Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery

2016 ◽  
Vol 124 (2) ◽  
pp. 362-368 ◽  
Author(s):  
George Djaiani ◽  
Natalie Silverton ◽  
Ludwik Fedorko ◽  
Jo Carroll ◽  
Rima Styra ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Absolute Risk ◽  
Controlled Trial ◽  
Absolute Risk Reduction ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Number Needed To Treat ◽  
Confusion Assessment ◽  
Institutional Ethics ◽  
Randomization Code

Abstract Background Postoperative delirium (POD) is a serious complication after cardiac surgery. Use of dexmedetomidine to prevent delirium is controversial. The authors hypothesized that dexmedetomidine sedation after cardiac surgery would reduce the incidence of POD. Methods After institutional ethics review board approval, and informed consent, a single-blinded, prospective, randomized controlled trial was conducted in patients 60 yr or older undergoing cardiac surgery. Patients with a history of serious mental illness, delirium, and severe dementia were excluded. Upon admission to intensive care unit (ICU), patients received either dexmedetomidine (0.4 μg/kg bolus followed by 0.2 to 0.7 μg kg−1 h−1 infusion) or propofol (25 to 50 μg kg−1 min−1 infusion) according to a computer-generated randomization code in blocks of four. Assessment of delirium was performed with confusion assessment method for ICU or confusion assessment method after discharge from ICU at 12-h intervals during the 5 postoperative days. Primary outcome was the incidence of POD. Results POD was present in 16 of 91 (17.5%) and 29 of 92 (31.5%) patients in dexmedetomidine and propofol groups, respectively (odds ratio, 0.46; 95% CI, 0.23 to 0.92; P = 0.028). Median onset of POD was on postoperative day 2 (1 to 4 days) versus 1 (1 to 4 days), P = 0.027, and duration of POD 2 days (1 to 4 days) versus 3 days (1 to 5 days), P = 0.04, in dexmedetomidine and propofol groups, respectively. Conclusions When compared with propofol, dexmedetomidine sedation reduced incidence, delayed onset, and shortened duration of POD in elderly patients after cardiac surgery. The absolute risk reduction for POD was 14%, with a number needed to treat of 7.1.

scholarly journals Is preoperative anxiety associated with postoperative delirium in older persons undergoing cardiac surgery? Secondary data analysis of a randomized controlled trial

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Koen Milisen ◽  
Bastiaan Van Grootven ◽  
Wim Hermans ◽  
Karen Mouton ◽  
Layth Al Tmimi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cardiac Surgery ◽  
State Anxiety ◽  
Postoperative Delirium ◽  
Controlled Trial ◽  
Secondary Data ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Preoperative Anxiety ◽  
Confusion Assessment

Abstract Background Although many studies have reported numerous risk factors for postoperative delirium, data are scarce about preoperative anxiety as a risk factor. The study aimed to investigate the association between preoperative anxiety and postoperative delirium in older patients undergoing cardiac surgery. Methods Secondary data analysis of a randomized, observer-blind, controlled trial. A total of 190 patients 65 years or older and admitted to the intensive care unit and cardiac surgery unit of a university hospital scheduled for elective on-pump cardiac surgery were included. State anxiety was measured preoperatively using the Amsterdam Preoperative Anxiety and Information Scale and the Visual Analogue Scale for anxiety. Incidence of delirium was measured during the first 5 postoperative days using the Confusion Assessment Method for Intensive Care Unit (when ventilated), or the 3 Minute Diagnostic Interview for Confusion Assessment Method (when extubated) and by daily chart review. Results Preoperative state anxiety was reported by 31% of the patients and 41% had postoperative delirium. A multiple step logistic regression analyses revealed no association between preoperative anxiety and postoperative delirium. Significant risk factors for postoperative delirium were age (OR = 1.10, 95% CI (1.03–1.18)), activities of daily living (0.69, 95% CI (0.50–0.96)), diabetes mellitus (OR = 3.15, 95% CI (1.42–7.00)) and time on cardiopulmonary bypass (OR = 1.01, 95% CI (1.00 to 1.02)). Conclusions No relationship could be found between preoperative anxiety and postoperative delirium.

