Nasal congestion is a health issue that affects approximately 70% of the general
population, with nasal septal deviations being the most common cause . Various nasal
septal surgeries, such as septoplasty or rhinoplasty, are performed to address aesthetic
concerns related to curvature and correct deviations. The most common issue encountered
during these operations is bleeding, which hinders the visibility of the surgical field.
To prevent bleeding in the surgical area, the Trendelenburg position and controlled
hypotension practices are frequently preferred . Controlled hypotension is defined as the
intentional, elective, and controlled reduction of systolic blood pressure to 80-90 mmHg,
the reduction of mean arterial pressure (MAP) to 50-65 mmHg, or a 30-50% reduction in
baseline MAP.
Controlled hypotension is employed to shorten the duration of surgical procedures, reduce
bleeding, decrease the need for blood transfusion, and enhance the quality of surgery by
providing a satisfactory and clear surgical field without causing organ dysfunction.
Cognitive function is a mental process encompassing an individual's learning,
understanding of oneself and the world, and acquired knowledge and beliefs about the
surroundings. It covers higher brain functions such as consciousness, attention,
learning, memory, perception, orientation, intelligence, action, emotion, imagination,
problem-solving, decision-making, speech, reading, writing, and calculation. Cognitive
function disorders are classified into delirium, dementia, amnestic disorder, cognitive
disorder not otherwise specified, and postoperative cognitive dysfunction (POCD). POCD is
a cognitive impairment that most commonly manifests with memory and concentration
disturbances, diagnosable through neuropsychiatric tests. It is objectively measured
cognitive decline beyond the expected duration for normal recovery from the physiological
and pharmacological effects of anesthesia and surgery. POCD can persist from one day to
years after surgery, increasing hospital stay and costs, affecting patients of all age
groups, but more prevalent in older individuals. Early risk factors for POCD include
anesthesia duration, low educational level, multiple surgical histories, postoperative
infection, and respiratory complications. Late POCD, on the other hand, is only
correlated with age among the identified risk factors. Bispectral index (BIS) and
near-infrared spectroscopy (NIRS) monitoring are utilized in the perioperative process to
prevent POCD . Studies have shown that lower BIS values in patients are associated with
less development of postoperative cognitive dysfunction . The results suggest that deep
anesthesia may have a protective effect by reducing cerebral metabolism and blood flow.
Cerebral oxygenation monitoring has also demonstrated potential usefulness in preventing
the development of postoperative cognitive dysfunction. Methods used for detecting
postoperative cognitive dysfunction include direct interviews, questionnaires, mental
status assessment tests, and neuropsychological tests . The most commonly used test among
these is the Mini-Mental State Examination (MMSE). The MMSE, developed by Folstein and
colleagues in 1975, evaluates cognitive functions and covers questions related to time
and place orientation, memory and recall, attention and calculation, orientation,
language, and visual structuring. A modified Mini-Mental test is used for those with no
education. Both tests have a maximum score of 30, with 0-9 indicating severe cognitive
impairment, 10-19 moderate cognitive impairment, 20-26 mild cognitive impairment, and
27-30 normal cognitive function.
Delirium is characterized by the acute onset, fluctuating course, and features such as
disruption of cognitive functions due to organic causes, changes in the sleep-wake cycle,
and decreased attention and perception . It is more common in intensive care units and
the postoperative period, with advanced age being a risk factor for delirium due to the
use of multiple medications and physical limitations. Various systemic illnesses and
conditions related to the central nervous system can lead to delirium.
"Delirium, as it exhibits fluctuation throughout the day, is not always easily
recognizable, and since only a medical professional can apply DSM criteria, the diagnosis
may be overlooked. Screening and diagnostic tools have been developed to be easily and
quickly applied using DSM criteria, allowing not only physicians but also nurses and
healthcare personnel to use them.
Several assessment tools have been developed to easily and quickly detect and evaluate
delirium. The Confusion Assessment Method (CAM) is a screening tool consisting of four
features: (a) acute onset and fluctuating mental status, (b) inattention, (c)
disorganized thinking, and (d) altered levels of consciousness.
Delirium can be diagnosed, especially using features (a) and (b), although (c) or (d) can
be selectively used. For the intensive care unit, the CAM for the intensive care unit is
a two-minute version of the CAM that can be easily applied in the intensive care unit
with an accuracy of over 93%. Qualified personnel with appropriate training can apply CAM
with high sensitivity.
The Richmond Agitation-Sedation Scale (RASS) is a tool used to assess the level of
sedation/agitation. The DSM-5 guide states that a level of significantly decreased
arousal above the level of coma (acutely onset) should be considered delirium, making
RASS considered useful in diagnosing delirium.
The Delirium Rating Scale-Revised-98 (DRS-R-98) is useful in assessing the presence and
severity of delirium but takes more time to administer than CAM. DRS-R-98 includes a
relatively broader range of symptoms, comprising 3 diagnostic items and 13 severity items
(total score ranging from 0 to 46, with a higher score indicating more severe delirium).
It is suggested that a severity score of 15 or higher may indicate dementia or other
psychiatric disorders.
Preventing the development of delirium is a primary approach in treatment. Identifying
the causes of delirium and correcting the underlying organic disorder is the first
treatment option. Measures to prevent delirium include ensuring the patient remains
active, using auxiliary devices such as hearing aids and glasses when the patient is
awake, avoiding restraints, and regulating the sleep-wake cycle. Therefore, nursing care
is crucial. The secondary approach is treatment aimed at shortening the duration and
reducing the severity of delirium in patients who develop delirium . Delirium is a
condition where the sensitivity of the brain is increased. Medications that have
anticholinergic side effects and lower the confusion threshold should be avoided.
Delirium tremens, which occurs due to alcohol withdrawal, is treated with benzodiazepine
derivatives . Benzodiazepine derivatives should not be used in treatment except for
benzodiazepine deficiency and delirium tremens. If the patient with delirium is highly
agitated and restless, haloperidol can be used as a sedative due to its low
anticholinergic effect. Olanzapine, risperidone, and aripiprazole are second-generation
antipsychotics. The use of these drugs is safe in delirium.