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Deschamps A, Ben Abdallah A, Jacobsohn E, Saha T, Djaiani G, El-Gabalawy R, Overbeek C, Palermo J, Courbe A, Cloutier I, Tanzola R, Kronzer A, Fritz BA, Schmitt EM, Inouye SK, Avidan MS. Electroencephalography-Guided Anesthesia and Delirium in Older Adults After Cardiac Surgery: The ENGAGES-Canada Randomized Clinical Trial. JAMA 2024; 332:112-123. [PMID: 38857019 PMCID: PMC11165413 DOI: 10.1001/jama.2024.8144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 04/18/2024] [Indexed: 06/11/2024]
Abstract
Importance Intraoperative electroencephalogram (EEG) waveform suppression, suggesting excessive general anesthesia, has been associated with postoperative delirium. Objective To assess whether EEG-guided anesthesia decreases the incidence of delirium after cardiac surgery. Design, Setting, and Participants Randomized, parallel-group clinical trial of 1140 adults 60 years or older undergoing cardiac surgery at 4 Canadian hospitals. Recruitment was from December 2016 to February 2022, with follow-up until February 2023. Interventions Patients were randomized in a 1:1 ratio (stratified by hospital) to receive EEG-guided anesthesia (n = 567) or usual care (n = 573). Patients and those assessing outcomes were blinded to group assignment. Main Outcomes and Measures The primary outcome was delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration and EEG suppression time. Secondary outcomes included intensive care and hospital length of stay. Serious adverse events included intraoperative awareness, medical complications, and 30-day mortality. Results Of 1140 randomized patients (median [IQR] age, 70 [65-75] years; 282 [24.7%] women), 1131 (99.2%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 102 of 562 patients (18.15%) in the EEG-guided group and 103 of 569 patients (18.10%) in the usual care group (difference, 0.05% [95% CI, -4.57% to 4.67%]). In the EEG-guided group compared with the usual care group, the median volatile anesthetic minimum alveolar concentration was 0.14 (95% CI, 0.15 to 0.13) lower (0.66 vs 0.80) and there was a 7.7-minute (95% CI, 10.6 to 4.7) decrease in the median total time spent with EEG suppression (4.0 vs 11.7 min). There were no significant differences between groups in median length of intensive care unit (difference, 0 days [95% CI, -0.31 to 0.31]) or hospital stay (difference, 0 days [95% CI, -0.94 to 0.94]). No patients reported intraoperative awareness. Medical complications occurred in 64 of 567 patients (11.3%) in the EEG-guided group and 73 of 573 (12.7%) in the usual care group. Thirty-day mortality occurred in 8 of 567 patients (1.4%) in the EEG-guided group and 13 of 573 (2.3%) in the usual care group. Conclusions and Relevance Among older adults undergoing cardiac surgery, EEG-guided anesthetic administration to minimize EEG suppression, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support EEG-guided anesthesia for this indication. Trial Registration ClinicalTrials.gov Identifier: NCT02692300.
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Affiliation(s)
- Alain Deschamps
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Eric Jacobsohn
- Department of Anesthesiology Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen’s University, Kingston, Ontario, Canada
| | - George Djaiani
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Renée El-Gabalawy
- Departments of Clinical Health Psychology and Anesthesiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Overbeek
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Jennifer Palermo
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Athanase Courbe
- Montreal Heart Institute, Department of Anesthesiology and Pain Medicine, Université de Montreal, Montreal, Quebec, Canada
| | - Isabelle Cloutier
- Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Rob Tanzola
- Department of Anesthesiology and Perioperative Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel-Deaconess Medical Center and the Marcus Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel-Deaconess Medical Center and the Marcus Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
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2
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Meng L, Zhao X, Sun Y, Cheng S, Bao L, Fang K, Yu Q, Zheng Y, Wang J, Luo M, Gunderman D, Vuckovic N, Sidhu AS, Li J, Li G, Wolfe JW, Liu Z, Adams DC. Characteristics associated with effectiveness in postoperative delirium research: a systematic review of randomised controlled trials with meta-regression and meta-analysis. Br J Anaesth 2024:S0007-0912(24)00349-0. [PMID: 38969535 DOI: 10.1016/j.bja.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Postoperative delirium remains prevalent despite extensive research through randomised trials aimed at reducing its incidence. Understanding trial characteristics associated with interventions' effectiveness facilitates data interpretation. METHODS Trial characteristics were extracted from eligible trials identified through two systematic literature searches. Multivariable meta-regression was used to investigate trial characteristics associated with effectiveness estimated using odds ratios. Meta-analysis was used to investigate pooled effectiveness. RESULTS We identified 201 eligible trials. Compared with China, trials from the USA/Canada (ratio of odds ratio, 1.89; 95% confidence interval, 1.45-2.45) and Europe/Australia/New Zealand (1.67; 1.29-2.18) had an 89% and 67% higher odds ratio, respectively, suggesting reduced effectiveness. The effectiveness was enhanced when the incidence of postoperative delirium increased (0.85; 0.79-0.92, per 10% increase). Trials with concerns related to deviations from intended interventions reported increased effectiveness compared with those at low risk (0.69; 0.53-0.90). Compared with usual care, certain interventions appeared to have reduced the incidence of postoperative delirium in low-risk trials with low-to-moderate certainty of evidence. However, these findings should be considered inconclusive because of challenges in grouping heterogeneous interventions, the limited number of eligible trials, the prevalence of small-scale studies, and potential publication bias. CONCLUSIONS The effectiveness of postoperative delirium trials varied based on the region of trial origin, the incidence of delirium, and the risk of bias. The limitations caution against drawing definitive conclusions from different bodies of evidence. These findings highlight the imperative need to improve the quality of research on a global scale. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42023413984).
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Affiliation(s)
- Lingzhong Meng
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanhua Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Shufen Cheng
- Department of Anesthesiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Lin Bao
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Kaiyun Fang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Qiong Yu
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yueying Zheng
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jin Wang
- Department of Anesthesiology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - David Gunderman
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Nikola Vuckovic
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Angad S Sidhu
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Jian Li
- Department of Anesthesiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Gang Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - John W Wolfe
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ziyue Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David C Adams
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
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3
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Wang X, Chen F, Li T. Dexmedetomidine for delirium in adults undergoing heart valve surgery. Anaesthesia 2024; 79:772. [PMID: 38330430 DOI: 10.1111/anae.16256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Affiliation(s)
- Xiaocou Wang
- The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Fang Chen
- The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ting Li
- The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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4
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Gagliardi JP. Finding Delirium Is Necessary-But Not Sufficient-To Improve Outcomes. Am J Geriatr Psychiatry 2024; 32:852-855. [PMID: 38395729 DOI: 10.1016/j.jagp.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Jane P Gagliardi
- Department of Psychiatry and Behavioral Sciences, Department of Medicine, Psychiatry and Behavioral Sciences, Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America.
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Jiang L, Xiong W, Yang Y, Qian J. Insight into Cardioprotective Effects and Mechanisms of Dexmedetomidine. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07579-9. [PMID: 38869744 DOI: 10.1007/s10557-024-07579-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE Cardiovascular disease remains the leading cause of death worldwide. Dexmedetomidine is a highly selective α2 adrenergic receptor agonist with sedative, analgesic, anxiolytic, and sympatholytic properties, and several studies have shown its possible protective effects in cardiac injury. The aim of this review is to further elucidate the underlying cardioprotective mechanisms of dexmedetomidine, thus suggesting its potential in the clinical management of cardiac injury. RESULTS AND CONCLUSION Our review summarizes the findings related to the involvement of dexmedetomidine in cardiac injury and discusses the results in the light of different mechanisms. We found that numerous mechanisms may contribute to the cardioprotective effects of dexmedetomidine, including the regulation of programmed cell death, autophagy and fibrosis, alleviation of inflammatory response, endothelial dysfunction and microcirculatory derangements, improvement of mitochondrial dysregulation, hemodynamics, and arrhythmias. Dexmedetomidine may play a promising and beneficial role in the treatment of cardiovascular disease.
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Affiliation(s)
- Leyu Jiang
- Department of Anesthesiology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Wei Xiong
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuqiao Yang
- Department of Anesthesiology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jinqiao Qian
- Department of Anesthesiology, First Affiliated Hospital of Kunming Medical University, Kunming, China.
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Besnier E, Moussa MD, Thill C, Vallin F, Donnadieu N, Ruault S, Lorne E, Scherrer V, Lanoiselée J, Lefebvre T, Sentenac P, Abou-Arab O. Opioid-free anaesthesia with dexmedetomidine and lidocaine versus remifentanil-based anaesthesia in cardiac surgery: study protocol of a French randomised, multicentre and single-blinded OFACS trial. BMJ Open 2024; 14:e079984. [PMID: 38830745 DOI: 10.1136/bmjopen-2023-079984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION Intraoperative opioids have been used for decades to reduce negative responses to nociception. However, opioids may have several, and sometimes serious, adverse effects. Cardiac surgery exposes patients to a high risk of postoperative complications, some of which are common to those caused by opioids: acute respiratory failure, postoperative cognitive dysfunction, postoperative ileus (POI) or death. An opioid-free anaesthesia (OFA) strategy, based on the use of dexmedetomidine and lidocaine, may limit these adverse effects, but no randomised trials on this issue have been published in cardiac surgery.We hypothesised that OFA versus opioid-based anaesthesia (OBA) may reduce the incidence of major opioid-related complications after cardiac surgery. METHODS AND ANALYSIS Multicentre, randomised, parallel and single-blinded clinical trial in four cardiac surgical centres in France, including 268 patients scheduled for coronary artery bypass grafting under cardiac bypass, with or without aortic valve replacement. Patients will be randomised to either a control OBA protocol using remifentanil or an OFA protocol using dexmedetomidine/lidocaine. The primary composite endpoint is the occurrence of at least one of the following: (1) postoperative cognitive disorder evaluated by the Confusion Assessment Method for the Intensive Care Unit test, (2) POI, (3) acute respiratory distress or (4) death within the first 48 postoperative hours. Secondary endpoints are postoperative pain, morphine consumption, nausea-vomiting, shock, acute kidney injury, atrioventricular block, pneumonia and length of hospital stay. ETHICS AND DISSEMINATION This trial has been approved by an independent ethics committee (Comité de Protection des Personnes Ouest III-Angers on 23 February 2021). Results will be submitted in international journals for peer reviewing. TRIAL REGISTRATION NUMBER NCT04940689, EudraCT 2020-002126-90.
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Affiliation(s)
- Emmanuel Besnier
- Department of Anesthesia and Critical Care, Rouen University Hospital, Rouen, France
- U1096, INSERM, Rouen, France
| | - Mouhamed Djahoum Moussa
- Department of Anesthesiology and Critical Care, Lille University Hospital, Lille, France
- ULR 2694-METRICS : évaluation des technologies de santé et des pratiques médicales, Univ.Lille, Lille, France
| | - Caroline Thill
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - Florian Vallin
- Research Department, Rouen University Hospital, Rouen, France
| | | | - Sophie Ruault
- Research Department, Rouen University Hospital, Rouen, France
| | - Emmanuel Lorne
- Anesthesia and Critical Care Medicine, Clinique du Millenaire, Montpellier, France
| | - Vincent Scherrer
- Department of Anesthesia and Critical Care, Rouen University Hospital, Rouen, France
| | - Julien Lanoiselée
- Department of Anesthesiology and Critical Care, Lille University Hospital, Lille, France
| | - Thomas Lefebvre
- Department of Anesthesiology and Critical Care, University Hospital Centre Amiens-Picardie, Amiens, France
| | - Pierre Sentenac
- Anesthesia and Critical Care Medicine, Clinique du Millenaire, Montpellier, France
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care, University Hospital Centre Amiens-Picardie, Amiens, France
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7
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Scurt FG, Bose K, Mertens PR, Chatzikyrkou C, Herzog C. Cardiac Surgery-Associated Acute Kidney Injury. KIDNEY360 2024; 5:909-926. [PMID: 38689404 PMCID: PMC11219121 DOI: 10.34067/kid.0000000000000466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/26/2024] [Indexed: 05/02/2024]
Abstract
AKI is a common and serious complication of cardiac surgery that has a significant impact on patient morbidity and mortality. The Kidney Disease Improving Global Outcomes definition of AKI is widely used to classify and identify AKI associated with cardiac surgery (cardiac surgery-associated AKI [CSA-AKI]) on the basis of changes in serum creatinine and/or urine output. There are various preoperative, intraoperative, and postoperative risk factors for the development of CSA-AKI which should be recognized and addressed as early as possible to expedite its diagnosis, reduce its occurrence, and prevent or ameliorate its devastating complications. Crucial issues are the inaccuracy of serum creatinine as a surrogate parameter of kidney function in the perioperative setting of cardiothoracic surgery and the necessity to discover more representative markers of the pathophysiology of AKI. However, except for the tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ratio, other diagnostic biomarkers with an acceptable sensitivity and specificity are still lacking. This article provides a comprehensive review of various aspects of CSA-AKI, including pathogenesis, risk factors, diagnosis, biomarkers, classification, prevention, and treatment management.
