Duration Of Postoperative Delirium Research Articles

Functional intervention following cardiac surgery to prevent postoperative delirium in older patients (FEEL WELL study)

BackgroundPostoperative delirium is a common complication in patients after cardiac surgery, especially in older patients, and can manifest as a disturbance of attention and consciousness. It can lead to increased postoperative morbidity, prolonged need for care, and mortality. The presented study investigates whether the occurrence of postoperative delirium after cardiac surgery can be prevented by a multisensory stimulation. It was conducted as a prospective, randomized, controlled, non-pharmacological intervention study in the years 2021 and 2022 at the University Hospital Bonn in Germany. A total of 186 patients over 65 years with elective cardiac surgery were enrolled. Patients were randomized either to the intervention or control group. In both groups, postoperative delirium was assessed with the 3-min diagnostic interview for confusion assessment method on the first 5 days after surgery and pain was assessed using the Numeric Rating Scale. Multisensory stimulation was performed 20 min a day for the first three postoperative days in the intervention group.ResultsThe incidence of postoperative delirium was 22.6% in the intervention group and 49.5% in the control group (p < 0.001). Duration of postoperative delirium was significantly shorter in the intervention group (p < 0.001). Stay in the intensive care unit was significantly longer in the control group (p = 0.006). In the regression model non-intervention, high pain scores, advanced age, and prolonged mechanical ventilation were associated with postoperative delirium (p = 0.007; p = 0.032; p = 0.006; p = 0.006, respectively).ConclusionsResults of the study imply that a multisensory stimulation done on the first 3 days after planned cardiac surgery can reduce the incidence and duration of postoperative delirium in older patients. Influence of the treatment on the incidence of delirium in other patient groups, the length of stay in the intensive care unit, and patients´ postoperative pain should be confirmed in further clinical studies.Trial registration: DRKS, DRKS00026909. Registered 28 October 2021, Retrospectively registered, https://drks.de/search/de/trial/DRKS00026909.

Pharmacological and non-pharmacological interventions to prevent delirium after cardiac surgery: a protocol for a systematic review and meta-analysis

IntroductionDelirium is a syndrome characterised by a disturbance in attention, awareness and cognition as a result of another physical condition. It occurs in up to 50% of patients after cardiac...

Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients.

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Reducing postoperative delirium in brain tumor patients through frailty-originated early rehabilitation: Findings from a prospective randomized study

ObjectiveThis study aims to examine the effects of frailty-originated, evidence-based early activity training on postoperative delirium in patients who have undergone brain tumor resection. MethodsA randomized controlled trial was carried out at the Second Affiliated Hospital of Zhejiang University School of Medicine from July 2019 to June 2020. Data encompassing patients’ general information, delirium incidence and duration, hospitalization period, and daily activities were collected. Starting from the day after surgery, patients were randomly assigned to either the traditional care group or the group receiving frailty-originated rehabilitation tailored for intracranial tumors using distinct evidence (FORTITUDE). Non-parametric, chi-square, and log-rank tests were employed to compare the onset time and duration of postoperative delirium, as well as daily activities, between the two groups. ResultsThe study involved a total of 291 patients, with 150 in the control group and 141 in the FORTITUDE group. Patients in the FORTITUDE group exhibited a lower occurrence of postoperative delirium (15.6% vs. 28.7%, P = 0.007), delayed onset of delirium (Z = −2.108, P = 0.035), shorter duration of postoperative delirium (χ2; = 26.67, P < 0.001), reduced hospital stay (Z = −2.037, P = 0.042), and higher scores in activities of daily living at one week (Z = −2.304, P = 0.021) and one month (Z = −2.724, P = 0.006) post-surgery in comparison to the control group. ConclusionsThe FORTITUDE program demonstrated both safety and effectiveness in diminishing the incidence and duration of postoperative delirium while enhancing the quality of life for patients who underwent brain tumor resection.

