Baden Prevention and Reduction of Incidence of Postoperative Delirium Trial (PRIDe): a phase IV multicenter, randomized, placebo-controlled, double-blind clinical trial of ketamine versus haloperidol for prevention of postoperative delirium

Postoperative delirium among elderly elective orthopedic patients in Addis Ababa Ethiopia: a multicentere longitudinal study

BACKGROUND

Delirium is a neurocognitive disorder characterized by an acute and relatively rapid decline in cognition, disturbance of consciousness, reduced ability to focus, and shift of attention. It mainly affects elderly patients with an incidence of about 8-23% after an operation. It frequently occurs between 24-hrs and 5 days after surgery. It results in serious medical management problems. Hence, identifying the incidence and associated factors may help prevent and manage its sequel in the elderly.

OBJECTIVE

Assessment of the incidence and associated factors of postoperative delirium(POD) among elderly elective orthopedic surgical patients in Addis Ababa public hospitals, Ethiopia, 2024.

METHODS

A multi-centered longitudinal study was conducted on 220 elderly (age ≥ 65 years) patients in four selected public hospitals of the study area from February 2024 to May 2024, and a systematic sampling technique was used to select the study units. Data was collected through chart review and interviews of patients, and postoperative delirium was assessed using the confusion assessment method (CAM). Both bivariable and multivariable logistic regression models were used for statistical analysis. The strength of association was determined with an adjusted odds ratio (AOR) with a 95% confidence interval(CI) at a p-value of < 0.05.

RESULTS

A total of 220 patients were studied, and the incidence of POD among elderly elective orthopedic surgical patients was 33.7%. Age 65-75(AOR = 0.47, 95%CI (0.226-0.97)), Induction using ketamine (AOR = 1.32, 95%CI(1.109-3.87), p = 0.003)), perioperative opioid use (AOR = 2.20, 95%CI(1.073 4.5313)), intraoperative anticholinergic use(AOR = 2.24,95%CI(1.831-4.235)), recent hospitalization history (AOR = 2.24,95%CI(1.202-4.206)), and transfusion (AOR = 2.83,95%CI(1.295-6.193)) were significantly associated with POD (p < 0.05).

CONCLUSION AND RECOMMENDATIONS

The incidence of POD in the study area was high (33.7%); advanced age, hospitalization history, Anesthesia induction by Ketamine, perioperative anticholinergic uses, opioid use, and blood transfusion use were associated factors for postoperative delirium. We recommend giving due attention to elderly patients with advanced age, history of hospitalization, perioperative Ketamie use, perioperative anticholinergic uses, opioid use, and blood transfusion use undergoing elderly elective orthopedic surgery.

A single preoperative low-dose dexamethasone may reduce the incidence and severity of postoperative delirium in the geriatric intertrochanteric fracture patients with internal fixation surgery: an exploratory analysis of a randomized, placebo-controlled trial

OBJECTIVE

Postoperative delirium (POD) is a common complication along with poor prognosis in geriatric intertrochanteric fracture (ITF) patients. However, the prevention and treatment of POD remain unclear. Previous studies have confirmed that POD is essentially a consequence of neuro-inflammatory responses. Dexamethasone is a glucocorticoid with comprehensive anti-inflammatory effects, while a high dose of dexamethasone correlates with many side effects or even adverse consequences. Thus, this prospective study aims to discuss whether a single preoperative low-dose dexamethasone can reduce the impact of POD on geriatric ITF patients with internal fixation surgery.

METHODS

Between June 2020 and October 2022, there were 219 consecutive ITF patients assessed in our department. Of the 219 ITF patients, 160 cases who met the inclusion and exclusion criteria were finally enrolled and randomly allocated to the dexamethasone group and the placebo group (80 geriatric ITF patients in each group) in this prospective study. The patients in the dexamethasone group received intravenous 10 mg (2 ml) dexamethasone while the patients in the placebo group received intravenous 2 ml saline in 30 min before being sent to the operating room, respectively. The baseline characteristics, surgical information, incidence and severity of POD as the efficacy-related outcomes, and infection events and hyperglycemia as safety-related outcomes (adverse events), were collected and analyzed between the two groups. The severity of POD was evaluated by Memorial Delirium Assessment Scale (MDAS) score.

RESULTS

There were no differences in baseline characteristics and surgical information between the dexamethasone group and the placebo group. The dexamethasone group had a lower incidence of POD than the placebo group within the first 5 days after surgery [(9/80, 11.3% vs. 21/80, 26.3%, RR = 0.83, 95% CI 0.71-0.97, P = 0.015]. The dexamethasone group had lower MDAS scores (Mean ± SD) than the placebo group [13.2 ± 1.0 (range 11 to 15) vs. 15.48 ± 2.9 (range 9 to 20), P = 0.011, effect size = 0.514]. There were no differences in infection events and hyperglycemia between the two groups.

