Dexmedetomidine improves early postoperative neurocognitive disorder in elderly male patients undergoing thoracoscopic lobectomy

Effectiveness of Roy Adaptation Model-Based Cognitive Stimulation Therapy in Elderly Patients with Non-Small Cell Lung Cancer Undergoing Curative Resection

This study aimed to investigate the effects of a Roy adaptation model (RAM)-based cognitive stimulation therapy (CST) intervention on elderly patients diagnosed with primary non-small cell lung cancer (NSCLC) undergoing curative resection. A total of 280 patients diagnosed with primary NSCLC were randomized into RAM-based CST group and control group. Outcomes were assessed at three intervals: pre-surgery, discharge, and one-month post-discharge. Cognitive function was evaluated using Mini-Cognitive test. Postoperative delirium prevalence was determined within 48 hours post-surgery using Nursing Delirium Screening Scale. The Hospital Anxiety and Depression Scale evaluated anxiety and depression symptoms, while Quality of Life (QoL) was assessed via Short Form-36 (SF36) Health Survey. The RAM-based CST group demonstrated significantly higher Mini-Cog test scores than the control group upon discharge and post-intervention. Patients with RAM-based CST exhibited a decrease in postoperative delirium compared to the control group. The RAM-based CST intervention yielded an improvement in anxiety and depression at discharge and 1-month post-discharge compared to preoperative levels. Additionally, the RAM-based CST group exhibited substantial enhancements in SF36 subcategory scores at 1-month post-discharge compared to pre-surgery. At post-intervention, the RAM-based CST group demonstrated significantly higher scores than the control group across various health-related domains, including role limitations due to emotional problems, mental health, general health perception, bodily pain, and role limitations due to physical problems. The RAM-based CST intervention in elderly NSCLC patients undergoing curative resection yielded significant enhancements in cognitive function, reduced delirium incidence, improved emotional well-being, and better QoL postoperatively.

Effects of dexmedetomidine on postoperative pain and early cognitive impairment in older male patients undergoing laparoscopic cholecystectomy

The primary aim of the present study was to investigate the effect of dexmedetomidine (DEX) on postoperative pain and early cognitive impairment in old male patients, who underwent laparoscopic cholecystectomy (LC). A total of 97 old patients, subjected to LC at the 980 Hospital of the Joint Service Support Force of the People's Liberation Army of China, were randomly divided into two groups, namely the DEX and normal saline groups. Patients in the DEX group received an intravenous infusion of 0.8 µg/kg DEX within 10 min following general anesthesia, followed by a maintenance infusion of 0.5 µg/(kg/h). Furthermore, patients in the normal saline group were treated with an equivalent volume of normal saline. Cognitive function was assessed using the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) tests at 6 h, 1, 2 and 3 days, postoperatively. The incidence of postoperative cognitive dysfunction (POCD) and postoperative adverse events were recorded for both groups. In addition, the Visual Analogue Scale (VAS) pain score was utilized to assess the pain level of all patients, while the Quality of Recovery-15 (QoR-15) scale was employed to analyze the postoperative recovery results. Therefore, the MoCA score was higher in the DEX group compared with the normal saline group at 6 h and day 1 postoperatively. Additionally, the MMSE score was higher at 6 h postoperatively in the DEX group compared with the normal saline group. Correspondingly, the incidence of POCD was lower in the DEX group compared with the normal saline group at 6 h and day 1, after LC (P<0.05). VAS score in resting state for patients in the DEX group was significantly lower compared with the normal-saline group (P<0.05). Furthermore, the QoR-15 scale score in patients in the DEX group was notably increased compared with the normal saline group on the first and second days after the operation (P<0.05). Overall, the present study verified that the continuous infusion of DEX at a rate of 0.5 µg/(kg/h) during LC could effectively reduce the incidence of early POCD and alleviate postoperative pain in old male patients, thus facilitating postoperative recovery.