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Affiliation(s)
- Florian G. Scurt
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Katrin Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Peter R. Mertens
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Christos Chatzikyrkou
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Carolin Herzog
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Granton D, Rodrigues M, Raparelli V, Honarmand K, Agarwal A, Friedrich JO, Perna B, Spaggiari R, Fortunato V, Risdonne G, Kho M, VanderKaay S, Chaudhuri D, Gomez-Builes C, D'Aragon F, Wiseman D, Lau VI, Lin C, Reid J, Trivedi V, Prakash V, Belley-Cote E, Al Mandhari M, Thabane L, Pilote L, Burns KEA. Sex and gender-based analysis and diversity metric reporting in acute care trials published in high-impact journals: a systematic review. BMJ Open 2024; 14:e081118. [PMID: 38719297 PMCID: PMC11103199 DOI: 10.1136/bmjopen-2023-081118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/23/2024] [Indexed: 05/22/2024] Open
Abstract
OBJECTIVE To characterise sex and gender-based analysis (SGBA) and diversity metric reporting, representation of female/women participants in acute care trials and temporal changes in reporting before and after publication of the 2016 Sex and Gender Equity in Research guideline. DESIGN Systematic review. DATA SOURCES We searched MEDLINE for trials published in five leading medical journals in 2014, 2018 and 2020. STUDY SELECTION Trials that enrolled acutely ill adults, compared two or more interventions and reported at least one clinical outcome. DATA ABSTRACTION AND SYNTHESIS 4 reviewers screened citations and 22 reviewers abstracted data, in duplicate. We compared reporting differences between intensive care unit (ICU) and cardiology trials. RESULTS We included 88 trials (75 (85.2%) ICU and 13 (14.8%) cardiology) (n=111 428; 38 140 (34.2%) females/women). Of 23 (26.1%) trials that reported an SGBA, most used a forest plot (22 (95.7%)), were prespecified (21 (91.3%)) and reported a sex-by-intervention interaction with a significance test (19 (82.6%)). Discordant sex and gender terminology were found between headings and subheadings within baseline characteristics tables (17/32 (53.1%)) and between baseline characteristics tables and SGBA (4/23 (17.4%)). Only 25 acute care trials (28.4%) reported race or ethnicity. Participants were predominantly white (78.8%) and male/men (65.8%). No trial reported gendered-social factors. SGBA reporting and female/women representation did not improve temporally. Compared with ICU trials, cardiology trials reported significantly more SGBA (15/75 (20%) vs 8/13 (61.5%) p=0.005). CONCLUSIONS Acute care trials in leading medical journals infrequently included SGBA, female/women and non-white trial participants, reported race or ethnicity and never reported gender-related factors. Substantial opportunity exists to improve SGBA and diversity metric reporting and recruitment of female/women participants in acute care trials. PROSPERO REGISTRATION NUMBER CRD42022282565.
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Affiliation(s)
- David Granton
- Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Myanca Rodrigues
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- University Center for Studies on Gender Medicine, University of Ferrara, Ferrara, Italy
| | - Kimia Honarmand
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Mackenzie Health, Vaughan, Ontario, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jan O Friedrich
- Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Critical Care and Medicine Departments, Unity Health Toronto, Toronto, Ontario, Canada
| | - Benedetta Perna
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Riccardo Spaggiari
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Valeria Fortunato
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Gianluca Risdonne
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Michelle Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Physiotherapy Department, Research Institute of St. Joe's Hamilton, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Sandra VanderKaay
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Dipayan Chaudhuri
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Carolina Gomez-Builes
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frédérick D'Aragon
- Department of Anesthesiology, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Daniel Wiseman
- Departments of Medicine and Critical Care Medicine, McGill University, Montreal, Quebec, Canada
| | - Vincent Issac Lau
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Celina Lin
- Department of Medicine, Division of Physical Medicine & Rehabilitation, McMaster University, Hamilton, Ontario, Canada
| | - Julie Reid
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Vatsal Trivedi
- Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Varuna Prakash
- Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Emilie Belley-Cote
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Divisions of Cardiology and Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Maha Al Mandhari
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Louise Pilote
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Ontario, Canada
| | - Karen E A Burns
- Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care and Medicine Departments, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Lu N, Chi Y, Liu M. Relationship Between Coronary Artery Revascularization and Postoperative Delirium: Progress and Perspectives. Angiology 2024:33197241252467. [PMID: 38712998 DOI: 10.1177/00033197241252467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Brain dysfunction resulting from damage to the heart-brain link leads to a decline in cognitive function. This, in turn, gives rise to the clinical symptom of perioperative delirium in patients undergoing coronary artery revascularization. Those affected are provided symptomatic treatment, but many do not recover fully. Thus, medium- and long-term mortality and adverse event rates remain relatively high in patients with perioperative delirium. Despite the relatively high incidence of perioperative delirium in patients undergoing coronary artery revascularization, it has not been systematically investigated. Inflammation, vascular damage, neuronal damage, and embolism are all involved in the injury process. Here, we discuss the incidence rate, pathological mechanisms, and prognosis of delirium after coronary artery revascularization. We also discuss in detail the risk factors for delirium after coronary artery revascularization, such as anxiety, depression, mode of operation, and drug use. We hope that prevention, early diagnosis, assessment, and potential treatment can be achieved by cardiologists to improve patient prognosis.
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Affiliation(s)
- Nan Lu
- Department of Psycho-cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, People's Republic of China
| | - Yunpeng Chi
- Department of Psycho-cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, People's Republic of China
| | - Meiyan Liu
- Department of Psycho-cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, People's Republic of China
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Pan Y, Liu Y, Peng Z, Yang Y, Liu L, Yang X, Hua K. The association between low serum calcium level and new-onset atrial fibrillation after coronary artery bypass grafting. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae077. [PMID: 38676569 PMCID: PMC11082466 DOI: 10.1093/icvts/ivae077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 04/02/2024] [Accepted: 04/25/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVES This study aims to investigate the relationship between serum calcium (SC) levels and the incidence of postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass graft surgery. METHODS This retrospective, observational cohort study consecutively enrolled patients undergoing isolated coronary artery bypass grafting in Beijing Anzhen Hospital from January 2018 to December 2021. Patients with a previous history of atrial fibrillation or atrial flutter or requiring concomitant cardiac surgery were excluded. A logistic regression model was used to determine predictors of POAF. Multivariable adjustment, inverse probability of treatment weighting and propensity score matching were used to adjust for confounders. Moreover, we conducted univariable and multivariable logistic regression analyses on preoperative and postoperative SC and ionized SC levels. RESULTS The analysis encompassed 12 293 patients. The POAF rate was significantly higher in patients with low SC level than those without (1379 [33.9%] vs 2375 [28.9%], P < 0.001). Low SC level was associated with an increased odds ratio of POAF (odds ratio [95% confidence interval]: 1.27 [1.18-1.37], P < 0.001). Inverse probability of treatment weighting and propensity score matching analyses confirmed the results. The increased POAF rate in low SC level group still existed among subgroup analysis based on different age, sex, body mass index, hypertension, hyperlipidaemia, CHA2DS2-VASc and magnesium. CONCLUSIONS Low SC level indicates elevated POAF risk in patients undergoing isolated coronary artery bypass graft surgery even after the adjustment for age, sex, cardiovascular risk factors, echocardiographic parameters and laboratory markers.
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Affiliation(s)
- Yilin Pan
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuhua Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhan Peng
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yunxiao Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Linqi Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiubin Yang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kun Hua
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Costa LGVD, Papa FV, Hare GMT, Salgado-Filho MF, Lineburger EB, Schmidt AP. Anemia and outcomes in cardiac surgery. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844504. [PMID: 38677651 PMCID: PMC11081777 DOI: 10.1016/j.bjane.2024.844504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Affiliation(s)
| | - Fabio V Papa
- University of Toronto, St. Michael's Hospital, Department of Anaesthesia, Toronto, Canada
| | - Gregory M T Hare
- University of Toronto, St. Michael's Hospital, Department of Anaesthesia, Toronto, Canada
| | | | - Eric B Lineburger
- Hospital São José, Departamento de Anestesia e Tratamento da Dor, Criciúma, SC, Brazil; Hospital São José, Centro de Pesquisa, Criciúma, SC, Brazil; Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - André P Schmidt
- Hospital de Clínicas de Porto Alegre (HCPA), Serviço de Anestesia e Medicina Perioperatória, Porto Alegre, RS, Brazil; Santa Casa de Porto Alegre, Serviço de Anestesia, Porto Alegre, RS, Brazil; Hospital Nossa Senhora da Conceição, Serviço de Anestesia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-graduação em Ciências Pneumológicas, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-graduação em Ciências Cirúrgicas, Porto Alegre, RS, Brazil; Programa de Pós-Graduação em Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
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12
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Ekkapat G, Kampitak W, Theerasuwipakorn N, Kittipongpattana J, Engsusophon P, Phannajit J, Chokengarmwong N. A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial. Indian J Crit Care Med 2024; 28:467-474. [PMID: 38738208 PMCID: PMC11080087 DOI: 10.5005/jp-journals-10071-24710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Aims and background The efficacy of dexmedetomidine and propofol in preventing postoperative delirium is controversial. This study aims to evaluate the efficacy of dexmedetomidine and propofol for preventing postoperative delirium in extubated elderly patients undergoing hip fracture surgery. Materials and methods This randomized controlled trial included participants undergoing hip fracture surgery. Participants were randomly assigned to receive dexmedetomidine, propofol, or placebo intravenously during intensive care unit (ICU) admission (8 p.m. to 6 a.m.). The drug dosages were adjusted to achieve the Richmond Agitation Sedation Scale (RASS) of 0 to -1. The primary outcome was postoperative delirium. The secondary outcomes were postoperative complications, fentanyl consumption, and length of hospital stay. Results 108 participants were enrolled (n = 36 per group). Postoperative delirium incidences were 8.3%, 22.2%, and 5.6% in the dexmedetomidine, propofol, and placebo groups, respectively. The hazard ratios of dexmedetomidine and propofol compared with placebo were 1.49 (95% CI, 0.25, 8.95; p = 0.66) and 4.18 (95% CI, 0.88, 19.69; p = 0.07). The incidence of bradycardia was higher in the dexmedetomidine group compared with others (13.9%; p = 0.01) but not for hypotension (8.3%; p = 0.32). The median length of hospital stays (8 days, IQR: 7, 11) and fentanyl consumption (240 µg, IQR: 120, 400) were not different among groups. Conclusion This study did not successfully demonstrate the impact of nocturnal low-dose dexmedetomidine and propofol in preventing postoperative delirium among elderly patients undergoing hip fracture surgery. While not statistically significant, it is noteworthy that propofol exhibited a comparatively higher delirium rate. How to cite this article Ekkapat G, Kampitak W, Theerasuwipakorn N, Kittipongpattana J, Engsusophon P, Phannajit J, et al. A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial. Indian J Crit Care Med 2024;28(5):467-474.
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Affiliation(s)
- Gamonmas Ekkapat
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Wirinaree Kampitak
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nonthikorn Theerasuwipakorn
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jirapat Kittipongpattana
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Phatthanaphol Engsusophon
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jeerath Phannajit
- Division of Nephrology and Clinical Epidemiology, Department of Medicine, and Center of Excellence for Metabolic Bone Disease in CKD patients, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nalin Chokengarmwong
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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13
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Zhao C, Liu S, Zhang H, Gao M. Does dexmedetomidine reduce the risk of acute kidney injury after cardiac surgery? A meta-analysis of randomized controlled trials. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744446. [PMID: 37453497 PMCID: PMC11148486 DOI: 10.1016/j.bjane.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Acute Kidney Injury (AKI) is a common complication after cardiac surgery and has been associated with poor outcomes. Dexmedetomidine (DEX) has been shown to confer direct renoprotection based on some animal and clinical studies, but data from other trials came to the opposite conclusion following cardiac surgery. This meta-analysis was conducted to evaluate the effects of perioperative DEX administration on the occurrence of AKI and the outcomes after cardiac surgery. METHODS We searched databases including EMBASE, PubMed, and Cochrane CENTRAL for Randomized Controlled Trials (RCTs) focused on DEX for AKI in adult patients after cardiac surgery. The primary outcome was incidence of AKI. Secondary outcomes were Mechanical Ventilation (MV) duration, Intensive Care Unit (ICU) Length Of Stay (LOS), hospital LOS and mortality. RESULTS Fifteen trials enrolling 2907 study patients were collected in the meta-analyses. Compared with controls, DEX reduced the incidence of postoperative AKI (Odds Ratio [OR = 0.66]; 95% Confidence Interval [95% CI 0.48-0.91]; p = 0.01), and there was no significant difference between groups in postoperative mortality (OR = 0.63; 95% CI 0.32-1.26; p = 0.19), MV duration (Weighted Mean Difference [WMD = -0.44]; 95% CI -1.50-0.63; p = 0.42), ICU LOS (WMD = -1.19; 95% CI -2.89-0.51; p = 0.17), and hospital LOS (WMD = -0.31; 95% CI -0.76-0.15; p = 0.19). CONCLUSIONS Perioperative DEX reduced the incidence of postoperative AKI in adult patients undergoing cardiac surgery. No significant decrease existed in mortality, MV duration, ICU LOS and hospital LOS owing to DEX administration.
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Affiliation(s)
- Chunxiao Zhao
- Capital Medical University, Beijing Shijitan Hospital, Department of Intensive Care Unit, Beijing, China.
| | - Shuo Liu
- Capital Medical University, Beijing Chest Hospital, Beijing Tuberculosis and Thoracic Tumor Research Institute, Department of Pharmacy, Beijing, China
| | - Huiquan Zhang
- Capital Medical University, Beijing Shijitan Hospital, Department of Intensive Care Unit, Beijing, China
| | - Mengqi Gao
- Capital Medical University, Beijing Shijitan Hospital, Department of Intensive Care Unit, Beijing, China
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Sari S, Brooker J, Montalvo-Campana M, Shehata P, Pu X, Insler S, Ruetzler K, Troianos CA, Turan A. The association of hemoglobin with postoperative delirium and atrial fibrillation after cardiac surgery: a retrospective sub-study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744424. [PMID: 36894011 PMCID: PMC11148484 DOI: 10.1016/j.bjane.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Most cardiac surgery patients experience postoperative anemia. Delirium and Atrial Fibrillation (AF) are common and independent predictors of morbidity and mortality. Few reports examine their association with postoperative anemia. This study aims to quantify the association between anemia and these outcomes in patients undergoing cardiac surgery. METHODS This post-hoc analysis of the DECADE randomized controlled trial ran at six academic US hospitals. Patients aged 18-85 years with heart rate > 50 bpm undergoing cardiac surgery who had daily hemoglobin measurements in the first 5 Postoperative Days (POD) were included. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU (CAM - ICU), preceded by the Richmond Agitation and Sedation Scale, with patients excluded from assessment if sedated. Patients had daily hemoglobin measurements, continuous cardiac monitoring plus twice-daily 12-lead electrocardiograms, up to POD4. AF was diagnosed by clinicians blinded to hemoglobin levels. RESULTS Five hundred and eighty-five patients were included. Mean postoperative hemoglobin Hazard Ratio (HR): 0.99 (95% CI 0.83, 1.19; p = 0.94) per 1 g.dL-1 hemoglobin decrease. 197 (34%) developed AF, mainly on POD = 2.3. Estimated HR = 1.04 (95% CI 0.93, 1.17; p = 0.51) per 1 g.dL-1 hemoglobin decrease. CONCLUSIONS Most patients undergoing major cardiac surgery were anemic in the postoperative phase. AF and delirium occurred in 34% and 12% of patients, respectively, but neither were significantly correlated with postoperative hemoglobin.
