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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; 133:565-583. [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] [MESH Headings] [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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Pettit RJ, Gregory B, Stahl S, Buller LT, Deans C. Total Joint Arthroplasty and Sleep: The State of the Evidence. Arthroplast Today 2024; 27:101383. [PMID: 39071825 PMCID: PMC11282419 DOI: 10.1016/j.artd.2024.101383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/01/2024] [Accepted: 03/18/2024] [Indexed: 07/30/2024] Open
Abstract
Background As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively. Methods A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively. Results Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids. Conclusions Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.
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Affiliation(s)
- Robert J. Pettit
- Department of Orthopaedic Surgery & Rehabilitation, University of Nebraska School of Medicine, Omaha, NE, USA
| | - Brandon Gregory
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Stephanie Stahl
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Leonard T. Buller
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher Deans
- Department of Orthopaedic Surgery & Rehabilitation, University of Nebraska School of Medicine, Omaha, NE, USA
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Shin HW, Kwak JS, Choi YJ, Kim JW, You HS, Shin HJ, Jang YK. Efficacy and safety of perioperative melatonin for postoperative delirium in patients undergoing surgery: a systematic review and meta-analysis. J Int Med Res 2024; 52:3000605241239854. [PMID: 38735057 PMCID: PMC11089947 DOI: 10.1177/03000605241239854] [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: 11/13/2023] [Accepted: 02/29/2024] [Indexed: 05/14/2024] Open
Abstract
OBJECTIVE To assess the efficacy and safety of perioperative melatonin and melatonin agonists in preventing postoperative delirium (POD). METHODS We conducted a systematic search for randomized controlled trials (RCTs) published through December 2022. The primary outcome was efficacy based on the incidence of POD (POD-I). Secondary outcomes included efficacy and safety according to the length of hospital or intensive care unit stay, in-hospital mortality, and adverse events. Subgroup analyses of POD-I were based on the type and dose of drug (low- and high-dose melatonin, ramelteon), the postoperative period (early or late), and the type of surgery. RESULTS In the analysis (16 RCTs, 1981 patients), POD-I was lower in the treatment group than in the control group (risk ratio [RR] = 0.57). POD-I was lower in the high-dose melatonin group than in the control group (RR = 0.41), whereas no benefit was observed in the low-dose melatonin and ramelteon groups. POD-I was lower in the melatonin group in the early postoperative period (RR = 0.35) and in patients undergoing cardiopulmonary surgery (RR = 0.54). CONCLUSION Perioperative melatonin or melatonin agonist treatment suppressed POD without severe adverse events, particularly at higher doses, during the early postoperative period, and after cardiopulmonary surgery.
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Affiliation(s)
- Hye Won Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Ji Su Kwak
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Yoon Ji Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Ansan Hospital, Gyeonggi-do Province, Republic of Korea
| | - Jae Woo Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hae Sun You
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hyun Ju Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Yoo Kyung Jang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
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Bandyopadhyay A, Yaddanapudi LN, Saini V, Sahni N, Grover S, Puri S, Ashok V. Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial. CRITICAL CARE SCIENCE 2024; 36:e20240144en. [PMID: 38656078 PMCID: PMC11098074 DOI: 10.62675/2965-2774.20240144-en] [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: 06/12/2023] [Accepted: 11/16/2023] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To determine whether enteral melatonin decreases the incidence of delirium in critically ill adults. METHODS In this randomized controlled trial, adults were admitted to the intensive care unit and received either usual standard care alone (Control Group) or in combination with 3mg of enteral melatonin once a day at 9 PM (Melatonin Group). Concealment of allocation was done by serially numbered opaque sealed envelopes. The intensivist assessing delirium and the investigator performing the data analysis were blinded to the group allocation. The primary outcome was the incidence of delirium within 24 hours of the intensive care unit stay. The secondary outcomes were the incidence of delirium on Days 3 and 7, intensive care unit mortality, length of intensive care unit stay, duration of mechanical ventilation and Glasgow outcome score (at discharge). RESULTS We included 108 patients in the final analysis, with 54 patients in each group. At 24 hours of intensive care unit stay, there was no difference in the incidence of delirium between Melatonin and Control Groups (29.6 versus 46.2%; RR = 0.6; 95%CI 0.38 - 1.05; p = 0.11). No secondary outcome showed a statistically significant difference. CONCLUSION Enteral melatonin 3mg is not more effective at decreasing the incidence of delirium than standard care is in critically ill adults.
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Affiliation(s)
- Anjishnujit Bandyopadhyay
- All India Institute of Medical SciencesJai Prakash Narayan Apex Trauma CenterPain Medicine and Critical CareNew DelhiIndiaDepartment of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences - New Delhi, India.
| | - Lakshmi Narayana Yaddanapudi
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of Anaesthesia and Intensive Care, Level 4ChandigarhIndiaDepartment of Anaesthesia and Intensive Care, Level 4, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
| | - Vikas Saini
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of Anaesthesia and Intensive Care, Level 4ChandigarhIndiaDepartment of Anaesthesia and Intensive Care, Level 4, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
| | - Neeru Sahni
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of Anaesthesia and Intensive Care, Level 4ChandigarhIndiaDepartment of Anaesthesia and Intensive Care, Level 4, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
| | - Sandeep Grover
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of PsychiatryChandigarhIndiaDepartment of Psychiatry, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
| | - Sunaakshi Puri
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of Anaesthesia and Intensive Care, Level 4ChandigarhIndiaDepartment of Anaesthesia and Intensive Care, Level 4, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
| | - Vighnesh Ashok
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of Anaesthesia and Intensive Care, Level 4ChandigarhIndiaDepartment of Anaesthesia and Intensive Care, Level 4, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
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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: 24] [Impact Index Per Article: 24.0] [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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Kinouchi M, Mihara T, Taguri M, Ogura M. The Efficacy of Ramelteon to Prevent Postoperative Delirium After General Anesthesia in the Elderly: A Double-Blind, Randomized, Placebo-Controlled Trial. Am J Geriatr Psychiatry 2023; 31:1178-1189. [PMID: 37567839 DOI: 10.1016/j.jagp.2023.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE Postoperative delirium is common and serious in elderly patients. Several drugs have been proposed as potential prophylactic agents for postoperative delirium. Studies on melatonin receptor agonists showed heterogeneity in age, cognitive function, anesthesia, surgery, interventions, methodologies for assessing outcomes, and results. Our objective was to examine the effect of ramelteon to prevent postoperative delirium in elderly patients, including those with dementia. DESIGN A stratified, double-blind, randomized, placebo-controlled trial (UMIN000028436, jRCTs031180054). SETTING Tertiary medical center. PARTICIPANTS Patients aged older than or equal to 65 years undergoing elective surgery under general anesthesia. INTERVENTION Ramelteon (8 mg orally) or placebo (lactose) for six nights (the preoperative night and five consecutive nights from postoperative day 1 to 5) at around 9 P.M. MEASUREMENTS Patients were screened for postoperative delirium using the Confusion Assessment Method for the Intensive Care Unit twice daily until the sixth postoperative day. Patients with positive results were referred to a consultant psychiatrist to establish the diagnosis of delirium. RESULTS A total of 108 patients were randomly assigned to receive ramelteon (n = 55) or placebo (n = 53). Most of the patients' characteristics were reasonably well-balanced between the two groups. The stratified log-rank test showed no significant difference in preventing postoperative delirium between ramelteon and placebo (χ2 = 0.30, degrees of freedom = 1, p = 0.60). The Cox proportional hazard ratio for ramelteon compared to placebo was 1.40 (95% confidence interval: 0.40-4.85, χ2 for likelihood ratio test = 0.29, degrees of freedom = 1, p = 0.60). CONCLUSION There was no significant difference in the incidence of postoperative delirium between ramelteon and placebo after general anesthesia in elderly patients.
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Affiliation(s)
- Mariko Kinouchi
- Healthy Aging Innovation Center (MK), Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan; Department of Biostatistics (MK), School of Medicine, Yokohama City University, Yokohama, Japan; Department of Anesthesiology (MK), Keiyu Hospital, Yokohama, Japan.
| | - Takahiro Mihara
- Department of Health Data Science (TM), Graduate School of Data Science, Yokohama City University, Yokohama, Japan; Department of Anesthesiology (TM), School of Medicine, Yokohama City University, Yokohama, Japan
| | - Masataka Taguri
- Department of Health Data Science (MT), Tokyo Medical University, Tokyo, Japan
| | - Makoto Ogura
- Department of Anesthesiology (MO), Saitama Cancer Center, Saitama, Japan
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Wada M, Yasuda H, Nakajima S, Etani T, Miura A, Asada S, Yoshida K, Noda Y, Takeuchi H. Efficacy and moderators of prevention and treatment of delirium with melatonin receptor agonists: A systematic review and meta-analysis of randomized controlled trials. Gen Hosp Psychiatry 2023; 85:71-79. [PMID: 37826886 DOI: 10.1016/j.genhosppsych.2023.08.011] [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: 07/15/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Delirium is a complex and heterogeneous condition that significantly affects patient outcome. This study aimed to conduct a systematic review and meta-analysis to investigate the effects of melatonin and melatonin receptor agonists (MRAs) on delirium prevention and treatment. METHOD Randomized controlled studies, using MRAs as an intervention and placebo as a control were included. We conducted meta-analyses with random-effects model and trial sequential analysis. RESULTS A total of 33 studies involving 4850 participants were included. The meta-analysis revealed a significant preventive effect of MRAs on delirium (risk ratio = 0.65, p < 0.01), while no significant therapeutic effect was observed. Additionally, MRAs were associated with a significant reduction in mortality rate (risk ratio = 0.90, p = 0.02) in delirium prevention studies. Furthermore, subgroup analyses revealed that assessment scales and the frequency of delirium detection may be significant moderators of the delirium-preventive efficacy of MRAs. CONCLUSION This study provides evidence of the potential effects of MRAs in preventing delirium and reducing mortality. Further research is required to elucidate the therapeutic potential of MRAs for delirium and identify specific patient populations that may benefit from this agent.
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Affiliation(s)
- Masataka Wada
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Yasuda
- Department of Psychiatry, Sekito Hospital, Shimane, Japan
| | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Takahide Etani
- School of Medicine, College of Medical, Pharmaceutical, and Health, Kanazawa University, Kanazawa, Japan; Graduate School of Media and Governance, Keio University, Fujisawa, Japan; Advanced Research Center for Human Sciences, Waseda University, Tokorozawa, Japan
| | - Akihiko Miura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Asada
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Tanenbaum Centre for Pharmacogenetics, Neurogenetics Section, Molecular Brain Sciences Research Department, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Yoshihiro Noda
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.
