Postoperative delirium in oral and maxillofacial surgery: a search for effective preventive interventions

Postoperative delirium (POD) represents a serious and debilitating complication in the postoperative period, especially in patients undergoing major procedures (1,2). Classified into hyperactive, hypoactive, and mixed subtypes, it is characterized by recurrent episodes of disorganized thinking, changes in levels of consciousness, inattention, and cognitive dysfunction. POD can lead to significant adverse outcomes, such as prolonged hospital stay, increased morbidity and mortality, and long-term cognitive deterioration. Diagnosis can be made based on behavioral changes that begin on the first to fourth day after long-term surgeries (3,4). In the field of oral and maxillofacial surgery, particularly in complex reconstructive surgeries associated with tumor removal and reconstruction, the incidence of POD is remarkably high (1,3,4), making the search for preventive strategies a clinical priority.

In this context, the retrospective study by Nitta et al., entitled “The impact of preoperative psychiatric intervention for postoperative delirium after major oral and maxillofacial surgery with free flap reconstruction”, addresses a question of immense relevance (4). The authors investigated whether preoperative psychiatric intervention could reduce the incidence of POD in a cohort of 86 patients. The main result, however, exposed the difficulty of the task: the psychiatric intervention did not demonstrate a significant protective effect, with the incidence of POD remaining at 29.1%, similarly distributed between the groups with and without intervention.

The strength of the study lies in its clinical relevance and in its attempt to evaluate a proactive intervention through preoperative psychiatric intervention and the identification of high-risk patients for POD. The authors should be commended for exploring an approach that goes beyond traditional risk factors. However, the negative result invites deeper reflection on the multifactorial nature of POD and the nuances of the proposed interventions. The main limitation, acknowledged by the authors themselves, is the lack of a standardized protocol for psychiatric intervention. The heterogeneity of treatment, dependent on the psychiatrist’s discretion, makes it difficult to assess the true effectiveness of the approach. Pharmacological interventions were applied to only a fraction of patients (15 of 50), and it is unclear what the weight of non-pharmacological guidance was, as there was no difference between the groups treated with or without prior medication.

It is plausible that the chosen medication or the administered “dose” were not sufficient to mitigate the cascade of pathophysiological events that culminate in POD, which involve surgical stress, systemic inflammation, neurotransmitter imbalance, and multiple other factors. Head and neck surgeries with free flap reconstruction pose unique challenges, such as prolonged surgical time, pain, the need for tracheostomy, and prolonged stay in the intensive care unit (ICU), all known risk factors for POD (5,6). A merely consultative intervention with optional and non-standardized medication may not be robust enough to demonstrate the real efficacy of this preventive treatment hypothesis.

Furthermore, criticism of the study by Nitta et al. can go beyond its acknowledged failure to standardize the intervention (4). The negative result raises a deeper conceptual question, already observed in other areas of intensive care: the very premise that a complex and multifactorial syndrome such as POD can be effectively mitigated by a single specialized consultation.

This expectation of a one-off intervention may be analogous to the concept of “fast food palliative care”, which questions whether quick, isolated, and reactive consultations can actually alter robust outcomes, such as post-traumatic stress disorder (PTSD) in family members of ICU patients (7) or the quality of life of cancer patients (8). Similarly, a “quick” psychiatric consultation, disconnected from a continuous perioperative protocol, will likely not have the robustness needed to impact the pathophysiological cascade of POD, which involves surgical stress, inflammation, and several other factors.

This reinforces our conclusion that the answer to POD does not lie in isolated interventions, but rather in sets of care applied systematically and in an integrated manner.

Furthermore, the study found no significant association between POD and risk factors classically described in the literature, such as advanced age, surgical duration, and use of sedatives such as dexmedetomidine (5,6,9). This finding may reflect the sample size or specificities of the study cohort. Although it may seem controversial, it reinforces the etiological complexity of POD and suggests that studies with robust methodologies should be conducted to determine the true validity of these factors.

The work by Nitta et al. should not be interpreted as evidence against psychiatric collaboration in perioperative care (4). On the contrary, it highlights the need to design and test more structured and standardized preventive interventions.

Future studies, ideally randomized multicenter clinical trials, should focus on formally testing the hypothesis that multifactorial and standardized intervention bundles can, in fact, significantly reduce perioperative delirium in high-risk patients.

To achieve this, it is necessary to go beyond isolated interventions and implement cohesive protocols. Such protocols should integrate a protocolized psychiatric intervention in high-risk patients (combining preoperative cognitive therapy and standardized prophylactic pharmacological management, with a clear definition of first-choice medications and dosage), associated with standardized postoperative multimodal analgesia aimed at minimizing opioid use. These approaches should be consolidated with consistently applied non-pharmacological measures, such as early mobilization (with physiotherapy and ambulation protocols), cognitive stimulation and reorientation, as well as sleep hygiene protocols.

Therefore, Nitta and his colleagues offer an honest and important contribution to the literature, highlighting that our current preventive approaches to POD in oral and maxillofacial surgery may be insufficient (4). The answer no longer lies in testing isolated interventions, but in a paradigm shift towards integrated care bundles. The next essential methodological step for the specialty is the development and, above all, the rigorous validation of these multifactorial protocols through multicenter randomized clinical trials. This is the scientifically viable path to determine which combinations of interventions can, in fact, alter the complex pathophysiology of delirium and improve patient outcomes.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Oral and Maxillofacial Anesthesia. The article has undergone external peer review.

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-32/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2025-32/coif). The authors have no conflicts of interest to declare.

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