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Affiliation(s)
- Sinem Sari
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, Ohio; Adnan Menderes University, Department of General Anesthesiology, Aydın, Turkey
| | - Jack Brooker
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, Ohio
| | - Mateo Montalvo-Campana
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, Ohio
| | - Peter Shehata
- Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesiology, Cleveland, Ohio
| | - Xuan Pu
- Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, Ohio
| | - Steven Insler
- Cleveland Clinic, Anesthesiology Institute, Department of Intensive Care & Resuscitation, Cleveland, Ohio
| | - Kurt Ruetzler
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, Ohio; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesiology, Cleveland, Ohio
| | | | - Alparslan Turan
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, Ohio; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesiology, Cleveland, Ohio.
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15
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Ham SY, Shim JK, Lee S, Ko SH, Soh S, Kwak YL. Effects of dexmedetomidine on renal function after cardiac surgery for infective endocarditis: An interim analysis of a randomized controlled trial. Asian J Surg 2024:S1015-9584(24)00688-2. [PMID: 38658274 DOI: 10.1016/j.asjsur.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 04/04/2024] [Accepted: 04/12/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Patients undergoing cardiac surgery for infective endocarditis (IE) are at a high risk of postoperative acute kidney injury (AKI) owing to heightened systemic inflammation. Therefore, we aimed to investigate the effect of dexmedetomidine on postoperative AKI in patients who underwent cardiac surgery for IE. METHODS A total of 63 patients who underwent cardiac surgery for IE were randomly assigned to receive either intravenous dexmedetomidine infusion of 0.4 μg kg-1 h-1 (DEX group) or normal saline infusion (control group) for 24 h after induction of anesthesia. The occurrence of AKI within seven days postoperation, epinephrine, norepinephrine, and interleukin-6 levels, as well as postoperative morbidities, were assessed. An intertrim analysis was conducted using Pocock's alpha spending function at α = 0.05 and β = 0.2. RESULTS This trial was early terminated according to the results of interim analysis performed when 60 % of the pre-set number of patients have been collected. The incidence of AKI was significantly lower in the DEX group than in the control group (32.3 % vs. 9.4 %, p = 0.025). Patients in the DEX group had significantly lower epinephrine levels than those in the control group, whereas norepinephrine and interleukin-6 levels were similar. Perioperative mean arterial pressure or heart rate did not differ between the groups. CONCLUSIONS Dexmedetomidine administration for 24 h starting from induction of anesthesia significantly reduced the incidence of postoperative AKI after cardiac surgery for IE (by 29 % vs. control) without hemodynamic side effects. This was accompanied by a significant attenuation of postoperative increase in serum epinephrine levels.
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Affiliation(s)
- Sung Yeon Ham
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sak Lee
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seo Hee Ko
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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16
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Jiang Y, Xie Y, Fang P, Shang Z, Chen L, Zhou J, Yang C, Zhu W, Hao X, Ding J, Yin P, Wang Z, Cao M, Zhang Y, Tan Q, Cheng D, Kong S, Lu X, Liu X, Sessler DI. Cognitive Training for Reduction of Delirium in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e247361. [PMID: 38652478 PMCID: PMC11040409 DOI: 10.1001/jamanetworkopen.2024.7361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/20/2024] [Indexed: 04/25/2024] Open
Abstract
IMPORTANCE Postoperative delirium is a common and impactful neuropsychiatric complication in patients undergoing coronary artery bypass grafting surgery. Cognitive training may enhance cognitive reserve, thereby reducing postoperative delirium. OBJECTIVE To determine whether preoperative cognitive training reduces the incidence of delirium in patients undergoing coronary artery bypass grafting. DESIGN, SETTING, and PARTICIPANTS This prospective, single-blind, randomized clinical trial was conducted at 3 university teaching hospitals in southeastern China with enrollment between April 2022 and May 2023. Eligible participants included those scheduled for elective coronary artery bypass grafting who consented and enrolled at least 10 days before surgery. INTERVENTIONS Participating patients were randomly assigned 1:1, stratified by site, to either routine care or cognitive training, which included substantial practice with online tasks designed to enhance cognitive functions including memory, imagination, reasoning, reaction time, attention, and processing speed. MAIN OUTCOMES AND MEASURES The primary outcome was occurrence of delirium during postoperative days 1 to 7 or until hospital discharge, diagnosed using the Confusion Assessment Method or the Confusion Assessment Method for Intensive Care Units. Secondary outcomes were postoperative cognitive dysfunction, delirium characteristics, and all-cause mortality within 30 days following the operation. RESULTS A total of 218 patients were randomized and 208 (median [IQR] age, 66 [58-70] years; 64 female [30.8%] and 144 male [69.2%]) were included in final analysis, with 102 randomized to cognitive training and 106 randomized to routine care. Of all participants, 95 (45.7%) had only a primary school education and 54 (26.0%) had finished high school. In the cognitive training group, 28 participants (27.5%) developed delirium compared with 46 participants (43.4%) randomized to routine care. Those receiving cognitive training were 57% less likely to develop delirium compared with those receiving routine care (adjusted odds ratio [aOR] 0.43; 95% CI, 0.23-0.77; P = .007). Significant differences were observed in the incidence of severe delirium (aOR, 0.46; 95% CI, 0.25-0.82; P = .01), median (IQR) duration of delirium (0 [0-1] days for cognitive training vs 0 [0-2] days for routine care; P = .008), and median (IQR) number of delirium-positive days (0 [0-1] days for cognitive training vs 0 [0-2] days for routine care; P = .007). No other secondary outcomes differed significantly. CONCLUSIONS AND RELEVANCE In this randomized trial of 208 patients undergoing coronary artery bypass grafting, preoperative cognitive training reduced the incidence of postoperative delirium. However, our primary analysis was based on fewer than 75 events and should therefore be considered exploratory and a basis for future larger trials. Trial Registration Chinese Clinical Trial Registry Identifier: ChiCTR2200058243.
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Affiliation(s)
- Yu Jiang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Yanhu Xie
- Department of Anesthesiology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Panpan Fang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Zixiang Shang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Lihai Chen
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jifang Zhou
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Chao Yang
- Department of Anesthesiology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Wenjie Zhu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Xixi Hao
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Jianming Ding
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Panpan Yin
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Zan Wang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Mengyuan Cao
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Yu Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Qilian Tan
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Dan Cheng
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Siyu Kong
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Xianfu Lu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Xuesheng Liu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical, University, Hefei, Anhui, China
| | - Daniel I. Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
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Verret M, Lam NH, Lalu M, Nicholls SG, Turgeon AF, McIsaac DI, Hamtiaux M, Bao Phuc Le J, Gilron I, Yang L, Kaimkhani M, Assi A, El-Adem D, Timm M, Tai P, Amir J, Srichandramohan S, Al-Mazidi A, Fergusson NA, Hutton B, Zivkovic F, Graham M, Lê M, Geist A, Bérubé M, Poulin P, Shorr R, Daudt H, Martel G, McVicar J, Moloo H, Fergusson DA. Intraoperative pharmacologic opioid minimisation strategies and patient-centred outcomes after surgery: a scoping review. Br J Anaesth 2024; 132:758-770. [PMID: 38331658 PMCID: PMC10925893 DOI: 10.1016/j.bja.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/08/2023] [Accepted: 01/02/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Postoperative patient-centred outcome measures are essential to capture the patient's experience after surgery. Although a large number of pharmacologic opioid minimisation strategies (i.e. opioid alternatives) are used for patients undergoing surgery, it remains unclear which strategies are most promising in terms of patient-centred outcome improvements. This scoping review had two main objectives: (1) to map and describe evidence from clinical trials assessing the patient-centred effectiveness of pharmacologic intraoperative opioid minimisation strategies in adult surgical patients, and (2) to identify promising pharmacologic opioid minimisation strategies. METHODS We searched MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL databases from inception to February 2023. We included trials investigating the use of opioid minimisation strategies in adult surgical patients and reporting at least one patient-centred outcome. Study screening and data extraction were conducted independently by at least two reviewers. RESULTS Of 24,842 citations screened for eligibility, 2803 trials assessed the effectiveness of intraoperative opioid minimisation strategies. Of these, 457 trials (67,060 participants) met eligibility criteria, reporting at least one patient-centred outcome. In the 107 trials that included a patient-centred primary outcome, patient wellbeing was the most frequently used domain (55 trials). Based on aggregate findings, dexmedetomidine, systemic lidocaine, and COX-2 inhibitors were promising strategies, while paracetamol, ketamine, and gabapentinoids were less promising. Almost half of the trials (253 trials) did not report a protocol or registration number. CONCLUSIONS Researchers should prioritise and include patient-centred outcomes in the assessment of opioid minimisation strategy effectiveness. We identified three potentially promising pharmacologic intraoperative opioid minimisation strategies that should be further assessed through systematic reviews and multicentre trials. Findings from our scoping review may be influenced by selective outcome reporting bias. STUDY REGISTRATION OSF - https://osf.io/7kea3.
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Affiliation(s)
- Michael Verret
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada; Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada.
| | - Nhat H Lam
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Manoj Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Ottawa Methods Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada; Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec-Université Laval, Université Laval, Québec City, QC, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Myriam Hamtiaux
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - John Bao Phuc Le
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ian Gilron
- Department of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies and School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Lucy Yang
- Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Alexandre Assi
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - David El-Adem
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Makenna Timm
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tai
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Joelle Amir
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Sriyathavan Srichandramohan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Abdulaziz Al-Mazidi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nicholas A Fergusson
- Department of Anesthesiology, Perioperative & Pain Medicine, University of Calgary, Calgary, AB, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Fiona Zivkovic
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Megan Graham
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Maxime Lê
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Allison Geist
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec-Université Laval, Université Laval, Québec City, QC, Canada; Faculty of Nursing, Université Laval, Québec City, QC, Canada; Quebec Pain Research Network, Sherbrooke, QC, Canada
| | - Patricia Poulin
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Risa Shorr
- Library Services, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Guillaume Martel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Jason McVicar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada
| | - Husein Moloo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Heo MH, Cho MJ, Lee SI, Kim KW. Dexmedetomidine as an effective alternative tool for heart rate control in atrial fibrillation during general anesthesia-A case report. Saudi J Anaesth 2024; 18:299-301. [PMID: 38654877 PMCID: PMC11033889 DOI: 10.4103/sja.sja_918_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 04/26/2024] Open
Abstract
Atrial fibrillation (AF) is a common arrhythmia requiring effective heart rate (HR) management. Conventional therapies may not always achieve the desired HR control during intraoperative conditions. We present two cases of AF patients in whom dexmedetomidine, an alpha-2 receptor agonist, was utilized during surgery when conventional treatments proved ineffective. In Case 1, a 65-year-old male with multiple comorbidities underwent surgery. Despite receiving intraoperative medications for AF, his HR remained uncontrolled. Dexmedetomidine successfully stabilized his HR without complications. In Case 2, a 75-year-old male with heart disease experienced a sudden HR surge during surgery, which remained uncontrolled despite conventional treatment. Dexmedetomidine effectively managed his HR, ensuring a safer surgical course. While the primary indication of dexmedetomidine is not arrhythmia management, this case report suggests its potential in challenging cases. Further research is needed to explore its therapeutic role in tachyarrhythmia management and establish appropriate dosing strategies.
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Affiliation(s)
- Min Hee Heo
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi-do, South Korea
| | - Min Ji Cho
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi-do, South Korea
| | - Sang Il Lee
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi-do, South Korea
| | - Kyung Woo Kim
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi-do, South Korea
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19
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Xu W, Zheng Y, Wang Q, Suo Z, Fang L, Yang J, Li S, Li P, Jia X, Liu X, Zheng H, Ni C. Impact of the addition of dexmedetomidine to patient-controlled intravenous analgesia on postoperative pain-sleep interaction cycle and delirium: A systematic review and meta-analysis of randomized controlled trials. Heliyon 2024; 10:e27623. [PMID: 38524538 PMCID: PMC10958226 DOI: 10.1016/j.heliyon.2024.e27623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 03/26/2024] Open
Abstract
Background The reciprocal nexus between sleep and pain is well-documented, with the deleterious impact of operative trauma potentially playing a pivotal role in the dysregulation of this interplay, which could significantly contribute to the manifestation of postoperative delirium (POD). Studies have investigated the effect of adding dexmedetomidine (DEX) to patient-controlled intravenous analgesia (PCIA) pumps on postoperative pain-sleep interaction cycle and POD, but conclusions remained uncertain. The objective of this investigation is to perform a meta-analysis that thoroughly assesses the impact of integrating DEX into PCIA, focusing on analgesic effectiveness, sleep quality, and the incidence of delirium in postoperative patients. Methods PubMed, Embase, Cochrane Library, SinoMed, and Wanfang Data Knowledge Service Platform were searched, for publications in any language, from database inception to September 2023. Our analysis encompassed randomized controlled trials (RCTs) that examine the therapeutic efficacy and risk profile of adding DEX to the PCIA on the postoperative pain-sleep interaction cycle, by focusing on changes in postoperative analgesia (Visual analog scale (VAS) score), sleep efficiency, sleep structure, subjective sleep score (Assen insomnia scale and numerical rating scale) and adverse event rate. Results 34 RCTs (4324 patients) were analyzed. This study shows DEX improved analgesia and reduced VAS scores at 6, 12, and 24 h after surgery. Sleep efficiency was enhanced on the 1st and 2nd postoperative night. DEX improved sleep structure at the 1st postoperative night by reducing non-rapid eye movement stage 1 (N1) sleep and increasing non-rapid eye movement stage 2 (N2) and non-rapid eye movement stage 3 (N3) sleep. At the 2nd night, DEX reduced N1 sleep and increased N2 sleep, but not N3 sleep. Data from AIS and NRS showed improvement in subjective sleep scores on the 1st postoperative night and 2nd night. Additionally, DEX decreased the occurrence of POD on the 24 h and first-three days. Conclusion This study shows that the typical DEX doses added to PCIA with sufentanil were 2-5 μg/kg or approximately 200-250 μg, and the addition of DEX to PCIA can improve pain-sleep interaction cycle from multiple perspectives, and further decrease the occurrence of POD.
