Volatile Versus Total Intravenous Anesthesia on Postoperative Delirium in Adult Patients Undergoing Cardiac Valve Surgery: A Randomized Clinical Trial

Abstract

BACKGROUND:The effect of anesthesia regimens on postoperative delirium after on-pump cardiac valve surgery is yet undetermined. This study aimed to evaluate the effect of volatile anesthesia compared with propofol-based total intravenous anesthesia (TIVA) on the occurrence of delirium after on-pump cardiac valve surgery. METHODS: This randomized clinical trial was conducted at a university academic hospital in China, from February 2019 to January 2021. Patients scheduled for on-pump cardiac valve surgery or combined valve with coronary artery bypass grafting (CABG) surgeries were randomly assigned to receive anesthesia maintenance with either a volatile anesthetic (sevoflurane or desflurane) or propofol-based TIVA. The primary outcome was the incidence of delirium during the first 7 days after surgery, assessed using the confusion assessment method for the intensive care unit (ICU). The secondary outcomes included duration of delirium, subtypes of delirium, 30-day mortality, pain score, major morbidity (including cerebral infarction, respiratory failure, and pneumonia), duration of mechanical ventilation, and lengths of ICU and hospital stay. The statistical analysis of the primary outcome variable was by Pearson's χ 2 test. RESULTS: Among the 684 patients analyzed (mean age, 53.8 years; 381 [55.7%] women), 676 were assessed for the primary outcome. Postoperative delirium occurred in 63 of 337 (18.7%) patients receiving volatile anesthesia versus 76 of 339 (22.4%) patients receiving propofolbased TIVA (relative risk, 0.80; 95% confidence interval [CI], 0.55-1.16; P = .231). There were no significant differences between the groups in any of the secondary outcomes. CONCLUSIONS: Among patients undergoing on-pump cardiac valve surgery, anesthesia maintenance with a volatile agent did not result in significantly fewer occurrences of postoperative delirium than propofol-based TIVA. (Anesth Analg 2023;136:60-9) KEY POINTS• Question: Dose volatile anesthesia reduces the occurrence of delirium after on-pump cardiac valve surgery when compared with intravenous anesthesia? • Findings: Compared with propofol-based intravenous anesthesia, anesthesia maintenance with a volatile agent did not result in fewer cases of postoperative delirium in patients undergoing on-pump cardiac valve surgery. • Meaning: Our data did not provide sufficient evidence that the choice of volatile or intravenous anesthesia affects the risk of developing delirium after on-pump cardiac valve surgery.

Development and validation of a post-operative delirium prediction model for patients undergoing abdominal surgery: A retrospective, observational, single-center study

“…According to previous reports, POD after major surgical procedures ranges from 17 to 61%, and it affects the patient's health and social statuses since POD may cause cognitive impairment, decreased functional independence, dementia, morbidity mortality, prolonged hospitalization time, increased caregiver physical as well as nancial burdens [4][5]. In line with previous reports, we noticed that POD is typically manifested during the rst 7 postoperative days [6][7][8][9]. Nevertheless, after an initial POD episode, postepisode treatment or intervention has little effect on severity, duration, or likelihood of recurrence [10][11].…”

Desflurane is risk factor for postoperative delirium in older patients’ independent from intraoperative burst suppression duration

“…In the studies by Royse et al (2011) and Jiang et al (2022) , the patients were also younger compared to our patients cohort (Royse: ~62 years; Jiang: ~54 years), which may also have contributed to the different results. For example, one might speculate that older patients have a lower ability to respond to the cerebral changes induced by desflurane administration than younger patients do.…”

“…Both studies were funded by Baxter. A more recent, larger randomized clinical trial (n = 684) compared propofol with volatile anesthesia (desflurane and sevoflurane) and the effects on the development of POD ( Jiang et al, 2022 ). In the volatile anesthetics group, 18.7% developed POD, compared with 22.4% in the propofol group.…”

The Impact of Total Intravenous Anesthesia Versus Inhalational Anesthesia on Postoperative Cognitive Dysfunction in Elderly Patients

“…This reduced inflammation may play a role in protecting cognitive function. High levels of inflammation are associated with cognitive decline in older people (Jiang et al, 2023).…”