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Niyogi SG, Naskar C, Singh A, Kumar B, Grover S. Melatonin and Melatonin Agonists for Prevention of Delirium in the Cardiac Surgical ICU: A Meta-analysis. Indian J Crit Care Med 2023; 27:837-844. [PMID: 37936806 PMCID: PMC10626232 DOI: 10.5005/jp-journals-10071-24571] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/29/2023] [Indexed: 11/09/2023] Open
Abstract
Aim and Background Delirium is highly prevalent in the immediate postoperative period following cardiac surgery and adversely impacts outcomes. Melatonin has been increasingly used in pharmacological prevention of delirium. We aimed to synthesize the available evidence concerning the role of melatonin and melatonin agonists in preventing delirium in patients after cardiac surgery. Materials and methods PubMed, Google Scholar, and Web of Science databases were searched for relevant randomized and non-randomized trials in adults undergoing cardiac surgery investigating melatonin agonists to prevent delirium. Studies incorporating transplants, preoperative organ support, prophylactic antipsychotics, or children were excluded. Risk-of-bias was assessed using Cochrane ROB 2.0 and ROBINS-I tools. A systematic review and meta-analysis were conducted, calculating pooled odds ratio (OR) for the incidence of postoperative delirium using a random effects model with the Mantel-Haenszel method with restricted maximum-likelihood estimator. Trial sequential analysis was also carried out for the primary outcome. Results Six randomized trials and one non-randomized trial involving 1,179 patients were included. Incidence of delirium was 16.7 and 29.6% in the intervention and comparator groups respectively, indicating a pooled OR of 0.44 [95% confidence interval (CI) 0.27 - 0.71, p = 0.04] favoring melatonin. Two studies had a high risk of bias, and I2 statistics indicated significant heterogeneity. However, publication bias was insignificant, and trial sequential analysis indicated the significance of the attained effect size. Conclusion Based on available studies, perioperative melatonin use significantly decreases postoperative incidence of delirium after adult cardiac surgery. However, the available quality of evidence is low, and larger trials with standardization of nonpharmacological delirium prevention interventions, in high-risk cohorts, and exploring various dosages and regimens should be carried out. How to cite this article Niyogi SG, Naskar C, Singh A, Kumar B, Grover S. Melatonin and Melatonin Agonists for Prevention of Delirium in the Cardiac Surgical ICU: A Meta-analysis. Indian J Crit Care Med 2023;27(11):837-844.
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Affiliation(s)
- Subhrashis Guha Niyogi
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chandrima Naskar
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Avneet Singh
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhupesh Kumar
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Faeder M, Hale E, Hedayati D, Israel A, Moschenross D, Peterson M, Peterson R, Piechowicz M, Punzi J, Gopalan P. Preventing and treating delirium in clinical settings for older adults. Ther Adv Psychopharmacol 2023; 13:20451253231198462. [PMID: 37701890 PMCID: PMC10493062 DOI: 10.1177/20451253231198462] [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] [Received: 04/24/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
Delirium is a serious consequence of many acute or worsening chronic medical conditions, a side effect of medications, and a precipitant of worsening functional and cognitive status in older adults. It is a syndrome characterized by fluctuations in cognition and impaired attention that develops over a short period of time in response to an underlying medical condition, a substance (prescribed, over the counter, or recreational), or substance withdrawal and can be multi-factorial. We present a narrative review of the literature on nonpharmacologic and pharmacologic approaches to prevention and treatment of delirium with a focus on older adults as a vulnerable population. Older adult patients are most at risk due to decreasing physiologic reserves, with delirium rates of up to 80% in critical care settings. Presentation of delirium can be hyperactive, hypoactive, or mixed, making identification and study challenging as patients with hypoactive delirium are less likely to come to attention in an inpatient or long-term care setting. Studies of delirium focus on prevention and treatment with nonpharmacological or medication interventions, with the preponderance of evidence favoring multi-component nonpharmacological approaches to prevention as the most effective. Though use of antipsychotic medication in delirium is common, existing evidence does not support routine use, showing no clear benefit in clinically significant outcome measures and with evidence of harm in some studies. We therefore suggest that antipsychotics be used to treat agitation, psychosis, and distress associated with delirium at the lowest effective doses and shortest possible duration and not be considered a treatment of delirium itself. Future studies may clarify the use of other agents, such as melatonin and melatonin receptor agonists, alpha-2 receptor agonists, and anti-epileptics.
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Affiliation(s)
- Morgan Faeder
- University of Pittsburgh School of Medicine, 3811 O’Hara Street, Pittsburgh, PA 15261, USA
| | - Elizabeth Hale
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Daniel Hedayati
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alex Israel
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Melanie Peterson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ryan Peterson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mariel Piechowicz
- University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
| | - Jonathan Punzi
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Priya Gopalan
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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10
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Mukundarajan R, Soni KD, Trikha A. Prophylactic Melatonin for Delirium in Intensive Care Unit: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2023; 27:675-685. [PMID: 37719343 PMCID: PMC10504656 DOI: 10.5005/jp-journals-10071-24529] [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: 08/20/2022] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction Delirium, being a common disorder among critically ill patients, has a reported incidence ranging 45-83% in the intensive care unit (ICU) population. The prophylactic use of melatonin and melatonergics has been shown to have a positive effect in reducing the incidence of delirium in many clinical trials. Our study was thus proposed to find out the role of melatonin on the incidence and severity of ICU delirium, ICU and hospital length of stay (LOS), requirement, duration of mechanical ventilation, and ICU mortality. Methodology A systematic search of various databases was performed to find out the trials which compare melatonin with a placebo or standard therapy for delirium prevention with the results conveyed as mean differences (MDs) or risk ratios. The statistical software, Review Manager (RevMan, version 5.4), was used for data synthesis. Results Twelve studies were included in the meta-analysis. Prophylactic administration of melatonin or ramelteon was not associated with a statistically significant reduction in the incidence of delirium (odds ratio [OR] 0.63; confidence interval [CI]: 0.60, 1.32; p = 0.22), the severity of delirium (MD: 0.22; 95% CI: From -1.36 to 1.81; p = 0.78), ICU LOS (MD: 0.05; 95% CI: From -0.65 to 0.75; p = 0.89), hospital LOS (MD: -1.46; 95% CI: From -4.50 to -1.59; p = 0.35), need for mechanical ventilation (OR: 0.74, 95% CI: 0.38-1.44; p = 0.37), and ICU mortality (MD: 0.78; 95% CI: 0.56; 1.11; p = 0.62). However, a significant reduction in the duration of mechanical ventilation (MD: -0.85; 95% CI: From -1.64 to -0.06; p = 0.03) was found. Conclusion Our meta-analysis suggests that melatonin when given prophylactically has no significant role in reducing the incidence and severity of delirium, ICU and hospital LOS, need for mechanical ventilation, duration of mechanical ventilation, and ICU mortality. Further studies are warranted. How to cite this article Mukundarajan R, Soni KD, Trikha A. Prophylactic Melatonin for Delirium in Intensive Care Unit: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2023;27(9):675-685.
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Affiliation(s)
- Ramkumar Mukundarajan
- Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil Dev Soni
- Department of Critical and Intensive Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Anjan Trikha
- Department of Anesthesia and Perioperative Care, School of Medicine, University of California, San Francisco, California, United States of America
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11
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Sadahiro R, Hatta K, Yamaguchi T, Masanori E, Matsuda Y, Ogawa A, Iwata Y, Tokoro A, Nakahara R, Hirayama T, Yanai Y, Ogawa Y, Kayano A, Ariyoshi K, Oyamada S, Uchitomi Y, Akechi T, Yamamoto N, Okita N, Yorikane E, Shimada K, Furukawa T, Hashimoto H, Maeda M, Sato T, Sekimoto A, Sasaki C, Saito E, Uezono Y, Matsuoka H. A multi-centre, double-blind, randomized, placebo-controlled trial to evaluate the effectiveness and safety of ramelteon for the prevention of postoperative delirium in elderly cancer patients: a study protocol for JORTC-PON2/J-SUPPORT2103/NCCH2103. Jpn J Clin Oncol 2023; 53:851-857. [PMID: 37340766 PMCID: PMC10473272 DOI: 10.1093/jjco/hyad061] [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: 03/30/2023] [Accepted: 05/25/2023] [Indexed: 06/22/2023] Open
Abstract
Postoperative delirium is an important issue in cancer patients, affecting surgical outcomes and the quality of life. Ramelteon is a melatonin receptor agonist with high affinity for MT1 and MT2 receptors. Clinical trials and observational studies in Japan, including in surgical cancer patients, have shown efficacy of ramelteon in delirium prevention, with no serious safety concerns. However, clinical trials from the USA have reported conflicting results. A Japanese phase II study investigated the efficacy and safety of ramelteon for delirium prevention following gastrectomy in patients aged ≥75 years, with findings suggesting the feasibility of a phase III trial. The aim of this multi-centre, double-blind, randomized placebo-controlled phase III trial is to evaluate the effectiveness and safety of oral ramelteon for postoperative delirium prevention in cancer patients aged ≥65 years as advanced medical care. The trial protocol is described here.
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Affiliation(s)
- Ryoichi Sadahiro
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Kotaro Hatta
- Department of Psychiatry, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Enokido Masanori
- Department of Psycho-Oncology, National Cancer Center East, National Cancer Center Japan, Chiba, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Asao Ogawa
- Department of Psycho-Oncology, National Cancer Center East, National Cancer Center Japan, Chiba, Japan
| | - Yusei Iwata
- Department of Psycho-Oncology, National Cancer Center East, National Cancer Center Japan, Chiba, Japan
| | - Akihiro Tokoro
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Rika Nakahara
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Takatoshi Hirayama
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Yuko Yanai
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Yuko Ogawa
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Ayako Kayano
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | | | | | - Yosuke Uchitomi
- Division of Survivorship Research, Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Noboru Yamamoto
- Department of Experimental Therapeutics, National Cancer Center Hospital, Tokyo, Japan
| | - Natsuko Okita
- Clinical Trial Support Office, National Cancer Center Hospital, Tokyo, Japan
| | - Eiko Yorikane
- Clinical Trial Support Office, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuaki Shimada
- National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Tetsuya Furukawa
- Department of Pharmacy, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Hironobu Hashimoto
- Department of Pharmacy, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Makoto Maeda
- Department of Pharmacy, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Tetsufumi Sato
- Department of Anesthesia and Intensive Care, National Cancer Center Japan, Tokyo, Japan
| | - Asuko Sekimoto
- Department of Nursing, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Chiyuki Sasaki
- Department of Nursing, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Eiko Saito
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasuhito Uezono
- Department of Pain Control Research, Jikei University School of Medicine, Tokyo, Japan
| | - Hiromichi Matsuoka
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
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12
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Tchouambou Youmbi C, Gilman TJ, Ndzana Siani IC, Olaye IE, Popoola AF, Yahya SA, Kyeremanteng K, Gandotra S, Casey JD, Semler MW, Mbuagbaw L, Khalifa A, Rochwerg B. Black representation in critical care randomized controlled trials: a meta-epidemiological study. Can J Anaesth 2023; 70:1064-1074. [PMID: 37173564 PMCID: PMC10180607 DOI: 10.1007/s12630-023-02462-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 09/22/2022] [Accepted: 10/03/2022] [Indexed: 05/15/2023] Open
Abstract
PURPOSE The under-representation of Black people within critical care research limits the generalizability of randomized controlled trials (RCTs). This meta-epidemiologic study investigated the proportionate representation of Black people enrolled at USA and Canadian study sites from high impact critical care RCTs. SOURCE We searched for critical care RCTs published in general medicine and intensive care unit (ICU) journals between 1 January 2016 and 31 December 2020. We included RCTs that enrolled critically ill adults at USA or Canadian sites and provided race-based demographic data by study site. We compared study-based racial demographics with site-level city-based demographics and pooled representation of Black people across studies, cities, and centres using a random effects model. We used meta-regression to explore the impact of the following variables on Black representation in critical care RCTs: country, drug intervention, consent model, number of centres, funding, study site city, and year of publication. PRINCIPAL FINDINGS We included 21 eligible RCTs. Of these, 17 enrolled at only USA sites, two at only Canadian sites, and two at both USA and Canadian sites. Black people were under-represented in critical care RCTs by 6% compared with population-based city demographics (95% confidence interval, 1 to 11). Using meta-regression, after controlling for pertinent variables, the country of the study site was the only significant source of heterogeneity (P = 0.02). CONCLUSION Black people are under-represented in critical care RCTs compared with site-level city-based demographics. Interventions are required to ensure adequate Black representation in critical care RCTs at both USA and Canadian study sites. Further research is needed to investigate the factors contributing to Black under-representation in critical care RCTs.