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Affiliation(s)
- Wenjie Xu
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yuxiang Zheng
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Qing Wang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zizheng Suo
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Lingling Fang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jing Yang
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Shuai Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Peng Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xixi Jia
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Xiaoyan Liu
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hui Zheng
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Cheng Ni
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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20
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Huang JX, Zhang SS, Wang SX, Xi DS, Luo FR, Liu CJ, Li H. The role of perioperative sedative anesthetics in preventing postoperative delirium: a systematic review and network-meta analysis including 6679 patients. BMC Cardiovasc Disord 2024; 24:147. [PMID: 38448835 PMCID: PMC10916082 DOI: 10.1186/s12872-024-03783-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/12/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVE Postoperative delirium is a common and debilitating complication that significantly affects patients and their families. The purpose of this study is to investigate whether there is an effective sedative that can prevent postoperative delirium while also examining the safety of using sedatives during the perioperative period. METHODS The net-meta analysis was used to compare the incidence of postoperative delirium among four sedatives: sevoflurane, propofol, dexmedetomidine, and midazolam. Interventions were ranked according to their surface under the cumulative ranking curve (SUCRA). RESULTS A total of 41 RCT studies involving 6679 patients were analyzed. Dexmedetomidine can effectively reduce the incidence of postoperative delirium than propofol (OR 0.47 95% CI 0.25-0.90), midazolam (OR 0.42 95% CI 0.17-1.00), normal saline (OR 0.42 95% CI 0.33-0.54) and sevoflurane (OR 0.39 95% CI 0.18-0.82). The saline group showed a significantly lower incidence of bradycardia compared to the group receiving dexmedetomidine (OR 0.55 95% CI 0.37-0.80). In cardiac surgery, midazolam (OR 3.34 95%CI 2.04-5.48) and normal saline (OR 2.27 95%CI 1.17-4.39) had a higher rate of postoperative delirium than dexmedetomidine, while in non-cardiac surgery, normal saline (OR 1.98 95%CI 1.44-2.71) was more susceptible to postoperative delirium than dexmedetomidine. CONCLUSION Our analysis suggests that dexmedetomidine is an effective sedative in preventing postoperative delirium whether in cardiac surgery or non-cardiac surgery. The preventive effect of dexmedetomidine on postoperative delirium becomes more apparent with longer surgical and extubation times. However, it should be administered with caution as it was found to be associated with bradycardia.
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Affiliation(s)
- Jin-Xiang Huang
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Shan-Shan Zhang
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Shu-Xian Wang
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Da-Shuang Xi
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Fang-Ru Luo
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Cheng-Jiang Liu
- Department of General Medicine, Affiliated Anqing First People's Hospital of Anhui Medical University, Anqing, China
| | - Hong Li
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China.
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21
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Xiong X, Shao Y, Chen D, Chen B, Lan X, Shi J. Effect of Esketamine on Postoperative Delirium in Patients Undergoing Cardiac Valve Replacement with Cardiopulmonary Bypass: A Randomized Controlled Trial. Anesth Analg 2024:00000539-990000000-00781. [PMID: 38446699 DOI: 10.1213/ane.0000000000006925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND The aim of this study was to investigate the effects of esketamine on the risk of postoperative delirium (POD) in adults undergoing on-pump cardiac valve surgery. METHODS In this randomized, triple-blind, controlled trial, 116 adult patients with an American Society of Anesthesiologists (ASA) grade Ⅱ or Ⅲ and a New York Heart Association (NYHA) grade Ⅱ or Ⅲ who underwent cardiac valve surgery with cardiopulmonary bypass were included. Esketamine (0.25 mg/kg) or normal saline was administered intravenously before anesthesia induction. The primary outcome was POD, defined as a positive delirium assessment according to the 3-minute confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) on a twice-daily basis for 7 days after surgery. Delirium duration and the delirium subtype were also recorded. The cognitive status of patients was measured according to the Mini-Mental State Examination at baseline, discharge, 30 days postoperatively and 3 months postoperatively. RESULTS A total of 112 patients (mean age, 52 years; 53.6% female) were enrolled; 56 were assigned to receive esketamine, and 56 were assigned to receive placebo. POD occurred in 13 (23.2%) patients in the esketamine group and in 25 (44.6%) patients in the placebo group (relative risk [RR], 0.52, 95% confidence interval [CI], 0.28-0.91; P = .018). Thirteen patients (23.2%) in the esketamine group and 24 (42.9%) patients in the placebo group had multiple episodes of delirium (RR, 0.54, 95% CI, 0.28-0.92), and 13 (23.2%) vs 22 (39.3%) patients exhibited the hyperactive subtype. CONCLUSIONS A single dose of esketamine (0.25 mg/kg) injected intravenously before anesthesia induction reduced the incidence of delirium in relatively young patients with ASA grade Ⅱ or Ⅲ who underwent on-pump cardiac surgery.
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Affiliation(s)
- Xinglong Xiong
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Yi Shao
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Dongxu Chen
- Department of Anesthesiology, West China Second Hospital, Sichuan University, Chengdu, P. R. China
| | - Bo Chen
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Xin Lan
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Jing Shi
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
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Huet O, Gargadennec T, Oilleau JF, Rozec B, Nesseler N, Bouglé A, Kerforne T, Lasocki S, Eljezi V, Dessertaine G, Amour J, Chapalain X. Prevention of post-operative delirium using an overnight infusion of dexmedetomidine in patients undergoing cardiac surgery: a pragmatic, randomized, double-blind, placebo-controlled trial. Crit Care 2024; 28:64. [PMID: 38419119 PMCID: PMC10902989 DOI: 10.1186/s13054-024-04842-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/19/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND After cardiac surgery, post-operative delirium (PoD) is acknowledged to have a significant negative impact on patient outcome. To date, there is no valuable and specific treatment for PoD. Critically ill patients often suffer from poor sleep condition. There is an association between delirium and sleep quality after cardiac surgery. This study aimed to establish whether promoting sleep using an overnight infusion of dexmedetomidine reduces the incidence of delirium after cardiac surgery. METHODS Randomized, pragmatic, multicentre, double-blind, placebo controlled trial from January 2019 to July 2021. All adult patients aged 65 years or older requiring elective cardiac surgery were randomly assigned 1:1 either to the dexmedetomidine group or the placebo group on the day of surgery. Dexmedetomidine or matched placebo infusion was started the night after surgery from 8 pm to 8 am and administered every night while the patient remained in ICU, or for a maximum of 7 days. Primary outcome was the occurrence of postoperative delirium (PoD) within the 7 days after surgery. RESULTS A total of 348 patients provided informed consent, of whom 333 were randomized: 331 patients underwent surgery and were analysed (165 assigned to dexmedetomidine and 166 assigned to placebo). The incidence of PoD was not significantly different between the two groups (12.6% vs. 12.4%, p = 0.97). Patients treated with dexmedetomidine had significantly more hypotensive events (7.3% vs 0.6%; p < 0.01). At 3 months, functional outcomes (Short-form 36, Cognitive failure questionnaire, PCL-5) were comparable between the two groups. CONCLUSION In patients recovering from an elective cardiac surgery, an overnight infusion of dexmedetomidine did not decrease postoperative delirium. Trial registration This trial was registered on ClinicalTrials.gov (number: NCT03477344; date: 26th March 2018).
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Affiliation(s)
- Olivier Huet
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital de la cavale Blanche, CHRU de Brest, Brest, France.
| | - Thomas Gargadennec
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital de la cavale Blanche, CHRU de Brest, Brest, France
| | - Jean-Ferréol Oilleau
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital de la cavale Blanche, CHRU de Brest, Brest, France
| | - Bertrand Rozec
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital Laennec, University Hospital Centre Nantes, Nantes, France
| | - Nicolas Nesseler
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, University Hospital of Rennes, Rennes, France
| | - Adrien Bouglé
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Thomas Kerforne
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine CHU de POITIERS, Poitiers, France
| | - Sigismond Lasocki
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, CHU de ANGERS, I, Angers, France
| | - Vedat Eljezi
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital Gabriel Montpied, CHU de Clermont Ferrand, Clermont Ferrand, France
| | - Géraldine Dessertaine
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Grenoble Alpes University Hospital, Grenoble, France
| | - Julien Amour
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital Privé Jacques Cartier, Massy, France
| | - Xavier Chapalain
- Department of Anaesthesia, Intensive Care Medicine and Peri-Operative Medicine, Hôpital de la cavale Blanche, CHRU de Brest, Brest, France
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23
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Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Aceto P, Audisio R, Cherubini A, Cunningham C, Dabrowski W, Forookhi A, Gitti N, Immonen K, Kehlet H, Koch S, Kotfis K, Latronico N, MacLullich AMJ, Mevorach L, Mueller A, Neuner B, Piva S, Radtke F, Blaser AR, Renzi S, Romagnoli S, Schubert M, Slooter AJC, Tommasino C, Vasiljewa L, Weiss B, Yuerek F, Spies CD. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol 2024; 41:81-108. [PMID: 37599617 PMCID: PMC10763721 DOI: 10.1097/eja.0000000000001876] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.
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Affiliation(s)
- César Aldecoa
- From the Department of Anaesthesia and Postoperative Critical Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Biomedical Studies, University of the Republic of San Marino, San Marino (GB), Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy (FB, AF, LM), Specialty of Anaesthetics & NHMRC Clinical Trials Centre, University of Sydney & Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital (RDS), Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt Universität zu Berlin, Campus Charité Mitte, and Campus Virchow Klinikum (CDS, SK, AM, BN, LV, BW, FY), Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (PA), Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy (PA), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden (RA), Geriatria, Accettazione Geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy (AC), School of Biochemistry and Immunology and Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland (CC), First Department of Anaesthesiology and Intensive Care Medical University of Lublin, Poland (WD), Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland (KI), Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland (KK), Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia (NG, NL, SP, SR), Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy (NL, SP), Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom (AMJM), Department of Anaesthesia and Intensive Care, Nykoebing Hospital; University of Southern Denmark, SDU (SK, FR), Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia (ARB), Center for Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland (ARB), Department of Health Science, Section of Anesthesiology, University of Florence (SR), Department of Anaesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy (SR), School of Health Sciences, Institute of Nursing, ZHAW Zurich University of Applied Science, Winterthur, Switzerland (MS), Departments of Psychiatry and Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (AJCS), Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium (AJCS) and Dental Anesthesia and Intensive Care Unit, Polo Universitario Ospedale San Paolo, Department of Biomedical, Surgical and Odontoiatric Sciences, University of Milano, Milan, Italy (CT)
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Chen Z, Hao Q, Sun R, Zhang Y, Fu H, Liu S, Luo C, Chen H, Zhang Y. Predictive value of the geriatric nutrition risk index for postoperative delirium in elderly patients undergoing cardiac surgery. CNS Neurosci Ther 2024; 30:e14343. [PMID: 37408469 PMCID: PMC10848042 DOI: 10.1111/cns.14343] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 05/07/2023] [Accepted: 06/24/2023] [Indexed: 07/07/2023] Open
Abstract
AIMS The aims of the study were to determine the relationship between preoperative geriatric nutritional risk index (GNRI) and the occurrence of postoperative delirium (POD) in elderly patients after cardiac surgery and to evaluate the additive value of GNRI for predicting POD. METHODS The data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC-IV) database. Patients who underwent cardiac surgery and were aged 65 or older were included. The relationship between preoperative GNRI and POD was investigated using logistic regression. We determined the added predictive value of preoperative GNRI for POD by measuring the changes in the area under the receiver operating characteristic curve (AUC) and calculating the net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS A total of 4286 patients were included in the study, and 659 (16.1%) developed POD. Patients with POD had significantly lower GNRI scores than patients without POD (median 111.1 vs. 113.4, p < 0.001). Malnourished patients (GNRI ≤ 98) had a significantly higher risk of POD (odds ratio, 1.83, 90% CI, 1.42-2.34, p < 0.001) than those without malnutrition (GNRI > 98). This correlation remains after adjusting for confounding variables. The addition of GNRI to the multivariable models slightly but not significantly increases the AUCs (all p > 0.05). Incorporating GNRI increases NRIs in some models and IDIs in all models (all p < 0.05). CONCLUSIONS Our results showed a negative association between preoperative GNRI and POD in elderly patients undergoing cardiac surgery. The addition of GNRI to POD prediction models may improve their predictive accuracy. However, these findings were based on a single-center cohort and will need to be validated in future studies involving multiple centers.
