The Preventive Effect of Transcutaneous Electrical Acupoint Stimulation on Postoperative Delirium in Elderly Patients with Time Factors: A Randomized Trial

Characteristics associated with effectiveness in postoperative delirium research: a systematic review of randomised controlled trials with meta-regression and meta-analysis

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).

Transcutaneous electrical acupoint stimulation reduces postoperative patients' length of stay and hospitalization costs: a systematic review and meta-analysis

OBJECTIVE

To study the effects of transcutaneous electrical acupoint stimulation (TEAS) on length of stay (LOS) and hospitalization costs in postoperative inpatients.

METHODS

Two researchers collectively searched PubMed, Embase, Cochrane Library, China Network Knowledge Infrastructure, and Wanfang Database. The search time was set from the beginning to 25 April 2023, to identify randomized controlled trials articles that met the criteria. Statistical analyses were performed using the Stata software (version 16.0). The risk of bias was assessed using the Cochrane risk-of-bias tool, and publication bias was evaluated using a funnel plot and Egger's test. The quality of evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

Thirty-four randomized controlled trials were included. The main results showed that TEAS reduced hospitalization costs [standardized mean difference (SMD)=-1.92; 95% CI: -3.40, -0.43), LOS (SMD=-1.00; 95% CI: -1.30, -0.70) and postoperative LOS (SMD=-0.70; 95% CI: -0.91, -0.49] in postoperative patients. Subgroup analyses further revealed that TEAS was effective in reducing both the overall and postoperative LOS in patients undergoing multiple surgical procedures. It is worth noting that the observed heterogeneity in the results may be attributed to variations in surgical procedures, stimulation frequencies, and stimulation points utilized in different trials.

CONCLUSIONS

TEAS can help postoperative patients reduce their LOS and hospitalization cost. However, considering the bias identified and heterogeneity, the results of this review should be interpreted with caution.

Effect of Transcutaneous Electrical Acupoint Stimulation on Extubation-Related Stress Response in Noncardiac Surgery Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

Stress response is a common complication during extubation, mainly manifested by dramatic hemodynamic fluctuations. Transcutaneous electrical acupoint stimulation (TEAS) is widely applied in the perioperative period. We performed this meta-analysis to evaluate whether the TEAS could relieve the stress response during extubation in noncardiac surgery patients.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

METHODS

We searched six databases (PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure, CNKI, and Wan Fang) for relevant literature. A risk of bias assessment was executed based on the Cochrane Criteria. We applied RevMan5.4.1 software to analyze data. When the χ2 test did not show heterogeneity, we adopted the fixed-effect model. Otherwise, the random-effect model was used.

FINDINGS

ln total, 12 randomized controlled trials with 1,347 participants were enrolled in this meta-analysis. Meta-analysis showed the heart rate and mean arterial pressure of the intervention group were significantly lower than the control group at immediately, 5 minutes, and 10 minutes after extubation. The occurrence rate of emergency agitation (RR 0.39, 95% CI [0.26,0.60]) and postoperative delirium (RR 0.40, 95% CI [0.22, 0.72] were also lower in the TEAS group. The consumption of propofol (standardized mean difference (SMD) 0.47, 95% CI [-0.77, -0.18]) and remifentanil (SMD 1.49, 95% CI [-2.01, -0.96]) of the intervention group were also significantly reduced compared with the control group.

CONCLUSIONS

TEAS was beneficial for improving stress response during extubation, emergence agitation, postoperative delirium, and reduced the consumption of intraoperative propofol and remifentanil, but it was necessary to note the limitations of the current evidence.

The effectiveness of preoperative delirium prevention in intermediate to high-risk older surgical patients: A systematic review

BACKGROUND

Few reviews have addressed delirium prevention among intermediate to high-risk older surgical patients.

AIMS

To map preoperative delirium prevention interventions for older surgical patients at intermediate to high risk of developing delirium, assess outcomes and identify gaps in knowledge.

DESIGN

Systematic narrative review of randomised controlled trials reported following the PRISMA checklist.

METHODS

A systematic search was conducted of the literature published from 1990 to October 2022 in Medline, CINAHL and Ageline and of the grey literature in Google Scholar. Randomised controlled trials were retrieved that assessed the effectiveness of preoperative delirium prevention interventions for older surgical patients at intermediate to high risk of delirium. Data were extracted using a data extraction tool, and results were tabulated. Studies were assessed for bias using the Cochrane Collaboration Risk of Bias tool.

RESULTS

Twenty-one studies met the selection criteria including N = 5096 participants. Two studies tested cognitive training, two studies tested fascia iliaca compartment block and one study assessed femoral nerve block. Ten studies tested prophylactic medications including methylprednisolone. Five studies investigated geriatric assessment and management. One study assessed transcutaneous electrical acupoint stimulation. In the two studies testing fascia iliaca compartment block, there was a reduction in postoperative delirium for orthopaedic patients. Methylprednisolone reduced postoperative delirium in orthopaedic patients and in those undergoing gastrointestinal surgery. Results of all other interventions on the occurrence of postoperative delirium and additional outcomes including the severity and duration of delirium were inconclusive.