Does melatonin administration reduce the incidence of postoperative delirium in adults? Systematic review and meta-analysis

Postoperative delirium (POD) is common. It is associated with increased morbidity and mortality. Many cases may be preventable and melatonin offers promise as a preventative agent.ObjectiveThis systematic review provides an...

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

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 Electroe ncephalography 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.

Association between preoperative on-site CCU visits and postoperative delirium in patients undergoing cardiac surgery: A retrospective cohort study.

Postoperative delirium (POD) is a common complication after cardiac surgery (CS), with symptoms like attention disorders and even delays patients' recovery. To evaluate the impact of preoperative on-site visits in the cardiac care unit (CCU) on POD after CS. Patients admitted to the CCU with extracorporeal CS were included in the visiting or non-visiting group according to whether they were on visiting week. The visiting group received a preoperative visit from a nurse-led multidisciplinary visiting team (including CCU nurses and physicians) 1 week before surgery in addition to standard care. The non-visiting group received standard care like unstructured information from the CS team and anesthesiologists and so on. The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) were used to evaluate the POD severity. The incidence, occurrence and duration of POD, as well as the CCU length of stay, postoperative mechanical ventilation duration and length of hospital stay were compared between the two groups. A total of 735 participants (369 in the visited group and 366 in the unvisited group) were included in this study. Preoperative on-site visits were associated with a decreased POD incidence (odds ratio [OR]: 0.524, 95% CI: 0.336-0.817), an improved POD severity (OR: 0.578, 95% CI: 0.359-0.932) and a shortening POD duration (OR: 0.972, 95% CI: 0.951-0.994). There was a significant difference between the visiting and non-visiting groups in the mechanical ventilation duration (OR: 0.987, 95% CI: 0.978-0.996). Preoperative on-site visits are associated with a reduction in the incidence, duration, and severity of POD, as well as the mechanical ventilation duration of patients. This study found that preoperative on-site visits were associated with the onset, duration, severity and duration of mechanical ventilation of POD. Although many factors influence the occurrence of POD, a multidisciplinary visiting team led by a nurse (including CCU nurses and physicians) can provide early nursing interventions through preoperative visits, better obtain postoperative cooperation from patients, establish a good nurse-patient relationship and provide better health services to patients. In a realistic CCU setting, nurses and physicians can act as educators, assessing patients before surgery, enhancing preoperative education, improving patient familiarity with the CCU environment and teaching sign language communication skills when patients are mechanically ventilated. These findings can therefore provide the basis for effective clinical care to prevent postoperative POD.

Effect of Perioperative Dexmedetomidine Infusion on Postoperative Delirium in Elderly Patients Undergoing Oral and Maxillofacial Surgery: A Randomized Controlled Clinical Trial.

PurposeThe aim of the study was to determine whether perioperative dexmedetomidine administration can improve postoperative delirium in elderly patients undergoing oral and maxillofacial surgery.Patients and MethodsThis was a prospective double-blind randomized controlled clinical trial conducted in Cangzhou Central Hospital from December 2021 to March 2022. Patients aged 65 and older underwent oral and maxillofacial surgery under general anesthesia. Eligible patients were randomly assigned to dexmedetomidine or control group. Dexmedetomidine was injected intravenously from 10 min before induction of anesthesia to 30 min before the end of surgery in dexmedetomidine group, while patients in the control group were given normal saline at the same rate during the same time period. The primary measurement indicators were the incidence and duration of delirium in the first five days after surgery. The secondary measurement indicators were Visual Analogue Score (VAS) for the first 24 hours following surgery, subjective sleep quality score within 24 hours postoperatively and intraoperative adverse reactions.ResultsOne hundred and twenty patients were randomly assigned. Baseline characteristics were similar between two groups. The incidence and duration of postoperative delirium did not differ statistically between two groups (all P > 0.05). Compared with control group, VAS scores in dexmedetomidine group were significantly lower at 6, 12, and 24 hours after surgery (all P < 0.05); moreover, Richards-Campbell Sleep Questionnaire (RCSQ) results were significantly improved 1 day after surgery in dexmedetomidine group (P < 0.05). Dexmedetomidine-related adverse reactions were similar in both groups (P > 0.05).ConclusionIntravenous infusion of dexmedetomidine 10 min before induction of anesthesia to half an hour before the end of surgery did not improve postoperative delirium in elderly patients undergoing oral and maxillofacial surgery; however, dexmedetomidine may be associated with decreased postoperative pain and improved postoperative sleep quality.

