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International Journal of Surgery... Nov 2023Surgery induces high rates of cognitive disorders, persisting for up to 12 months in elderly adults. This review aimed to assess the currently debated preventive effect... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Surgery induces high rates of cognitive disorders, persisting for up to 12 months in elderly adults. This review aimed to assess the currently debated preventive effect of perioperative ketamine on postoperative delirium and postoperative neurocognitive disorders (POND).
MATERIALS AND METHODS
Systematic review and meta-analysis including all randomized controlled trials investigating the effects of perioperative ketamine administration in adult patients compared to placebo or no intervention on postoperative delirium and/or POND between January 2007 and April 2022. Database searches were conducted in PubMed, Medline, Embase, Scopus, and Central. Random effects models were used to pool overall estimates. The GRADE approach was used to assess the quality of the evidence.
RESULTS
From 1379 records screened, 14 randomized controlled trials with 1618 patients randomized met our inclusion criteria with a high level of consensus among reviewers, amongst whom 50% were at low-moderate risk of bias. There was no between-group difference in postoperative delirium [8 trials, 1265 patients, odds ratio (OR) 0.93, 95% CI (0.51-1.70), I2 =28%] and POND [5 trials, 494 patients, OR 0.52, 95% CI (0.15-1.80); I2 =78%]. There was no significant between-group difference in postoperative psychological adverse effects, level of pain, hospital length of stay, or mortality. Between-group subgroup analyses showed no difference in delirium or POND incidence according to surgical setting, ketamine dose, mode of administration, combination or not with other drug(s), and assessment timing or definition of cognitive disorders.
CONCLUSION
Perioperative ketamine does not prevent postoperative delirium or POND. Significant study heterogeneity suggests that standardized measures for POND assessment and a specific focus on patients at high risk for POND should be used to improve the comparability of future studies.
Topics: Adult; Humans; Aged; Ketamine; Emergence Delirium; Cognition Disorders; Cognitive Dysfunction; Randomized Controlled Trials as Topic
PubMed: 37526094
DOI: 10.1097/JS9.0000000000000619 -
BMC Anesthesiology Jul 2023Dexmedetomidine is a medication that has analgesic, sedative, and anti-anxiety properties. In the clinical, it is often used to prevent common complications associated... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Dexmedetomidine is a medication that has analgesic, sedative, and anti-anxiety properties. In the clinical, it is often used to prevent common complications associated with strabismus surgery, including postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex. However, its effectiveness and side effects of the present studies are different. The sample sizes of the present studies on the prevention of complications of dexmedetomidine are small. Therefore, this study evaluates the efficacy of dexmedetomidine in preventing anesthesia-related complications in strabismus surgery through a systematic review and meta-analysis.
METHODS
Literature was retrieved from 10 commonly used databases and randomized controlled trials published up to May 2022 were sought. The included studies compared the intervention effects of dexmedetomidine versus placebo on anesthesia-related complications in surgery. The occurrence rates of postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex in patients undergoing strabismus surgery were evaluated. Statistical analyses and forest plots were generated using Review Manager and STATA software. Binary outcomes were measured using relative risk (RR) with a 95% confidence interval for each outcome. The Cochrane risk of bias tool was used to assess the bias and risk in the studies that met the inclusion criteria.
RESULTS
A total of 13 articles were ultimately included in the analysis, comprising 1,018 patients who underwent strabismus surgery. The dexmedetomidine group, compared to the placebo group, demonstrated significant reductions in the incidence of postoperative delirium (RR = 0.73, P = 0.001), severe postoperative delirium (RR = 0.45, P = 0.005), postoperative nausea and vomiting (RR = 0.48, P < 0.0001), and the need for supplemental analgesia postoperatively (RR = 0.60, P = 0.004). Additionally, subgroup analysis revealed that intravenous administration of dexmedetomidine significantly reduced the incidence of oculocardiac reflex (RR = 0.50, P = 0.001). In contrast, intranasal administration of dexmedetomidine did not have a significant effect on the incidence of oculocardiac reflex (RR = 1.22, P = 0.15). There was a significant difference between the subgroups (P = 0.0005, I2 = 91.7%).
CONCLUSION
Among patients undergoing strabismus surgery, the use of dexmedetomidine can alleviate postoperative delirium and reduce the incidence of postoperative nausea and vomiting, as well as postoperative pain. Moreover, intravenous administration of dexmedetomidine can lower the occurrence rate of the oculocardiac reflex.