Intravenous infusion of dexmedetomidine during the surgery to prevent postoperative delirium and postoperative cognitive dysfunction undergoing non-cardiac surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Dexmedetomidine plays a pivotal role in mitigating postoperative delirium and cognitive dysfunction while enhancing the overall quality of life among surgical patients. Nevertheless, the influence of dexmedetomidine on such complications in various anaesthesia techniques remains inadequately explored. As such, in the present study, a meta-analysis was conducted to comprehensively evaluate its effects on postoperative delirium and cognitive dysfunction.

METHODS

A number of databases were searched for randomised controlled trials comparing intravenous dexmedetomidine to other interventions in preventing postoperative delirium and cognitive dysfunction in non-cardiac and non-neurosurgical patients. These databases included PubMed, Embase, and Cochrane Library. Statistical analysis and graphing were performed using Review Manager, STATA, the second version of the Cochrane risk-of-bias tool for randomised controlled trials, and GRADE profiler.

MAIN RESULTS

This meta-analysis comprised a total of 24 randomised controlled trials, including 20 trials assessing postoperative delirium and 6 trials assessing postoperative cognitive dysfunction. Across these 24 studies, a statistically significant positive association was observed between intravenous administration of dexmedetomidine and a reduced incidence of postoperative delirium (RR: 0.55; 95% CI 0.47 to 0.64, p < 0.00001, I2 = 2%) and postoperative cognitive dysfunction (RR: 0.60; 95% CI 0.38 to 0.96, p = 0.03, I2 = 60%). Subgroup analysis did not reveal a significant difference in the incidence of postoperative delirium between the general anaesthesia and non-general anaesthesia groups, but a significant difference was observed in the incidence of postoperative cognitive dysfunction. Nonetheless, when the data were pooled, it was evident that the utilisation of dexmedetomidine was associated with an increased incidence of hypotension (RR: 1.42; 95% CI 1.08 to 1.86, p = 0.01, I2 = 0%) and bradycardia (RR: 1.66; 95% CI 1.23 to 2.26, p = 0.001, I2 = 0%) compared with other interventions. However, there was no significantly higher occurrence of hypertension in the DEX groups (RR = 1.35, 95% CI 0.81-2.24, p = 0.25, I2 = 0%).

CONCLUSION

Compared with other interventions, intravenous dexmedetomidine infusion during non-cardiac and non-neurosurgical procedures may significantly reduce the risk of postoperative delirium and cognitive dysfunction. The results of subgroup analysis reveal a consistent preventive effect on postoperative delirium in both general and non-general anaesthesia groups. Meanwhile, continuous infusion during general anaesthesia was more effective in reducing the risk of cognitive dysfunction. Despite such findings, hypotension and bradycardia were more frequent in patients who received dexmedetomidine during surgery.

Effect of comfort nursing on postoperative recovery and life quality of patients undergoing thoracic surgery

OBJECTIVE

To evaluate the effect of comfort nursing on postoperative recovery and life quality of patients undergoing thoracic surgery.

METHODS

A total of 400 patients undergoing thoracic surgery in our hospital from October 2017 to July 2020 were identified as research subjects and retrospectively studied. These patients were assigned to a control group (Con group, n=196, given conventional nursing) and an observation group (Obs group, n=204, given conventional nursing combined with comfort nursing) according to nursing modality. The following items of the two groups were compared: incidence of adverse reactions after surgery, MOS 36-Item Short-Form Health Survey (SF-36) score, visual analog scale (VAS) scores at 24, 48, and 72 h after surgery, length of stay, first postoperative exhaust time, drainage duration, nursing satisfaction, and systolic blood pressure (SBP), diastolic blood pressure (DBP), mean atrial pressure (MAP), and heart rate before and after the intervention.

RESULTS

Compared with the Con group, the Obs group showed a notably lower total incidence of adverse reactions and had higher SF-36 scores after surgery. The Obs group had lower VAS scores at 24, 48, and 72 h after surgery than the Con group. The Obs group also experienced significantly shorter length of stay and drainage duration and earlier first postoperative exhaust time in contrast to the Con group. In addition, the Obs group obtained a higher satisfaction rate than the Con group, and patients in the Obs group had better treatment compliance and emotionalal status than those in the Con group. Moreover, the two groups presented no significant difference in SBP, DBP, MAP, or heart rate before and after intervention (all P>0.05).

