RESUMEN
Postoperative delirium (POD) is a prevalent perioperative complication among elderly individuals and is a cause of significant detrimental consequences for both individuals and society. Pharmacological and nonpharmacological prevention methods/therapies have been proposed to mitigate the risk of POD. Nevertheless, the efficacy of pharmacological interventions is controversial, and some of them cause side effects. Therefore, numerous studies have explored the effectiveness of nonpharmacological interventions in mitigating POD and have recommended the use of nonpharmacological multicomponent interventions by an interdisciplinary team as primary interventions. However, dedicated units aimed at promoting comanagement are rare and are only present in academic hospitals. Therefore, there is increasing interest in nonpharmacological mono-component interventions for preventing POD, which offer advantages such as easy application, cost-effectiveness, patient acceptability and noninvasiveness. These interventions are divided into cognitive training and noncognitive interventions. The former is aimed at increasing cognitive reserve, thus decreasing the incidence rate of POD. Noncognitive interventions, including sensory stimuli (music therapy, odor enrichment), improving sleep disturbances, physical activity, acupuncture and transcranial magnetic/direct current stimulation, are aimed at decreasing the risk factors for POD. This review provides a comprehensive overview of recently reported nonpharmacological mono-component interventions for preventing POD and briefly describes their clinical value.
Asunto(s)
Delirio , Complicaciones Posoperatorias , Humanos , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/terapia , Delirio/prevención & control , Delirio/etiología , Delirio/terapiaRESUMEN
BACKGROUND: Postoperative delirium (POD) is a serious and common complication. The aim of present study is to investigate the diurnal variation of POD and the effects of esketamine in elderly patients. METHODS: A randomized, double-blind, placebo-controlled clinical trial with factorial design was conducted. Patients (aged 65 to 85 years) with normal Mini-Mental State Examination (MMSE) score were stratified by age (≤70 vs. >70) and American Society of Anesthesiologists physical status classification (â ¡ vs. â ¢), then randomly assigned to either morning (08:00-12:00) or afternoon (14:00-18:00) noncardiac operation under general anesthesia with or without esketamine administration (0.2 mg/kg). The primary outcome was the incidence of POD (3-Minute Diagnostic Interview for Confusion Assessment Method-defined Delirium, 3D-CAM) on postoperative days 1, 3, and 7. The secondary outcomes were the scores of MMSE and Hospital Anxiety and Depression Scale. The intention-to-treat analysis of the outcomes were performed by generalized estimating equation. RESULTS: Six patients who did not receive an intervention because of canceled operation were excluded after randomization. The datasets containing 426 cases were analyzed following the intention-to-treat principle after handling missing data via multiple imputation method. The incidence of POD declined from about 55% on postoperative day 1 to 31 and 18% on postoperative days 3 and 7, respectively. Afternoon operation [B=-0.583, OR (95% CI) 0.558 (0.319-0.976); P=0.041], but not esketamine, significantly decreased the incidence of POD. Both esketamine and operation time failed to significantly affect MMSE, HAD, and NRS score. There was no interaction among operation time, esketamine, and follow up time. CONCLUSION: Elderly patients undergoing elective noncardiac surgery in the afternoon displayed lower POD incidence than those operated in the morning. A single low-dose of esketamine before general anesthesia induction failed to significantly decrease the risk of POD but decrease the risk of intraoperative hypotension and emergence agitation.