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Affiliation(s)
- Zhiqiang Chen
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Quanshui Hao
- Department of AnesthesiologyHuanggang Central Hospital of Yangtze UniversityHuanggangChina
| | - Rao Sun
- Department of Anesthesiology, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yanjing Zhang
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Hui Fu
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Shile Liu
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Chenglei Luo
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Hanwen Chen
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Yiwen Zhang
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
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Zhang S, Zhao D, Yang Z, Wang F, Yang S, Wang C. Circulating mitochondria promoted endothelial cGAS-derived neuroinflammation in subfornical organ to aggravate sympathetic overdrive in heart failure mice. J Neuroinflammation 2024; 21:27. [PMID: 38243316 PMCID: PMC10799549 DOI: 10.1186/s12974-024-03013-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/03/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Sympathoexcitation contributes to myocardial remodeling in heart failure (HF). Increased circulating pro-inflammatory mediators directly act on the Subfornical organ (SFO), the cardiovascular autonomic center, to increase sympathetic outflow. Circulating mitochondria (C-Mito) are the novel discovered mediators for inter-organ communication. Cyclic GMP-AMP synthase (cGAS) is the pro-inflammatory sensor of damaged mitochondria. OBJECTIVES This study aimed to assess the sympathoexcitation effect of C-Mito in HF mice via promoting endothelial cGAS-derived neuroinflammation in the SFO. METHODS C-Mito were isolated from HF mice established by isoprenaline (0.0125 mg/kg) infusion via osmotic mini-pumps for 2 weeks. Structural and functional analyses of C-Mito were conducted. Pre-stained C-Mito were intravenously injected every day for 2 weeks. Specific cGAS knockdown (cGAS KD) in the SFO endothelial cells (ECs) was achieved via the administration of AAV9-TIE-shRNA (cGAS) into the SFO. The activation of cGAS in the SFO ECs was assessed. The expression of the mitochondrial redox regulator Dihydroorotate dehydrogenase (DHODH) and its interaction with cGAS were also explored. Neuroinflammation and neuronal activation in the SFO were evaluated. Sympathetic activity, myocardial remodeling, and cardiac systolic dysfunction were measured. RESULTS C-Mito were successfully isolated, which showed typical structural characteristics of mitochondria with double-membrane and inner crista. Further analysis showed impaired respiratory complexes activities of C-Mito from HF mice (C-MitoHF) accompanied by oxidative damage. C-Mito entered ECs, instead of glial cells and neurons in the SFO of HF mice. C-MitoHF increased the level of ROS and cytosolic free double-strand DNA (dsDNA), and activated cGAS in cultured brain endothelial cells. Furthermore, C-MitoHF highly expressed DHODH, which interacted with cGAS to facilitate endothelial cGAS activation. C-MitoHF aggravated endothelial inflammation, microglial/astroglial activation, and neuronal sensitization in the SFO of HF mice, which could be ameliorated by cGAS KD in the ECs of the SFO. Further analysis showed C-MitoHF failed to exacerbate sympathoexcitation and myocardial sympathetic hyperinnervation in cGAS KD HF mice. C-MitoHF promoted myocardial fibrosis and hypertrophy, and cardiac systolic dysfunction in HF mice, which could be ameliorated by cGAS KD. CONCLUSION Collectively, we demonstrated that damaged C-MitoHF highly expressed DHODH, which promoted endothelial cGAS activation in the SFO, hence aggravating the sympathoexcitation and myocardial injury in HF mice, suggesting that C-Mito might be the novel therapeutic target for sympathoexcitation in HF.
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Affiliation(s)
- Shutian Zhang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, 200032, China
| | - Dajun Zhao
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, 200032, China
| | - Zhaohua Yang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, 200032, China
| | - Fanshun Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, 200032, China
| | - Shouguo Yang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
- Shanghai Institute of Cardiovascular Diseases, Shanghai, 200032, China.
| | - Chunsheng Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
- Shanghai Institute of Cardiovascular Diseases, Shanghai, 200032, China.
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Langnas E, Maze M. Clinical Use of Adrenergic Receptor Ligands in Acute Care Settings. Handb Exp Pharmacol 2024. [PMID: 38177400 DOI: 10.1007/164_2023_705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
In this chapter, we review how ligands, both agonists and antagonists, for the major classes of adrenoreceptors, are utilized in acute care clinical settings. Adrenergic ligands exert their effects by interacting with the three major classes of adrenoceptors. Adrenoceptor agonists and antagonists have important applications, ranging from treatment of hypotension to asthma, and have proven to be extremely useful in a variety of clinical settings of acute care from the operating room to the critical care environment. Continued research interpreting the mechanisms of adrenoreceptors may help the discovery of new drugs with more desirable clinical profiles.
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Affiliation(s)
- Erica Langnas
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA.
- Center for Cerebrovascular Research, UCSF, San Francisco, CA, USA.
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Cocchieri R, Mousavi I, Verbeek EC, Riezebos RK, Yazdanbakhsh AP, de Mol BAMJ. Elderly patients benefit from minimally invasive mitral valve surgery: perioperative risk management matters. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivad211. [PMID: 38191999 PMCID: PMC10799754 DOI: 10.1093/icvts/ivad211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/28/2023] [Accepted: 01/10/2024] [Indexed: 01/10/2024]
Abstract
OBJECTIVES The goal was to assess the single-centre results of minimally invasive mitral valve surgery (MIMVS) in the elderly population. METHODS All patients referred for minimally invasive valve surgery underwent a standardized preoperative screening. We performed a retrospective analysis of 131 consecutive elderly patients (≥75 years) who underwent endoscopic MIMVS through a right mini-thoracotomy. Survival and postoperative course were assessed in 2 groups: a repair group and a replacement group. RESULTS Eighty-five patients underwent mitral valve repair, and 46 had mitral valve replacement. The mean age was 79 ± 2.9 years, and the median follow-up duration was 3.8 years. The cardiopulmonary bypass time (128.7 min vs 155.9 min, P = 0.012) and the cross-clamp time (84.9 min vs 124.1 min, P = 0.005) were significantly longer in the replacement group. Except for more reinterventions for bleeding in the replacement group (10.9% vs 0%, P = 0.005), there were no significant differences in the postoperative course between the 2 groups. Low mortality rates at the midterm follow-up were observed in both groups, and no differences were observed between the 4-and the 12-month follow-up. Survival rates after 1 year and 5 years were 97.6% and 88.6%, respectively, with no significant differences between the 2 groups. CONCLUSIONS MIMVS is an excellent treatment option in vulnerable elderly patients with excellent short- and long-term results. Although other studies suggest that repair could be superior to replacement even in older patients, our experience suggests that replacement is equivalent to repair in terms of mortality and major adverse cardiac and cerebrovascular events. Experience and standardized preoperative screening are mandatory to achieve optimal results.
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Affiliation(s)
| | - Iman Mousavi
- Department of Cardiothoracic Surgery, OLVG, Amsterdam, the Netherlands
| | - Eva C Verbeek
- Department of Cardiothoracic Surgery, OLVG, Amsterdam, the Netherlands
| | | | | | - Bas A M J de Mol
- Department of Cardiothoracic Surgery, AUMC, Amsterdam, the Netherlands
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Zhu S, Liu Y, Wang X, Wang L, Li J, Xue X, Li Z, Liu J, Liu X, Zhao S. Different Sedation Strategies in Older Patients Receiving Spinal Anesthesia for Hip Surgery on Postoperative Delirium: A Randomized Clinical Trial. Drug Des Devel Ther 2023; 17:3845-3854. [PMID: 38169975 PMCID: PMC10759919 DOI: 10.2147/dddt.s439543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
Background Postoperative delirium (POD) is of great concern as a complication of surgery in older adult patients. Sedation strategies influence the development of POD. This study compared how sedation strategies administered during spinal anesthesia influenced POD in patients aged ≥65 years undergoing elective surgery for hip fracture repair. Patients and Methods A randomized clinical trial was conducted from 1 August 2021 to 30 June 2022 at a single academic medical center. Two hundred and twenty-six patients were randomly divided into four groups: lighter sedation with propofol (LP), heavier sedation with propofol (HP), lighter sedation with dexmedetomidine (LD), and heavier sedation with dexmedetomidine (HD). The incidence of delirium was the primary outcome and was assessed daily by the blinded Confusion Assessment Method. Results There was a significant association between dexmedetomidine (LD+HD group) and a lower incidence of delirium (11.9% [13/109] vs the propofol group (23.6% [26/110]; Risk ratio, 0.51; 95% CI, 0.274 to 0.929; p=0.024). In the propofol group, heavier sedation had a higher rate of POD (32.7% [18/55] vs the lighter sedation group (14.5% [8/55]; Risk ratio, 2.25; 95% CI, 1.069 to 4.736; p=0.025). Conclusion Dexmedetomidine was associated with a lower incidence of delirium than that with propofol among older patients with hip fractures. In patients that received propofol, heavier sedation was associated with high incidence of POD.
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Affiliation(s)
- Shuxing Zhu
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People’s Republic of China
| | - Yaqing Liu
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People’s Republic of China
| | - Xiuli Wang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People’s Republic of China
| | - Liang Wang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People’s Republic of China
| | - Jinru Li
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People’s Republic of China
| | - Xiaoming Xue
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People’s Republic of China
| | - Zhao Li
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People’s Republic of China
| | - Jiaxin Liu
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People’s Republic of China
| | - Xin Liu
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People’s Republic of China
| | - Shuang Zhao
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People’s Republic of China
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Lei L, Li Y, Xu H, Zhang Q, Wu J, Zhao S, Zhang X, Xu M, Zhang S. Incidence, associated factors, and outcomes of delirium in critically ill children in china: a prospective cohort study. BMC Psychiatry 2023; 23:925. [PMID: 38082396 PMCID: PMC10712132 DOI: 10.1186/s12888-023-05406-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/26/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Delirium occurs frequently in critically ill children and has been reported in many countries, but delirium is not well-characterized in China. The aim of this study was to represent the incidence of delirium in critically ill children in China, its associated factors, and the influence of delirium on in-hospital outcomes. METHODS This observational prospective cohort study was set up in a large academic medical center with a 57-bed PICU in southwestern China. Critically ill children who required PICU stays over 24 h and were admitted between November 2019 and February 2022 were included in this study. The Cornell Assessment of Pediatric Delirium was used twice daily for delirium evaluation by bedside nurses, and twenty-four clinical features were collected from medical and nursing records during hospitalization. RESULTS The incidence of delirium was 26.0% (n = 410/1576). Multivariate analysis revealed that seven independent risk factors including days of mechanical ventilation and physical restraints, admission diagnosis (neurologic disorder), sleep deprivation, use of benzodiazepines and dexmedetomidine, liver failure/liver dysfunction associated with delirium in critically ill children. One potentially protective factor was the watching television /listening to music/playing with toys. Children with delirium had longer lengths of stay in the PICU (median 11 vs. 10 days, p < 0.001) and hospital (median 18 vs. 15 days, p < 0.001) compared to those without delirium. Additionally, the in-hospital mortality rates were 4.63% and 0.77% in patients with and without delirium (p < 0.05). CONCLUSIONS Delirium is common in critically ill children in China and related to poor outcomes. Interventional studies are warranted to determine the best practices to reduce delirium exposure in at-risk children.
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Affiliation(s)
- Lei Lei
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Yi Li
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Huilin Xu
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Qin Zhang
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Jiacai Wu
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Shoujv Zhao
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Xiaochao Zhang
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Min Xu
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Shuai Zhang
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
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Tian L, Wang H, Jia Y, Jin L, Zhou C, Zhou H, Yuan S. Effect of percutaneous cerebral oximetry-guided anaesthetic management on postoperative delirium in older adults undergoing off-pump coronary artery bypass grafting: study protocol for a single-centre prospective randomised controlled trial in a tertiary academic hospital in China. BMJ Open 2023; 13:e076419. [PMID: 38070897 PMCID: PMC10729170 DOI: 10.1136/bmjopen-2023-076419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Postoperative delirium is a prominent and clinically important complication in older adults after coronary artery bypass grafting (CABG) surgery, resulting in prolonged hospital stay, long-term cognitive impairment and increased morbidity and mortality. Many studies have shown that cerebral desaturation is associated with increased risk of postoperative delirium during on-pump cardiac surgery. However, few studies have focused on the effect of optimising regional cerebral oxygen saturation (rSO2) on postoperative delirium during off-pump CABG. The purpose of this study is to investigate whether intraoperative anaesthetic management based on percutaneous cerebral oximetry monitoring decreases the incidence of postoperative delirium in older adults undergoing off-pump CABG. METHODS This single-centre randomised controlled trial will randomly assign 200 patients to the intervention group or the control group at a ratio of 1:1. The patients in the intervention group will be observed by percutaneous cerebral oximetry monitoring that the desaturation (a drop of more than 20% from baseline value or rSO2 less than 55% for >60 consecutive seconds at either probe) during the procedure triggered the intervention strategies, while the cerebral oximetry data of the control group will be hidden from the clinical team and patients will be anaesthetised by the usual anaesthetic management. The primary outcome will be the incidence of postoperative delirium during the first 7 days after off-pump CABG. Delirium will be comprehensively evaluated by the combination of the Richmond Agitation Sedation Scale and the Confusion Assessment Method for the intensive care unit. The secondary outcomes will include the incidence of postoperative acute kidney injury and myocardial infarction during the hospital stay, as well as the intensive care unit and hospital length of stay. ETHICS AND DISSEMINATION This study was approved by the Ethics Committee of the Chinese Academy of Medical Sciences, Fuwai Hospital (No 2022-1824). Written informed consent will be obtained from each patient or their legal representatives before enrolment. The results of this trial will be published in an international peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER ChiCTR2300068537.
