit. 2020;26:e926526.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim EJ, Koh WU, Kim H, Kim HJ, Shon HC, Kim JW. Regional Nerve Block Decreases the Incidence of Postoperative Delirium in Elderly Hip Fracture [J]. J Clin Med, 2021, 10(16).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi YW, Li HJ, Li HJ, Zhao BJ, Guo XY, Feng Y, et al. Delirium in Older Patients after Combined Epidural-General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial [J]. Anesthesiology. 2021;135(2):218\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi T, Li J, Yuan L, Wu J, Jiang C, Daniels J, et al. Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial [J]. JAMA. 2022;327(1):50\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeriatric Anesthesiology Group C S O A. Multidisciplinary expert consensus on perioperative brain health in elderly patients in China [J]. Chin Med J. 2019;99(29):2252\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee SS, Kim JH, Lee JJ, Kwon YS, Seo EM. The Impact of Blood Transfusion in Developing Postoperative Delirium in Patients with Hip Fracture Surgery [J]. J Clin Med, 2023, 12(14).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElsamadicy AA, Adil SM, Charalambous L, Drysdale N, Koo AB, Lee M, et al. Independent Association Between Type of Intraoperative Blood Transfusion and Postoperative Delirium After Complex Spinal Fusion for Adult Deformity Correction [J]. Spine (Phila Pa 1976). 2020;45(4):268\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bundle Interventions, Delphi Technique, Peri-anesthetic, Postoperative Delirium","lastPublishedDoi":"10.21203/rs.3.rs-8338925/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8338925/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePostoperative delirium (POD) is a preventable complication that can prolong hospitalization and increase healthcare costs.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to establish a streamlined, comprehensive peri-anesthetic bundle of interventions to prevent postoperative delirium in thoracic patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe assembled a multidisciplinary team of experts and conducted a Delphi method to develop bundle strategies. Our group initially formed the intervention questionnaire through a literature review. Plan to perform 2\u0026ndash;3 rounds of expert consultations to finalize the prevention strategy.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA panel consisting of twelve experts was convened. After two rounds of consultations, we developed an initial version of the peri-anesthetic bundle. The main contents comprise four programs: perioperative neurocognitive function assessment and cognitive function exercises, perioperative pain management with multimodal analgesia, intraoperative anesthesia management, and Anesthesia recovery period management.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe have established a bundle anesthesia program for thoracic patients using the Delphi method. Clinical trials have been conducted to confirm the scheme's effectiveness and to offer a new approach to preventing postoperative delirium.\u003c/p\u003e","manuscriptTitle":"Development of a Comprehensive Peri-anesthetic Bundle of Postoperative Delirium Interventions for Thoracic Patients: a Delphi Method Consensus Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 16:16:50","doi":"10.21203/rs.3.rs-8338925/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-07T08:05:20+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"296763420602959197716355527816409485155","date":"2026-03-23T04:56:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283665812985357013918048911743600795575","date":"2026-03-01T18:04:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-25T12:10:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59137858695596149096708492905023677331","date":"2026-02-20T08:23:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-19T08:16:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-19T08:05:18+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-05T12:26:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-05T01:45:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Research Notes","date":"2026-02-05T01:39:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8be3ec98-bde5-4dac-b9b5-26fbc397542c","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T06:54:07+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-24 16:16:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8338925","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8338925","identity":"rs-8338925","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}