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Spence J, Belley-Côté E, Jacobsohn E, Lee SF, D’Aragon F, Avidan M, Mazer CD, Rousseau-Saine N, Rajamohan R, Pryor K, Klein R, Tan E(CH, Cameron M, Di Sante E, DeBorba E, Mustard M, Couture E, Zamper R, Law M, Djaiani G, Saha T, Choi S, Hedlin P, Pikaluk R, Lam WY, Deschamps A, Whitlock R, Dulong B, Devereaux P, Beaver C, Kloppenburg S, Oczkowski S, McIntyre WF, McFarling M, Lamy A, Vincent J, Connolly S. Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free): A Protocol for a Multi-centre Randomized Cluster Crossover Trial. CJC Open 2023; 5:691-699. [PMID: 37744662 PMCID: PMC10516716 DOI: 10.1016/j.cjco.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/01/2023] [Indexed: 09/26/2023] Open
Abstract
Delirium is common after cardiac surgery and is associated with adverse outcomes. Administration of benzodiazepines before and after cardiac surgery is associated with delirium; guidelines recommend minimizing their use. Benzodiazepine administration during cardiac surgery remains common because of its recognized benefits. The Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free) trial is a randomized cluster crossover trial evaluating whether an institutional policy of restricting intraoperative benzodiazepine administration (ie, ≥ 90% of patients do not receive benzodiazepines during cardiac surgery), as compared with a policy of liberal intraoperative benzodiazepine administration (ie, ≥ 90% of patients receive ≥ 0.03 mg/kg midazolam equivalent), reduces delirium. Hospitals performing ≥ 250 cardiac surgeries a year are included if their cardiac anesthesia group agrees to apply both benzodiazepine policies per their randomization, and patients are assessed for postoperative delirium every 12 hours in routine clinical care. Hospitals apply the restricted or liberal benzodiazepine policy during 12 to 18 crossover periods of 4 weeks each. Randomization for all periods takes place in advance of site startup; sites are notified of their allocated policy during the last week of each crossover period. Policies are applied to all patients undergoing cardiac surgery during the trial period. The primary outcome is the incidence of delirium at up to 72 hours after surgery. The B-Free trial will enroll ≥ 18,000 patients undergoing cardiac surgery at 20 hospitals across North America. Delirium is common after cardiac surgery, and benzodiazepines are associated with the occurrence of delirium. The B-Free trial will determine whether an institutional policy restricting the administration of benzodiazepines during cardiac surgery reduces the incidence of delirium after cardiac surgery. Clinicaltrials.gov registration number: NCT03928236 (First registered April 26, 2019).
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Affiliation(s)
- Jessica Spence
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University; and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Emilie Belley-Côté
- Departments of Medicine (Cardiology and Critical Care), and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Perioperative Medicine and Medicine (Critical Care), University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shun Fu Lee
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
| | - Frederick D’Aragon
- Département d'anesthésiologie, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michael Avidan
- Department of Anesthesia, Washington University at St. Louis, St. Louis, Missouri, USA
| | - C. David Mazer
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, and Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Raja Rajamohan
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kane Pryor
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Rael Klein
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Matthew Cameron
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Emily Di Sante
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Erin DeBorba
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mary Mustard
- St. Michael's Hospital, Toronto, Ontario, Canada
| | - Etienne Couture
- Département d'anesthésiologie, Université Laval, Quebec City, Quebec, Canada
| | - Raffael Zamper
- Department of Anesthesia, University of Western Ontario, London, Ontario, Canada
| | - Michael Law
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
| | - George Djaiani
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tarit Saha
- Department of Anesthesia, Queen's University, Kingston, Ontario, Canada
| | - Stephen Choi
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter Hedlin
- Department of Anesthesia, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ryan Pikaluk
- Department of Anesthesia, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Wing Ying Lam
- Department of Anesthesia, University of Alberta, Edmonton, Alberta, Canada
| | - Alain Deschamps
- Département d'anesthésiologie, Université de Montréal, Montréal, Quebec, Canada
| | - Richard Whitlock
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Braden Dulong
- Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada
| | - P.J. Devereaux
- Departments of Medicine (Cardiology and Critical Care), and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | | | - Simon Oczkowski
- Department of Medicine (Critical Care), McMaster University, Hamilton, Ontario, Canada
| | - William Finlay McIntyre
- Department of Medicine (Cardiology), McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Matthew McFarling
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Andre Lamy
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jessica Vincent
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stuart Connolly
- Department of Medicine (Cardiology), McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
| | - B-Free Investigators∗
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University; and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Departments of Medicine (Cardiology and Critical Care), and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Departments of Anesthesia and Perioperative Medicine and Medicine (Critical Care), University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
- Département d'anesthésiologie, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Anesthesia, Washington University at St. Louis, St. Louis, Missouri, USA
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, and Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Département d'anesthésiologie, Université de Montréal, Montréal, Quebec, Canada
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
- Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- St. Michael's Hospital, Toronto, Ontario, Canada
- Département d'anesthésiologie, Université Laval, Quebec City, Quebec, Canada
- Department of Anesthesia, University of Western Ontario, London, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, Queen's University, Kingston, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Department of Anesthesia, University of Alberta, Edmonton, Alberta, Canada
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Sheridan College, Brampton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine (Critical Care), McMaster University, Hamilton, Ontario, Canada
- Department of Medicine (Cardiology), McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine (Cardiology), McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
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