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Affiliation(s)
- Lijuan Tian
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hongbai Wang
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuan Jia
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lei Jin
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Chenghui Zhou
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hongyan Zhou
- Department of Intensive Care Unit, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Jiang S, Liao X, Chen Y, Li B. Exploring postoperative atrial fibrillation after non-cardiac surgery: mechanisms, risk factors, and prevention strategies. Front Cardiovasc Med 2023; 10:1273547. [PMID: 38130687 PMCID: PMC10733488 DOI: 10.3389/fcvm.2023.1273547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023] Open
Abstract
Atrial fibrillation (AF) stands as the most prevalent persistent arrhythmia and a common complication after surgical procedures. Although the majority of non-cardiac surgery patients experience postoperative AF (POAF) and the condition is typically self-limited and asymptomatic, its detrimental impact on patient outcomes, prolonged hospitalization, and heightened risk of stroke and overall mortality has become increasingly evident. Of significant concern, POAF emerges as a noteworthy risk factor for stroke, myocardial infarction, and mortality in comparison to patients with non-surgical atrial fibrillation. Multiple studies have corroborated the association between POAF and an elevated risk of stroke and mortality. The development of postoperative atrial fibrillation is multifactorial, with the inflammatory response being a primary contributor; additionally, factors such as hypovolemia, intraoperative hypotension, anemia, trauma, and pain can trigger POAF. Risk factors for POAF in non-cardiac surgery primarily relate to age, hypertension, obesity, prior cardiac disease, obstructive sleep apnea, and male sex. Prophylactic treatment with β-blockers, amiodarone, or magnesium has demonstrated efficacy, but further trials are warranted, especially in high-risk populations. This review provides an account of the incidence rate, pathophysiology, and prognosis of atrial fibrillation after non-cardiac surgery, elucidates the underlying mechanisms of its occurrence, and explores various preventive strategies investigated in this domain.
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Affiliation(s)
- Shengjie Jiang
- Department of Anesthesiology, Zhongshan City People’s Hospital, Zhongshan, Guangdong, China
| | | | | | - Binfei Li
- Department of Anesthesiology, Zhongshan City People’s Hospital, Zhongshan, Guangdong, China
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Jufar AH, May CN, Booth LC, Evans RG, Cochrane AD, Marino B, Birchall I, Hood SG, McCall PR, Sanders RD, Yao ST, Ortega-Bernal V, Skene A, Bellomo R, Miles LF, Lankadeva YR. Effects of dexmedetomidine on kidney and brain tissue microcirculation and histology in ovine cardiopulmonary bypass: a randomised controlled trial. Anaesthesia 2023; 78:1481-1492. [PMID: 37880924 DOI: 10.1111/anae.16152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/27/2023]
Abstract
Cardiac surgery requiring cardiopulmonary bypass is associated with postoperative acute kidney injury and neurocognitive disorders, including delirium. Intra-operative inflammation and/or impaired tissue perfusion/oxygenation are thought to be contributors to these outcomes. It has been hypothesised that these problems may be ameliorated by the highly selective α2 -agonist, dexmedetomidine. We tested the effects of dexmedetomidine on renal and cerebral microcirculatory tissue perfusion, oxygenation and histology in a clinically relevant ovine model. Sixteen sheep were studied while conscious, after induction of anaesthesia and during 2 h of cardiopulmonary bypass. Eight sheep were allocated randomly to receive an intravenous infusion of dexmedetomidine (0.4-0.8 μg.kg-1 .h-1 ) from induction of anaesthesia to the end of cardiopulmonary bypass, and eight to receive an equivalent volume of matched placebo (0.9% sodium chloride). Commencement of cardiopulmonary bypass decreased renal medullary tissue oxygenation in the placebo group (mean (95%CI) 5.96 (4.24-7.23) to 1.56 (0.84-2.09) kPa, p = 0.001), with similar hypoxic levels observed in the dexmedetomidine group (6.33 (5.33-7.07) to 1.51 (0.33-2.39) kPa, p = 0.002). While no differences in kidney function (i.e. reduced creatinine clearance) were evident, a greater incidence of histological renal tubular injury was observed in sheep receiving dexmedetomidine (7/8 sheep) compared with placebo (2/8 sheep), p = 0.041. Graded on a semi-quantitative scale (0-3), median (IQR [range]) severity of histological renal tubular injury was higher in the dexmedetomidine group compared with placebo (1.5 (1-2 [0-3]) vs. 0 (0-0.3 [0-1]) respectively, p = 0.013). There was no difference in cerebral tissue microglial activation (neuroinflammation) between the groups. Dexmedetomidine did not reduce renal medullary hypoxia or cerebral neuroinflammation in sheep undergoing cardiopulmonary bypass.
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Affiliation(s)
- A H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - C N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - L C Booth
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - R G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - A D Cochrane
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - B Marino
- Cell Saving and Perfusion Resources, Melbourne, Australia
| | - I Birchall
- Neurohistology Laboratory, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - S G Hood
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - P R McCall
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - R D Sanders
- Central Clinical School and NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - S T Yao
- Cardiovascular Neuroscience Laboratory, Department of Anatomy and Physiology, University of Melbourne, Melbourne, Australia
| | - V Ortega-Bernal
- Cardiovascular Neuroscience Laboratory, Department of Anatomy and Physiology, University of Melbourne, Melbourne, Australia
| | - A Skene
- Department of Anatomical Pathology, Austin Health, Melbourne, Australia
| | - R Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - L F Miles
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Y R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
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Grant MC, Chappell D, Gan TJ, Manning MW, Miller TE, Brodt JL. Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society. J Thorac Cardiovasc Surg 2023; 166:1695-1706.e2. [PMID: 36868931 DOI: 10.1016/j.jtcvs.2023.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/07/2023] [Accepted: 01/19/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND Opioid-based anesthesia and analgesia is a traditional component of perioperative care for the cardiac surgery patient. Growing enthusiasm for Enhanced Recovery Programs (ERPs) coupled with evidence of potential harm associated with high-dose opioids suggests that we reconsider the role of opioids in cardiac surgery. METHODS An interdisciplinary North American panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus recommendations for optimal pain management and opioid stewardship for cardiac surgery patients. Individual recommendations are graded based on the strength and level of evidence. RESULTS The panel addressed 4 main topics: the harms associated with historical opioid use, the benefits of more targeted opioid administration, the use of nonopioid medications and techniques, and patient and provider education. A key principle that emerged is that opioid stewardship should apply to all cardiac surgery patients, entailing judicious and targeted use of opioids to achieve optimal analgesia with the fewest potential side effects. The process resulted in the promulgation of 6 recommendations regarding pain management and opioid stewardship in cardiac surgery, focused on avoiding the use of high-dose opioids, as well as encouraging more widespread application of foundational aspects of ERPs, such as the use of multimodal nonopioid medications and regional anesthesia techniques, formal patient and provider education, and structured system-level opioid prescription practices. CONCLUSIONS Based on the available literature and expert consensus, there is an opportunity to optimize anesthesia and analgesia for cardiac surgery patients. Although additional research is needed to establish specific strategies, core principles of pain management and opioid stewardship apply to the cardiac surgery population.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
| | - Michael W Manning
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Timothy E Miller
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Jessica L Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, Calif.
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Mondal S, Bergbower EAS, Cheung E, Grewal AS, Ghoreishi M, Hollander KN, Anders MG, Taylor BS, Tanaka KA. Role of Cardiac Anesthesiologists in Intraoperative Enhanced Recovery After Cardiac Surgery (ERACS) Protocol: A Retrospective Single-Center Study Analyzing Preliminary Results of a Yearlong ERACS Protocol Implementation. J Cardiothorac Vasc Anesth 2023; 37:2450-2460. [PMID: 36517338 DOI: 10.1053/j.jvca.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 10/24/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Enhanced recovery after cardiac surgery (ERACS) has been gaining rapid acceptance after multiple studies have demonstrated promising results in improved outcomes of enhanced recovery after surgery in other surgical fields (eg, colorectal, orthopedic, thoracic, etc). Cardiac surgery has several unique challenges, including sternotomy, cardiopulmonary bypass and associated coagulopathy, blood transfusion, and postoperative intensive care requirement. Nonetheless, selective cardiac surgical patients can still benefit from ERACS. Guidelines for perioperative care in cardiac surgery, previously published by the ERACS Society, are weighted heavily in preoperative and postoperative management without much focus on intraoperative care provided by anesthesiologists. To address this gap and to explore anesthesiology's contribution in achieving ERACS, the study authors' cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol in their institution in February 2020. METHODS The cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol consisting of multimodal opioid-sparing analgesia, including the introduction of regional blocks, hemostasis management protocol, reversal of neuromuscular blockade, and administration of antiemetics in the authors' institution in February 2020. They have conducted a retrospective chart review study comparing patients who have received ERACS measures with a similar historic cohort who underwent cardiac surgery prior to initiation of an ERACS protocol. The primary outcomes of the study were to determine patients' time to extubation, postoperative opioid consumption, intensive care unit (ICU) length of stay (LOS), and incidence of postoperative complications (eg, postoperative nausea vomiting [PONV], bleeding, ICU readmission, delirium. RESULTS The ERACS patients showed reduced opioid consumption (intraoperative fentanyl; postoperative fentanyl, as well as oxycodone, in the first 6 hours postoperatively), lesser mechanical ventilation (2.5 hours less), shorter ICU stays (5 hours less), shorter hospital LOS (1 day), and lesser incidence of PONV. None of the ERACS patients required blood transfusion. The study authors performed an anonymous survey among the anesthesiologists and ICU providers to assess providers' satisfaction, which showed 92% of survey takers agreed that the ERACS protocol should be continued for future cardiac patients, and 61% of survey takers reported superior pain control in ERACS group of patients while managing those patients. DISCUSSION The ERACS is achievable after the careful implementation of a series of measures. It does not signify only fast-track extubation and opioid-sparing analgesia, and must be implemented in the entire perioperative period beginning from preoperative clinic to postoperative rehabilitation. Cardiac anesthesiologists play a vital role in execution of intraoperative ERACS measures. Both providers and patients themselves are key stakeholders. A larger randomized prospective trial is warranted to solidify the inference.
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Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
| | - Emily A S Bergbower
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Enoch Cheung
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Ashanpreet S Grewal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Mehrdad Ghoreishi
- Department of Surgery, Cardiothoracic division, University of Maryland School of Medicine, Baltimore, MD
| | - Kimberly N Hollander
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Megan G Anders
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Bradley S Taylor
- Department of Surgery, Cardiothoracic division, University of Maryland School of Medicine, Baltimore, MD
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Li L, Liu M, Li S, Xu J, Zheng J, Lv C, Wu L, Heng L. Influence of Regional Nerve Block in Addition to General Anesthesia on Postoperative Delirium, Pain, and In-hospital Stay in Patients Undergoing Cardiothoracic Surgery: A Meta-analysis. J Cardiovasc Pharmacol 2023; 82:496-503. [PMID: 37548460 DOI: 10.1097/fjc.0000000000001469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/14/2023] [Indexed: 08/08/2023]
Abstract
ABSTRACT This study aims to investigate whether venous injection of sedative agent or regional nerve block in alliance with major anesthesia could decrease the risk of postoperative delirium occurrence in patients receiving cardiothoracic surgery. Electronic academic databases were retrieved for related publications, and statistical software was used for data pooling and analysis. Forest plot was used to show the pooled sensitivity, specificity, and diagnostic odds ratio. Combined receiver operating characteristic curve was used to show the area under the curve of complex data. Seven studies were included for analysis. The risk of occurrence of delirium still showed no difference (risk rate = 0.93, 95% CI, 0.85-1.03) between the intervention group and placebo group. Postoperative pain feeling was more alleviated in patients with prophylactic application of regional nerve block. In addition, prophylactic application of regional nerve block could decrease the risk of postoperative in-hospital stay (risk rate = 0.28, 95% CI, 0.02-0.54). Our study demonstrated that, in elderly patients or pediatric patients undergoing cardiac surgery, prophylactic application of regional nerve block failed to decrease the incidence of postoperative delirium. However, the option of regional nerve block could decrease the duration of in-hospitalization stay and alleviate the acute pain during the postoperative period after open-heart surgery.
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Affiliation(s)
- Li Li
- Department of Critical Care Medicine, First People's Hospital of Xuzhou, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University, Affiliated Hospital of Mining and Technology of China University, Xuzhou, Jiangsu, China
| | - Min Liu
- Department of Thoracic Surgery, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Songsong Li
- Department of Orthopedics, First People's Hospital of Xuzhou, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University, Affiliated Hospital of Mining and Technology of China University, Xuzhou, Jiangsu, China
| | - Jiahui Xu
- Department of Ophthalmology, First People's Hospital of Xuzhou, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University, Affiliated Hospital of Mining and Technology of China University, Xuzhou, Jiangsu, China
| | - Jun Zheng
- Department of Orthopedics, First People's Hospital of Xuzhou, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University, Affiliated Hospital of Mining and Technology of China University, Xuzhou, Jiangsu, China
| | - Chengwei Lv
- Department of Critical Care Medicine, First People's Hospital of Xuzhou, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University, Affiliated Hospital of Mining and Technology of China University, Xuzhou, Jiangsu, China
| | - Linlin Wu
- Department of Hemodialysis, First People's Hospital of Xuzhou, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University, Affiliated Hospital of Mining and Technology of China University, Xuzhou, Jiangsu, China
| | - Lei Heng
- Department of Anesthesiology, Xuzhou Cancer Hospital, Xuzhou City, Jiangsu Province, China
- Department of Anesthesiology, Xuzhou New Healthy Geriatric Hospital, Xuzhou City, Jiangsu Province, China; and
- Department of Anesthesiology, the Affiliated Xuzhou Hospital of JiangSu University, Xuzhou City, Jiangsu Province, China
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Gilbey T, Milne B, de Somer F, Kunst G. Neurologic complications after cardiopulmonary bypass - A narrative review. Perfusion 2023; 38:1545-1559. [PMID: 35986553 PMCID: PMC10612382 DOI: 10.1177/02676591221119312] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
Neurologic complications, associated with cardiac surgery and cardiopulmonary bypass (CPB) in adults, are common and can be devastating in some cases. This comprehensive review will not only consider the broad categories of stroke and neurocognitive dysfunction, but it also summarises other neurological complications associated with CPB, and it provides an update about risks, prevention and treatment. Where appropriate, we consider the impact of off-pump techniques upon our understanding of the contribution of CPB to adverse outcomes.