Topics: Humans; Postoperative Nausea and Vomiting; Dexmedetomidine; Emergence Delirium; Pain, Postoperative; Strabismus; Anesthesia
PubMed: 37491215
DOI: 10.1186/s12871-023-02215-9 -
BMC Anesthesiology Jul 2023Evidence-based effect of anesthetic regimens on postoperative delirium (POD) incidence after hip fracture surgery is still debated. Randomized trials have reported... (Meta-Analysis)
Meta-Analysis
Neuraxial versus general anesthesia in elderly patients undergoing hip fracture surgery and the incidence of postoperative delirium: a systematic review and stratified meta-analysis.
BACKGROUND
Evidence-based effect of anesthetic regimens on postoperative delirium (POD) incidence after hip fracture surgery is still debated. Randomized trials have reported inconsistent contradictory results largely attributed to small sample size, use of outdated drugs and techniques, and inconsistent definitions of adverse outcomes. The primary objective of this meta-analysis was to investigate the impact of different anesthesia regimens on POD, cognitive impairment, and associated complications including mortality, duration of hospital stay, and rehabilitation capacity.
METHODS
We identified randomized controlled trials (RCTs) published from 2000 to December 2021, in English and non-English language, comparing the effect of neuraxial anesthesia (NA) versus general anesthesia (GA) in elderly patients undergoing hip fracture surgery, from PubMed, EMBASE, Google Scholar, Web of Science and the Cochrane Library database. They were included if POD incidence, cognitive impairment, mortality, duration of hospital stay, or rehabilitation capacity were reported as at least one of the outcomes. Study protocols, case reports, audits, editorials, commentaries, conference reports, and abstracts were excluded. Two investigators (KYC and TXY) independently screened studies for inclusion and performed data extraction. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. The quality of the evidence for each outcome according to the GRADE working group criteria. The odds ratio (OR) and 95% confidence intervals (CI) were calculated to assess the pooled data.
RESULTS
A total of 10 RCTs with 3968 patients were included in the present analysis. No significant differences were found in the incidence of POD comparing NA vs GA [OR 1.10, 95% CI (0.89 to 1.37)], with or without including patients with a pre-existing condition of dementia or delirium, POD incidence from postoperative day 2-7 [OR 0.31, 95% CI (0.06 to -1.63)], in mini-mental state examination (MMSE) score [OR 0.07, 95% CI (-0.22 to 0.36)], or other neuropsychological test results. NA appeared to have a shorter duration of hospital stay, especially in patients without pre-existing dementia or delirium, however the observed effect did not reach statistical significance [OR -0.23, 95% CI (-0.46 to 0.01)]. There was no difference in other outcomes, including postoperative pain control, discharge to same preadmission residence [OR 1.05, 95% CI (0.85 to 1.31)], in-hospital mortality [OR 1.98, 95% CI (0.20 to 19.25)], 30-day [OR 1.03, 95% CI (0.47 to 2.25)] or 90-day mortality [OR 1.08, 95% CI (0.53-2.24)].
CONCLUSIONS
No significant differences were detected in incidence of POD, nor in other delirium-related outcomes between NA and GA groups and in subgroup analyses. NA appeared to be associated with a shorter hospital stay, especially in patients without pre-existing dementia, but the observed effect did not reach statistical significance. Further larger prospective randomized trials investigating POD incidence and its duration and addressing long-term clinical outcomes are indicated to rule out important differences between different methods of anesthesia for hip surgery.
TRIAL REGISTRATION
10.17605/OSF.IO/3DJ6C.
Topics: Aged; Humans; Emergence Delirium; Incidence; Hip Fractures; Anesthesia, General; Dementia
PubMed: 37481517
DOI: 10.1186/s12871-023-02196-9 -
Frontiers in Aging Neuroscience 2023POD places a heavy burden on the healthcare system as the number of elderly people undergoing surgery is increasing annually because of the aging population. As a large...
BACKGROUND
POD places a heavy burden on the healthcare system as the number of elderly people undergoing surgery is increasing annually because of the aging population. As a large country with a severely aging population, China's elderly population has reached 267 million. There has been no summary analysis of the pooled incidence of POD in the elderly Chinese population.
METHODS
Systematic search databases included PubMed, Web of Science, EMBASE, Cochrane Library Databases, China Knowledge Resource Integrated Database (CNKI), Chinese Biomedical Database (CBM), WanFang Database, and Chinese Science and Technology Periodicals (VIP). The retrieval time ranged from the database's establishment to February 8, 2023. The pooled incidence of delirium after non-cardiac surgery was calculated using a random effects model. Meta-regression, subgroup, and sensitivity analyses were used to explore the source of heterogeneity.