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Affiliation(s)
- Cheikh Tchouambou Youmbi
- McMaster Faculty of Health Sciences, McMaster University, Hamilton, ON Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Tyler Jordan Gilman
- McMaster Faculty of Health Sciences, McMaster University, Hamilton, ON Canada
| | | | - Ida-Ehosa Olaye
- Department of Kinesiology, McMaster University, Hamilton, ON Canada
| | | | | | | | - Sheetal Gandotra
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama Birmingham, Birmingham, AL USA
| | - Jonathan Dale Casey
- Department of Medicine, Vanderbilt University, Nashville, TN USA
- Pragmatic Critical Care Research Group, Vanderbilt University, Nashville, TN USA
| | - Matthew Wall Semler
- Department of Medicine, Vanderbilt University, Nashville, TN USA
- Pragmatic Critical Care Research Group, Vanderbilt University, Nashville, TN USA
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
| | - Abubaker Khalifa
- Department of Medicine (Critical Care), Juravinski Hospital, McMaster University, Hamilton, ON Canada
| | - Bram Rochwerg
- Department of Medicine (Critical Care), Juravinski Hospital, McMaster University, Hamilton, ON Canada
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13
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Tsukinaga A, Mihara T, Takeshima T, Tomita M, Goto T. Effects of melatonin on postoperative sleep quality: a systematic review, meta-analysis, and trial sequential analysis. Can J Anaesth 2023; 70:901-914. [PMID: 36977935 DOI: 10.1007/s12630-023-02442-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/08/2022] [Accepted: 12/08/2022] [Indexed: 03/30/2023] Open
Abstract
PURPOSE Postoperative sleep disturbances are common. Although several studies have examined the effect of melatonin on postoperative sleep disturbances, the results have not reached any definitive conclusion. We sought to conduct a systematic review to compare the effects of melatonin and melatonin agonists on postoperative sleep quality with those of placebo or no treatment in adult patients who underwent surgery under general or regional anesthesia. METHODS We searched MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, ClinicalTrials.gov, and the UMIN Clinical Trials Registry up to 18 April 2022. Randomized clinical trials examining the effects of melatonin or melatonin agonists in patients undergoing general or regional anesthesia with sedation for any surgery were eligible for inclusion. The primary outcome was sleep quality measured using a visual analog scale (VAS). The secondary outcomes were postoperative sleep duration, sleepiness, pain, opioid consumption, quality of recovery, and adverse events. A random-effects model was used to combine the results. We assessed study quality with the Cochrane Risk of Bias Tool version 2. We applied a trial sequential analysis to assess the precision of the combined results. RESULTS Eight studies (516 participants) were analyzed for sleep quality. Of those, four studies used only a short duration of melatonin, either on the night before and the day of surgery or only on the day of surgery. A random-effects meta-analysis showed that melatonin did not improve sleep quality measured by VAS compared with placebo (mean difference, -0.75 mm; 95% confidence interval, -4.86 to 3.35), with low heterogeneity (I2, 5%). Trial sequential analysis revealed that the accrued information size (n = 516) reached the estimated required information size (n = 295). We downgraded the certainty of the evidence because of the high risk of bias. The effect on postoperative adverse events was comparable between the melatonin and control groups. CONCLUSION Our results indicate that melatonin supplementation does not improve postoperative sleep quality measured with the VAS compared with placebo in adult patients (GRADE: moderate). STUDY REGISTRATION PROSPERO (CRD42020180167); registered 27 October 2022.
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Affiliation(s)
- Akito Tsukinaga
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, 236-8511, Japan
- Department of Anesthesiology, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Takahiro Mihara
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, 236-8511, Japan.
- Department of Anesthesiology, School of Medicine, Yokohama City University, Yokohama, Japan.
| | - Teppei Takeshima
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, 236-8511, Japan
| | - Makoto Tomita
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, 236-8511, Japan
| | - Takahisa Goto
- Department of Anesthesiology, School of Medicine, Yokohama City University, Yokohama, Japan
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Knauert MP, Ayas NT, Bosma KJ, Drouot X, Heavner MS, Owens RL, Watson PL, Wilcox ME, Anderson BJ, Cordoza ML, Devlin JW, Elliott R, Gehlbach BK, Girard TD, Kamdar BB, Korwin AS, Lusczek ER, Parthasarathy S, Spies C, Sunderram J, Telias I, Weinhouse GL, Zee PC. Causes, Consequences, and Treatments of Sleep and Circadian Disruption in the ICU: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2023; 207:e49-e68. [PMID: 36999950 PMCID: PMC10111990 DOI: 10.1164/rccm.202301-0184st] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
Background: Sleep and circadian disruption (SCD) is common and severe in the ICU. On the basis of rigorous evidence in non-ICU populations and emerging evidence in ICU populations, SCD is likely to have a profound negative impact on patient outcomes. Thus, it is urgent that we establish research priorities to advance understanding of ICU SCD. Methods: We convened a multidisciplinary group with relevant expertise to participate in an American Thoracic Society Workshop. Workshop objectives included identifying ICU SCD subtopics of interest, key knowledge gaps, and research priorities. Members attended remote sessions from March to November 2021. Recorded presentations were prepared and viewed by members before Workshop sessions. Workshop discussion focused on key gaps and related research priorities. The priorities listed herein were selected on the basis of rank as established by a series of anonymous surveys. Results: We identified the following research priorities: establish an ICU SCD definition, further develop rigorous and feasible ICU SCD measures, test associations between ICU SCD domains and outcomes, promote the inclusion of mechanistic and patient-centered outcomes within large clinical studies, leverage implementation science strategies to maximize intervention fidelity and sustainability, and collaborate among investigators to harmonize methods and promote multisite investigation. Conclusions: ICU SCD is a complex and compelling potential target for improving ICU outcomes. Given the influence on all other research priorities, further development of rigorous, feasible ICU SCD measurement is a key next step in advancing the field.
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15
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Yu CL, Carvalho AF, Thompson T, Tsai TC, Tseng PT, Tu YK, Yang SN, Yang FC, Chang CH, Hsu CW, Hsu TW, Liang CS. Ramelteon for delirium prevention in hospitalized patients: An updated meta-analysis and trial sequential analysis of randomized controlled trials. J Pineal Res 2023; 74:e12857. [PMID: 36726202 DOI: 10.1111/jpi.12857] [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: 01/07/2023] [Revised: 01/19/2023] [Accepted: 01/29/2023] [Indexed: 02/03/2023]
Abstract
Although ramelteon has been examined as a relatively new therapeutic option for delirium prevention, current evidence to evaluate its efficacy is limited. We conducted an updated meta-analysis and examine the reliability of existing evidence regarding the effect of ramelteon on delirium prevention in hospitalized patients. Seven major electronic databases were systematically searched to identify randomized controlled trials examining the efficacy of ramelteon in delirium prevention. Data were pooled using a frequentist-restricted maximum-likelihood random-effects model. A trial sequential analysis was performed using relative risk reduction thresholds of 50%. The primary outcome was the incidence of delirium (reported as odds ratio with 95% confidence intervals). The secondary outcomes were the days of delirium, all-cause mortality, and all-cause discontinuation. Of 187 potentially eligible studies identified, 8 placebo-controlled randomized controlled trials (n = 587) were included. This updated meta-analysis showed that ramelteon was associated with lower odds of delirium occurrence than placebo (0.50; 0.29-0.86; I2 = 17.48%). In trial sequential analysis, the effect of ramelteon across the superiority boundary when using a relative risk reduction threshold ranging from 40% to 60%. In subgroup analyses, ramelteon compared with placebo was associated with lower odds of delirium occurrence in the elderly group (k = 5; 0.28; 0.09-0.85; I2 = 27.93%) and multiple dosage group (k = 5; 0.34; 0.14-0.82; I2 = 44.24%) but not in the non-elderly and non-multiple dosage groups. When considering surgical patients and medical patients separately, ramelteon showed a trend in the treatment of delirium prevention in both groups, while these findings were not statistically significant. No significant between-group differences were found in the secondary outcomes. The current meta-analysis provides updated and reliable evidence that ramelteon, in comparison with placebo, reduces the risk of delirium among hospitalized patients.