CONCLUSION

For patients undergoing thoracic surgery, comfort nursing can greatly improve their life quality and contribute to their postoperative recovery.

Implication of age-related changes on anesthesia management

Elderly patients have a high risk of perioperative morbidity and mortality. Pluri-morbidities, polypharmacy, and functional dependence may have a great impact on intraoperative management and request specific cautions. In addition to surgical stress, several perioperative noxious stimuli such as fasting, blood loss, postoperative pain, nausea and vomiting, drug adverse reactions, and immobility may trigger a derangement leading to perioperative complications. Older patients have a high risk of major hemodynamic derangement due to aging of the cardiovascular system and associated comorbidities. The hemodynamic monitoring as well as fluid therapy should be the most accurate as possible. Aging is accompanied by decreased renal function, which is related to a reduction in renal blood flow, renal mass, and the number and size of functioning nephrons. Drugs eliminated predominantly by the renal route need dosage adjustments based on residual renal function. Liver mass, hepatic blood flow, and intrinsic metabolic activity are decreased in the elderly, and all drugs metabolized by the liver have a variable half-life, thus requiring dose reduction. Decreased neural plasticity contributes to a high risk for postoperative delirium. Monitoring of anesthesia depth should be mandatory to avoid overdosage of hypnotic drugs. Prevention of postoperative pulmonary complications requires both protective ventilation strategies and adequate recovery of neuromuscular function at the end of surgery. Avoidance of hypothermia cannot be missed. The aim of this review is to describe comprehensive strategies for intraoperative management plans tailored to meet the unique needs of elderly surgical patients, thus improving outcomes in this vulnerable population.

Effects of dexmedetomidine at different dosages on perioperative haemodynamics and postoperative recovery quality in elderly patients undergoing hip replacement surgery under general anaesthesia: a randomized controlled trial

BACKGROUND

Dexmedetomidine could provide some advantages to prevent postoperative complications in elderly patients undergoing under general anaesthesia. However, dexmedetomidine inhibits haemodynamics to some extent due to its sympathetic inhibition.

OBJECTIVE

To evaluate the effects of different doses of dexmedetomidine on haemodynamics during surgery and recovery after general anaesthesia in elderly patients undergoing hip replacement.

METHODS

This was a prospective randomized double-blind controlled clinical trial. Eligible patients were randomly allocated into comparative groups (normal saline (NS) and midazolam (MD), n = 30) and dexmedetomidine groups at different doses (D0.25/D0.5/D0.75, n = 30). In the D0.25/D0.5/D0.75 groups, dexmedetomidine was administered at different initial loading doses (0.25/0.5/0.75 μg/kg for 15 min) following 0.5 μg/kg/h continuous infusion until the end of the operation. In the MD group, patients were administered 0.03 mg/kg midazolam at the beginning of anaesthesia induction.

RESULTS

Compared to the MD and NS groups, there were significant decreases in MAP in the D0.5 and D0.75 groups at many time points, such as skin incision, end of operation, and from extubation until 30 min after extubation (P < 0.05); there were also significant decreases in HR in the D0.5 and D0.75 groups at time points including anaesthesia induction, end of operation, and from extubation to 2 h after operation (P < 0.05). In the D0.25 group, there were few differences in the changes in MAP and HR compared to the MD and NS groups during the entire perioperative period (P > 0.05). Moreover, the percentage of patients whose MAP and HR decreased > 20% of baseline was higher in the D0.75 and D0.5 groups than that in all other groups. Compared to the NS group, from the beginning to the end of the operation, the 95% confidence interval (CI) of RR for MAP below > 20% of baseline in the D0.5 and D0.75 groups was greater than 1. In particular, the CI of the RR in the D0.75 group was greater than 1 until the patient awoke from general anaesthesia (P < 0.05). In addition, the CI of the RR for HR below > 20% of baseline in the D0.5 group was greater than 1 compared to the NS group at the time of induction and extubation (P < 0.05). There was no significant difference in the possibility of developing hypotension or bradycardia in the MD or D0.25 groups compared to the NS group (P > 0.05). The recovery quality of patients during the post-anaesthesia period was also observed. No differences were observed among all the groups in the time to awakening or extubation after general anaesthesia (P > 0.05). According to the Riker Sedation-agitated Scale, dexmedetomidine significantly alleviated emergency agitation or delirium compared to NS (P < 0.05). In addition, the scores in the D0.5 and D0.75 groups were lower than those in the D0.25 group (P < 0.05).