RESULTS
A total of 52 studies met the inclusion criteria, involving 18,410 participants. The pooled incidence of delirium after non-cardiac surgery in the elderly Chinese population was 18.6% (95% : 16.4-20.8%). The meta-regression results revealed anesthesia method and year of publication as a source of heterogeneity. In the subgroup analysis, the gender subgroup revealed a POD incidence of 19.6% (95% : 16.9-22.3%) in males and 18.3% (95% : 15.7-20.9%) in females. The year of publication subgroup analysis revealed a POD incidence of 20.3% (95% : 17.4-23.3%) after 2018 and 14.6 (95% : 11.6-17.6%) in 2018 and before. In the subgroup of surgical types, the incidence of hip fracture surgery POD was 20.7% (95% : 17.6-24.3%), the incidence of non-cardiac surgery POD was 18.4% (95% : 11.8-25.1%), the incidence of orthopedic surgery POD was 16.6% (95% : 11.8-21.5%), the incidence of abdominal neoplasms surgery POD was 14.3% (95% : 7.6-21.1%); the incidence of abdominal surgery POD was 13.9% (95% : 6.4-21.4%). The anesthesia methods subgroup revealed a POD incidence of 21.5% (95% : 17.9-25.1%) for general anesthesia, 15.0% (95% : 10.6-19.3%) for intraspinal anesthesia, and 8.3% (95% : 10.6-19.3%) for regional anesthesia. The measurement tool subgroup revealed a POD incidence of 19.3% (95% : 16.7-21.9%) with CAM and 16.8% (95% : 12.6-21.0%) with DSM. The sample size subgroup revealed a POD incidence of 19.4% (95% : 16.8-22.1%) for patients ≤ 500 and 15.3% (95% : 11.0-19.7%) for patients > 500. The sensitivity analysis suggested that the pooled incidence of postoperative delirium in this study was stable.
CONCLUSION
Our systematic review of the incidence of delirium after non-cardiac surgery in elderly Chinese patients revealed a high incidence of postoperative delirium. Except for cardiac surgery, the incidence of postoperative delirium was higher for hip fracture surgery than for other types of surgery. However, this finding must be further explored in future large-sample studies.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/, identifier: PROSPERO CRD42023397883.
PubMed: 37455941
DOI: 10.3389/fnagi.2023.1188967 -
Effect of Ketamine on Postoperative Neurocognitive Disorders: A Systematic Review and Meta-Analysis.Journal of Clinical Medicine Jun 2023Neurocognitive alterations in the perioperative period might be caused by a wide variety of factors including pain, blood loss, hypotension, hypoxia, micro- and... (Review)
Review
BACKGROUND
Neurocognitive alterations in the perioperative period might be caused by a wide variety of factors including pain, blood loss, hypotension, hypoxia, micro- and macroemboli, cardiopulmonary bypass (CPB), reperfusion damage, and surgery itself, and all are risk factors for developing postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). The objective of this study was to evaluate the effect of ketamine on neurocognitive dysfunction after anesthesia.
METHODS
We conducted a meta-analysis of randomized controlled trials (RCTs) comparing ketamine use (experimental group) with placebo (controls).
RESULTS
The model favors the control group over the experimental group in terms of frequency of hallucinations (the risk ratio with 95% CI is 1.54 [1.09, 2.19], -value = 0.02), the number of patients readmitted within 30 days (RR with 95% CI is 0.25 [0.09, 0.70]), and the number of adverse events (overall RR with 95% CI is 1.31 [1.06, 1.62]). In terms of morphine consumption, the model favors the experimental group.
CONCLUSION
There was no statistically significant difference in incidences of postoperative delirium, vasopressor requirement, and fentanyl consumption between the ketamine and control groups. However, hallucinations were more frequently reported in the ketamine group.
PubMed: 37445346
DOI: 10.3390/jcm12134314 -
Frontiers in Neurology 2023Randomized controlled trials (RCTs) have shown conflicting results regarding the effects of perioperative cognitive training (CT) on the incidence of postoperative...
BACKGROUND
Randomized controlled trials (RCTs) have shown conflicting results regarding the effects of perioperative cognitive training (CT) on the incidence of postoperative cognitive dysfunction (POCD) and postoperative delirium (POD). We, therefore, performed a meta-analysis to assess the overall effects of studies on this topic.
METHODS
We searched PubMed, Embase, the Cochrane Library, and Web of Science for all RCTs and cohort studies that investigated the effects of perioperative CT on the incidence of POCD and POD. Data extraction and quality assessment were conducted independently by two researchers.