CONCLUSIONS

Despite the promising results for fascia iliaca compartment block and methylprednisolone, there is limited knowledge regarding evidence-based delirium prevention interventions. Most studies had small sample sizes indicating that the current evidence is exploratory. There is an urgent need for the funding and conduct of trials to test preventative interventions for older surgical patients at intermediate to high risk of developing delirium.

Transcutaneous electrical acupoint stimulation for the prevention of postoperative delirium in elderly surgical patients: A systematic review and meta-analysis

Objective

This systematic review and meta-analysis aimed to evaluate the preventive effect of transcutaneous electrical acupoint stimulation on postoperative delirium in elderly surgical patients.

Methods

PubMed, CENTRAL, China National Knowledge Infrastructure, and WanFang databases were searched for randomized controlled trials regarding the effect of transcutaneous electrical acupoint stimulation on preventing postoperative delirium in elderly patients undergoing any type of surgery. The primary outcome was the incidence of postoperative delirium. The secondary outcome was the duration of postoperative delirium. All analyses were conducted using RevMan 5.3 and Stata 13.0 software.

Results

Twelve trials with 991 participants were included, and most of them were at high/unclear risk of bias. Meta-analysis showed transcutaneous electrical acupoint stimulation could reduce the incidence of postoperative delirium (RR = 0.40, 95%CI = 0.29 to 0.55, p < 0.00001) and shorten the duration of postoperative delirium (MD = -0.97 days, 95%CI = -1.72 to -0.22, p = 0.01). Subgroup analyses demonstrated that transcutaneous electrical acupoint stimulation reduced the incidence of postoperative delirium in elderly patients undergoing orthopedic surgery and thoracic surgery, but not digestive surgery; transcutaneous electrical acupoint stimulation with dilatational wave and with continuous wave were both beneficial; and transcutaneous electrical acupoint stimulation was favored when compared to blank and sham control.

Conclusion

Transcutaneous electrical acupoint stimulation could reduce the incidence of postoperative delirium and shorten the duration of postoperative delirium in elderly surgical patients. The findings should be interpreted with caution due to weak evidence. High-quality, large sample, and multi-center trials are needed to further confirm the preliminary findings.Systematic review registration: https://inplasy.com/inplasy-2022-7-0096/, identifier: INPLASY202270096.

Transcutaneous electrical acupoint stimulation combined with an integrated perioperative nursing program prevents subsyndromal delirium in older patients after joint replacement

OBJECTIVES

This study aimed to develop transcutaneous electrical acupoint stimulation combined with an integrated perioperative nursing program and evaluate its effects on preventing subsyndromal delirium (SSD) and postoperative delirium (POD) in older patients after joint replacement surgery.

METHODS

Participants were randomly divided into two groups, the experimental group (n = 48) was given transcutaneous electrical acupoint stimulation combined with an integrated perioperative nursing program based on the routine care of the control group (n = 49). The incidence of SSD and POD in a week after surgery was recorded. Assessments of delirium severity, cognition, anxiety, and depression were also conducted at baseline and on postoperative day 7.

RESULTS

The findings indicate that the intervention program had significant advances in alleviating the severity of delirium, cognitive impairment, anxiety, and depression but failed to reduce the incidence of SSD and POD.

CONCLUSIONS

Our study indicated that TEAS combined with an integrated perioperative nursing program has a beneficial effect on alleviating symptoms of delirium, cognitive dysfunction, anxiety, and depression in older adults after joint replacement surgery.

Transcutaneous Electrical Acupoint Stimulation for Preventing Postoperative Delirium: A Meta-Analysis

Objective

This meta-analysis of randomized controlled trials (RCTs) aims to evaluate the efficacy and safety of transcutaneous electrical acupoint stimulation (TEAS) for postoperative delirium (POD) in surgical patients.

Methods

Based on database searches of the Wanfang, China National Knowledge Infrastructure (CNKI), VIP, Chinese Biology Medicine (CBM), PubMed, Cochrane Library, and Web of Science, relevant RCTs published before December 30, 2022, were extracted. Outcome indicators included the incidence of POD, changes in Confusion Assessment Method (CAM) scores, Visual Analogue Scale (VAS) scores, and the intraoperative consumption of anesthetics. Data were pooled and analyzed by Review Manager 5.3, and publication bias detection was conducted using Stata 17.0.

Results

A meta-analysis containing 715 experimental and 717 control participants from 12 RCTs was performed. The overall results showed that TEAS had obvious superiority with a lower incidence of POD on any day during the postoperative 1 week. In subgroup analyses, the CAM scores on the third postoperative day were significantly lower in the TEAS group than in the control group (MD = -0.52, 95% CI: -1.02 to -0.03, P = 0.04), the VAS scores on the first postoperative day were significantly lower in the TEAS group than in the control group (MD = -0.19, 95% CI: -0.36 to -0.02, P = 0.03), the consumption of propofol and remifentanil were both significantly lower in the TEAS group compared with the control group (MD = -23.1, 95% CI: -37.27 to -8.94, P = 0.001; MD = -105.69, 95% CI: -174.20 to -37.19, P = 0.002). No serious adverse events of TEAS were reported in any of the referenced studies.

Conclusion

TEAS has an obvious curative effect in preventing POD and pain in the earlier stage of surgical patients. It could be a promising assisted anesthesia technique in the future.