Postoperative Delirium after Dexmedetomidine versus Propofol Sedation in Healthy Older Adults Undergoing Orthopedic Lower Limb Surgery with Spinal Anesthesia: A Randomized Controlled Trial

Abstract

Background Delirium is a critical postoperative complication in older patients. Based on the hypothesis that intraoperative dexmedetomidine sedation would lower postoperative delirium than propofol sedation would, the authors compared the incidence of postoperative delirium in older adults, using the mentioned sedatives. Methods This double-blinded, randomized controlled study included 748 patients, aged 65 yr or older, who were scheduled for elective lower extremity orthopedic surgery, between June 2017 and October 2021. Patients were randomized equally into two groups in a 1:1 ratio according to the intraoperative sedative used (dexmedetomidine vs. propofol). The postoperative delirium incidence was considered the primary outcome measure; it was determined using the confusion assessment method, on the first three postoperative days. The mean arterial pressure and heart rate were evaluated as secondary outcomes. Results The authors enrolled 732 patients in the intention-to-treat analyses. The delirium incidence was lower in the dexmedetomidine group than in the propofol group (11 [3.0%] vs. 24 [6.6%]; odds ratio, 0.42; 95% CI, 0.201 to 0.86; P = 0.036). During sedation, the mean arterial pressure (median [interquartile range] mmHg) was higher in the dexmedetomidine group (77 [71 to 84]) than in the propofol group (74 [69 to 79]; P < 0.001); however, it significantly fell lower (74 [68 to 80]) than that of the propofol group (80 [74 to 87]) in the postanesthesia care unit (P < 0.001). Lower heart rates (beats/min) were recorded with the use of dexmedetomidine than with propofol, both during sedation (60 [55 to 66] vs. 63 [58 to 70]) and in the postanesthesia care unit (64 [58 to 72] vs. 68 [62–77]; P < 0.001). Conclusions Dexmedetomidine showed a lower incidence of postoperative delirium than propofol in healthy older adults undergoing lower extremity orthopedic surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Depth of anesthesia, temperature, and postoperative delirium in children and adolescents undergoing cardiac surgery

“…In another study, older patients with elective lower extremity orthopedic surgery under spinal anesthesia were randomized to receive dexmedetomidine or propofol sedation. Patients with dexmedetomidine sedation had a lower incidence of delirium than patients with propofol sedation [ 39 ].…”

Sedatives and Postoperative Delirium: Comment

“…We read with interest the randomized controlled trial in the journal by Shin et al 1 comparing postoperative delirium rates in patients undergoing major joint replacement surgery under spinal anesthesia using propofol versus dexmedetomidine sedation. Not only does this trial inform on which agent may result in decreased postoperative delirium, but it also illuminates the imperfections and vulnerabilities in Bayesian logic that underpin much of modern-day medical research.…”

Sedatives and Postoperative Delirium: Comment

“…We read with great interest, “Postoperative Delirium after Dexmedetomidine versus Propofol Sedation in Healthy Older Adults Undergoing Orthopedic Lower Limb Surgery with Spinal Anesthesia: A Randomized Controlled Trial” by Shin et al 1 It reported that the incidence of delirium was less in the group receiving propofol versus dexmedetomidine. The article notes that certain postoperative medications, such as opioids and benzodiazepines, can affect postoperative delirium rates.…”