CONCLUSION

Dexmedetomidine could alleviate the agitation of elderly patients undergoing hip replacement after intravenous general anaesthesia combined with inhaled sevoflurane without delayed recovery. However, it is necessary to be vigilant about the haemodynamic inhibition of the drug at high dosages throughout the perioperative period. Dexmedetomidine 0.25-0.5 μg/kg as the initial loading dose followed by 0.5 μg/kg/h continuous infusion might provide comfortable recovery after general anaesthesia with slight haemodynamic inhibition.

TRAIL REGISTRATION

ClinicalTrial.gov, No. NCT05567523. Registered 05 October 2022, https://clinicaltrials.gov/ct2/show/NCT05567523?term=NCT05567523&draw=2&rank=1 .

Dexmedetomidine Increases MMP-12 and MBP Concentrations after Coronary Artery Bypass Graft Surgery with Extracorporeal Circulation Anaesthesia without Impacting Cognitive Function: A Randomised Control Trial

Postoperative neurological deficits remain a concern for patients undergoing cardiac surgeries. Even minor injuries can lead to neurocognitive decline (i.e., postoperative cognitive dysfunction). Dexmedetomidine may be beneficial given its reported neuroprotective effect. We aimed to investigate the effects of dexmedetomidine on brain injury during cardiac surgery anaesthesia. This prospective observational study analysed data for 46 patients who underwent coronary artery bypass graft surgery with extracorporeal circulation between August 2018 and March 2019. The patients were divided into two groups: control (CON) with typical anaesthesia and dexmedetomidine (DEX) with dexmedetomidine infusion. Concentrations of the biomarkers matrix metalloproteinase-12 (MMP-12) and myelin basic protein (MBP) were measured preoperatively and at 24 and 72 h postoperatively. Cognitive evaluations were performed preoperatively, at discharge, and 3 months after discharge using Addenbrooke's Cognitive Examination version III (ACE-III). The primary endpoint was the ACE-III score at discharge. Increased MMP-12 and MBP concentrations were observed in the DEX group 24 and 72 h postoperatively. No significant differences in ACE-III scores were observed between the groups at discharge; however, the values were increased when compared with initial values after 3 months (p = 0.000). The current results indicate that the administration of dexmedetomidine as an adjuvant to anaesthesia can increase MMP-12 and MBP levels without effects on neurocognitive outcomes at discharge and 3 months postoperatively.

Effect of dexmedetomidine on the Montreal Cognitive Assessment in older patients undergoing pulmonary surgery

Objective

We investigated the effect of dexmedetomidine anesthesia on postoperative cognitive function after pulmonary surgery.

Methods

A blinded, prospective, randomized, placebo-controlled study was performed on 60 patients (age range 65–74 years) undergoing lobectomy by video-assisted thoracoscopic surgery (29 in the dexmedetomidine group; 31 in the placebo group). Dexmedetomidine group patients received dexmedetomidine, and placebo group patients received an equal volume of physiological saline 20 minutes before anesthesia induction. Cognitive function was evaluated using the Montreal Cognitive Assessment 1 day before surgery and on postoperative day (POD)1, POD3, and POD7. The regional cerebral oxygen saturation (rSO₂) was monitored continuously by near-infrared spectroscopy before anesthesia.