RESULTS
This study included nine clinical trials with a total of 975 patients. The results showed that perioperative CT significantly reduced the incidence of POCD compared with the control group [risk ratio (RR) = 0.5, 95% CI (confidence interval): 0.28-0.89, = 0.02]. Nevertheless, for the incidence of POD, the difference between the two groups was not statistically significant (RR = 0.64; 95% CI: 0.29-1.43, = 0.28). In addition, the CT group had less postoperative decline in the cognitive function scores compared with the control group [mean differences (MD): 1.58, 95% CI: 0.57-2.59, = 0.002]. In addition, there were no statistically differences in length of hospital stay between the two groups (MD: -0.18, 95% CI: -0.93-0.57, = 0.64). Regarding CT adherence, the proportion of patients in the cognitive training group who completed the planned duration of CT was 10% (95% CI: 0.05-0.14, = 0.258).
CONCLUSION
Our meta-analysis revealed that perioperative cognitive training is possibly an effective measure to reduce the incidence of POCD, but not for the incidence of POD.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022371306, identifier: CRD42022371306.
PubMed: 37416309
DOI: 10.3389/fneur.2023.1146164 -
Frontiers in Pediatrics 2023Pain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision... (Review)
Review
Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis.
BACKGROUND
Pain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision making. However, a comprehensive review is lacking. This systematic review aimed to assess the effectiveness, quality, and implementation of algorithms for the management of pain, sedation, delirium, and iatrogenic withdrawal syndrome in all pediatric intensive care settings.
METHODS
A literature search was conducted on November 29, 2022, in PubMed, Embase, CINAHL and Cochrane Library, ProQuest Dissertations & Theses, and Google Scholar to identify algorithms implemented in pediatric intensive care and published since 2005. Three reviewers independently screened the records for inclusion, verified and extracted data. Included studies were assessed for risk of bias using the JBI checklists, and algorithm quality was assessed using the PROFILE tool (higher % = higher quality). Meta-analyses were performed to compare algorithms to usual care on various outcomes (length of stay, duration and cumulative dose of analgesics and sedatives, length of mechanical ventilation, and incidence of withdrawal).
RESULTS
From 6,779 records, 32 studies, including 28 algorithms, were included. The majority of algorithms (68%) focused on sedation in combination with other conditions. Risk of bias was low in 28 studies. The average overall quality score of the algorithm was 54%, with 11 (39%) scoring as high quality. Four algorithms used clinical practice guidelines during development. The use of algorithms was found to be effective in reducing length of stay (intensive care and hospital), length of mechanical ventilation, duration of analgesic and sedative medications, cumulative dose of analgesics and sedatives, and incidence of withdrawal. Implementation strategies included education and distribution of materials (95%). Supportive determinants of algorithm implementation included leadership support and buy-in, staff training, and integration into electronic health records. The fidelity to algorithm varied from 8.2% to 100%.
CONCLUSIONS
The review suggests that algorithm-based management of pain, sedation and withdrawal is more effective than usual care in pediatric intensive care settings. There is a need for more rigorous use of evidence in the development of algorithms and the provision of details on the implementation process.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276053, PROSPERO [CRD42021276053].
PubMed: 37397149
DOI: 10.3389/fped.2023.1204622 -
Journal of Anesthesia, Analgesia and... Dec 2022The leading cause of emergence delirium (ED) in children postoperatively is the exposure to inhalational anaesthetics. ED can occur immediately after waking from... (Review)
Review
The efficacy and safety of dexmedetomidine in preventing emergence delirium in paediatric patients following ophthalmic surgery: a systematic review and meta-analysis of randomised controlled trials.
BACKGROUND
The leading cause of emergence delirium (ED) in children postoperatively is the exposure to inhalational anaesthetics. ED can occur immediately after waking from anaesthesia, making patients generally uncooperative and agitated. Dexmedetomidine has sedative and analgesic effects and helps to reduce agitation and delirium and improve hemodynamic stability and the recovery of respiratory function; in addition to decreasing pain intensity, it is also well known for helping reduce nausea and vomiting.
OBJECTIVES
This updated systematic review meta-analysis investigate and summarise currently available evidence on the use of dexmedetomidine to prevent ED, reduce postoperative nausea and vomiting (PONV) and decrease the need for rescue analgesia in paediatric patients undergoing ophthalmic surgery.
METHODS
The medical databases EMBASE, PubMed and Cochrane Library were searched for randomised controlled trials published between January 2020 and August 2022 that used Dexmedetomidine in paediatric patients undergoing ophthalmic surgery. The protocol was prospectively registered with PROSPERO (CRD42022343622). The review was accomplished according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses', and the meta-analysis was conducted by using RevMan5.4. These studies examine the efficacy of dexmedetomidine in preventing ED in children undergo ophthalmic surgery. The Cochrane ROB-1 was used to assess risk of bias (ROB).