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Affiliation(s)
- Chia-Ling Yu
- Department of Pharmacy, Chang-Gung Memorial Hospital, Linkou, Taiwan
| | - Andre F Carvalho
- IMPACT (Innovation in Mental and Physical Health and Clinical Treatment) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia
| | - Trevor Thompson
- Centre for Chronic Illness and Ageing, University of Greenwich, London, UK
| | - Tzu-Cheng Tsai
- Department of Pharmacy, Chang-Gung Memorial Hospital, Linkou, Taiwan
| | - Ping-Tao Tseng
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung City, Taiwan
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
- Institute of Precision Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Szu-Nian Yang
- Department of Psychiatry, National Defense Medical Centre Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan
- Department of Psychiatry, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan
- Graduate Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fu-Chi Yang
- Department of Neurology, National Defense Medical Centre, Tri-Service General Hospital, Taipei, Taiwan
| | - Cheng-Ho Chang
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tien-Wei Hsu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Sung Liang
- Department of Psychiatry, National Defense Medical Centre Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan
- Department of Psychiatry, National Defense Medical Centre, Taipei, Taiwan
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Barnes J, Sewart E, Armstrong RA, Pufulete M, Hinchliffe R, Gibbison B, Mouton R. Does melatonin administration reduce the incidence of postoperative delirium in adults? Systematic review and meta-analysis. BMJ Open 2023; 13:e069950. [PMID: 36990485 PMCID: PMC10069576 DOI: 10.1136/bmjopen-2022-069950] [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: 11/07/2022] [Accepted: 02/14/2023] [Indexed: 03/31/2023] Open
Abstract
Postoperative delirium (POD) is common. It is associated with increased morbidity and mortality. Many cases may be preventable and melatonin offers promise as a preventative agent. OBJECTIVE This systematic review provides an up-to-date synthesis of the evidence on the effect of melatonin in preventing POD. DESIGN A systematic search of randomised controlled trials of melatonin in POD was run across multiple databases (EMBASE, MEDLINE, CINAHL, PsycINFO) and a clinical trials registry (ClinicalTrials.org) (1 January 1990 to 5 April 2022). Studies examining the effects of melatonin on POD incidence in adults are included. Risk of bias was assessed using the Cochrane risk of bias 2 tool. OUTCOME MEASURES The primary outcome is POD incidence. Secondary outcomes are POD duration and length of hospital stay. Data synthesis was undertaken using a random-effects meta-analysis and presented using forest plots. A summary of methodology and outcome measures in included studies is also presented. RESULTS Eleven studies, with 1244 patients from a range of surgical specialties were included. Seven studies used melatonin, in variable doses, and four used ramelteon. Eight different diagnostic tools were used to diagnose POD. Time points for assessment also varied. Six studies were assessed as low risk of bias and five as some concern. The combined OR of developing POD in the melatonin groups versus control was 0.41 (95% CI 0.21 to 0.80, p=0.01). CONCLUSION This review found that melatonin may reduce the incidence of POD in adults undergoing surgery. However, included studies displayed inconsistency in their methodology and outcome reporting. Further work to determine the optimum regime for melatonin administration, along with consensus of how best to evaluate results, would be beneficial. PROSPERO REGISTRATION NUMBER CRD42021285019.
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Affiliation(s)
- Jonathan Barnes
- Department of Anaesthesia, Bristol Royal Infirmary, Bristol, UK
| | - Emma Sewart
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | | | | | - Robert Hinchliffe
- Department of Surgery, North Bristol NHS Trust, Bristol, UK
- Department of Population Health Sciences, Bristol Centre for Surgical Research, Bristol, UK
| | - Ben Gibbison
- Department of Anaesthesia, Bristol Royal Infirmary, Bristol, UK
- University of Bristol, Bristol, UK
| | - Ronelle Mouton
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
- Department of Population Health Sciences, Bristol Centre for Surgical Research, Bristol, UK
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Ishida K, Kohno H, Matsuura K, Watanabe M, Sugiura T, Jujo Sanada T, Naito A, Shigeta A, Suda R, Sekine A, Masuda M, Sakao S, Tanabe N, Tatsumi K, Matsumiya G. Modification of pulmonary endarterectomy to prevent neurologic adverse events. Surg Today 2023; 53:369-378. [PMID: 36018416 DOI: 10.1007/s00595-022-02573-w] [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: 04/08/2022] [Accepted: 07/16/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE Neurologic adverse events (NAEs) are a major complication after pulmonary endarterectomy (PEA) performed under periods of deep hypothermic circulatory arrest (HCA) for chronic thromboembolic pulmonary hypertension. We modified the PEA strategy to prevent NAEs and evaluated the effectiveness of these modifications. METHODS We reviewed the surgical outcomes of 87 patients divided into the following three groups based on the surgical strategy used: group S (n = 49), periods of deep HCA with alpha-stat strategy; group M1 (n = 19), deep HCA with modifications of slower cooling and rewarming rates and the pH-stat strategy for cooling: and group M2 (n = 13), multiple short periods of moderate HCA. RESULTS PEA provided significant improvement of pulmonary hemodynamics in each group. Sixteen (29%) of the 49 group S patients suffered NAEs, associated with total circulatory arrest time (cutoff, 57 min) and Jamieson type I disease. The Group M1 and M2 patients did not suffer NAEs, although the group M1 patients had prolonged cardiopulmonary bypass (CPB) and more frequent respiratory failure. CONCLUSIONS NAEs were common after PEA performed under periods of deep HCA. The modified surgical strategy could decrease the risk of NAEs but increase the risk of respiratory failure. Multiple short periods of moderate HCA may be useful for patients at risk of NAEs.
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Affiliation(s)
- Keiichi Ishida
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan.
| | - Hiroki Kohno
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Kaoru Matsuura
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Michiko Watanabe
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Toshihiko Sugiura
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Takayuki Jujo Sanada
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Akira Naito
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Ayako Shigeta
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Rika Suda
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Ayumi Sekine
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Masahisa Masuda
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Seiichiro Sakao
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Nobuhiro Tanabe
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
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18
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Jaiswal SJ, Bagsic SRS, Takata E, Kamdar BB, Ancoli-Israel S, Owens RL. Actigraphy-based sleep and activity measurements in intensive care unit patients randomized to ramelteon or placebo for delirium prevention. Sci Rep 2023; 13:1450. [PMID: 36702822 PMCID: PMC9879948 DOI: 10.1038/s41598-023-28095-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 01/12/2023] [Indexed: 01/27/2023] Open
Abstract
Patients in the ICU often sleep poorly for various reasons, which may predispose to delirium. We previously conducted a clinical trial in which we tested the efficacy of ramelteon, a melatonin-receptor agonist used to treat insomnia, versus placebo, in preventing ICU delirium in patients who underwent elective pulmonary thromboendarterectomy (PTE) surgery. Here we examine sleep, activity, and circadian patterns, measured with actigraphy, to understand changes in these metrics with our intervention and in those with and without delirium. Participants wore wrist actigraphy devices while recovering post-operatively in the ICU. For sleep analysis, we extracted total sleep time and sleep fragmentation metrics over the 22:00 to 06:00 period nightly, and daytime nap duration from the daytime period (0:600 to 22:00) for each participant. For activity analyses, we extracted the following metrics: total daytime activity count (AC), maximum daytime AC, total nighttime AC, and maximum nighttime AC. Next, we performed a nonparametric circadian analysis on ACs over each 24-h day and extracted the following: interdaily stability (IS), intra-daily variability (IV), relative amplitude (RA), and low and high periods of activity (L5 and M10) as well as their start times. These metrics were compared between patients who received ramelteon versus placebo, and between patients who became delirious versus those who did not develop delirium. We additionally made comparisons between groups for daytime and nighttime light levels. No differences in sleep, activity, circadian metrics or light levels were found between drug groups. Delirious patients, when compared to those who were never delirious, had a lower IS (0.35 ± 0.16 vs. 0.47 ± 0.23; P = 0.006). Otherewise, no differences in IV, L5, M10, or RA were found between groups. L5 and M10 activity values increased significantly over the post-extubation for the whole cohort. No differences were found for daytime or nighttime light levels between groups. Overall, ramelteon did not impact sleep or circadian metrics in this cohort. Consistent with clinical experience, delirious patients had less inter-daily stability in their rest-activity rhythms. These data suggest that actigraphy might have value for individual assessment of sleep in the ICU, and for determining and detecting the impact of interventions directed at improving sleep and circadian activity rhythms in the ICU.Trial registration: REGISTERED at CLINICALTRIALS.GOV: NCT02691013. Registered on February 24, 2016 by principal investigator, Dr. Robert L. Owens.
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Affiliation(s)
| | | | - Emerson Takata
- The Scripps Research Institute, La Jolla, CA, 92037, USA
| | - Biren B Kamdar
- University of California San Diego School of Medicine, La Jolla, CA, USA
| | | | - Robert L Owens
- University of California San Diego School of Medicine, La Jolla, CA, USA
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19
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Dang V, Mansukhani MP, Wang Z, Kinzelman Vesely E, Kolla BP. Prophylactic Use of Ramelteon for Delirium in Hospitalized Patients: A Systematic Review and Meta-Analyses. J Acad Consult Liaison Psychiatry 2023; 64:65-72. [PMID: 35718086 DOI: 10.1016/j.jaclp.2022.06.002] [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] [Received: 02/16/2022] [Revised: 05/19/2022] [Accepted: 06/09/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Small prospective studies, case reports, as well as some randomized placebo-controlled trials and previous meta-analyses have shown that ramelteon, a melatonin agonist, may reduce the risk of developing delirium. OBJECTIVE The goal of this systemic review and meta-analyses was to assess the current evidence supporting the use of ramelteon in delirium prevention by including data from larger (>100 subjects) and more recent trials since the most recent meta-analyses were published in 2019. There were no exclusions for trial size, age, ramelteon dose, length of treatment, or hospital setting. METHODS Medline, Embase, PsycINFO, EBM Reviews, Scopus, and Web of Science databases were queried using the search terms delirium (with subterms including prevention and control), ramelteon, Rozerem, or melatonin receptor agonists, for English-language publications until March 16, 2021. Randomized placebo-controlled trials of hospitalized subjects receiving ramelteon for delirium prevention were included. The primary outcome of interest was delirium incidence. Odds ratios of the risk of developing incident delirium and 95% confidence intervals were calculated using a random effects model. RESULTS A total of 177 articles were identified by the literature search. Five studies (n = 443, 53.7% male) met criteria for inclusion in the final meta-analyses. The meta-analyses of the randomized placebo-controlled trials revealed that ramelteon did not result in a reduction in the risk of incident delirium (n = 443; odds ratio = 0.49; 95% confidence interval = 0.13-1.85). A moderate degree of heterogeneity was noted among the studies (I2 = 53%). CONCLUSIONS Current evidence suggests that ramelteon is ineffective as a prophylactic drug in reducing the incidence of delirium in hospitalized patients.
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Affiliation(s)
- Vanessa Dang
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | | | - Zhen Wang
- Health Services Research, Rochester, MN
| | | | - Bhanu Prakash Kolla
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; Center for Sleep Medicine, Mayo Clinic, Rochester, MN.