CONCLUSIONS

A single preoperative low-dose dexamethasone may reduce the incidence and severity of POD in geriatric ITF patients with internal fixation surgery.

TRIAL REGISTRATION

ChiCTR2200055281.

Temporal Trends and Variability in Ketamine Use for Mechanically Ventilated Adults in the United States

Rationale The epidemiology of continuous ketamine use in the management of critically ill adults receiving invasive mechanical ventilation (MV) in the U.S. is unknown. Objective To quantify the temporal trends and variation across U.S. hospitals in continuous ketamine use. Methods We performed a retrospective cohort study of adults (age ≥18) receiving MV who were discharged (alive or dead) from U.S. hospitals contributing data to the Premier Healthcare Database between January 2008 and September 2018. We used mixed effects multivariable logistic regression modeling (fixed effects: patient and hospital characteristics; random effect: discharge hospital) to evaluate the associations of discharge quarter and discharge hospital with continuous ketamine use (defined as a charge for intravenous ketamine on ≥2 consecutive calendar days). Results We identified 2,059,599 MV adults across 842 hospitals; of these, 7,927 (0.4%) received continuous ketamine. Ketamine use increased over time from 0.07% of all patients in quarter 1 2008 to 1.1% of all patients in quarter 3 2018. After adjustment, the odds of receiving continuous ketamine were consistently increased starting in quarter 4 2011 (odds ratio [95% confidence interval]: 1.83 [1.09-3.06] vs quarter 1 2008, p=0.023) with >10-fold increased odds starting in quarter 2 2017. Out of 842 hospitals, 486 (57.7%) used continuous ketamine on at least one cohort patient during the study period. Across these hospitals ever using ketamine, median use was 0.2% (IQR 0.08%-0.5%) with 5 hospitals using continuous ketamine in >5% of patients. The adjusted median odds ratio for discharge hospital was 3.72 (95% confidence interval: 3.37-4.13) which was higher than the odds ratio for any patient or hospital covariable other than discharge quarter. Conclusions In U.S. hospitals, use of continuous infusion ketamine increased markedly over time in critically ill patients receiving MV, with substantial variability between hospitals. Given the unique properties of ketamine as a sedative, further research is needed to assess its safety and utility in critically ill populations.

Related Factors and Treatment of Postoperative Delirium in Old Adult Patients: An Integrative Review

“Postoperative delirium” is defined as delirium occurring in the hospital up to one week after a procedure or before discharge (whichever occurs first) that meets the DSM-5 diagnostic criteria. Objectives: To describe the risk factors related to this pathology and identify effective non-pharmacological forms of treatment. An integrative review of the available literature was performed. The search results considered included all quantitative studies published between 2011 and 2019 in both English and Spanish. A total of 117 studies were selected. Advanced age was identified as the principal risk factor for postoperative delirium. Nursing interventions appear to be the key to preventing or reducing the seriousness of delirium after an anaesthetic episode. The aetiology of postoperative delirium remains unknown, and no treatment exists to eliminate this pathology. The role of nursing staff is fundamental in the prevention, diagnosis, and management of the pathology.

Nursing Delirium Screening Scale, a Tool for Early Detection of Delirium: Integrative Review

Objective: To analyze the context and use of the Nursing Delirium Screening Scale (Nu-DESC) for early detection of delirium in adult patients, compiling the available evidence. Method: Searching for relevant articles on databases such as Cinahl, Medline, Ovid, Scopus, and Web of Science. Inclusion criteria: Articles written in English, Spanish, and Portuguese, published between January 2013 and October 2019. Search terms: “nursing delirium screen,” “inpatient delirium screening,” and “nursing assessment.” We identified 23 articles in which the Nu-DESC was used. Two reviewers independently assessed the articles using the CASPe (Critical Appraisal Skills Program in Spanish) tool. Results: The Nu-DESC is employed in different contexts such as the adult intensive care unit (ICU), post-anesthetic care unit (PACU), palliative care unit, and hospitalization unit. It is more frequently used in the PACU with a more sensitive threshold (≥ 1); the test showed greater sensitivity of 54.5 % (95 % CI: 32.2–75.6) and specificity of 97.1 % (95 % CI: 95.3–98.4). Conclusion: The Nu-DESC facilitates the recognition of delirium episodes by the nursing team, makes care quicker and individualized for each patient, avoiding immediate pharmacological interventions, and coordinate interdisciplinary actions for diagnosis, especially in post-anesthetic care units.