scholarly journals Postoperative delirium after cardiac surgery of elderly patients as an independent risk factor for prolonged length of stay in intensive care unit and in hospital

2021 ◽  
Author(s):  
Andrea Kirfel ◽  
Jan Menzenbach ◽  
Vera Guttenthaler ◽  
Johanna Feggeler ◽  
Andreas Mayr ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Length Of Stay ◽  
Elderly Patients ◽  
Postoperative Delirium ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Hospital Length Of Stay ◽  
Confusion Assessment

Abstract Background Postoperative delirium (POD) is a relevant and underdiagnosed complication after cardiac surgery that is associated with increased intensive care unit (ICU) and hospital length of stay (LOS). The aim of this subgroup study was to compare the frequency of tested POD versus the coded International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis of POD and to evaluate the influence of POD on LOS in ICU and hospital. Methods 254 elective cardiac surgery patients (mean age, 70.5 ± 6.4 years) at the University Hospital Bonn between September 2018 and October 2019 were evaluated. The endpoint tested POD was considered positive, if one of the tests Confusion Assessment Method for ICU (CAM-ICU) or Confusion Assessment Method (CAM), 4 'A's Test (4AT) or Delirium Observation Scale (DOS) was positive on one day. Results POD occurred in 127 patients (50.0%). LOS in ICU and hospital were significantly different based on presence (ICU 165.0 ± 362.7 h; Hospital 26.5 ± 26.1 days) or absence (ICU 64.5 ± 79.4 h; Hospital 14.6 ± 6.7 days) of POD (p < 0.001). The multiple linear regression showed POD as an independent predictor for a prolonged LOS in ICU (48%; 95%CI 31–67%) and in hospital (64%; 95%CI 27–110%) (p < 0.001). The frequency of POD in the study participants that was coded with the ICD F05.0 and F05.8 by hospital staff was considerably lower than tests revealed by the study personnel. Conclusion Approximately 50% of elderly patients who underwent cardiac surgery developed POD, which is associated with an increased ICU and hospital LOS. Furthermore, POD is highly underdiagnosed in clinical routine.

scholarly journals Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial

F1000Research ◽  
2019 ◽  
Vol 8 ◽  
pp. 1165 ◽  
Author(s):  
Alain Deschamps ◽  
Tarit Saha ◽  
Renée El-Gabalawy ◽  
Eric Jacobsohn ◽  
Charles Overbeek ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Postoperative Delirium ◽  
Anesthetic Management ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Adverse Outcomes ◽  
Minimum Concentration ◽  
Confusion Assessment

Background:  There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery.  There is limited evidence in this regard for cardiac surgery.  A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death.  However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods:  The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites.  The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery.  One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25).  The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients.  The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review.  Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion:  The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov (NCT02692300) 26/02/2016

Abstract 3544: One year follow-up after acute Coronary Artery Disease (CAD) - Immediate hospital discharge vs. cardiac rehabilitation

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Bernhard Schwaab ◽  
Annika Waldmann ◽  
Alexander Katalinic ◽  
Britta Poppe ◽  
Abdolhamid Sheikhzadeh ◽  
...  
Keyword(s):  
Risk Reduction ◽  
Absolute Risk ◽  
Controlled Trial ◽  
Absolute Risk Reduction ◽  
Number Needed To Treat ◽  
Preventive Medication ◽  
All Cause Mortality ◽  
Artery Disease ◽  
One Year ◽  
The Impact