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20
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Yan W, Li C, Song X, Zhou W, Chen Z. Prophylactic melatonin for delirium in critically ill patients: A systematic review and meta-analysis with trial sequential analysis. Medicine (Baltimore) 2022; 101:e31411. [PMID: 36316858 PMCID: PMC9622662 DOI: 10.1097/md.0000000000031411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Up to 80% of patients in the intensive care unit (ICU) suffer from delirium. Studies on the preventative use of melatonin in the ICU have produced mixed results. We performed a systematic review and meta-analysis to evaluate whether early administration of melatonin reduces the prevalence of delirium in critically ill patients. METHODS We searched Medline, Embase, and the Cochrane Library for randomized controlled trials comparing melatonin or melatonin agonists to placebo in ICU setting. The population included adult patients in the ICU. The primary outcome was the prevalence of delirium. Secondary outcomes included duration of delirium, delirium-free day, serum melatonin concentration, need for sedation, duration of mechanical ventilation, hospital and ICU length of stay (LOS), all-cause mortality, sleep quality, and adverse events. Trial sequential analysis (TSA) was performed on the primary outcome to prevent the risk of random error and multiplicity phenomenon as a result of repeated significance testing across all the included trials. RESULTS Twelve trials with a total of 2538 patients were analyzed. When all trials were pooled, the incidence of delirium in ICU patients who received melatonin was significantly lower than in those who received placebo (risk ratio, 0.77; 95% confidence interval: 0.61-0.96; I2 = 56%). There were no significant differences in secondary outcomes including duration of delirium, duration of mechanical ventilation, ICU LOS, hospital LOS, and mortality. TSA indicated that Z-curve crossed the traditional boundary, but did not cross the monitoring boundary for benefit, which indicated that it is still inconclusive that melatonin affects the incidence of delirium. CONCLUSIONS This meta-analysis found that early administration of melatonin may result in a decreased delirium prevalence in critically ill patients. However, the sensitivity analysis of high-quality studies did not support this finding. In addition, TSA demonstrated that the result may have false-positive error. Therefore, this finding should be interpreted with caution. Further studies are needed to examine the effectiveness of prophylactic melatonin on the prevalence and duration of ICU delirium in the future.
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Affiliation(s)
- Wenqing Yan
- Medical Department of Nanchang University, Nanchang, Jiangxi, China
- Department of Emergency, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
| | - Chen Li
- Department of Traumatology, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Xin Song
- Medical Department of Nanchang University, Nanchang, Jiangxi, China
- Department of Emergency, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
| | - Wenqiang Zhou
- Medical Department of Nanchang University, Nanchang, Jiangxi, China
- Department of Emergency, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
| | - Zhi Chen
- Department of Emergency, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
- * Correspondence: Zhi Chen, Department of Emergency, Jiangxi Provincial People’s Hospital, 92 Ai Guo Street, Nanchang, Jiangxi 330006, China (e-mail: )
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21
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Sadahiro R, Wada S, Matsuoka YJ, Uchitomi Y, Yamaguchi T, Sato T, Esaki M, Yoshimoto S, Daiko H, Kanemitsu Y, Kawai A, Kato T, Fujimoto H, Uezono Y, Shimizu K, Matsuoka H. Prevention of delirium with agitation by yokukansan in older adults after cancer surgery. Jpn J Clin Oncol 2022; 52:1276-1281. [PMID: 35907781 DOI: 10.1093/jjco/hyac123] [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: 05/31/2022] [Accepted: 07/14/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Preventing postoperative delirium with agitation is vital in the older population. We examined the preventive effect of yokukansan on postoperative delirium with agitation in older adult patients undergoing highly invasive cancer resection. METHODS We performed a secondary per-protocol analysis of 149 patients' data from a previous clinical trial. Patients underwent scheduled yokukansan or placebo intervention 4-8 days presurgery and delirium assessment postoperatively. Delirium with agitation in patients aged ≥75 years was assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the Japanese version of the Delirium Rating Scale-Revised-98. We assessed odds ratios for yokukansan (TJ-54) compared with placebo for the manifestation of postoperative delirium with agitation across patients of all ages (n = 149) and those aged ≥65 years (n = 82) and ≥ 75 years (n = 21) using logistic regression. RESULTS Delirium with agitation manifested in 3/14 and 5/7 patients in the TJ-54 and placebo groups, respectively, among those aged ≥75 years. The odds ratio for yokukansan vs. placebo was 0.11 (95% confidence interval: 0.01-0.87). An age and TJ-54 interaction effect was detected in patients with delirium with agitation. No intergroup differences were observed in patients aged ≥65 years or across all ages for delirium with agitation. CONCLUSIONS This is the first study investigating the preventive effect of yokukansan on postoperative delirium with agitation in older adults. Yokukansan may alleviate workforce burdens in older adults caused by postoperative delirium with agitation following highly invasive cancer resection.
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Affiliation(s)
- Ryoichi Sadahiro
- Department of Psycho-Oncology, National Cancer Center Japan, Tokyo, Japan
| | - Saho Wada
- Department of Psycho-Oncology, National Cancer Center Japan, Tokyo, Japan.,Department of Neuropsychiatry, Nippon Medical School, Tama Nagayama Hospital, Tokyo, Japan
| | - Yutaka J Matsuoka
- Former Division Chief of Health Care Research, Center for Public Health Sciences, National Cancer Center Japan, Tokyo, Japan
| | - Yosuke Uchitomi
- Department of Psycho-Oncology, National Cancer Center Japan, Tokyo, Japan.,Group for Supportive Care and Survivorship Research, Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Tetsufumi Sato
- Department of Anesthesia and Intensive Care, National Cancer Center Japan, Tokyo, Japan
| | - Minoru Esaki
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Japan, Tokyo, Japan
| | - Seiichi Yoshimoto
- Department of Head and Neck Surgery, National Cancer Center Japan, Tokyo, Japan
| | - Hiroyuki Daiko
- Department of Esophageal Surgery, National Cancer Center Japan, Tokyo, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Japan, Tokyo, Japan
| | - Akira Kawai
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Japan, Tokyo, Japan
| | - Tomoyasu Kato
- Department of Gynecology, National Cancer Center Japan, Tokyo, Japan
| | | | - Yasuhito Uezono
- Department of Pain Control Research, Jikei University School of Medicine, Tokyo, Japan
| | - Ken Shimizu
- Department of Psycho-Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Matsuoka
- Department of Psycho-Oncology, National Cancer Center Japan, Tokyo, Japan
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22
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LaBuzetta JN, Malhotra A, Zee PC, Maas MB. Optimizing Sleep and Circadian Health in the NeuroICU. Curr Treat Options Neurol 2022; 24:309-325. [PMID: 35855215 PMCID: PMC9283559 DOI: 10.1007/s11940-022-00724-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 12/04/2022]
Abstract
Purpose of Review This article introduces fundamental concepts in circadian biology and the neuroscience of sleep, reviews recent studies characterizing circadian rhythm and sleep disruption among critically ill patients and potentially links to functional outcomes, and draws upon existing literature to propose therapeutic strategies to mitigate those harms. Particular attention is given to patients with critical neurologic conditions and the unique environment of the neuro-intensive care unit. Recent Findings Circadian rhythm disruption is widespread among critically ill patients and sleep time is reduced and abnormally fragmented. There is a strong association between the degree of arousal suppression observed at the bedside and the extent of circadian disruption at the system (e.g., melatonin concentration rhythms) and cellular levels (e.g., core clock gene transcription rhythms). There is a paucity of electrographically normal sleep, and rest-activity rhythms are severely disturbed. Common care interventions such as neurochecks introduce unique disruptions in neurologic patients. There are no pharmacologic interventions proven to normalize circadian rhythms or restore physiologically normal sleep. Instead, interventions are focused on reducing pharmacologic and environmental factors that perpetuate disruption. Summary The intensive care environment introduces numerous potent disruptors to sleep and circadian rhythms. Direct neurologic injury and neuro-monitoring practices likely compound those factors to further derange circadian and sleep functions. In the absence of direct interventions to induce normalized rhythms and sleep, current therapy depends upon normalizing external stimuli.
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Affiliation(s)
- Jamie Nicole LaBuzetta
- Department of Neurosciences, Division of Neurocritical Care, University of California, San Diego, San Diego, USA
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, USA
| | - Phyllis C. Zee
- Department of Neurology, Division of Sleep Medicine, Northwestern University, Chicago, USA
| | - Matthew B. Maas
- Department of Neurology, Division of Neurocritical Care, Northwestern University, 626 N Michigan Ave, Chicago, IL 60611 USA
- Department of Anesthesiology, Section of Critical Care Medicine, Northwestern University, 626 N Michigan Ave, Chicago, IL 60611 USA
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23
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Han Y, Tian Y, Wu J, Zhu X, Wang W, Zeng Z, Qin Z. Melatonin and Its Analogs for Prevention of Post-cardiac Surgery Delirium: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:888211. [PMID: 35665270 PMCID: PMC9157569 DOI: 10.3389/fcvm.2022.888211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/21/2022] [Indexed: 11/24/2022] Open
Abstract
Background The effectiveness of melatonin and its analogs in preventing postoperative delirium (POD) following cardiac surgery is controversial. The purpose of this systematic review and meta-analysis was to confirm the benefits of melatonin and its analogs on delirium prevention in adults who underwent cardiac surgery. Methods We systematically searched the PubMed, Cochrane Library, Web of Science, Embase, and EBSCOhost databases, the last search was performed in October 2021 and repeated before publication. The controlled studies were included if investigated the impact of melatonin and its analogs on POD in adults who underwent cardiac surgery. The primary outcome was the incidence of delirium. The Stata statistical software 17.0 was used to perform this study. Results This meta-analysis included eight randomized controlled trials (RCTs) and two cohort studies with a total of 1,714 patients. The results showed that melatonin and ramelteon administration were associated with a significantly lower incidence of POD in adults who underwent cardiac surgery (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.29–0.74; P = 0.001). The subgroup analyses confirmed that melatonin 3 mg (OR, 0.37; 95% CI, 0.18–0.76; P = 0.007) and 5 mg (OR, 0.34; 95% CI, 0.21–0.56; P < 0.001) significantly reduced the incidence of POD. Conclusion Melatonin at dosages of 5 and 3 mg considerably decreased the risk of delirium in adults who underwent cardiac surgery, according to our results. Cautious interpretation of our results is important owing to the modest number of studies included in this meta-analysis and the heterogeneity among them. Systematic Review Registration PROSPERO registration number: CRD42021246984.