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Affiliation(s)
- Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Filip de Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King’s College London British Heart Foundation Centre of Excellence, London, UK
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Huang D, Chai D, Huang P, Zhu H, Jiang X, Shu H, Shi X, Yu W, Su D. Continuous theta burst stimulation for the treatment of delirium after non-cardiac surgery. J Clin Anesth 2023; 90:111217. [PMID: 37494881 DOI: 10.1016/j.jclinane.2023.111217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/11/2023] [Accepted: 07/18/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Dan Huang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200127, China
| | - Di Chai
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200127, China
| | - Ping Huang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200127, China
| | - Hao Zhu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200127, China
| | - Xin Jiang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200127, China
| | - Huigang Shu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200127, China
| | - Xiao Shi
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200127, China
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200127, China.
| | - Diansan Su
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200127, China.
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Ferreira LO, Vasconcelos VW, Lima JDS, Vieira Neto JR, da Costa GE, Esteves JDC, de Sousa SC, Moura JA, Santos FRS, Leitão Filho JM, Protásio MR, Araújo PS, Lemos CJDS, Resende KD, Lopes DCF. Biochemical Changes in Cardiopulmonary Bypass in Cardiac Surgery: New Insights. J Pers Med 2023; 13:1506. [PMID: 37888117 PMCID: PMC10608001 DOI: 10.3390/jpm13101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/19/2023] [Accepted: 08/23/2023] [Indexed: 10/28/2023] Open
Abstract
Patients undergoing coronary revascularization with extracorporeal circulation or cardiopulmonary bypass (CPB) may develop several biochemical changes in the microcirculation that lead to a systemic inflammatory response. Surgical incision, post-CPB reperfusion injury and blood contact with non-endothelial membranes can activate inflammatory signaling pathways that lead to the production and activation of inflammatory cells, with cytokine production and oxidative stress. This inflammatory storm can cause damage to vital organs, especially the heart, and thus lead to complications in the postoperative period. In addition to the organic pathophysiology during and after the period of exposure to extracorporeal circulation, this review addresses new perspectives for intraoperative treatment and management that may lead to a reduction in this inflammatory storm and thereby improve the prognosis and possibly reduce the mortality of these patients.
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Affiliation(s)
- Luan Oliveira Ferreira
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
- Laboratory of Experimental Neuropathology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil
| | - Victoria Winkler Vasconcelos
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Janielle de Sousa Lima
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Jaime Rodrigues Vieira Neto
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Giovana Escribano da Costa
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Jordana de Castro Esteves
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Sallatiel Cabral de Sousa
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Jonathan Almeida Moura
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Felipe Ruda Silva Santos
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - João Monteiro Leitão Filho
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | | | - Pollyana Sousa Araújo
- Department of Cardiovascular Anesthesiology, Hospital Clínicas Gaspar Vianna, Belém 66083-106, Brazil; (P.S.A.); (C.J.d.S.L.)
| | - Cláudio José da Silva Lemos
- Department of Cardiovascular Anesthesiology, Hospital Clínicas Gaspar Vianna, Belém 66083-106, Brazil; (P.S.A.); (C.J.d.S.L.)
| | - Karina Dias Resende
- Residency Program in Anesthesiology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil; (V.W.V.); (J.d.S.L.); (J.R.V.N.); (G.E.d.C.); (J.d.C.E.); (S.C.d.S.); (J.A.M.); (F.R.S.S.); (J.M.L.F.); (K.D.R.)
| | - Dielly Catrina Favacho Lopes
- Laboratory of Experimental Neuropathology, João de Barros Barreto University Hospital, Federal University of Pará, Belém 66073-000, Brazil
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Luca E, Schipa C, Cambise C, Sollazzi L, Aceto P. Implication of age-related changes on anesthesia management. Saudi J Anaesth 2023; 17:474-481. [PMID: 37779561 PMCID: PMC10540993 DOI: 10.4103/sja.sja_579_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 10/03/2023] Open
Abstract
Elderly patients have a high risk of perioperative morbidity and mortality. Pluri-morbidities, polypharmacy, and functional dependence may have a great impact on intraoperative management and request specific cautions. In addition to surgical stress, several perioperative noxious stimuli such as fasting, blood loss, postoperative pain, nausea and vomiting, drug adverse reactions, and immobility may trigger a derangement leading to perioperative complications. Older patients have a high risk of major hemodynamic derangement due to aging of the cardiovascular system and associated comorbidities. The hemodynamic monitoring as well as fluid therapy should be the most accurate as possible. Aging is accompanied by decreased renal function, which is related to a reduction in renal blood flow, renal mass, and the number and size of functioning nephrons. Drugs eliminated predominantly by the renal route need dosage adjustments based on residual renal function. Liver mass, hepatic blood flow, and intrinsic metabolic activity are decreased in the elderly, and all drugs metabolized by the liver have a variable half-life, thus requiring dose reduction. Decreased neural plasticity contributes to a high risk for postoperative delirium. Monitoring of anesthesia depth should be mandatory to avoid overdosage of hypnotic drugs. Prevention of postoperative pulmonary complications requires both protective ventilation strategies and adequate recovery of neuromuscular function at the end of surgery. Avoidance of hypothermia cannot be missed. The aim of this review is to describe comprehensive strategies for intraoperative management plans tailored to meet the unique needs of elderly surgical patients, thus improving outcomes in this vulnerable population.
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Affiliation(s)
- Ersilia Luca
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Chiara Schipa
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Chiara Cambise
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Liliana Sollazzi
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paola Aceto
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
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Luo D, Zhou Y, Yue Z, Shi M, Shao L, Hui K, Gu Z, Duan M. Factors responsible for unanticipated hypertension during emergence from general anesthesia. Chin Med J (Engl) 2023; 136:2263-2265. [PMID: 37612244 PMCID: PMC10508461 DOI: 10.1097/cm9.0000000000002809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Indexed: 08/25/2023] Open
Affiliation(s)
- Dongxue Luo
- Department of Anesthesiology, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210008, China
| | - Yaqing Zhou
- College of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Zichuan Yue
- Department of Anesthesiology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Min Shi
- Department of Anesthesiology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Luyi Shao
- College of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Kangli Hui
- Department of Anesthesiology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Zhongya Gu
- Department of Anesthesiology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Manlin Duan
- College of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
- Department of Anesthesiology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
- Department of Anesthesiology, Nanjing BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu 210019, China
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Klaschik S, Coburn M. [Special features of the perioperative course in patients with frailty syndrome]. DIE ANAESTHESIOLOGIE 2023; 72:685-694. [PMID: 37594509 DOI: 10.1007/s00101-023-01321-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 08/19/2023]
Abstract
The demographic change with an increase in the number of geriatric patients presents major challenges for perioperative medicine. Frailty is a multimorbidity complex that incorporates a combination of various factors, such as physical weakness, slower walking speed and unwanted weight loss. It is of great importance that these patients receive an individually adapted perioperative care. This includes, among others, a preoperative examination for frailty, a structured prehabilitation according to the concept of better in, better out, the compliance with the guidelines on prevention and timely treatment of postoperative delirium as well as the continuous maintenance of the body's homeostasis. By means of these measures the risk of complications in this patient group can be reduced and the best possible postoperative results can be achieved.
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Affiliation(s)
- Sven Klaschik
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Mark Coburn
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinik Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
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Schaffer AJ, Li G, McIlroy DR, Lopez MG, Freundlich RE. Effects of Postoperative Blood Pressure Management on Delirium Among Patients in the Intensive Care Unit After Cardiac Surgery: An Observational Cohort Study. J Cardiothorac Vasc Anesth 2023; 37:1683-1690. [PMID: 37244820 PMCID: PMC10524613 DOI: 10.1053/j.jvca.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/17/2023] [Accepted: 05/05/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVES This study aimed to determine whether blood pressure control in the early postoperative period was associated with postoperative delirium in the cardiovascular intensive care unit (ICU). DESIGN Observational cohort study. SETTING Single large academic institution with a high volume of cardiac surgery. PARTICIPANTS Cardiac surgery patients admitted to the cardiovascular ICU after surgery. INTERVENTIONS Observational study. MEASUREMENTS AND MAIN RESULTS A total of 517 cardiac surgery patients had mean arterial pressure (MAP) data recorded minute-by-minute for 12 postoperative hours. The time spent in each of the 7 prespecified blood pressure bands was calculated, and the development of delirium was recorded in the ICU. A multivariate Cox regression model was developed using the least absolute shrinkage and selection operator approach to identify associations between time spent in each MAP range band and delirium. Compared with the reference band of 60-to-69 mmHg, longer durations spent in 3 bands were independently associated with a lower risk of delirium: 50-to-59 mmHg band (adjusted hazard ratio [HR] 0.907 [per 10 minutes]; 95% CI 0.861-0.955); 70-to-79 mmHg band (adjusted HR 0.923 [per 10 minutes]; 95% CI 0.902-0.944); 90-to-99 mmHg band (adjusted HR 0.898 [per 10 minutes]; 95% CI 0.853-0.945). CONCLUSIONS The MAP range bands above and below the authors' reference band of 60-to- 69 mmHg were associated with decreased risk of ICU delirium development; however, this was difficult to reconcile with a plausible biologic mechanism. Therefore, the authors did not find a correlation between early postoperative MAP control and increased risk of the development of ICU delirium after cardiac surgery.
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Affiliation(s)
| | - Gen Li
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David R McIlroy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Anaesthesia & Perioperative Medicine, Monash University, Melbourne, Australia
| | - Marcos G Lopez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert E Freundlich
- Department of Anesthesiology, Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.
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Yu M, Li Y, Li B, Ge Q. Inflammatory biomarkers and delirium: a Mendelian randomization study. Front Aging Neurosci 2023; 15:1221272. [PMID: 37649721 PMCID: PMC10464607 DOI: 10.3389/fnagi.2023.1221272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/25/2023] [Indexed: 09/01/2023] Open
Abstract
Background The association between inflammatory biomarkers and individual delirium symptoms remains controversial in observational studies. We investigated the relationship between inflammatory biomarkers and the risk of developing delirium. Methods A bidirectional two-sample Mendelian randomization (MR) was performed. Genetic instruments associated with peripheral tumor necrosis factor-a (TNF-a) C-reactive protein (CRP), interleukin (IL)-1α, IL-1β, IL-2, IL-8, IL-6, soluble IL-6 receptor alpha (sIL-6Rα), and soluble gp130 were identified in three different large summary genome-wide association studies (GWAS) conducted in the European population. Summary-level statistics for delirium not induced by alcohol and other psychoactive substances were obtained from the FinnGen consortium (2,612 cases and 325,306 controls). The estimated causal effects were performed using instruments' variants at the genome-wide significant level (P < 5e-8 and P < 5e-6), applying a linkage disequilibrium clumping approach with a threshold of r2 < 0.001 for each of the exposures. Reverse causation was also performed. The inverse-variance weighted method (IVW), MR-Egger method, weighted median method, MR-Egger regression, and MR Pleiotropy RESidual Sum were used for MR analyses. Results At the genome-wide significant level (P < 5e-8, r2 < 0.001), genetically predicted sIL-6Rα was significantly associated with a decreased risk of delirium with less than three single-nucleotide polymorphisms (SNPs) in all three GWAS data sources (ORWaldratio = 0.89, 95% CI: 0.79-0.96, PWaldratio = 0.0016; ORIVW = 0.88, 95% CI: 0.79-0.97, PIVW = 0.008; ORIVW = 0.88, 95% CI: 0.80-0.96, PIVW = 0.004). The causal relationship between sIL-6Rα and delirium became non-significant when a more liberal threshold of P of < 5e-6 was applied (all PIVW > 0.05). At the two genome-wide significance levels (P < 5e-8 and P < 5e-6), we found no evidence for the causal effects of peripheral TNF-α, CRP, IL-1α, IL-1β, IL-2, IL-6, IL-8, and soluble gp130 on delirium (all P > 0.05). The MR-Egger intercept and MR-PRESSO results indicated that no SNP had possible pleiotropy (all P > 0.05). Regarding the reverse, no evidence for an effect of delirium on these inflammatory biomarkers could be found (all P > 0.05). Conclusion The results of this MR analysis did not support that peripheral TNF-α, CRP, IL-1α, IL-1β, IL-2, IL-6, sIL-6Rα, soluble gp130, and IL-8 were causally associated with delirium. More research is needed to explore the role of inflammatory factors in the pathogenesis of delirium.
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Affiliation(s)
- Miao Yu
- Department of Nursing, Peking University Third Hospital, Beijing, China
| | - Yuxuan Li
- Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
| | - Baohua Li
- Department of Nursing, Peking University Third Hospital, Beijing, China
| | - Qinggang Ge
- Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
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Makkad B, Heinke TL, Sheriffdeen R, Khatib D, Brodt JL, Meng ML, Grant MC, Kachulis B, Popescu WM, Wu CL, Bollen BA. Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2. Anesth Analg 2023; 137:26-47. [PMID: 37326862 DOI: 10.1213/ane.0000000000006506] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.