Is there evidence for using anticonvulsants in the prevention and/or treatment of delirium among older adults?

This systematic review aims to identify published randomized controlled trials (RCTs) that evaluated the use of anticonvulsants for the prevention and/or treatment of delirium among older adults. A comprehensive search of databases: MEDLINE ALL (Ovid), Embase (Ovid), PsycINFO (Ovid), Web of Science Core Collection and Cochrane Central Register of Controlled was conducted. The search identified four RCTs that evaluated the use of anticonvulsants among older adults with delirium. One RCT evaluated the perioperative use of gabapentin among individuals undergoing spinal surgery and the development of postoperative delirium. One RCT evaluated the relationship between the use of perioperative gabapentin and the development of postoperative delirium among individuals undergoing spinal surgery and hip and knee arthroplasty. Two post-hoc analyses of RCTs evaluated the use of gabapentin and pregabalin among individuals undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). The perioperative use of gabapentin reduced the incidence of postoperative delirium among older adults undergoing spinal surgery. The perioperative use of gabapentin did not reduce the rates, severity or duration of postoperative delirium among older adults who were undergoing spine and hip and knee arthroplasty. The perioperative use of gabapentin did not reduce the incidence or duration of postoperative delirium among older adults undergoing elective TKA. The perioperative use of pregabalin did not reduce the incidence of postoperative delirium among older adults undergoing elective THA. Gabapentin and pregabalin were well tolerated among the individuals enrolled in these trials. There were no RCTs identified that evaluated the use of other anticonvulsants for the prevention and/or treatment of delirium among older adults. Based on current evidence, the routine use of anticonvulsants for the prevention and/or treatment of delirium among older adults cannot be recommended.

Is there evidence for using anticonvulsants in the prevention and/or treatment of delirium among older adults?

