Effect of sedative premedication with oral midazolam on postanesthesia care unit delirium in older adults: a secondary analysis following an uncontrolled before-after design

Preoperative Midazolam and Patient-Centered Outcomes of Older Patients: The I-PROMOTE Randomized Clinical Trial

Importance

The effect of oral midazolam premedication on patient satisfaction in older patients undergoing surgery is unclear, despite its widespread use.

Objective

To determine the differences in global perioperative satisfaction in patients with preoperative administration of oral midazolam compared with placebo.

Design, Setting, and Participants

This double-blind, parallel-group, placebo-controlled randomized clinical trial was conducted in 9 German hospitals between October 2017 and May 2019 (last follow-up, June 24, 2019). Eligible patients aged 65 to 80 years who were scheduled for elective inpatient surgery for at least 30 minutes under general anesthesia and with planned extubation were enrolled. Data were analyzed from November 2019 to December 2020.

Interventions

Patients were randomized to receive oral midazolam, 3.75 mg (n = 309), or placebo (n = 307) 30 to 45 minutes prior to anesthesia induction.

Main Outcomes and Measures

The primary outcome was global patient satisfaction evaluated using the self-reported Evaluation du Vécu de l'Anesthésie Generale (EVAN-G) questionnaire on the first postoperative day. Key secondary outcomes included sensitivity and subgroup analyses of the primary outcome, perioperative patient vital data, adverse events, serious complications, and cognitive and functional recovery up to 30 days postoperatively.

Results

Among 616 randomized patients, 607 were included in the primary analysis. Of these, 377 (62.1%) were male, and the mean (SD) age was 71.9 (4.4) years. The mean (SD) global index of patient satisfaction did not differ between the midazolam and placebo groups (69.5 [10.7] vs 69.6 [10.8], respectively; mean difference, -0.2; 95% CI, -1.9 to 1.6; P = .85). Sensitivity (per-protocol population, multiple imputation) and subgroup analyses (anxiety, frailty, sex, and previous surgical experience) did not alter the primary results. Secondary outcomes did not differ, except for a higher proportion of patients with hypertension (systolic blood pressure ≥160 mm Hg) at anesthesia induction in the placebo group.

Conclusion and Relevance

A single low dose of oral midazolam premedication did not alter the global perioperative patient satisfaction of older patients undergoing surgery or that of patients with anxiety. These results may be affected by the low dose of oral midazolam. Further trials-including a wider population with commonplace low-dose intravenous midazolam and plasma level measurements-are needed.

Trial Registration

ClinicalTrials.gov Identifier: NCT03052660.

A new view on old problems in paediatric anaesthesia: premedication, postoperative agitation and dosing

PURPOSE OF REVIEW

The aim of this review is to discuss recent developments in paediatric anaesthesia, which have evolved in an undulating fashion.

RECENT FINDINGS

The role and efficacy of pharmacological premedication is reevaluated. The anxiolytic and sedative properties of midazolam and α 2 -agonists have now been defined more precisely. Both classes of drugs have their unique profile, and there is no reason to condemn one or the other. Midazolam is an excellent anxiolytic, whereas dexmedetomidine is superior in the postoperative period and for sedation during diagnostic imaging.A total intravenous technique with propofol is often considered to be the standard for the prevention of emergence agitation; but alternatives do exist, such as a co-medication with dexmedetomidine or opioids. In clinical reality, a multimodal approach may often be advisable.The theoretical basis for propofol dosing has recently been adapted. In contrast to previous beliefs, the context-sensitive half-life of propofol seems to be quite short beyond the first year of life.

SUMMARY

Midazolam and dexmedetomidine are not interchangeable; each compound has its pros and cons. As an anxiolytic drug, midazolam indisputably deserves its place, whereas dexmedetomidine is a better sedative and particularly beneficial in the postoperative period. New data will allow more precise age-adapted dosing of propofol.

Preoperative anxiety

PURPOSE OF REVIEW

With first research reports dating back to the 1970s, the important role of anxiety in the perioperative period has been recognized for a long time and remains in effect.

RECENT FINDINGS

The global pooled prevalence of preoperative anxiety among 14 000 surgical patients was reported to be 48%. The underlying fears among surgical patients include: fear of surgical complications, worry about the duration and degree of disability after the procedure, concerns about general anesthesia and the associated loss of control, as well as fear of waking up and experiencing discomfort and pain during or after surgery. The type and invasiveness of the planned procedure contribute to differences in preoperative anxiety levels. While preoperative anxiety is higher in younger, female patients as well as in those with a high need for information, prior exposure to anesthesia or surgery was associated with lower anxiety levels. High levels of preoperative anxiety may lead to poor postoperative pain control and increased morbidity. Due to adverse effects such as delirium, the use of benzodiazepines to manage preoperative anxiety has decreased.

SUMMARY

Preoperative anxiety remains a critical issue in the perioperative period. Further research is needed to develop effective management strategies, which may need to be tailored to the patient's individual need.

Prevalence of Emergence Delirium and Associated Factors among Older Patients Who Underwent Elective Surgery: A Multicenter Observational Study

Background

Emergence delirium is a common and serious postoperative complication in older surgical patients. It occurs at any time in the perioperative period, during or immediately following emergence from general anesthesia. Unfortunately, it is highly associated with postoperative complications such as a decrease in functional capacity, prolonged hospital stay, an increase in health care costs, and morbidity and mortality. The goal of this study was to determine the prevalence of emergence delirium and associated factors among older patients who underwent elective surgery in the teaching hospitals of Ethiopia at the postanesthesia care unit in 2021.

Methods

A multicenter prospective observational study was conducted at the postanesthetic care unit in the four teaching hospitals of Ethiopia. Older surgical patients admitted to the postanesthesia care unit who underwent elective surgery in the four teaching hospitals of Ethiopia were selected by using simple random sampling. Pretested structured questionnaire was used to collect data. Data were entered into EpiData (version 4.6) and exported to the SPSS (version 25.0). Binary logistic regression was used to identify factors independently associated with the emergence delirium.

Results

Out of 384 older patients included in the study, the prevalence of emergence delirium was 27.6%. Preoperative low hemoglobin levels (AOR: 2.0, 95% CI; 1.77–3.46), opioid (AOR: 8.0, 95% CI; 3.22–27.8), anticholinergic premedications (AOR: 8.5, 95% CI; 6.85–17.35), and postoperative pain (AOR: 3.10, 95 CI; 2.07–9.84) at PACU were independently associated with emergence delirium.

Conclusion

The prevalence of emergence delirium was high among older patients who underwent elective surgery. Opioid and anticholinergic premedication, low preoperative hemoglobin, and the presence of postoperative pain were independently associated with the emergence delirium. Adequate preoperative optimization and postoperative analgesia may reduce the prevalence of emergence delirium.