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Affiliation(s)
- Yunyang Han
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yu Tian
- Department of Anesthesiology, Guangdong Women and Children Hospital, Guangzhou, China
| | - Jie Wu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoqin Zhu
- Department of Anesthesiology, Guangdong Women and Children Hospital, Guangzhou, China
| | - Wei Wang
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- *Correspondence: Zhenhua Zeng
| | - Zaisheng Qin
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Zaisheng Qin
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24
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Paribello P, Manchia M, Bosia M, Pinna F, Carpiniello B, Comai S. Melatonin and aggressive behavior: A systematic review of the literature on preclinical and clinical evidence. J Pineal Res 2022; 72:e12794. [PMID: 35192237 PMCID: PMC9285357 DOI: 10.1111/jpi.12794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/04/2022] [Accepted: 02/18/2022] [Indexed: 11/27/2022]
Abstract
The melatonin system and circadian disruption have well-established links with aggressive behaviors; however, the biological underpinnings have not been thoroughly investigated. Here, we aimed at examining the current knowledge regarding the neurobiological and psychopharmacological involvement of the melatonin system in aggressive/violent behaviors. To this end, we performed a systematic review on Embase and Pubmed/MEDLINE of preclinical and clinical evidence linking the melatonin system, melatonin, and melatoninergic drugs with aggressive/violent behaviors. Two blinded raters performed an independent screening of the relevant literature. Overall, this review included 38 papers distributed between clinical and preclinical models. Eleven papers specifically addressed the existing evidence in rodent models, five in fish models, and 21 in humans. The data indicate that depending on the species, model, and timing of administration, melatonin may exert a complex influence on aggressive/violent behaviors. Particularly, the apparent contrasting findings on the link between the melatonin system and aggression/violence (with either increased, no, or decreased effect) shown in preclinical models underscore the need for further research to develop more accurate and fruitful translational models. Likewise, the significant heterogeneity found in the results of clinical studies does not allow yet to draw any firm conclusion on the efficacy of melatonin or melatonergic drugs on aggressive/violent behaviors. However, findings in children and in traits associated with aggressive/violent behavior, including irritability and anger, are emerging and deserve empirical attention given the low toxicity of melatonin and melatonergic drugs.
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Affiliation(s)
- Pasquale Paribello
- Section of Psychiatry, Department of Medical Sciences and Public HealthUniversity of CagliariCagliariItaly
- Unit of Clinical PsychiatryUniversity Hospital Agency of CagliariCagliariItaly
| | - Mirko Manchia
- Section of Psychiatry, Department of Medical Sciences and Public HealthUniversity of CagliariCagliariItaly
- Unit of Clinical PsychiatryUniversity Hospital Agency of CagliariCagliariItaly
- Department of PharmacologyDalhousie UniversityHalifaxNova ScotiaCanada
| | - Marta Bosia
- Division of NeuroscienceSan Raffaele Scientific InstituteMilanItaly
- School of MedicineVita Salute San Raffaele UniversityMilanItaly
| | - Federica Pinna
- Section of Psychiatry, Department of Medical Sciences and Public HealthUniversity of CagliariCagliariItaly
- Unit of Clinical PsychiatryUniversity Hospital Agency of CagliariCagliariItaly
| | - Bernardo Carpiniello
- Section of Psychiatry, Department of Medical Sciences and Public HealthUniversity of CagliariCagliariItaly
- Unit of Clinical PsychiatryUniversity Hospital Agency of CagliariCagliariItaly
| | - Stefano Comai
- Division of NeuroscienceSan Raffaele Scientific InstituteMilanItaly
- Department of PsychiatryMcGill UniversityMontrealQuebecCanada
- Department of Pharmaceutical and Pharmacological SciencesUniversity of PaduaPaduaItaly
- Department of Biomedical SciencesUniversity of PaduaPaduaItaly
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25
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You W, Fan XY, Lei C, Nie CC, Chen Y, Wang XL. Melatonin intervention to prevent delirium in hospitalized patients: A meta-analysis. World J Clin Cases 2022; 10:3773-3786. [PMID: 35647160 PMCID: PMC9100708 DOI: 10.12998/wjcc.v10.i12.3773] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/01/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Evaluation of the effectiveness of melatonin is necessary to prevent the development of delirium in hospitalized patients. Melatonin (N-acetyl-5-methoxytryptamine) is a hormone produced by the pineal gland of the brain from the amino acid tryptophan. Synthetic melatonin supplements have been used for various medical conditions, especially sleep-related diseases, and have proved to be successful.
AIM To determine the effect of melatonin on the prevention of delirium in hospitalized patients.
METHODS A literature search of the CNKI, Wanfang Database, VIP Database, China Biomedical Literature Database, PubMed, Embase, Cochrane Library, Web of Science, and other databases was conducted. The CNKI, Wanfang Database, VIP Database (VIP), and China Biomedical Literature Database were searched for Chinese studies, and PubMed, Embase, Cochrane Library, Web of Science and other databases were searched for international studies. It will be established in June 2021 in a randomized controlled trial (RCT) whether melatonin treatment for 6 mo prevents delirium in hospitalized patients. Literature screening, quality review, and data extraction were carried out using the Cochrane Manual 5.1.0 systematic evaluation method, and Stata 15.0 software and Review Manager 5.3 were used for meta-analysis and processing.
RESULTS A total of 18 new RCT articles and 18 experimental subjects were identified. The results of the meta-analysis showed that following the occurrence of delirium, melatonin reduced the incidence of delirium in patients (RR = 0.69, 95%CI: 0.60-0.80), which is of significance, but heterogeneity was significant I2 = 62%. Subgroup analysis was performed to examine the source of heterogeneity, and it was found that different patient types were the source of heterogeneity; the research on subgroup analysis was of high quality and homogeneous. To determine the reliability and robustness of the research results, a sensitivity analysis was carried out. The results showed that after excluding individual studies one by one, the effect size was still within 95%CI, which strengthened the reliability of the original meta-analysis results. Melatonin has a significant preventive effect on delirium in hospitalized medical patients [RR = 0.60, 95%CI: 0.47-0.76), P < 0.001].
CONCLUSION Melatonin can reduce the rate of delirium in medical patients, and the role of melatonin in reducing the incidence of delirium in surgical patients and critical care unit patients requires further study.
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Affiliation(s)
- Wei You
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Xiao-Yu Fan
- Department of General Surgery, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Cheng Lei
- School of Public Health and Management, Chongqing Medical University, Chongqing 400000, Chongqing, China
| | - Chen-Cong Nie
- Department of Nursing, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Yao Chen
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Xue-Lian Wang
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
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Differential Effects of Gamma-Aminobutyric Acidergic Sedatives on Risk of Post-Extubation Delirium in the ICU: A Retrospective Cohort Study From a New England Health Care Network. Crit Care Med 2022; 50:e434-e444. [PMID: 34982739 DOI: 10.1097/ccm.0000000000005425] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether different gamma-aminobutyric acidergic (GABAergic) sedatives such as propofol and benzodiazepines carry differential risks of post-extubation delirium in the ICU. DESIGN Retrospective cohort study. SETTING Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS Ten thousand five hundred and one adult patients mechanically ventilated for over 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We tested the hypothesis that benzodiazepine versus propofol-based sedation is associated with fewer delirium-free days within 14 days after extubation. Further, we hypothesized that the measured sedation level evoked by GABAergic drugs is a better predictor of delirium than the drug dose administered. The proportion of GABAergic drug-induced deep sedation was defined as the ratio of days with a mean Richmond Agitation-Sedation Scale of less than or equal to -3 during mechanical ventilation. Multivariable regression and effect modification analyses were used. Delirium-free days were lower in patients who received a high proportion of deep sedation using benzodiazepine compared with propofol-based sedation (adjusted absolute difference, -1.17 d; 95% CI, -0.64 to -1.69; p < 0.001). This differential effect was magnified in elderly patients (age > 65) and in patients with liver or kidney failure (p-for-interaction < 0.001) but not observed in patients who received a low proportion of deep sedation (p = 0.95). GABAergic-induced deep sedation days during mechanical ventilation was a better predictor of post-extubation delirium than the GABAergic daily average effective dose (area under the curve 0.76 vs 0.69; p < 0.001). CONCLUSIONS Deep sedation during mechanical ventilation with benzodiazepines compared with propofol is associated with increased risk of post-extubation delirium. Our data do not support the view that benzodiazepine-based compared with propofol-based sedation in the ICU is an independent risk factor of delirium, as long as deep sedation can be avoided in these patients.
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Lam MTY, Malhotra A, LaBuzetta JN, Kamdar BB. Sleep in Critical Illness. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Maneeton B, Kongsaengdao S, Maneeton N, Likhitsathian S, Woottiluk P, Kawilapat S, Srisurapanont M. Melatonin Receptor Agonists for the Prevention of Delirium: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials. Curr Neuropharmacol 2022; 20:1956-1968. [PMID: 35524672 PMCID: PMC9886800 DOI: 10.2174/1570159x20666220507024219] [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: 07/26/2021] [Revised: 02/10/2022] [Accepted: 04/19/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although a previous review illustrated the efficacy of melatonin receptor agonists (MRAs) in preventing delirium, some recent randomized controlled trials (RCTs) did not confirm these effects. OBJECTIVES This study systematically reviewed the efficacy, acceptability, and tolerability of MRAs for delirium prevention. MATERIALS AND METHODS We searched electronic databases, including Scopus, PubMed, CINAHL, and Controlled Trials Register, from their inception to February 20, 2022. The primary efficacy outcome was delirium incidence rate after MRA administration; relative risks (RRs), overall discontinuation, and discontinuation due to adverse events are also presented. RESULTS The overall pooled incidence rates of delirium in MRA-treated and placebo-treated groups were significantly different with RR (95% CI)=0.66(0.52, 0.84, ), I2=59%. Similarly, the incidence rate was significantly lower in the melatonin-treated group than in the placebo-treated group [RR (95% CI) =0.65 (0.49, 0.88), I2=65%]. Unfortunately, incidence rates were not significantly different between ramelteon-treated and placebo-treated groups [RR (95% CI) =0.67 (0.42, 1.08), I2=50%]. The pooled incidence rate of delirium in either melatonin or ramelteon-treated groups was not significantly different from the placebo-treated group in elderly patients. The pooled incidence rate of delirium was significantly lower in the melatonin-treated group than in the benzodiazepinetreated group. CONCLUSION Based on this review, melatonin could prevent delirium with a small effect size. However, ramelteon did not show efficacy in preventing delirium. Additionally, neither melatonin nor ramelteon individually showed effectiveness in preventing delirium in elderly patients. Therefore, using MRAs to prevent delirium in clinical practice should be cautious. However, future welldefined and large sample size studies could verify these findings.
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Affiliation(s)
| | | | - Narong Maneeton
- Address correspondence to this author at the Department of Psychiatry, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphum, Amphur Muang, Chiang Mai 50200, Thailand; Tel: +66 53 93 5422; Fax: +66 53 5426; E-mail:
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O’Gara BP, Gao L, Marcantonio ER, Subramaniam B. Sleep, Pain, and Cognition: Modifiable Targets for Optimal Perioperative Brain Health. Anesthesiology 2021; 135:1132-1152. [PMID: 34731233 PMCID: PMC8578455 DOI: 10.1097/aln.0000000000004046] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The prevention of perioperative neurocognitive disorders is a priority for patients, families, clinicians, and researchers. Given the multiple risk factors present throughout the perioperative period, a multicomponent preventative approach may be most effective. The objectives of this narrative review are to highlight the importance of sleep, pain, and cognition on the risk of perioperative neurocognitive disorders and to discuss the evidence behind interventions targeting these modifiable risk factors. Sleep disruption is associated with postoperative delirium, but the benefit of sleep-related interventions is uncertain. Pain is a risk factor for postoperative delirium, but its impact on other postoperative neurocognitive disorders is unknown. Multimodal analgesia and opioid avoidance are emerging as best practices, but data supporting their efficacy to prevent delirium are limited. Poor preoperative cognitive function is a strong predictor of postoperative neurocognitive disorder, and work is ongoing to determine whether it can be modified to prevent perioperative neurocognitive disorders.