Ketamine vs. haloperidol for prevention of cognitive dysfunction and postoperative delirium: A phase IV multicentre randomised placebo-controlled double-blind clinical trial

STUDY OBJECTIVE

Delirium is frequently observed in the postoperative and intensive care unit (ICU) population. Due to the multifactorial origin of delirium and according to international guidelines (e.g., American Geriatrics Society; Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) guideline), there are several but no incontestable options for prevention and symptomatic treatment. The purpose of the Baden PRIDe (Prevention and Reduction of Incidence of postoperative Delirium) trial was to determine whether postoperative cognitive dysfunction and delirium could be prevented by the combination of possible preventive agents such as haloperidol and ketamine. In addition, pre- and postoperative levels of the biomarkers cortisol, neuron specific enolase (NSE) and S100β were measured to investigate their dynamics in delirious and non-delirious patients after surgery.

DESIGN

The Baden PRIDe Trial was an investigator-initiated, phase IV, two-centre, randomised, placebo-controlled, double-blind clinical trial.

SETTING

Perioperative care.

PATIENTS

182 adult patients that underwent elective or emergency surgery under general or combined (i.e., general and regional) anaesthesia.

INTERVENTIONS

Pre-anaesthetic, pharmacologic prevention of postoperative brain dysfunction with haloperidol, ketamine, and the combination of both vs. placebo.

MEASUREMENTS

Assessment of cognitive performance pre- and postoperatively with the MMSE, the DOS, the Nursing Delirium Screening Scale (Nu-DESC) or the Intensive Care Delirium Screening Checklist (ICDSC) during ICU stay.

MAIN RESULTS

None of the three study arms - haloperidol, ketamine, or both drugs combined - was significantly superior to placebo for prevention of postoperative brain dysfunction and delirium (P = 0.39). Measured levels of postoperative cortisol were significantly higher in delirious patients. S-100β levels were significantly higher in all postoperative outcome groups (cognitive impairment, delirium, no cognitive decline), whereas postoperative NSE levels declined in all groups.

CONCLUSIONS

The study results offer no possibility for a novel recommendation for prevention of postoperative cognitive decline including delirium. Perioperative S-100β trajectories in patients with cognitive deterioration suggest affection of glial cells in particular.

TRIAL REGISTRATION

ClinicalTrials.govNCT02433041; registered on April 7, 2015.

The pharmacotherapeutic management of postoperative delirium: an expert update

INTRODUCTION

Postoperative delirium is a common sequela in older adults in the peri-operative period leading to poor outcomes with a complex pathophysiology which has led to a variety of different pharmacologic agents employed in attempts to prevent and treat this syndrome. No pharmacologic agent has been approved to treat this disorder, but this review discusses the pharmacologic strategies which have been tried based on the hypotheses of the causation of the syndrome including neurotransmitter imbalance, inflammation, and oxidative stress.

AREAS COVERED

Systematic reviews and meta-analyses of randomized clinical trials (RCTs) were included via search of electronic databases specifically for the terms postoperative delirium and pharmacologic treatments. With this approach, the recurrent topics of analgesia and sedation, antipsychotics, acetylcholinesterase inhibitors (AchE-Is), inflammation, and melatonin were emphasized and provided the outline for this review.

EXPERT OPINION

Research evidence does not support any particular agent in any of the pharmacologic classes reviewed. However, there is some potential benefit with dexmedetomidine, melatonin, and the monitoring of anesthetic agents all of which need further clinical trials to validate these conclusions. Exploration of ways to improve studies and the application of novel pharmacologic agents may offer future benefit.

Serum biomarkers of delirium in the elderly: a narrative review

Delirium after surgery and in the intensive care unit (ICU) remains a challenge for patients, families, and caregivers. Over the years, many promising biomarkers have been investigated as potential instruments for risk stratification of delirium. This review aimed to identify and assess the clinical usefulness of candidate serum biomarkers associated with hospital delirium in patients aged 60 years and older. We performed a time-unlimited review of publications indexed in PubMed, Cochrane, Embase, and MEDLINE databases until June 2019 that evaluated baseline and/or longitudinal biomarker measurements in patients suffering from delirium at some point during their hospital stay. A total of 32 studies were included in this review reporting information on 7610 patients. Of these 32 studies, twenty-four studies reported data from surgical patients including four studies in ICU cohorts, five studies reported data from medical patients (1026 patients), and three studies reported data from a mixed cohort (1086 patients), including one study in an ICU cohort. Findings confirm restricted clinical usefulness to predict or diagnose delirium due to limited evidence on which biomarkers can be used and limited availability due to non-routine use.