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Affiliation(s)
- Benu Makkad
- From the Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Raiyah Sheriffdeen
- Department of Anesthesiology, Medstar Washington Hospital Center, Washington, DC
| | - Diana Khatib
- Department of Anesthesiology, Weil Cornell Medical College, New York, New York
| | - Jessica Louise Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bessie Kachulis
- Department of Anesthesiology, Columbia University, New York, New York
| | - Wanda Maria Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher L Wu
- Department of Anesthesiology, Hospital of Special Surgery, Weill Cornell Medical College, New York, New York
| | - Bruce Allen Bollen
- Missoula Anesthesiology, Missoula, Montana
- The International Heart Institute of Montana, Missoula, Montana
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周 晨, 汪 晖, 吴 前, 周 雁, 王 兰, 王 萧, 曾 莹, 代 玲, 张 娜, 瞿 茜. [Postoperative Delirium in Patients on Cardiopulmonary Bypass for Cardiovascular Surgeries: Incidence and Influencing Factors]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2023; 54:752-758. [PMID: 37545069 PMCID: PMC10442630 DOI: 10.12182/20230760105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Indexed: 08/08/2023]
Abstract
Objective To investigate the incidence and influencing factors of postoperative delirium (POD) and subsyndromal delirium (SSD) in patients connected to cardiopulmonary bypass during cardiovascular surgeries. Methods We collected the general data and the data for the perioperative hematological, physiological, and biochemical indicators and the surgical and therapeutic conditions of patients connected to cardiopulmonary bypass during the course of cardiovascular surgeries conducted at a tertiary-care hospital in Hubei province between May 2022 and September 2022. The outcome indicators, including the incidence of POD and SSD, were assessed with the Nursing Delirium Screening Scale (Nu-DESC). Multinomial logistic regression was performed to analyze the influencing factors of patients with different statuses of POD and SSD. Results Among the 202 patients, the incidence of SSD, SSD progressing to POD, and no POD or SSD (ND) progressing to POD were 13.4%, 6.4%, and 34.2%, respectively. Regression analysis showed that, with ND patients as the controls, the influencing factors for SSD were preoperative blood glucose (odds ratio [ OR]=0.38, 95% confidence interval [ CI]: 0.19-0.76), intraoperative platelet transfusion ( OR=0.37, 95% CI: 0.15-0.92), intraoperative etomidate ( OR=0.93, 95% CI: 0.87-0.98), and postoperative total bilirubin level ( OR=1.04, 95% CI: 1.01-1.07). For the progression of SSD to POD, the influencing factors were age ( OR=1.09, 95% CI: 1.01-1.17), ASA classification of IV and above ( OR=10.72, 95% CI: 1.85-62.08), intraoperative dexmedetomidine ( OR=1.01, 95% CI: 1.003-1.02), and the duration of mechanical ventilation ( OR=1.04, 95% CI: 1.01-1.07). For the progression of ND to POD, the influencing factors were age ( OR=1.06, 95% CI: 1.02-1.10), middle or high school education ( OR=0.35, 95% CI: 0.15-0.83), and the duration of mechanical ventilation ( OR=1.04, 95% CI: 1.01-1.07). Conclusion Age, education, ASA classification, preoperative blood glucose, intraoperative platelet transfusion, intraoperative etomidate, intraoperative dexmedetomidine, postoperative total bilirubin, and the duration of mechanical ventilation are influencing factors for different statuses of POD and SSD among patients connected to cardiopulmonary bypass when they are undergoing cardiovascular surgeries. The influencing factors vary across groups of patients with different statuses of POD and SSD. Therefore, we should accurately assess the risk factors of patients with different statuses of POD and SSD and carry out corresponding interventions, thereby preventing or reducing the occurrence of POD and SSD, and ultimately promoting enhanced recovery after surgery.
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Affiliation(s)
- 晨曦 周
- 华中科技大学同济医学院附属同济医院 护理部 (武汉 430030)Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - 晖 汪
- 华中科技大学同济医学院附属同济医院 护理部 (武汉 430030)Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - 前胜 吴
- 华中科技大学同济医学院附属同济医院 护理部 (武汉 430030)Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - 雁荣 周
- 华中科技大学同济医学院附属同济医院 护理部 (武汉 430030)Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - 兰 王
- 华中科技大学同济医学院附属同济医院 护理部 (武汉 430030)Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - 萧萧 王
- 华中科技大学同济医学院附属同济医院 护理部 (武汉 430030)Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - 莹 曾
- 华中科技大学同济医学院附属同济医院 护理部 (武汉 430030)Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - 玲 代
- 华中科技大学同济医学院附属同济医院 护理部 (武汉 430030)Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - 娜 张
- 华中科技大学同济医学院附属同济医院 护理部 (武汉 430030)Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - 茜 瞿
- 华中科技大学同济医学院附属同济医院 护理部 (武汉 430030)Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Kotake K, Matsunuma S, Takahashi T, Kitamura N, Kawakami Y. Yokukansan (TJ-54) in patients undergoing surgery: A systematic review and meta-analysis. Geriatr Nurs 2023; 52:8-15. [PMID: 37196515 DOI: 10.1016/j.gerinurse.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/21/2023] [Accepted: 04/21/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVES To evaluate the efficacy and safety of Yokukansan (TJ-54) in patients undergoing surgery. METHODS Efficacy was assessed by the onset of delirium, delirium rating scales, anxiety evaluated by Hospital Anxiety and Depression Scale-Anxiety (HADS-A) score, and safety was assessed by any reported adverse events. RESULTS Six studies were included. There were no significant differences between the groups in the onset of delirium (risk ratio 1.15, 95% confidence interval [CI] 0.77-1.72), delirium rating scales (early postoperative period: standardized mean difference [SMD] -0.24, 95% CI -1.11 to 0.63; late postoperative period: SMD -0.06, 95% CI -1.56 to 1.45), HADS-A score (mean difference -0.47, 95% CI -1.90 to 0.96), and any adverse events (risk ratio 1.18, 95% CI 0.35-4.00). CONCLUSIONS The use of TJ-54 in patients undergoing surgery is not an effective strategy for postoperative delirium and anxiety. Further research considering target patients and durations of administration should be conducted.
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Affiliation(s)
- Kazumasa Kotake
- Department of Pharmacy, Okayama Saiseikai General Hospital, Japan.
| | - Satoru Matsunuma
- Department of Pharmacy, Tokyo Medical University Hachioji Medical Center, Japan
| | | | - Naoya Kitamura
- Department of Neuropsychiatry, Okayama Saiseikai General Hospital, Japan
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Wittwer ED, Cerhan JH, Schroeder DR, Schaff HV, Mauermann WJ. Impact of ketamine versus propofol for anesthetic induction on cognitive dysfunction, delirium, and acute kidney injury following cardiac surgery in elderly, high-risk patients. Ann Card Anaesth 2023; 26:274-280. [PMID: 37470525 PMCID: PMC10451121 DOI: 10.4103/aca.aca_106_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/20/2022] [Accepted: 09/02/2022] [Indexed: 07/21/2023] Open
Abstract
Objective Evaluate the effects of ketamine versus propofol when used for induction of anesthesia in elderly, high-risk cardiac surgical patients on postoperative complications including cognitive dysfunction, delirium, and acute kidney injury. Methods Prospective, randomized study performed at a tertiary medical center. A total of 52 patients aged ≥70 and older presenting for complex cardiac surgery were randomized to receive either ketamine or propofol for induction of anesthesia. Patients underwent a battery of cognitive testing preoperatively and postoperatively and the incidence of delirium and acute kidney injury were measured. Norepinephrine (NEE) equivalents following induction were assessed for each group. Results A total of 49 patients were included, 25 in the ketamine group and 24 in the propofol group with 3 patients excluded from the analysis. No difference was found between groups in either postoperative cognitive dysfunction or delirium incidence. Acute kidney injury occurred in 6 (24%) patients in the ketamine group in 12 (50%) patients in the propofol group, but the difference did not meet statistical significance (P = 0.08; Relative Risk = 2.1, 95% CI 0.9-4.7). NEE equivalents were lower in the ketamine group, 9.6 ± 22.2 versus 32.7 ± 46.0, P < 0.03. Conclusions The use of ketamine versus propofol for induction of anesthesia did not impact the incidence of postoperative cognitive dysfunction or delirium. Twice as many patients in the propofol group developed acute kidney injury, although not reaching statistical significance and warranting further investigation. In elderly, high-risk patients, ketamine was associated with a significantly reduced need for vasopressor support following induction.
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Affiliation(s)
- Erica D. Wittwer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jane H. Cerhan
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Hartzell V. Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William J. Mauermann
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Tsivitis A, Wang A, Murphy J, Khan A, Jin Z, Moore R, Tateosian V, Bergese S. Anesthesia, the developing brain, and dexmedetomidine for neuroprotection. Front Neurol 2023; 14:1150135. [PMID: 37351266 PMCID: PMC10282145 DOI: 10.3389/fneur.2023.1150135] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/18/2023] [Indexed: 06/24/2023] Open
Abstract
Anesthesia-induced neurotoxicity is a set of unfavorable adverse effects on central or peripheral nervous systems associated with administration of anesthesia. Several animal model studies from the early 2000's, from rodents to non-human primates, have shown that general anesthetics cause neuroapoptosis and impairment in neurodevelopment. It has been difficult to translate this evidence to clinical practice. However, some studies suggest lasting behavioral effects in humans due to early anesthesia exposure. Dexmedetomidine is a sedative and analgesic with agonist activities on the alpha-2 (ɑ2) adrenoceptors as well as imidazoline type 2 (I2) receptors, allowing it to affect intracellular signaling and modulate cellular processes. In addition to being easily delivered, distributed, and eliminated from the body, dexmedetomidine stands out for its ability to offer neuroprotection against apoptosis, ischemia, and inflammation while preserving neuroplasticity, as demonstrated through many animal studies. This property puts dexmedetomidine in the unique position as an anesthetic that may circumvent the neurotoxicity potentially associated with anesthesia.
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Affiliation(s)
- Alexandra Tsivitis
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, New York, NY, United States
| | - Ashley Wang
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, New York, NY, United States
| | - Jasper Murphy
- Renaissance School of Medicine, Stony Brook University, Stony Brook, New York, NY, United States
| | - Ayesha Khan
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, New York, NY, United States
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, New York, NY, United States
| | - Robert Moore
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, New York, NY, United States
| | - Vahe Tateosian
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, New York, NY, United States
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, New York, NY, United States
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Li HX, Li BL, Wang TH, Xu X, Wang F, Zhang X, Zhang X, Li HY, Mu B, Sun YL, Zheng H, Yan T. Comparison of the effects of remimazolam tosylate and propofol on postoperative delirium among older adults undergoing major non-cardiac surgery: protocol for a randomised controlled trial. BMJ Open 2023; 13:e071912. [PMID: 37247962 DOI: 10.1136/bmjopen-2023-071912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common cognitive disturbance in elderly individuals that is characterised by acute and fluctuating impairments in attention and awareness. Remimazolam tosylate is a novel, ultrashort-acting benzodiazepine, and there is limited evidence of its correlation with the incidence of early POD. The aim of this study is to evaluate the incidence of POD after anaesthesia induction and maintenance with remimazolam tosylate or propofol in elderly patients undergoing major non-cardiac surgery. METHODS AND ANALYSIS This is a single-centre, randomised controlled trial. 636 elderly patients undergoing major non-cardiac surgery will be enrolled and randomised at a 1:1 ratio to receive total intravenous anaesthesia with either remimazolam tosylate or propofol. The primary outcome is the incidence of POD within 5 days after surgery. Delirium will be assessed twice daily by the 3 min Diagnostic Interview for the Confusion Assessment Method or the Confusion Assessment Method for the intensive care unit (ICU) for ICU patients. Secondary outcomes are the onset and duration of delirium, cognitive function at discharge and within 1-year postoperatively, postoperative analgesia within 5 days, chronic pain at 3 months, quality of recovery and postoperative inflammatory biomarker levels. ETHICS AND DISSEMINATION The study was approved by the institutional ethics committee of the National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (approval No. 22/520-3722). Written informed consent will be obtained from each patient before enrolment. The results of this trial will be presented at scientific conferences and in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER ChiCTR2300067368.
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Affiliation(s)
- Hui-Xian Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bao-Li Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tai-Hang Wang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Xu
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Wang
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao Zhang
- Department of Pathergasiology, Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
| | - Xin Zhang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong-Yi Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing Mu
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Lin Sun
- State Key Laboratory of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Zheng
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Yan
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Nakamura R, Miyamoto K, Tsuji K, Ozaki K, Kunimoto H, Honda K, Nishimura Y, Kato S. The impact of a preoperative nurse-led orientation program on postoperative delirium after cardiovascular surgery: a retrospective single-center observational study. J Intensive Care 2023; 11:20. [PMID: 37198714 DOI: 10.1186/s40560-023-00666-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Postoperative delirium in intensive care is common and associated with mortality, cognitive impairment, prolonged hospital stays and high costs. We evaluate whether a nurse-led orientation program could reduce the incidence of delirium in the intensive care unit after cardiovascular surgery. METHODS In this retrospective cohort study, we enrolled patients admitted to the intensive care unit for planned cardiovascular surgery between January 2020 and December 2021. A nurse-led orientation program based on a preoperative visit was routinely introduced from January 2021. We assessed the association between these visits and postoperative delirium in the intensive care unit. We also assessed predictors of postoperative delirium with baseline and intraoperative characteristics. RESULTS Among 253 patients with planned cardiovascular surgery, 128 (50.6%) received preoperative visits. Valve surgery comprised 44.7%, coronary surgery 31.6%, and aortic surgery 20.9%. Cardiopulmonary bypass use and transcatheter surgery were 60.5% and 12.3%, respectively. Incidence of delirium was lower in patients that received preoperative visits, and median hospital stay was shorter than in those without visits (18 patients [14.1%] vs 34 patients [27.2%], P < 0.01; 14 days vs 17 days, P < 0.01). After adjusting predefined confounders, preoperative visits were independently associated with decreased incidence of delirium (adjusted odds ratio [aOR] 0.45; 95% confidence interval [95% CI] 0.22-0.84). Other predictors of delirium were higher European System for Cardiac Operative Risk Evaluation II score and lower minimum intraoperative cerebral oxygen saturation. CONCLUSIONS A preoperative nurse-led orientation program was associated with reduction of postoperative delirium and could be effective against postoperative delirium after cardiovascular surgery. Trial registration UMIN Clinical Trial Registry no. UMIN000048142. Registered 22, July, 2022, retrospectively registered, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000054862 .
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Affiliation(s)
- Ryo Nakamura
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan.
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan.
| | - Kyohei Miyamoto
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Kaori Tsuji
- Department of Nursing, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Kana Ozaki
- Department of Nursing, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Hideki Kunimoto
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Kentaro Honda
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Yoshiharu Nishimura
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Seiya Kato
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
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