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Affiliation(s)
- Brian P O’Gara
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
| | - Lei Gao
- Massachusetts General Hospital. Department of Anesthesia. Harvard Medical School. Boston, MA, USA
| | - Edward R Marcantonio
- Beth Israel Deaconess Medical Center. Department of Medicine. Harvard Medical School. Boston, MA, USA
| | - Balachundhar Subramaniam
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
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Louzon PR, Heavner MS, Herod K, Wu TT, Devlin JW. Sleep-Promotion Bundle Development, Implementation, and Evaluation in Critically Ill Adults: Roles for Pharmacists. Ann Pharmacother 2021; 56:839-849. [PMID: 34612725 DOI: 10.1177/10600280211048494] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To review evidence for intensive care unit (ICU) sleep improvement bundle use, identify preferred sleep bundle components and implementation strategies, and highlight the role for pharmacists in developing and evaluating bundle efforts. DATA SOURCES Multiple databases were searched from January 1, 1990, to September 1, 2021, using the MeSH terms sleep, intensive care or critical care, protocol or bundle to identify comparative studies evaluating ICU sleep bundle implementation. STUDY SELECTION AND DATA EXTRACTION Study screening, data extraction, and risk-of-bias evaluation were conducted in tandem. The ICU quality improvement literature and Institute for Healthcare Improvement bundle improvement guidance were also reviewed to identify recommended strategies for successful sleep bundle use. DATA SYNTHESIS Nine studies (3 randomized, 1 quasi-experimental, 5 before-and-after) were identified. Bundle elements varied and were primarily focused on nonpharmacological interventions designed to be performed during either the day or night; only 2 studies included a medication-based strategy. Five studies were associated with reduced delirium; 2 studies were associated with improved total sleep time and 2 with improved patient-perceived sleep. Pharmacists were involved directly in 4 studies. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Sleep improvement bundles are recommended for use in all critically ill adults; specific bundle elements and ICU team member roles should be individualized at the institution/ICU level. Pharmacists can help lead bundle development efforts and routinely deliver key elements. CONCLUSIONS Pharmacists can play an important role in the development and implementation of ICU sleep bundles. Further research regarding the relative benefit of individual bundle elements on relevant patient outcomes is needed.
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Affiliation(s)
| | | | - Kyle Herod
- Portsmouth Regional Hospital, Portsmouth NH, USA
| | - Ting Ting Wu
- Northeastern University, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - John W Devlin
- Northeastern University, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
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Li X, Wang Y, Liu J, Xiong Y, Chen S, Han J, Xie W, Wu Q. Effects of perioperative interventions for preventing postoperative delirium: A protocol for systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e26662. [PMID: 34398027 PMCID: PMC8294881 DOI: 10.1097/md.0000000000026662] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) not only increases the medical burden but also adversely affects patient prognosis. Although some cases of delirium can be avoided by early intervention, there is no clear evidence indicating whether any of these measures can effectively prevent POD in specific patient groups. OBJECTIVE The aim of this meta-analysis was to compare the efficacy and safety of the existing preventive measures for managing POD. METHODS The PubMed, OVID (Embase and MEDLINE), Web of Science, and the Cochrane Library databases were searched for articles published before January 2020. The relevant randomized controlled trials (RCTs) were selected based on the inclusion and exclusion criteria. Data extraction and methodological quality assessment were performed according to a predesigned data extraction form and scoring system, respectively. The interventions were compared on the basis of the primary outcome like incidence of POD, and secondary outcomes like duration of delirium and the length of intensive care unit and hospital stay. RESULTS Sixty-three RCTs were included in the study, covering interventions like surgery, anesthesia, analgesics, intraoperative blood glucose control, cholinesterase inhibitors, anticonvulsant drugs, antipsychotic drugs, sleep rhythmic regulation, and multi-modal nursing. The occurrence of POD was low in 4 trials that monitored the depth of anesthesia with bispectral index during the operation (P < .0001). Two studies showed that supplementary analgesia was useful for delirium prevention (P = .002). Seventeen studies showed that perioperative sedation with α2-adrenergic receptor agonists prevented POD (P = .0006). Six studies showed that both typical and atypical antipsychotic drugs can reduce the incidence of POD (P = .002). Multimodal nursing during the perioperative period effectively reduced POD in 6 studies (P < .00001). Furthermore, these preventive measures can reduce the duration of delirium, as well as the total and postoperative length of hospitalized stay for non-cardiac surgery patients. For patients undergoing cardiac surgery, effective prevention can only reduce the length of intensive care unit stay. CONCLUSION Measures including intraoperative monitoring of bispectral index, supplemental analgesia, α2-adrenergic receptor agonists, antipsychotic drugs, and multimodal care are helpful to prevent POD effectively. However, larger, high-quality RCTs are needed to verify these findings and develop more interventions and drugs for preventing postoperative delirium.
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Melatonin and melatonergic agents for the prevention of postoperative delirium: A meta-analysis of randomized placebo-controlled trials. Asian J Surg 2021; 45:27-32. [PMID: 34092473 DOI: 10.1016/j.asjsur.2021.04.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/09/2021] [Accepted: 04/26/2021] [Indexed: 11/24/2022] Open
Abstract
Studies on melatonin and melatonergic agents (MMA) for the prevention of postoperative delirium (POD) have produced inconsistent findings. We conducted a meta-analysis to assess the effect of perioperative MMA on the prevention for POD. This meta-analysis is registered in the PROSPERO (CRD42020164900). We searched PubMed, Embase, and Cochrane Library through August 1, 2020 to identify randomized placebo-controlled trials (RCTs) that assessed MMA for the prevention for POD in adult patients undergoing surgery. The primary outcome was POD. Relative risk (RR) with 95% confidence interval (CI) was pooled using a random-effects model. Nine RCTs with 1452 patients were included. The incidence of POD was 23.8% (173/726) and 24.4% (177/726) in the MMA and placebo groups, respectively. Compared with placebo, MMA did not reduce the occurrence of POD (9 trails, 1452 patients, RR 0.93, 95% CI 0.70-1.24), with modest heterogeneity (I2 = 40%). Sensitivity analyses suggested that MMA also did not reduce the occurrence of POD in elderly patients (age ≥65 years) (6 trails, 810 patients, RR 0.71, 95% CI 0.38-1.32), patients given melatonin (4 trails, 806 patients, RR 0.78, 95% CI 0.43-1.41) or ramelteon (4 trails, 345 patients, RR 0.89, 95% CI 0.44-1.78), and patients undergoing general anesthesia (4 trails, 681 patient, RR 1.02, 95% CI 0.82-1.28). Based on the current evidence, perioperative MMA may have no effect on the prevention of POD.
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Characterization of Nocturnal Neuroactive Medication Use and Related Sleep Documentation in Critically Ill Adults. Crit Care Explor 2021; 3:e0367. [PMID: 33786443 PMCID: PMC7994043 DOI: 10.1097/cce.0000000000000367] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We retrospectively characterized scheduled, newly initiated, nocturnal neuroactive medication use, and related clinician documentation, in a cohort of consecutive adults admitted greater than or equal to 24 hours to seven different medical/surgical ICUs at two academic centers who had not received a scheduled nocturnal neuroactive medication prior to admission, over a 5-month period (April 1, 2017, to August 31, 2017). A total of 207 different newly initiated, scheduled nocturnal neuroactive medication orders were written (melatonin agonist 101 [48.8%], antipsychotic 80 [38.6%], antidepressant 17 [8.2%], benzodiazepine 9 [4.3%]) in 189 (9.7%) of the 1,955 patients. Among the 1,553 nights, the 189 patients spent in the ICU, a scheduled nocturnal neuroactive medication was administered on 1,103 (71%), an “as needed” nocturnal neuroactive medication was solely administered on 183 (11.8%), delirium occurred on 736 (47.4%), and nurses were twice as likely as physicians (28.8% vs 11.4%; p < 0.0001) to document a note about sleep quality. Among the 69.8% of patients discharged to the floor, and the 64.5% from the hospital, the scheduled nocturnal neuroactive medication was continued in 85.6% and 87.3%, respectively. Scheduled nocturnal neuroactive medication initiation is common, often continued beyond hospital discharge, and poorly documented.
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Marsh J, Alexander E. Update on the Prevention and Treatment of Intensive Care Unit Delirium. AACN Adv Crit Care 2021; 32:5-10. [PMID: 33725100 DOI: 10.4037/aacnacc2021494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Jennifer Marsh
- Jennifer Marsh is a Critical Care Pharmacist, Department of Pharmacy Services, Tampa General Hospital, 1 Tampa General Circle, Tampa, FL 33601
| | - Earnest Alexander
- Earnest Alexander is Assistant Director, Clinical Pharmacy Services, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida
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Oh ES, Leoutsakos JM, Rosenberg PB, Pletnikova AM, Khanuja HS, Sterling RS, Oni JK, Sieber FE, Fedarko NS, Akhlaghi N, Neufeld KJ. Effects of Ramelteon on the Prevention of Postoperative Delirium in Older Patients Undergoing Orthopedic Surgery: The RECOVER Randomized Controlled Trial. Am J Geriatr Psychiatry 2021; 29:90-100. [PMID: 32532654 PMCID: PMC8809889 DOI: 10.1016/j.jagp.2020.05.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Postoperative delirium, associated with negative consequences including longer hospital stays and worse cognitive and physical outcomes, is frequently accompanied by sleep-wake disturbance. Our objective was to evaluate the efficacy and short-term safety of ramelteon, a melatonin receptor agonist, for the prevention of postoperative delirium in older patients undergoing orthopedic surgery. DESIGN A quadruple-masked randomized placebo-controlled trial (Clinical Trials.gov NCT02324153) conducted from March 2017 to June 2019. SETTING Tertiary academic medical center. PARTICIPANTS Patients aged 65 years or older, undergoing elective primary or revision hip or knee replacement. INTERVENTION Ramelteon (8 mg) or placebo MEASUREMENTS: Eighty participants were randomized to an oral gel cap of ramelteon or placebo for 3 consecutive nights starting the night before surgery. Trained research staff conducted delirium assessments for 3 consecutive days starting on postoperative day (POD) 0, after recovery from anesthesia, and on to POD2. A delirium diagnosis was based upon DSM-5 criteria determined by expert panel consensus. RESULTS Of 80 participants, five withdrew consent (one placebo, four ramelteon) and four were excluded (four ramelteon) after randomization. Delirium incidence during the 2 days following surgery was 7% (5 of 71) with no difference between the ramelteon versus placebo: 9% (3 of 33) and 5% (2 of 38), respectively. The adjusted odds ratio for postoperative delirium as a function of assignment to the ramelteon treatment arm was 1.28 (95% confidence interval: 0.21-7.93; z-value 0.27; p-value = 0.79). Adverse events were similar between the two groups. CONCLUSION In older patients undergoing elective primary or revision hip or knee replacement, ramelteon was not efficacious in preventing postoperative delirium.