Results

The Montreal Cognitive Assessment score was significantly different between the two groups on POD1 (dexmedetomidine 26.4  ±  0.73 vs. placebo 25.5 ± 0.96) and POD3 (dexmedetomidine 27.1 ± 0.79 vs. placebo 26.6 ± 0.80). Specifically, attention and orientation scores were increased in the dexmedetomidine group on POD1 and POD3. The rSO₂ was not significantly different between the dexmedetomidine and placebo groups.

Conclusion

Dexmedetomidine given before induction of anesthesia could reduce the risk of postoperative cognitive dysfunction and might not decrease rSO₂. Hence, dexmedetomidine could be employed in pulmonary surgical procedures, especially for older patients with a high risk of cognitive dysfunction.

Influence of dexmedetomidine on postoperative cognitive dysfunction in the elderly: A meta-analysis of randomized controlled trials

INTRODUCTION

Dexmedetomidine (Dex) is suggested to be neuroprotective. However, influence of Dex on postoperative cognitive dysfunction (POCD) in the elderly remains unknown.

METHODS

We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of Dex on POCD. Relevant studies were obtained by search of PubMed, Embase, and Cochrane's Library databases. A random-effect model was used to pool the results.

RESULTS

Fourteen RCTs including 1626 adults of 60 years or older who received surgery with general anesthesia were included. Because methodologically diverse scales were used for POCD, eight RCTs with POCD diagnosed with Mini-Mental State Examination (MMSE) were included in the meta-analysis, while the remaining six RCTs with POCD diagnosed with other scales were qualitative synthesized. Pooled results of RCTs with MMSE showed that Dex significantly reduced the incidence of POCD (risk ratio: 0.47, 95% confidence interval: 0.37-0.60, p < 0.001) with no significant heterogeneity (I²  = 0%) or publication bias (p for Egger's regression test = 0.579). For the remaining six RCTs with POCD diagnosed with other scales, three of them showed that Dex was associated with a significantly lower incidence of POCD, while the other three RCTs did not show a significant difference.

CONCLUSIONS

Dex is associated with a reduced risk of POCD in elderly patients receiving surgeries with general anesthesia, and the results were mainly obtained in studies with POCD diagnosed with MMSE. Based on these findings, Dex may be considered as a preventative measure for POCD in elderly patients.

Effects of Glucocorticoids on Postoperative Neurocognitive Disorders in Adult Patients: A Systematic Review and Meta-Analysis

Background

Postoperative neurocognitive disorders (PNDs) is common among surgical patients, however, the effect of glucocorticoids for preventing PNDs is not clear. This review aims to evaluate the effect of glucocorticoids on the incidence of PNDs in adult patients undergoing surgery.

Methods

The databases of PubMed/Medline, Embase, the Cochrane Library, and Web of science were searched for all available randomized controlled trials (RCTs) from inception to April 30, 2022. RCTs comparing the effect of glucocorticoids with placebo on the incidence of PNDs in adult surgical patients (≥18 years old) were eligible. Subgroup analyses and meta-regressions were performed to evaluate sources of clinical heterogeneity. The level of certainty for main outcomes were assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

Results

Eleven trials with a total of 10,703 patients were identified. Compared with the control group, glucocorticoids did not reduce the incidence of PNDs (RR: 0.84, 95% CI: 0.67 to 1.06, P = 0.13, GRADE = moderate). Secondary analyses for primary outcome did not change the result. In addition, the length of ICU stay was decreased in glucocorticoids group (RR: −13.58, 95% CI: −26.37 to −0.80, P = 0.04, GRADE = low). However, there were no significant differences between groups with regards to the incidence of postoperative infection (RR: 0.94, 95% CI: 0.84 to 1.06, P = 0.30, GRADE = moderate), blood glucose level (RR: 1.05, 95% CI: −0.09 to 2.19, P = 0.07, GRADE = low), duration of mechanical ventilation (RR: −2.44, 95% CI: −5.47 to 0.59, P = 0.14, GRADE = low), length of hospital stay (RR: −0.09, 95% CI: −0.27 to 0.09, P = 0.33, GRADE = moderate) and 30-day mortality (RR: 0.86, 95% CI: 0.70 to 1.06, P = 0.16, GRADE = moderate).