<h3>Introduction</h3> Delirium is an acute neuropsychiatric syndrome characterized by impaired attention, awareness and cognition. It develops over a short period of time (hours to days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day. The highest prevalence of delirium is found in the older adults, being particularly high in the hospitalized older adults. The highest incidence rates for delirium among the older adults are observed in the intensive care units, and in postoperative and palliative care settings. Delirium is associated with poorer clinical outcomes including a worsening of nutritional status, cognition and medical co-morbidities. It is associated with greater lengths and costs of hospitalization, and greater burden of care on the nursing staff. Delirium also increases the risk for developing cognitive impairment, institutionalization and death. The average medical care cost for individuals with delirium is more than two-and-a half times the cost for individuals without. Both non-pharmacologic and pharmacologic treatments are used in the management of delirium. Non-pharmacologic treatments that benefit older adults with delirium include frequent reorientation, making eye contact, frequent touching and using clear verbal instructions when talking to patients. Additionally, minimizing of sensory impairments including vision and hearing loss by use of assistive devices, reducing the use of physical restraints, providing treatment in a non-stimulating environment and minimizing staff and room changes, have proven beneficial as well. Pharmacotherapy is often used to treat the underlying causes of delirium in older adults, especially in the management of behaviors that are not managed by non-pharmacological strategies. Agents that have shown benefit among older adults with delirium include antipsychotics, cholinesterase inhibitors and benzodiazepines. Valproic acid derivatives have been used in the treatment of delirium among younger adults with some success. Many different mechanisms have been proposed for this, including the actions of valproic acid derivatives on the glutamatergic system, dopaminergic system, GABAergic system, Kynurenine Pathway. Oral or intravenous valproic acid preparations appear to be efficacious in delirium when antipsychotics and/or benzodiazepines are ineffective, the management requires large and/or frequent dosing of medications, or the medications cause significant adverse effects. Valproic acid derivatives have been beneficial in over 70% of the cases, with benefits noted in the first week of treatment, and the medication was well tolerated. Given the emerging evidence for the efficacy of valproic acid preparations among individuals with delirium, we decided to conduct a systematic review that examined the current evidence for using anticonvulsants in the prevention and/or treatment of delirium among older adults from published randomized control trials (RCTs). If there is good evidence for their use in the older adult population, then it would broaden the pharmaceutic options available to manage this serious condition among a vulnerable group of individuals. <h3>Methods</h3> A comprehensive search of databases: MEDLINE ALL (Ovid), Embase (Ovid), PsycINFO (Ovid), Web of Science Core Collection and Cochrane Central Register of Controlled was conducted. <h3>Results</h3> The search identified four RCTs that evaluated the use of anticonvulsants among older adults with delirium. One RCT evaluated the perioperative use of gabapentin among patients undergoing spinal surgery and the development of postoperative delirium. One RCT evaluated the relationship between the use of perioperative gabapentin and the development of postoperative delirium among patients undergoing spinal surgery and hip and knee arthroplasty. Two post-hoc analyses of RCTs that evaluated the use of gabapentin and pregabalin among patients undergoing total knee replacement (TKA) and total hip replacement (THA). The perioperative use of gabapentin reduced the incidence of postoperative delirium among older adults undergoing spinal surgery. The perioperative use of gabapentin did not reduce the rates, severity or duration of postoperative delirium among older adults who were undergoing spine and hip and knee arthroplasty. The perioperative use of gabapentin did not reduce the incidence or duration of postoperative delirium among older adults undergoing elective TKA. The perioperative use of pregabalin did not reduce the incidence of postoperative delirium among older adults undergoing elective THA. Gabapentin and pregabalin were well tolerated among the patients enrolled in these trials. There were no RCTs identified that evaluated the use of other anticonvulsants for the prevention and/or treatment of delirium among older adults. <h3>Conclusions</h3> Based on current evidence, the routine use of anticonvulsants for the prevention and/or treatment of delirium among older adults cannot be recommended.

Abnormal phosphorylation of tau protein and neuroinflammation induced by laparotomy in an animal model of postoperative delirium.

Postoperative delirium (POD) is an acute neuropsychological disturbance after surgery, whoseprevalenceis related with advancing age. Neuroinflammation and abnormal tau phosphorylation that commonly presenting in Alzheimer's disease (AD) may contribute to the progression and duration of POD. To study the acute influence of surgery on cognitive function, wild type male C57BL/6N mice were randomly divided into three groups: Control (CON), Laparotomy at 4h and 24h (LAP-4h, LAP-24h), then subjected to laparotomy under sevoflurane anaesthesia. The cognitive performance, peripheral and central inflammatory responses and tau phosphorylation levels were evaluated at 4h and 24h postoperatively. When LAP4-hrs displayed anxiety behaviors with high mRNA levels of inflammatory cytokines, such as interleukin-1β (IL-1β), IL-6, IL-8, TNF-α and MCP-1 in the liver, and IL-8 in the hippocampus, results at 24h were different. In the liver, only IL-10 protein was obviously elevated, but in the hippocampus, both pro- and anti-inflammatory cytokines were significantly decreased whilst the elimination of anxiety. The activity of major related kinases and phosphatases was remarkably changed which may contribute to the dephosphorylated tau protein. With tremendous neuropathological changes and significant numbers of activated microglias and astrocytes observed in the sub-regions of hippocampus, the memory impairment existed at both 4h and 24h. Since the association of dephosphorylated tau with POD, these findings may supply novel implications for the understanding of tauopathies and as a theoretical basis for preventions from the postoperative cognitive dysfunction (POCD).