Asunto(s)
Procedimientos Quirúrgicos Electivos , Ketamina , Complicaciones Posoperatorias , Humanos , Ketamina/administración & dosificación , Anciano , Femenino , Masculino , Método Doble Ciego , Anciano de 80 o más Años , Procedimientos Quirúrgicos Electivos/efectos adversos , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Anestesia General/efectos adversos , Ritmo Circadiano , Delirio/prevención & control , Delirio/epidemiología , Delirio/diagnóstico , Delirio del Despertar/prevención & control , Delirio del Despertar/epidemiología , Delirio del Despertar/diagnósticoRESUMEN
OBJECTIVES: To synthesise and map the evidence of a theory- and evidence-based nursing intervention for the prevention of ICU-acquired weakness and evaluate its effectiveness in terms of the incidence of ICU-acquired weakness, incidence of delirium, and length of hospital stay. METHODS: We searched PubMed, CINAHL, MEDLINE, Academic Search Complete, Embase, Scopus, Web of Science and the Cochrane Library from database inception to November 2023. The eligible studies focused on critically ill patients in the intensive care unit, used a theory- and evidence-based nursing intervention, and reported the incidence of ICU-acquired weakness and/or used the Medical Research Council Scale. The methodological quality of the included studies was critically appraised by two authors using the appropriate Joanna Briggs Institute appraisal tool for randomised controlled trials, quasi-experimental studies, and cohort studies. Additionally, the weighted kappa coefficient was used to assess inter-rater agreement of the quality assessment. Data were reported using a narrative synthesis. This systematic review was registered by the International Prospective Register of Systematic Review (PROSPERO; CRD42023477011). RESULTS: A total of 5162 studies were initially retrieved, and 9 studies were eventually included after screening. This systematic review revealed that preventive nursing interventions for ICU-acquired weakness mainly include (a) physiotherapy, including neuromuscular electrical stimulation and early rehabilitation, and (b) nutritional support. In addition, (c) airway management, (d) sedation and analgesia management, (e) complication prevention (delirium, stress injury and deep vein thrombosis prevention), and (f) psychological care were also provided. The theories are dominated by goal-oriented theories, and the evidence is mainly the ABCDE bundle in the included studies. The results show that theory- or evidence-based nursing interventions are effective in reducing the incidence of ICU-acquired weakness (or improving the Medical Research Council Scale scores), decreasing the incidence of delirium, shortening the length of hospital stay, and improving patients' self-care and quality of life. CONCLUSION: Theory- and evidence-based nursing interventions have good results in preventing ICU-acquired weakness in critically ill patients. Current nursing interventions favour a combination of multiple interventions rather than just a single intervention. Therefore, preventive measures for ICU-acquired weakness should be viewed as complex interventions and should be based on theory or evidence. This systematic review is based on a small number of trials. Thus, more high-quality randomised controlled trials are needed to draw definitive conclusions about the impact of theory- and evidence-based nursing interventions on the prevention of ICU-acquired weakness.
Asunto(s)
Unidades de Cuidados Intensivos , Debilidad Muscular , Humanos , Debilidad Muscular/prevención & control , Delirio/prevención & control , Enfermería Basada en la Evidencia , Enfermedad Crítica , Tiempo de InternaciónRESUMEN
OBJECTIVES: This randomized controlled trial investigated whether the regional cerebral oxygenation saturation (rScO2)-guided lung-protective ventilation strategy could improve brain oxygen and reduce the incidence of postoperative delirium (POD) in patients older than 65 years. METHODS: This randomized controlled trial enrolled 120 patients undergoing thoracic surgery who received one-lung ventilation (OLV). Patients were randomly assigned to the lung-protective ventilation group (PV group) or rScO2-oriented lung-protective ventilation group (TPV group). rScO2 was recorded during the surgery, and the occurrence of POD was assessed. RESULTS: The incidence of POD 3 days after surgery-the primary outcome-was significantly lower in the TPV group (23.3% versus 8.5%). Meanwhile, the levels of POD-related biological indicators (S100ß, neuron-specific enolase, tumor necrosis factor-α) were lower in the TPV group. Considering the secondary outcomes, both groups exhibited a lower oxygenation index after OLV, whereas partial pressure of carbon dioxide and mean arterial pressure were significantly increased in the TPV group. In addition, minimum rScO2 during surgery and mean rScO2 were higher in the TPV group than in the PV group. CONCLUSION: Continuous intraoperative monitoring of brain tissue oxygenation and active intervention measures guided by cerebral oxygen saturation are critical for improving brain metabolism and reducing the risk of POD.
Asunto(s)
Encéfalo , Delirio , Ventilación Unipulmonar , Saturación de Oxígeno , Complicaciones Posoperatorias , Humanos , Ventilación Unipulmonar/métodos , Masculino , Femenino , Anciano , Delirio/prevención & control , Delirio/metabolismo , Delirio/etiología , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/etiología , Encéfalo/metabolismo , Encéfalo/cirugía , Toracoscopía/métodos , Oxígeno/metabolismo , Oxígeno/sangre , Anciano de 80 o más AñosRESUMEN
PURPOSE: We aimed to develop a simulation program for physicians and nurses involved in virtual reality (VR) and augmented reality (AR) treatment and care from the perspective of these professionals and older adults with dementia who developed delirium, and to test the effectiveness of the program. METHODS: effectiveness of the program was analyzed through free-response statements from 67 nurses (84.8%) and 12 doctors (15.2%) who participated in the program between February 16 and April 18, 2023. RESULTS: Regarding the experience of delirium from the perspective of older adults with dementia (personal experience), the following statements were extracted "1. I do not understand where I am, the situation, and the treatment/care that is about to be given"; "2. I want the situation to be explained to me so that I can understand the reasons for my hospitalization and the treatment/care I am receiving"; "3. The eerie environment of the hospital and the high pressure of the staff made me feel anxious and fearful"; "4. Please respect my existence as I endure pain, anxiety, and loneliness"; "5. I feel relieved when doctors and nurses deal with me from my point of view"; and "6. I feel relieved when there is a familiar presence, such as a family member or the name I am calling on a daily basis". CONCLUSION: Specific categories of self-oriented empathy were extracted from the experience of physical restraint at night using VR and the experience of delirium using AR. This suggests the possibility of objective effects on treatment and care in future practice.