Conclusions

This meta-analysis suggests that perioperative administration of glucocorticoids may not reduce the incidence of PNDs after surgery. The effect of glucocorticoids on decreased length of ICU stay needs further researches. Future high-quality trials using acknowledged criteria and validated diagnostic tools are needed to determine the influence of glucocorticoids on long-term PNDs.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022302262, identifier: CRD42022302262.

Effect of Dexmedetomidine on Postoperative Sleep Quality: A Systematic Review

In this article, we conduct a systematic review of the literature to explore the specific role of dexmedetomidine (DEX) on postoperative sleep and its associated mechanisms at present. The electronic database Embase, MEDLINE/PubMed, the Cochrane Library, Web of Science, and Google Scholar were searched. The restriction terms included “dexmedetomidine”, “sleep” and “surgery”. The inclusion criteria were as following: 1) patients 18 years old or older; 2) DEX used in the perioperative period not just for critically ill patients in the intensive care unit (ICU); 3) prospective or retrospective studies. The review articles, conference abstracts, and animal studies were excluded. Out of the 22 articles which met the above criteria, 20 of them were randomized controlled studies and 2 of them were retrospective cohort studies. Infusion of DEX including during the surgery and after surgery at a low or high dose was shown to improve subjective and objective sleep quality, although 2 studies showed there is no evidence that the use of DEX improves sleep quality and 1 showed less sleep efficiency and shorter total sleep time in the DEX group. Other postoperative outcomes evaluated postoperative nausea and vomiting, pain, postoperative delirium bradycardia and hypotension. Outcomes of our systematic review showed that DEX has advantages in improving patients’ postoperative sleep quality. Combined with the use of general anesthetic, DEX provides a reliable choice for procedural sedation.

Effect of intraoperative blood transfusion on Treg and FOXP3 in patients with digestive tract malignancies and different ABO blood types

Background

Blood transfusion can cause immunosuppression and lead to worse outcomes in patients with digestive tract malignancies; however, the specific mechanism behind this is not completely understood. One theory is that increased numbers of regulatory CD3⁺CD4⁺CD25⁺FOXP3⁺ T cells (Tregs) and forkhead box protein-3 mRNA (FOXP3) expression in the blood after transfusion contribute to these outcomes. The effect of blood transfusion on immune function in patients with different ABO blood types is variable. This study investigates the effect of intraoperative blood transfusion on the number of Tregs and the expression of FOXP3 in the blood of patients with different ABO blood types and digestive tract malignancies.

Methods

Patients with digestive tract malignancies who underwent radical resection and received intraoperative blood transfusion were divided into four groups according to their blood types:blood group A, blood group B, blood group O and blood group AB (n = 20 for each group). Blood was collected from all patients before surgery, immediately after transfusion, 1 day after transfusion, and 5 days after transfusion. The number of Tregs was measured by flow cytometry. The expression of FOXP3 was detected by real time reverse transcription polymerase chain reaction (RT-PCR).

Results

There was no significant difference in the number of Tregs or expression of FOXP3 mRNA among patients with different blood types before surgery. However, the number of Tregs and the expression of FOXP3 increased after blood transfusion in all blood type groups. This increase was especially evident and statistically significant on the first day after blood transfusion when compared with measures obtained before the surgery. Measures returned to the preoperative level five days after surgery. There were significant differences in the increase of Tregs and expression of FOXP3 among patients with different blood types. The greatest increase was seen in patients with blood group B and the least in blood group A.

Conclusions

Intraoperative blood transfusion can lead to an increase in blood Tregs and FOXP3 expression in patients with digestive tract malignancies. Increases were greatest on the first day after surgery and differed among patients with different blood types. Increases were greatest in blood type B and least in blood type A.