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Affiliation(s)
- Esther S Oh
- Departments of Medicine (ESO, AP, NSF, NA), Johns Hopkins University School of Medicine, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences (ESO, JML, PBR, KJN), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pathology (ESO), Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins University School of Nursing (ESO, KJN), Baltimore, MD.
| | - Jeannie-Marie Leoutsakos
- Departments of Psychiatry and Behavioral Sciences (ESO, JML, PBR, KJN), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul B Rosenberg
- Departments of Psychiatry and Behavioral Sciences (ESO, JML, PBR, KJN), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra M Pletnikova
- Departments of Medicine (ESO, AP, NSF, NA), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Harpal S Khanuja
- Departments of Orthopedic Surgery (HSK, RSS, JKO), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert S Sterling
- Departments of Orthopedic Surgery (HSK, RSS, JKO), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Julius K Oni
- Departments of Orthopedic Surgery (HSK, RSS, JKO), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Frederick E Sieber
- Departments of Anesthesiology and Critical Care Medicine (FES), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Neal S Fedarko
- Departments of Medicine (ESO, AP, NSF, NA), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Narjes Akhlaghi
- Departments of Medicine (ESO, AP, NSF, NA), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karin J Neufeld
- Departments of Psychiatry and Behavioral Sciences (ESO, JML, PBR, KJN), Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins University School of Nursing (ESO, KJN), Baltimore, MD
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Khaing K, Nair BR. Melatonin for delirium prevention in hospitalized patients: A systematic review and meta-analysis. J Psychiatr Res 2021; 133:181-190. [PMID: 33348252 DOI: 10.1016/j.jpsychires.2020.12.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/17/2020] [Accepted: 12/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Melatonin, a pineal gland hormone is reported to have a protective effect against delirium. This systematic review and meta-analysis explores the effect of melatonin and melatonin receptor agonist, ramelteon on delirium prevention in adult hospitalized patients. METHODS Randomized Controlled trials of melatonin/ramelteon published up to May 7, 2020 were identified from MEDLINE, PREMEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled trials, PubMed, and Google Scholar. The primary outcome was delirium incidence. The secondary outcomes were sleep quality, sedation score, sedatives requirement, delirium duration, length of hospital stay, length of Intensive Care Unit (ICU) stay, mortality and adverse events. A meta-analysis with a random-effects models was performed. Estimates were presented as Risk Ratio (RR) or Mean Differences (MD) with 95% Confidence Interval (CI). FINDINGS Fourteen studies with 1712 participants were included. Melatonin/ramelteon significantly reduced delirium incidence (RR 0·61, 95% CI 0·42-0·89, p 0·009) with risk reduction of 49% in surgical patients and 34% in ICU patients. Non-significant reduction was found in medical patients. Melatonin/ramelteon were associated with improvement in sleep quality, increased sedation score and lower sedatives consumption. However, they did not reduce delirium duration, length of hospital stay, length of ICU stay and mortality. Hallucinations, nightmares and gastrointestinal disorders were prevalent in melatonin group. INTERPRETATION Melatonin/ramelteon are associated with reduction in delirium incidence in hospitalized patients. However, this effect seems confined to surgical and ICU patients. The optimum dosage and formulation of melatonin, and treatment duration remain uncleared and open to further studies with larger sample sizes.
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Affiliation(s)
- Kay Khaing
- Hunter New England Health, 2 Lookout Road, New Lambton Heights, 2305, NSW, Australia.
| | - Balakrishnan R Nair
- University of Newcastle, The Lodge, John Hunter Hospital Campus, New Lambton Heights, 2305, NSW, Australia
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Hokuto D, Nomi T, Yoshikawa T, Matsuo Y, Kamitani N, Sho M. Preventative effects of ramelteon against postoperative delirium after elective liver resection. PLoS One 2020; 15:e0241673. [PMID: 33137161 PMCID: PMC7605698 DOI: 10.1371/journal.pone.0241673] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/19/2020] [Indexed: 12/15/2022] Open
Abstract
Background Postoperative delirium was reported to be associated with increased postoperative mortality after liver resection. Therefore, it is crucial to prevent postoperative delirium in such cases. Ramelteon, an agonist of melatonin receptor has been suggested to be useful for preventing delirium. The aim of this study was to examine whether ramelteon is effective at preventing delirium after elective liver resection. Methods The cases of patients who underwent liver resection at Nara Medical University (Nara, Japan) between January 2014 and August 2018 were analyzed. During the period from January 2017 to August 2018, ramelteon was prospectively administered to patients who underwent liver resection [8 mg/day on the day before surgery and on postoperative days 1 to 3] (ramelteon group), whereas ramelteon was not administered during the period from January 2014 to December 2016 (control group). The perioperative outcomes of the two groups were compared. Results There were 120 patients in the ramelteon group and 186 patients in the control group. No significant intergroup differences in background factors, including age, gender, and preoperative serological laboratory data, were detected. The incidence of postoperative delirium was significantly lower in the ramelteon group (5.8% vs. 15.1%, P = 0.035). Multivariate analysis revealed that being aged ≥75 (P = 0.002), being male (P = 0.020), cardiovascular disease (P = 0.023), blood loss ≥1000ml (P = 0.001) and the absence of ramelteon treatment (P = 0.046) were independent risk factors for postoperative delirium. Conclusion The administration of ramelteon might reduce the risk of postoperative delirium after elective liver resection.
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Affiliation(s)
- Daisuke Hokuto
- Department of Surgery, Nara Medical University, Kashihara-shi, Nara, Japan
- * E-mail:
| | - Takeo Nomi
- Department of Surgery, Nara Medical University, Kashihara-shi, Nara, Japan
| | - Takahiro Yoshikawa
- Department of Surgery, Nara Medical University, Kashihara-shi, Nara, Japan
| | - Yasfuko Matsuo
- Department of Surgery, Nara Medical University, Kashihara-shi, Nara, Japan
| | - Naoki Kamitani
- Department of Surgery, Nara Medical University, Kashihara-shi, Nara, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara-shi, Nara, Japan
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Melatonin, Ramelteon, Suvorexant, and Dexmedetomidine to Promote Sleep and Prevent Delirium in Critically Ill Patients: A Narrative Review With Practical Applications. Crit Care Nurs Q 2020; 43:232-250. [PMID: 32084065 DOI: 10.1097/cnq.0000000000000304] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Sleep plays an important role in the recovery of critically ill patients. However, patients in the intensive care unit (ICU) often suffer sleep disturbances and abnormal circadian rhythms, which may increase delirium and lengthen ICU stay. Nonpharmacologic strategies for preventing and treating sleep disturbances and delirium, such as overnight eye masks and ear plugs, are usually employed first, given the lack of adverse effects. However, a multimodal approach to care including pharmacotherapy may be necessary. Despite the limited available data supporting their use, medications such as melatonin, ramelteon, suvorexant, and dexmedetomidine may promote sleep and improve a variety of patient-centric outcomes such as delirium. This narrative review focuses on these nonbenzodiazepine agents used for sleep in the ICU. Practical application of each of these agents is described for when providers choose to utilize one of these pharmacotherapies to promote sleep or prevent delirium.
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Lewandowska K, Małkiewicz MA, Siemiński M, Cubała WJ, Winklewski PJ, Mędrzycka-Dąbrowska WA. The role of melatonin and melatonin receptor agonist in the prevention of sleep disturbances and delirium in intensive care unit - a clinical review. Sleep Med 2020; 69:127-134. [PMID: 32074506 DOI: 10.1016/j.sleep.2020.01.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 12/16/2019] [Accepted: 01/15/2020] [Indexed: 12/19/2022]
Abstract
AIM The intensive care unit (ICU) environment contributes to the development of sleep disturbances. Sleep disturbances, sleep fragmentation, and multiple awakening episodes lead to the circadian rhythm disorder, which increases the risk of delirium. Melatonin and melatonin receptor agonist is widely used agent in the therapy of sleep disturbances. However, there is also some for its efficacy in ICU delirium. Enteral melatonin and ramelteon supplementation eliminates (partially) the delirium inducing factors. METHODS PubMed/MEDLINE, OVID, Embase, Cochrane Library, and Web of Science databases were searched using adequate key words. We reviewed the literature on the role of melatonin and ramelteon in the prevention of sleep disturbances and delirium in intensive care units and analysed the methods of melatonin therapy in an ICU setting. Review followed the PRISMA statement. A review written protocol was not drafted. RESULTS Originally 380 studies were searched in five scientific databases. After rejecting the duplicate results, 125 results were obtained. Finally, 10 scientific studies were included in the review. In selected articles, the leading topics analysed were the role of melatonin and ramelteon in the prevention of delirium and sleep disorders. In addition, the noted effect of therapy with these agents on reducing the ventilation time of mechanical time and the demand for psychoactive substances in the ICU environment. CONCLUSION Reduction of either the incidence or the severity of delirium course is possible by eliminating its risk factors. Risk factors are directly related to sleep disorders. To reduce the problem, therefore, a holistic approach to the source is necessary. The efficacy of melatonin therapy in an ICU setting requires confirmation in studies including a greater number of participants as the impact of melatonin on these factors is yet to be fully elucidated. However, the prognosis is predictive because this concept provides patients with a minimally invasive and natural form of therapy.
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Affiliation(s)
- Katarzyna Lewandowska
- Department of Anaesthesiology Nursing and Intensive Care, Medical University of Gdansk, Gdansk, Poland
| | - Marta A Małkiewicz
- Department of Human Physiology, Medical University of Gdansk, Gdansk, Poland; Department of Psychiatry, Medical University of Gdansk, Gdansk, Poland
| | - Mariusz Siemiński
- Department of Emergency Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Wiesław J Cubała
- Department of Psychiatry, Medical University of Gdansk, Gdansk, Poland
| | - Paweł J Winklewski
- Department of Human Physiology, Medical University of Gdansk, Gdansk, Poland; Department of Clinical Anatomy and Physiology, Pomeranian University of Slupsk, Slupsk, Poland
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Ramelteon for ICU Delirium Prevention: Is It Time to Melt Away? Crit Care Med 2019; 47:1813-1815. [PMID: 31738252 DOI: 10.1097/ccm.0000000000004052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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