Effects of Intraoperative Dexmedetomidine Infusion on Postoperative Delirium in Elderly Patients Undergoing Total Hip Arthroplasty

Objective To investigate the effects of dexmedetomidine on postoperative delirium in elderly patients undergoing total hip arthroplasty. Methods A total of 100 patients, 42 male and 58 female, ages 60 to 85 years, American Society of Anesthesiologists grade I or II, who were undergoing total hip arthroplasty were randomly divided into 2 groups: a dexmedetomidine group (group D; n = 50) and a control group (group C; n = 50). Group D patients were infused with 0.3 μg · kg−1 · h−1 of dexmedetomidine from 5 minutes prior to anesthesia induction until the end of surgery. Group C patients received an equal volume of saline. Heart rate and mean arterial pressure (MAP) were recorded before anesthesia induction (T0), 1 minute before extubation (T1), and 30 minutes after extubation (T2). The Visual Analog Score (VAS) at 1, 2, and 3 days after surgery, the incidence and duration of postoperative delirium, and the length of hospital stay were recorded. Adverse reactions, such as nausea, vomiting, and lethargy, were also recorded. Results The Visual Analog Scores in the 2 groups were similar. In group D, there was no significant difference in heart rate (P = 0.232) and MAP (P = 0.056) between T0 and T1. However, in group C, heart rate significantly increased by 15.3 bpm (P = 0.000) and MAP significantly increased by 10.7 mmHg (P = 0.001) at T1 compared with those at T0. The incidence of postoperative delirium in group D (10%) was significantly lower than that in group C (26%; P = 0.037). The duration of delirium in group D (1.3 ± 0.6 days) was shorter than that in group C (3.0 ± 0.5 days; P = 0.000). The length of hospital stay in group D (13.2 ± 0.9 days) was shorter than that in group C (16.1 ± 0.7 days; P = 0.000). No significant differences were observed in adverse effects between the 2 groups. Conclusion Intravenous infusion of dexmedetomidine can not only reduce the incidence and duration of postoperative delirium, but also shorten the length of hospital stay in elderly patients undergoing total hip arthroplasty.

Postoperative delirium after coronary artery bypass graft surgery: Dexmedetomidine infusion alone or with the addition of oral melatonin

ABSTRACT Introduction: Postoperative delirium is a common complication of cardiac surgery. This study aimed to assess the effect of supplementing dexmedetomidine infusion with oral melatonin in prevention of postoperative delirium after coronary artery bypass graft surgery. Methods: 110 patients of both sexes above 60 years of age were included. Anesthetic management was standardized. Patients were randomly allocated into one of the two study groups, dexmedetomidine/melatonin (DM) group or dexmedetomidine (D) group. Patients in the DM group received oral Melatonin tablet 5 mg the night before surgery and same dose was repeated every 24 hours for 3 postoperative days. After completion of surgery and upon ICU arrival, patients in both groups received a bolus of 0.4 µg/kg dexmedetomidine followed by 0.2–0.7 µg/kg/h infusion, for 24 maximum hours. Delirium was assessed for 5 days postoperatively at 12 hr intervals using confusion assessment method (CAM) for ICU and after discharge from ICU to surgical ward using CAM. Delirious patients were treated with IV haloperidol. Results: No significant differences between studied groups regarding baseline, preoperative, intraoperative and postoperative characteristics. Incidence of delirium was significantly lower, onset significantly more delayed, and duration was significantly shorter in group-DM as compared to group-D. No significant differences between all cases, cases who had delirium, and cases who did not have delirium in the two groups as regards extubation time, ICU stay, and hospital stay. Conclusion: supplementing dexmedetomidine with melatonin decreases incidence, delays onset, and shortens duration of postoperative delirium in patients above 60 years of age undergoing CABG surgery.

Preoperative Cognitive Impairment and Postoperative Delirium Predict Decline in Activities of Daily Living after Cardiac Surgery-A Prospective, Observational Cohort Study.