Background: The evidence of cardiac Rehab is not fully settled as meta-analysis mostly included studies without acute revascularisation and modern preventive medication. Method: In a multicentre randomised controlled trial, 1.474 patients (pts.) with acute CAD were included to investigate the impact of telemedicine on chronic CAD: 679 pts. were included immediately at discharge from the hospital (Hosp), 795 pts. after three week in-patient Rehab. All pts. had acute coronary angiography and were followed for one year. As Hosp pts. were included 11,3 ± 3 days (median 11) earlier than Rehab pts., events in the Hosp group were counted from day 12. Results: Rehab pts. were older (64 ±10 vs. 62 ±10 years; p<.001), had more congestive heart failure (64 vs. 40%, p<.001), renal insufficiency (10 vs. 7%, p=.036), hypercholesterolemia (79 vs. 74%, p=.023), and carotid stenosis (8 vs. 4%, p=.004). Telemedicine device prescription, gender, atrial fibrillation, peripheral artery disease, diabetes, hypertension, education and social status were similar in groups. After one year, Rehab pts. had more β-blockers (88 vs. 75%, p<.001), ACE-inhibitors (81 vs. 70%, p<.001), lower LDL-C (102 ±35 vs. 121 ±47 mg/dl, p<.001) and a higher proportion of non-smokers (62 vs. 56%, p=.024). There was no difference in platelet inhibition, anticoagulation and statin therapy (81 vs. 79%). The primary combined endpoint of all-cause mortality, acute myocardial infarction (AMI), coronary revascularisation and hospitalisation occurred in 32.6% of Rehab pts. and in 38.7% of Hosp pts. (p=.014; absolute risk reduction (ARR) 0.0615, relative risk reduction (RRR) 16%, number needed to treat (NNT) 17). AMI (1.8 vs. 3.8%, p=.015; ARR 0.0207, RRR 54%, NNT 49) was reduced. Revascularisation (4.2 vs. 5.4%), hospitalisation (33.6 vs. 38.0%) and all-cause mortality (2.1 vs. 2.4%) were similar between groups. After multivariate analysis, the primary endpoint was still significant: OR 0.716 (95% CI 0.575–0.892; p=0.003) giving a RRR of 28% in favour of Rehab therapy. Conclusion: Although Rehab pts. were sicker at entry, cardiac Rehab substantially reduced relevant clinical endpoints within one year. With a very low NNT, Rehab is highly effective and should be advised to all suitable patients with acute CAD.

scholarly journals Intraoperative Tight Glucose Control Using Hyperinsulinemic Normoglycemia Increases Delirium after Cardiac Surgery

2015 ◽  
Vol 122 (6) ◽  
pp. 1214-1223 ◽  
Author(s):  
Leif Saager ◽  
Andra E. Duncan ◽  
Jean-Pierre Yared ◽  
Brian D. Hesler ◽  
Jing You ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Blood Glucose ◽  
Glucose Control ◽  
Postoperative Delirium ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Tight Glucose Control ◽  
Double Blind ◽  
Mortality And Morbidity ◽  
Confusion Assessment

Abstract Background: Postoperative delirium is common in patients recovering from cardiac surgery. Tight glucose control has been shown to reduce mortality and morbidity. Therefore, the authors sought to determine the effect of tight intraoperative glucose control using a hyperinsulinemic–normoglycemic clamp approach on postoperative delirium in patients undergoing cardiac surgery. Methods: The authors enrolled 198 adult patients having cardiac surgery in this randomized, double-blind, single-center trial. Patients were randomly assigned to either tight intraoperative glucose control with a hyperinsulinemic–normoglycemic clamp (target blood glucose, 80 to 110 mg/dl) or standard therapy (conventional insulin administration with blood glucose target, &lt;150 mg/dl). Delirium was assessed using a comprehensive delirium battery. The authors considered patients to have experienced postoperative delirium when Confusion Assessment Method testing was positive at any assessment. A positive Confusion Assessment Method was defined by the presence of features 1 (acute onset and fluctuating course) and 2 (inattention) and either 3 (disorganized thinking) or 4 (altered consciousness). Results: Patients randomized to tight glucose control were more likely to be diagnosed as being delirious than those assigned to routine glucose control (26 of 93 vs. 15 of 105; relative risk, 1.89; 95% CI, 1.06 to 3.37; P = 0.03), after adjusting for preoperative usage of calcium channel blocker and American Society of Anesthesiologist physical status. Delirium severity, among patients with delirium, was comparable with each glucose management strategy. Conclusion: Intraoperative hyperinsulinemic–normoglycemia augments the risk of delirium after cardiac surgery, but not its severity.

Comparison of the clinical benefit of an adjuvant therapy in gastrointestinal stromal tumors (GIST) with other adjuvant cancer therapies.