RESULTS
Eight studies comprised of 629 participants, of which 315 received dexmedetomidine and 314 placebos were examined. PAED score identified ED following surgery. A review and meta-analysis indicated that dexmedetomidine reduces ED incidence (RR = 0.39; 95% CI 0.25-0.62). Similarly, it reduces the use of rescue analgesia (RR = 0.38; 95% CI 0.25-0.57). However, dexmedetomidine did not help prevent PONV since no difference was found between groups (RR = 0.33; 95% CI 0.21-0.54).
CONCLUSION
This review showed that dexmedetomidine helped to reduce ED incidence in paediatric patients after ophthalmic surgery and reduced the need for rescue analgesia compared to placebo or other medications.
PubMed: 37386601
DOI: 10.1186/s44158-022-00079-y -
Cancers May 2023The increase in life expectancy worldwide has led to a larger population of older people, which in turn entails a rising prevalence of cancer. One of the main... (Review)
Review
BACKGROUND
The increase in life expectancy worldwide has led to a larger population of older people, which in turn entails a rising prevalence of cancer. One of the main complications of cancer is delirium, especially in advanced stages.
OBJECTIVE
To determine which delirium screening instrument is the most accurate in older people with cancer.
METHODS
A systematic review was designed. A literature search was performed in MEDLINE, EBSCO and SCOPUS; additional records were identified by handsearching. Selection criteria were studies involving people with cancer and a mean sample age of 60 years or older, assessing delirium, and reporting the metric properties of the assessment instrument. Studies with post-surgical patients and substance abuse delirium were excluded.
RESULTS
From 2001 to 2021, 14 eligible studies evaluated 13 different assessment tools, reporting an incidence of delirium ranging from 14.3% to 68.3%. The Delirium Observation Screening Scale (DOSS) showed the best metric properties, followed by the Nursing Delirium Screening Scale (NuDESC), Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS). Only two studies were considered to be at low risk of bias using the QUADAS-2 Tool. No study exclusively examined this population group.
CONCLUSIONS
Screening tools for delirium are heterogeneous for older people with cancer, and there is a need to analyze metric properties exclusively in the older population. Registered on PROSPERO ID: CRD42022303530.
PubMed: 37345143
DOI: 10.3390/cancers15102807 -
Journal of Orthopaedic Surgery and... Jun 2023The optimal anesthesia technique for older patients undergoing hip fracture surgery remains controversial. We performed a systematic review and meta-analysis of updated... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The optimal anesthesia technique for older patients undergoing hip fracture surgery remains controversial. We performed a systematic review and meta-analysis of updated randomized controlled trials (RCTs) to assess whether regional anesthesia was superior to general anesthesia in hip fracture surgery.
METHODS
We searched PubMed, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials from January 2000 until April 2022. RCTs directly comparing regional and general anesthesia in hip fracture surgery were included in the analysis. The incidence of delirium and mortality were the primary outcomes and other perioperative outcomes including complications were secondary outcomes.
RESULTS
Thirteen studies involving 3736 patients were included in this study. There was no significant difference in the incidence of delirium (odds ratio [OR] 1.09; 95% confidence interval [CI] 0.86, 1.37) and mortality (OR 1.08; 95% CI 0.71, 1.64) between the two groups. Patients receiving regional anesthesia in hip fracture surgery were associated with a reduction in operative time (weighted mean difference [WMD]: - 4.74; 95% CI - 8.85, - 0.63), intraoperative blood loss (WMD: - 0.25; 95% CI - 0.37, - 0.12), postoperative pain score (WMD: - 1.77; 95% CI - 2.79, - 0.74), length of stay (WMD: - 0.10; 95% CI - 0.18, - 0.02), and risk of acute kidney injury (AKI) (OR 0.56; 95% CI 0.36, 0.87). No significant difference was observed in the other perioperative outcomes.
CONCLUSIONS
For older patients undergoing hip fracture surgery, RA did not significantly reduce the incidence of postoperative delirium and mortality compared to GA. Due to the limitations of this study, the evidence on delirium and mortality was still inconclusive and further high-quality studies are needed.
Topics: Aged; Humans; Anesthesia, General; Delirium; Hip Fractures; Randomized Controlled Trials as Topic; Anesthesia, Conduction; Fracture Fixation
PubMed: 37312156
DOI: 10.1186/s13018-023-03903-5