Abstract
BackgroundPostoperative delirium (POD) is characterized by acute brain dysfunction, especially in elderly patients. Postoperative pain is an important factor in the development of delirium, and effective pain management can reduce the risk of POD. Thoracic paravertebral block (TPVB) can effectively relieve postoperative pain and inhibit the perioperative stress and inflammatory response. We investigated whether the combination of TPVB with general anesthesia reduced the occurrence of POD following thoracoscopic lobectomy.MethodsA total of 338 elderly patients, aged 65–80 years, who underwent elective surgery for video-assisted thoracoscopic lobectomy (VATS) were randomly assigned to either a patient-controlled intravenous analgesia group (PIA) or a patient-controlled paravertebral-block analgesia group (PBA). POD was evaluated using the 3-min diagnostic confusion assessment method (3D-CAM). The postoperative quality of recovery (QoR) was assessed with Chinese version of QoR-40 scale. Pain intensity was measured using the visual analog scale (VAS) score. Tumor necrosis factor-α (TNF-α) and neurofilament light (NFL) levels were determined using enzyme-linked immunosorbent assay (ELISA) kits.ResultsDelirium occurred in 47 (28%) of 168 cases in the PIA group and 28 (16.5%) of 170 cases in the PBA group (RR 1.7, p = 0.03). PBA was also associated with a higher rate of overall recovery quality at day 7 after surgery (27.1% vs. 17.3%, P = 0.013) compared with PIA. The incremental change in surgery-induced TNF-α and NFL was greater in the PIA group than PBA group (p < 0.05).ConclusionThoracic paravertebral block analgesia is associated with lower incidence of postoperative delirium, probably due to its anti-neuroinflammatory effects. Furthermore, as a component of multimodal analgesia, TPVB provides not only superior analgesic but also opioid-sparing effects.Trial registrationThe study was registered on the Chinese Clinical Trial Registry Center (www.chictr.org.cn; registration number: ChiCTR 2,000,033,238) on 25/05/2018.
Highlights
Postoperative delirium (POD) is characterized by acute brain dysfunction, especially in elderly patients
Overall POD was detected in 75/338 (22.1%) patients, with 47/168 (28%) in the patient-controlled intravenous analgesia group (PIA) group and 28/170 (16.5%) in the paravertebral-block analgesia group (PBA) group: relative risk 1.7, 95%confidence intervals (CI) (1.29 to 1.93), p = 0.03
This is the first study with a large sample size to evaluate the effects of PBA regime on postoperative delirium in the elderly patients undergoing video-assisted thoracoscopic lobectomy (VATS) lobectomy
Summary
Postoperative delirium (POD) is characterized by acute brain dysfunction, especially in elderly patients. Postoperative pain is an important factor in the development of delirium, and effective pain management can reduce the risk of POD. Thoracic paravertebral block (TPVB) can effectively relieve postoperative pain and inhibit the perioperative stress and inflammatory response. Postoperative delirium (POD) is an acute and fluctuating disorder of the mental state with reduced awareness and disturbance of attention [1]. Lung cancer is a common malignancy in China and is ranked first among all malignancies. Thoracic surgeries are closely related to severe pain, and unsatisfactory postoperative pain management could impede recovery and increase the risk of postoperative delirium. A recent meta-analysis showed that effective postoperative analgesia could reduce the risk of POD following hip fracture surgery [6]. Observational studies have found that a higher postoperative pain score is associated with increased risk of delirium [7]
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