The use of dexmedetomidine and intravenous acetaminophen for the prevention of postoperative delirium in cardiac surgery patients over 60 years of age: a pilot study

Abstract

Background: Delirium is associated with many negative health outcomes. Postoperative sedation and opioid administration may contribute to delirium. We hypothesize that the use of dexmedetomidine and Intravenous acetaminophen (IVA) may lead to reduced opioid consumption and decreased incidence of postoperative delirium. This pilot study aims to assess feasibility of using dexmedetomidine and IVA in cardiac surgical patients, and estimate the effect size for incidence and duration of delirium. Methods: A total of 12 adult patients >60 years of age undergoing cardiac surgery were recruited and randomized into 4 groups: Propofol only (P), Propofol with IVA (P+A), Dexmedetomidine only (D), Dexmedetomidine with IVA (D+A). Preoperative baseline cognition and postoperative delirium was assessed daily until discharge. The feasibility was assessed by the number of patients who completed the study. Results: All patients completed the study successfully. The total incidence of delirium in the study population was 42% (5/12): 67% (2/3) in the group P, and 67% (2/3) in the group D, 33% (1/3) in D+A group and 0%(0/3) P+A group. The incidence of delirium was 17% (1/6) in the group receiving IVA compared to 67% (4/6) that did not receive IVA. The mean range of duration of delirium was 0-1 days. One patient expired after surgery, unrelated to the study protocol. One patient in the D group experienced hypotension (systolic blood pressure <90 mm of Hg.) Conclusions: The feasibility of performing a project is ascertained by the study. Patients receiving IVA had lower incidence of delirium compared to patients not receiving IVA which suggests that IVA may have a role in reducing the incidence of delirium. A prospective randomized, placebo-controlled trial will be the next step in investigating the role of dexmedetomidine and IVA in reducing the incidence of delirium.

Comparative effectiveness of pharmacological interventions to prevent postoperative delirium: a network meta-analysis

“…First, we performed a subgroup analyses of cardiac 10 , 18 , 44 – 69 and non-cardiac surgery 5 – 9 , 16 , 17 , 21 , 22 , 70 – 116 . Second, we conducted a subgroup analysis for the studies which used CAM or CAM-ICU 6 , 9 , 10 , 17 , 18 , 21 , 22 , 48 , 49 , 51 – 53 , 55 , 57 , 59 , 61 , 62 , 65 , 66 , 69 , 70 , 74 – 80 , 83 – 85 , 88 , 89 , 92 – 102 , 106 , 107 , 115 , 117 . Third, we also performed a subgroup analysis for the studies which enrolled only old patients with age more than 70 years 5 – 10 , 17 , 18 , 22 , 55 , 57 , 59 , 66 , 72 , 73 , 77 – 80 , 85 , 88 , 93 , 94 , 97 , 98 , 101 , 102 , …”

Pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a systematic review and network meta-analysis

“…1 ), with a total of 17,140 participants [ 34 – 113 ]. Included trials were comprised of 54 (67.5%) pharmacological or sedation intervention studies [ 34 – 36 , 38 – 40 , 42 – 45 , 47 , 49 – 51 , 55 – 57 , 59 – 63 , 67 – 69 , 71 , 73 – 76 , 78 , 79 , 81 , 82 , 85 – 87 , 89 , 90 , 92 – 94 , 97 – 100 , 102 , 103 , 105 – 108 , 110 , 112 , 113 ] with 14,224 participants, 25 (31.3%) studies of non-pharmacological single or multi-component interventions with 2904 participants [ 37 , 41 , 46 , 48 , 52 , 53 , 57 , 58 , 64 – 66 , 70 , 72 , 77 , 80 , 83 , 84 , 88 , 91 , 95 , 96 , 101 , 104 , 109 , 111 ], and 1 study (1.2%) included a combination non-pharmacological with a pharmacological intervention with 12 participants [ 54 ]. Key features of all included trials are presented in detail in eTable 2.…”

Pharmacological strategies to prevent postoperative delirium: a systematic review and network meta-analysis

“…Twenty-seven types of pharmacological agents, including dexmedetomidine (Dexm) [ 2 , 4 , 6 , 31 , 33 , 35 , 36 , 38 – 45 , 47 , 50 , 51 , 62 , 63 , 65 , 66 , 69 , 70 ], propofol (Prop) [ 4 , 33 , 42 – 44 , 47 , 51 , 66 , 70 ], acetaminophen (AAP) [ 70 ], midazolam (Mida) [ 4 , 6 , 77 ], remifentanil (Remi) [ 62 ], morphine (Morp) [ 31 ], methylprednisolone (MPDL) [ 32 , 34 , 48 ], melatonin (Mela) [ 58 , 77 ], dexamethasone (Dexa) [ 52 , 59 , 61 ], haloperidol (Halo) [ 37 , 54 , 55 , 60 ], rivastigmine (Riva) [ 64 ], ketamine (Keta) [ 39 , 71 ], olanzapine (Olan) [ 72 ], gabapentin (Gaba) [ 73 , 76 ], nimodipine (Nimo) [ 1 ], cyproheptadine (Cypr) [ 53 ], ondansetron (Onda) [ 49 ], risperoidone (Risp) [ 67 ], L-tryptophan(L-tyr) [ 74 ...…”

“…The types of surgery investigated included cardiovascular surgery [ 4 , 31 – 35 , 42 , 43 , 47 , 50 – 52 , 59 , 61 , 62 , 64 , 67 , 70 , 71 ], orthopedic surgery [ 1 , 2 , 6 , 39 , 40 , 44 , 46 , 48 , 49 , 54 , 58 , 60 , 68 , 72 , 73 , 75 – 77 ], thoracoscopic and pulmonary surgery [ 41 , 56 , 65 , 74 ], abdominal and laparoscopic surgery [ 54 – 57 , 63 , 66 ], vascular and urology surgery [ 74 ], free flap [ 38 ], oral cancer surgery [ 45 ], and non-cardiac surgery [ 36 , 37 , 53 , 69 ]. The anesthesia method in the studies included only general anesthesia [ 1 , 2 , 4 , 6 , 31 – 35 , 38 , 39 , 41 – 43 , …”

“…The evaluation of the network inconsistency using the design-by-treatment interaction model suggested no significant inconsistency (χ 2 [ 8 ] =13.37, P = 0.100). Of the 14 closed loops in the network for the comparison of postoperative delirium, four loops (Dexm-Dexm + AAP-pro + AAP [01-04-05] [ 70 ], Dexm-Keta-Keta + Dexm [01-09-22] [ 39 ], Pro-Dexm + AAP-Prop + AAP [03-04-05] [ 70 ], Mida-Mela-Clon [06-11-25] [ 77 ]) were formed only by multi-arm trials. Thus, local inconsistency was evaluated in 10 loops.…”