2012 ◽  
Vol 30 (4_suppl) ◽  
pp. 129-129 ◽  
Author(s):  
Morgan Deflin ◽  
Anju Parthan ◽  
Douglas Taylor ◽  
John Coombs ◽  
Medha Sasane ◽  
...  
Keyword(s):  
Absolute Risk ◽  
Controlled Trial ◽  
Absolute Risk Reduction ◽  
Study Groups ◽  
Number Needed To Treat ◽  
Cancer Therapies ◽  
Adjuvant Imatinib ◽  
Cancer Types ◽  
Over Time

129 Background: Imatinib in the adjuvant setting for GIST has shown significant improvements in recurrence- free survival (RFS) vs placebo. Number needed to treat (NNT) is a useful measure to compare effectiveness across treatments (txts) from a health policy or population perspective. The objective of this study is to compare the NNT for adjuvant imatinib in GIST with other adjuvant cancer txts at both 1 and 3 yrs of follow-up using RFS. Methods: In the absence of a placebo controlled trial for 3 yr imatinib, data from ACOSOG Z9001 and SSGXVIII/AIO trials were used to indirectly estimate NNT for adjuvant imatinib in GIST. Adjuvant txts in other cancer types were identified from published literature. Studies meeting the following criteria were included in the analysis: (1) study population consisted of cancer patients (pts) who underwent surgical resection of the primary tumor and considered cancer-free, (2) a randomized clinical trial conducted in pts in the US or Europe, (3) comparators were either placebo or no txt (4) RFS was reported and showed benefit with the experimental txt. NNT is defined as the number needed to treat to prevent 1 recurrence or death. NNT was calculated as the inverse of the absolute risk reduction (difference in event rate) between the study groups in each trial. Results: 24 adjuvant txts in 8 different cancer types were identified. With longer follow-up (3 yrs vs 1 yr), 62.5% of txts showed a decreased NNT, including imatinib which decreased from 7 (1 yr) to 4 (3 yrs). The largest relative decrease in NNT over time was 91% for trastuzumab & cyclophosphamide (both used for breast cancer). About 25.0% of the txts had an increase in NNT over time. NNT for imatinib was lower than all other txts at 3 yrs of follow-up and lower than all but 2 txts at 1 yr of follow-up (mitomycin + tegafur [gastric cancer, NNT = 5] and gemcitabine [pancreatic cancer, NNT = 4]). About 28.0% and 41.7% of txts had an NNT less than 10 at 1 and 3 yrs of follow up, respectively. Conclusions: Imatinib has one of the lowest NNTs among other adjuvant txts, at 1 and 3 yrs of follow-up. With longer follow-up duration, most adjuvant cancer txts show a decreased NNT.

Validation of the Confusion Assessment Method in Detecting Postoperative Delirium in Cardiac Surgery Patients

2015 ◽  
Vol 24 (6) ◽  
pp. 480-487 ◽  
Author(s):  
N. Smulter ◽  
H. C. Lingehall ◽  
Y. Gustafson ◽  
B. Olofsson ◽  
K. G. Engstrom
Keyword(s):  
Cardiac Surgery ◽  
Postoperative Delirium ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Confusion Assessment

scholarly journals Original article. Efficacy of intravenous dexamethasone for the prevention of vomiting associated with intrathecal chemotherapy and ketamine sedation in children: a randomized, double-blinded, crossover, placebocontrolled trial

2011 ◽  
Vol 5 (4) ◽  
pp. 441-448 ◽  
Author(s):  
Chanchai Traivaree ◽  
Kitti Torcharus ◽  
Rachata Lumkul ◽  
Chulalak Komoltri ◽  
Somrat Charuluxananan
Keyword(s):  
Absolute Risk ◽  
Controlled Trial ◽  
Absolute Risk Reduction ◽  
Intrathecal Chemotherapy ◽  
Number Needed To Treat ◽  
Period Effect ◽  
Hospital Patients ◽  
Carry Over ◽  
Double Blinded ◽  
To Receive