Cardiac surgery and subsequent treatment in the intensive care unit (ICU) has been shown to be associated with functional decline, especially in elderly patients. Due to the different assessment tools and assessment periods, it remains yet unclear what parameters determine unfavorable outcomes. This study sought to identify risk factors during the entire perioperative period and focused on the decline in activity of daily living (ADL) half a year after cardiac surgery. Follow-ups of 125 patients were available. It was found that in the majority of patients (60%), the mean ADL declined by 4.9 points (95% CI, −6.4 to −3.5; p < 0.000). In the “No decline” -group, the ADL rose by 3.3 points (2.0 to 4.6; p < 0.001). A multiple regression analysis revealed that preoperative cognitive impairment (MMSE ≤ 26; Exp(B) 2.862 (95%CI, 1.192–6.872); p = 0.019) and duration of postoperative delirium ≥ 2 days (Exp(B) 3.534 (1.094–11.411); p = 0.035) was independently associated with ADL decline half a year after the operation and ICU. Of note, preoperative ADL per se was neither associated with baseline cognitive function nor a risk factor for functional decline. We conclude that the preoperative assessment of cognitive function, rather than functional assessments, should be part of risk stratification when planning complex cardiosurgical procedures.

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

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 Electroe ncephalography 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

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

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 Electroe ncephalography 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.

Risk Factors and Incidence of Postoperative Delirium in Patients Undergoing Laryngectomy

To explore the risk factors and incidence of postoperative delirium (POD) in patients undergoing laryngectomy for laryngeal cancer. Prospective cohort study. Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University. A total of 323 patients underwent laryngectomy from April 4, 2018, to December 28, 2018. Perioperative data were collected. The primary outcome was the presence of POD as defined by the Confusion Assessment Method diagnostic algorithm. Univariate and multivariable logistic regression analyses were used to identify risk factors associated with POD. Of the patients who underwent laryngectomy during the study period, 99.1% were male, with a mean age of 60.0 years. Of these patients, 28 developed POD, with most episodes (88.1%) occurring during the first 3 postoperative days. The type of POD was hyperactive in 7 cases and hypoactive in 21 cases. The mean duration of POD was 1 day. The mean Delirium Rating Scale-Revised-98 score (a measure of POD severity) was 11.5. For the multivariable analysis, risk factors associated with POD included advanced cancer stage, lower educational level, higher American Society of Anesthesiologists classification, and intraoperative hypotension lasting at least 30 minutes. Intraoperative dexmedetomidine use was protective against POD. This study identified risk factors associated with POD, providing a target population for quality improvement initiatives. Furthermore, intraoperative dexmedetomidine use can reduce POD.

Effect of perioperative administration of dexmedetomidine on delirium after cardiac surgery in elderly patients: a double-blinded, multi-center, randomized study.

ObjectivePostoperative delirium (POD) is a serious complication in elderly patients undergoing cardiac surgery. This study was aimed at investigating the effect of perioperative administration of dexmedetomidine for general anesthesia maintenance on occurrence and duration of POD in elderly patients after cardiac surgery.MethodsOne hundred and sixty-four patients were enrolled after cardiac surgery between June 2009 and December 2016. Patients were assigned by a computer-generated randomization sequence in a 1:1 ratio to receive dexmedetomidine general anesthesia maintenance or propofol general anesthesia maintenance. POD was assessed every day with confusion assessment method for intensive care units (ICU) during the first 5 postoperative days.ResultsThere was no significance in incidence of POD between the dexmedetomidine group and the propofol group (P=0.0758). In patients treated with dexmedetomidine, the median onset time of delirium was delayed (second day vs first day) and the duration of delirium reduced (2 days vs 3 days) when compared with propofol-treated patients. The dexmedetomidine-treated patients also displayed a lower VAS score and less opiate analgesic consumption. No difference was observed in respect to other postoperative outcomes.ConclusionFor elderly patients, perioperative administration of dexmedetomidine reduced incidence, delayed onset and shortened duration of POD after cardiac surgery.

