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Tong L, Solla C, Staack JB, May K, Tran B. Perioperative Pain Management for Thoracic Surgery: A Multi-Layered Approach. Semin Cardiothorac Vasc Anesth 2024:10892532241235750. [PMID: 38506340 DOI: 10.1177/10892532241235750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.
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Affiliation(s)
- Larry Tong
- Virginia Commonwealth University, Richmond, VA, USA
| | - Che Solla
- University of Tennessee, Knoxville, TN, USA
| | | | - Keith May
- University of Tennessee, Knoxville, TN, USA
| | - Bryant Tran
- Virginia Commonwealth University, Richmond, VA, USA
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Liu M, Su J, Wang B, Yu D, Li J, Cao X. The effect of haloperidol's perioperative application on postoperative delirium in elderly patients: a systematic review and meta-analysis. BMC Anesthesiol 2024; 24:49. [PMID: 38308229 PMCID: PMC10837937 DOI: 10.1186/s12871-024-02434-8] [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: 10/06/2023] [Accepted: 01/26/2024] [Indexed: 02/04/2024] Open
Abstract
OBJECTIVES To systematically review the evidence about the effect of haloperidol on postoperative delirium in elderly patients. METHODS PubMed, Embase, the Cochrane Library and China National Knowledge Infrastructure were used to find concerned studies for meta-analysis. The main outcome was the incidence of postoperative delirium, and the secondary outcomes were side effects of haloperidol and the length of hospital stay. The meta-analyses were conducted using the Review Manager Version 5.1. This study was conducted based on the PRISMA statement. RESULTS Eight RCTs (1569 patients) were included in the meta-analysis. There was a significant difference in the incidence of postoperative delirium between haloperidol and control groups (OR = 0.62, 95%CI 0.48-0.80, P = 0.0002, I2 = 20%). In addition, side effects of haloperidol and the duration of hospitalization were comparable (OR = 0.58, 95%CI 0.25-1.35, P = 0.21, I2 = 0%; MD =-0.01, 95%CI -0.16-0.15, P = 0.92, I2 = 28%). Subgroup analysis implied the effect of haloperidol on postoperative delirium might vary with the dose (5 mg daily: OR = 0.40, 95%CI 0.22-0.71, P = 0.002, I2 = 0%; <5 mg daily: OR = 0.72, 95%CI 0.42-1.23, P = 0.23, I2 = 0%). CONCLUSIONS The meta-analysis revealed perioperative application of haloperidol could decrease the occurrence of postoperative delirium without obvious side effects in elderly people, and high-dose haloperidol (5 mg daily) possessed a greater positive effect.
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Affiliation(s)
- Meinv Liu
- Department of Anaesthesiology, Hebei General Hospital, Shijiazhuang, 050051, China
| | - Jie Su
- Department of Anaesthesiology, Hebei General Hospital, Shijiazhuang, 050051, China
| | - Bei Wang
- Department of Gynaecology, Hebei General Hospital, Shijiazhuang, 050051, China
| | - Dongdong Yu
- Department of Anaesthesiology, Hebei General Hospital, Shijiazhuang, 050051, China
| | - Jianli Li
- Department of Anaesthesiology, Hebei General Hospital, Shijiazhuang, 050051, China.
| | - Xinyu Cao
- Department of Anaesthesiology, Hebei General Hospital, Shijiazhuang, 050051, China
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei Province, 050011, China
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Abd Ellatif SE, Mowafy SMS, Shahin MA. Ketofol versus Dexmedetomidine for preventing postoperative delirium in elderly patients undergoing intestinal obstruction surgeries: a randomized controlled study. BMC Anesthesiol 2024; 24:1. [PMID: 38166598 PMCID: PMC10759539 DOI: 10.1186/s12871-023-02378-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024] Open
Abstract
PURPOSE Postoperative delirium (POD) is considered the most common postoperative neurological complication in elderly patients. The aim of this study was to evaluate the efficacy of the administration of ketofol versus dexmedetomidine (DEX) for minimizing POD in elderly patients undergoing urgent exploration for intestinal obstruction. METHODS This prospective double-blinded randomized clinical trial was conducted on 120 elderly patients undergoing urgent exploration for intestinal obstruction. Patients were randomly allocated to one of the three groups: Group C (control group) patients received normal saline 0.9%, group D received dexmedetomidine, and group K received ketofol (ketamine: propofol was 1:4). The primary outcome was the incidence of POD. Secondary outcomes were incidence of emergence agitation, postoperative pain, consumption of rescue opioids, hemodynamics, and any side effects. RESULTS The incidence of POD was statistically significantly lower in ketofol and DEX groups than in the control group at all postoperative time recordings. Additionally, VAS scores were statistically significantly decreased in the ketofol and DEX groups compared to the control group at all time recordings except at 48 and 72 h postoperatively, where the values of the three studied groups were comparable. The occurrence of emergence agitation and high-dose opioid consumption postoperatively were found to be significant predictors for the occurrence of POD at 2 h and on the evening of the 1st postoperative day. CONCLUSION The administration of ketofol provides a promising alternative option that is as effective as DEX in reducing the incidence of POD in elderly patients undergoing urgent exploration for intestinal obstruction. TRIAL REGISTRATION This clinical trial was approved by the Institutional Review Board (IRB) at Zagazig University (ZU-IRB# 6704// 3/03/2021) and ClinicalTrials.gov (NCT04816162, registration date 22/03/ 2021). The first research participant was enrolled on 25/03/2021).