AbstractBackground: Chemotherapy-induced nausea and vomiting remains a significant problem for children with leukemia. There is limited evidence to support using prophylactic antiemetic prior to the administration of intrathecal chemotherapy.Objective: Determine whether vomiting and nausea associated with intravenous ketamine and intrathecal chemotherapy may be reduced by the addition of prophylactic dexamethasone in children.Method:A randomized, double-blinded, crossover, placebo-controlled trial was completed in 33 children receiving intrathecal chemotherapy with methotrexate and ketamine sedation at Pharmongkutklao Hospital. Patients were randomly assigned in a double-blinded fashion to receive one of two interventions during the first period, either an infusion of normal saline or intravenous dexamethasone at 0.25 mg/kg/dose. Each patient acted as his or her own control, and each patient was studied at two time-points.Results: Period effect, sequence effect, and carry over effect were not demonstrated. The absolute risk reduction of vomiting was significantly greater after infusion of dexamethasone than after placebo at 33.3 % (p=0.02). The number needed to treat was three to prevent one episode of vomiting. Fifteen patients in the treatment group reported nausea versus 26 patients in the placebo group (p= 0.007). In the group of patients treated with dexamethasone, five required antiemetic vs. 16 of those receiving placebo (p=0.02). There was no complication from dexamethasone.Conclusion: Intravenous dexamethasone reduced vomiting associated with intrathecal chemotherapy and ketamine sedation, without significant side-effects. It may be recommended a reasonable option before intrathecal chemotherapy

scholarly journals Is Perioperative Dexmedetomidine Associated With a Reduced Risk of Perioperative Neurocognitive Disorders Following Cardiac Surgery? A Systematic Review and Meta-Analysis With Trial Sequential Analysis of Randomized Controlled Trials

2021 ◽  
Vol 8 ◽  
Author(s):  
Xinglong Xiong ◽  
Dongxu Chen ◽  
Jing Shi
Keyword(s):  
Cardiac Surgery ◽  
Sequential Analysis ◽  
Meta Analysis ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Trial Sequential Analysis ◽  
Controlled Trials ◽  
Confusion Assessment ◽  
Randomized Controlled ◽  
Firm Evidence

Background: To assess the effect of dexmedetomidine on the reducing risk of perioperative neurocognitive disorders (PNDs) following cardiac surgery.Methods: A systematic review and meta-analysis with trial sequential analysis (TSA) of randomized controlled trials were performed. PubMed, Embase, Cochrane Library, and CNKI databases (to August 16, 2020) were searched for relevant articles to analyze the incidence of PND for intraoperative or postoperative dexmedetomidine administration after cardiac surgery. PND included postoperative cognitive dysfunction (POCD) and postoperative delirium (POD).Results: A total of 24 studies with 3,610 patients were included. Compared with the control group, the incidence of POD in the dexmedetomidine group was significantly lower (odds ratio [OR]: 0.59, 95% CI: 0.43–0.82, P = 0.001), with firm evidence from TSA. Subgroup analyses confirmed that dexmedetomidine reduced the incidence of POD with firm evidence following coronary artery bypass grafting surgery (OR: 0.45, 95% CI: 0.26–0.79, P = 0.005), and intervention during the postoperative period (OR: 0.48, 95% CI: 0.34–0.67, P &lt; 0.001). Furthermore, the incidence of POD in the dexmedetomidine group was also decreased in mixed cardiac surgery (OR: 0.68, 95% CI: 0.47–0.98, P = 0.039). Irrespective of whether “Confusion Assessment Method/Confusion Assessment Method for intensive care unit” or “other tools” were used as diagnostic tools, the results showed a decreased risk of POD in the dexmedetomidine group. There was no significant difference in the incidence of POCD (OR: 0.47, 95% CI: 0.22–1.03, P = 0.060) between the two groups, but this result lacked firm evidence from TSA.Conclusion: The administration of dexmedetomidine during the perioperative period reduced the incidence of POD in patients after cardiac surgery, but there was no significant benefit in the incidence of POCD. The effect of dexmedetomidine on the incidence of POD or POCD following different types of surgery and the optimal dose and timing of dexmedetomidine warrant further investigation.Trial registration: PROSPERO registration number: CRD42020203980. Registered on September 13, 2020.

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