Yokukansan for perioperative psychiatric symptoms in cancer patients undergoing high invasive surgery. J-SUPPORT 1605 (ProD Study): study protocol for a randomized controlled trial

BackgroundPreoperative anxiety and postoperative delirium affect both short- and long-term prognoses in patients with cancer; therefore, these conditions require early prevention and treatment. However, no standard preventive or therapeutic methods have been established for them. Yokukansan, a Japanese herbal medicine for the treatment of insomnia and anxiety, causes relatively few adverse drug reactions and effectively improves the behavioral and psychological symptoms of dementia. Thus, it is expected to be useful for treating and/or preventing perioperative psychiatric symptoms in patients with cancer. The objective of this study is to clarify the therapeutic effect of Yokukansan for preoperative anxiety and its preventive effect on postoperative delirium in cancer patients, as well as to confirm its safety profile.MethodsThis study is a randomized, double-blind, placebo-controlled study in cancer patients scheduled to undergo tumor resection. Patients who provide consent are randomly allocated to receive oral administration of Yokukansan or placebo, and study drug administration is continued for 4 days or longer prior to surgery. We defined two primary endpoints, change in preoperative anxiety and incidence of postoperative delirium. Secondary endpoints are severity score of postoperative delirium, duration of postoperative delirium, amount of benzodiazepines used prior to surgery, amount of antipsychotic agents used after surgery, and number of postoperative hospitalization days. We plan to complete the analysis on March 31, 2021. The target number of registered patients is 110 per group, or 220 in total.DiscussionThis study is the first randomized, double-blind, placebo-controlled study intended to clarify the effects of a Japanese herbal medicine, Yokukansan, in the prevention and treatment of perioperative psychiatric symptoms in patients with cancer. The trial was initiated on August 14, 2017, with 195 subjects randomized by October 5, 2018.Trial registrationUMIN Clinical Trials Registry (UMIN-CTR), UMIN000027561. Registered on 31 May 2017.

Pharmacologic prevention of postoperative delirium after on-pump cardiac surgery

Background:Postoperative delirium is a prevalent and disabling mental disorder in patients undergoing on-pump cardiac surgery. There is some evidence that the use of pharmacological interventions may reduce the risk of developing of postoperative delirium. Therefore, the aim of this meta-analysis was to determine the effect of pharmacologic agents for the prevention postoperative delirium after cardiac surgery.Methods:Randomized controlled trials (RCTs) were identified through a systematic literature search of electronic databases and article references up to October 2016. End points included incidence of postoperative delirium, severity of postoperative delirium, cognitive disturbances of postoperative delirium, duration of postoperative delirium, length of stay in intensive care unit (ICU) and hospital, and short-term mortality.Results:A total of 14 RCTs with an aggregate of 14,139 patients were included. The results of the present meta-analysis show that pharmacologic agents significantly decrease postoperative delirium [relative risk (RR), 0.83; 95% confidence interval (95% CI), 0.75–0.91, P < .00001] and duration of postoperative delirium (RR = −0.37, 95% CI = −0.47 to −0.27, P < .00001) after on-pump cardiac surgery. In addition, subgroup analysis shows that dexamethasone and dexamethasone were associated with a trend toward a reduction in postoperative delirium (RR, 0.45; 95% CI, 0.30–0.66, P < .0001; RR, 0.80; 95% CI, 0.68–0.93, P = .003, respectively). However, our results fail to support the assumption that pharmacologic prophylaxis is associated with a positively reduction in short-term mortality, length of ICU, or hospital stay.Conclusion:This meta-analysis suggests that the perioperative use of pharmacologic agents can prevent postoperative delirium development in patients undergoing cardiac surgery. However, there remain important gaps in the evidence base on a few small studies with multiple limitations. Further large-scale, high-quality RCTs are needed in this area.