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Affiliation(s)
- Shereen E Abd Ellatif
- Department of Anesthesia, Intensive Care, and Pain Management. Faculty of Medicine, Zagazig University, Zagazig, Egypt.
| | - Sherif M S Mowafy
- Department of Anesthesia, Intensive Care, and Pain Management. Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mona A Shahin
- Department of Anesthesia, Intensive Care, and Pain Management. Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Zhu Y, Feng W, Kong Q, Sheng F, Li Z, Xu W, Li Q, Han Y, Wu X, Jia C, Guo J, Zhao Y. Evaluating the effects of S-ketamine on postoperative delirium in elderly patients following total hip or knee arthroplasty under intraspinal anesthesia: a single-center randomized, double-blind, placebo-controlled, pragmatic study protocol. Front Aging Neurosci 2023; 15:1298661. [PMID: 38099265 PMCID: PMC10720081 DOI: 10.3389/fnagi.2023.1298661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Postoperative delirium (POD) is an acute, transient brain disorder associated with decreased postoperative quality of life, dementia, neurocognitive changes, and mortality. A small number of trials have explored the role of S-ketamine in the treatment of POD due to its neuroprotective effects. Surprisingly, these trials have failed to yield supportive results. However, heterogeneity in delirium assessment methodologies, sample sizes, and outcome settings as well as deficiencies in S-ketamine use methods make the evidence provided by these studies less persuasive. Given the severe impact of POD on the health of elderly patients and the potential for S-ketamine to prevent it, we believe that designing a large sample size, and rigorous randomized controlled trial for further evaluation is necessary. Methods This is a single-center, randomized, double-blind, placebo-controlled, pragmatic study. Subjects undergoing total hip or knee arthroplasty will be randomized in a 1:1 ratio to intervention (n = 186) and placebo (n = 186) groups. This trial aims to explore the potential role of S-ketamine in the prevention of POD. Its primary outcome is the incidence of POD within 3 postoperative days. Secondary outcomes include the number of POD episodes, the onset and duration of POD, the severity and subtype of POD, pain scores and opioid consumption, sleep quality, clinical outcomes, and safety outcomes. Discussion To our knowledge, this is the first pragmatic study that proposes to use S-ketamine to prevent POD. We reviewed a large body of literature to identify potential preoperative confounding variables that may bias associations between the intervention and primary outcome. We will use advanced statistical methods to correct potential confounding variables, improving the test's power and external validity of test results. Of note, the patient population included in this trial will undergo intraspinal anesthesia. Although large, multicenter, randomized controlled studies have found no considerable difference in the effects of regional and general anesthesia on POD, patients receiving intraspinal anesthesia have less exposure to at-risk drugs, such as sevoflurane, propofol, and benzodiazepines, than patients receiving general anesthesia. At-risk drugs have been shown to negatively interfere with the neuroprotective effects of S-ketamine, which may be the reason for the failure of a large number of previous studies. There is currently a lack of randomized controlled studies evaluating S-ketamine for POD prevention, and our trial helps to fill a gap in this area.Trial registration: http://www.chictr.org.cn, identifier ChiCTR2300075796.
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Affiliation(s)
- Youzhuang Zhu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Wei Feng
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Qinghan Kong
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Fang Sheng
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Zhichao Li
- Department of Anesthesiology, Cancer Hospital Chinese Academy of Medical Science, Beijing, China
| | - Weilong Xu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Qun Li
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yan Han
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xiuyun Wu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Changxin Jia
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Jie Guo
- Department of Anesthesiology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Yang Zhao
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
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Mayanagi S, Haneda R, Inoue M, Ishii K, Tsubosa Y. Ramelteon and suvorexant for postoperative delirium in elderly patients with esophageal cancer. Esophagus 2023; 20:635-642. [PMID: 37561254 DOI: 10.1007/s10388-023-01019-7] [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: 01/31/2023] [Accepted: 06/19/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND There is no clear evidence on the prevention of postoperative delirium with pharmacotherapy in elderly patients with esophageal cancer. This retrospective study aimed to evaluate the efficacy of ramelteon and suvorexant in preventing postoperative delirium in this patient group. METHODS Data on 251 patients who received radical esophagectomy for thoracic esophageal cancer were collected from January 2010 to September 2021. In total, 74 patients did not receive preventive intervention, and 177 received ramelteon and suvorexant. After propensity score matching, the rate of postoperative delirium was compared between the two groups. RESULTS Seventy-two well-balanced patients in each group demonstrated similar clinical and pathological characteristics. The mean ages of the intervention and control groups were 70.8 and 70.3 years, respectively. All the patients underwent McKeown esophagectomy, and in the volume of intraoperative blood loss or operative time did not significantly differ between the two groups. The incidence rates of postoperative hyperactive delirium were 7% (5/72) in the intervention group and 32% (23/72) in the control group (p < 0.001). No severe adverse event potentially attributable to the intervention drug was observed. The multivariate analysis showed that the use of ramelteon and suvorexant was the only independent protective factor against postoperative delirium (hazard ratio 0.157, 95% CI 0.055-0.448, p < 0.001). CONCLUSIONS Ramelteon and suvorexant may play an important role in reducing postoperative delirium in elderly patients with esophageal cancer.
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Affiliation(s)
- Shuhei Mayanagi
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1004 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Ryoma Haneda
- Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu City , Shizuoka, Japan
| | - Masazumi Inoue
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1004 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kenjiro Ishii
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1004 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Yasuhiro Tsubosa
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1004 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
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