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Delirio , Demencia , Realidad Virtual , Humanos , Delirio/prevención & control , Delirio/terapia , Anciano , Realidad Aumentada , Femenino , MasculinoRESUMEN
To investigate effectiveness of the ABCDEF bundle to manage and prevent delirium. BACKGROUND: ICU delirium is a common hospital problem that 80% of critically ill patients in the ICU experience. The ABCDEF bundle is one of the tools that included in Delirium guidelines to manage critically ill patients. RESEARCH DESIGN: Pre- and post intervention a quasi-experimental design was utilized in the present study. SETTING: This study was conducted in the intensive care units of Assiut University Hospital. METHODS: A total of 60 mechanically ventilated patients were recruited using inclusion and exclusion criteria. The ABCDEF bundle was implemented every day for the first 7 days of ICU admission, and patient sedation and delirium status were assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Sedation instrument measures were utilized in data collection. RESULTS: Significant differences were found in the incidence of delirium: 20% in the study group versus 70% in the control group. The increased mean of days without delirium ICU stay was 4.6333 in the study group and 1.1000 in the control group, with P value = .001. CONCLUSION: The mechanically ventilated patients exposed to the implementation of the ABCDE bundle experienced fewer delirium signs than before the ABCDE bundle was implemented.
Asunto(s)
Enfermedad Crítica , Delirio , Unidades de Cuidados Intensivos , Respiración Artificial , Humanos , Delirio/prevención & control , Delirio/diagnóstico , Masculino , Femenino , Persona de Mediana Edad , Paquetes de Atención al Paciente , Anciano , Tiempo de Internación/estadística & datos numéricos , Adulto , IncidenciaRESUMEN
The underlying mechanism of postoperative delirium (POD) in elderly people remains unclear. Perioperative hyperglycemia (POHG) is an independent risk indicator for POD, particularly in the elderly. Under cerebral desaturation (hypoxia) during general anesthesia, hypoxia-inducible factor (HIF) is neuroprotective during cerebral hypoxia via diverse pathways, like glucose metabolism and angiogenesis. Hyperglycemia can repress HIF expression and activity. On the other hand, POHG occurred among patients undergoing surgery. For surgical stress, hypothalamic-pituitary-adrenal activation and sympathoadrenal activation may increase endogenous glucose production via gluconeogenesis and glycogenolysis. Thus, under the setting of cerebral hypoxia during general anesthesia, we speculate that POHG prevents HIF-1α levels and function in the brain of aged patients, thus exacerbating the hypoxic response of HIF-1 and potentially contributing to POD. This paper sketches the underlying mechanisms of HIF in POD in elderly patients and offers novel insights into targets for preventing or treating POD in the same way as POHG.
Asunto(s)
Hiperglucemia , Complicaciones Posoperatorias , Humanos , Hiperglucemia/metabolismo , Hiperglucemia/etiología , Anciano , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/metabolismo , Complicaciones Posoperatorias/prevención & control , Delirio/etiología , Delirio/metabolismo , Delirio/prevención & control , Subunidad alfa del Factor 1 Inducible por Hipoxia/metabolismo , Factor 1 Inducible por Hipoxia/metabolismo , Anestesia General/efectos adversosRESUMEN
OBJECTIVE: To study the effect of cluster nursing care based on 10S continuous quality improvement (CQI) on the incidence of postoperative delirium in patients with BPH. METHODS: This study included 96 BPH patients undergoing transurethral resection of the prostate (TURP) in our department from August 2021 to February 2023. We randomly divided the patients into two groups of equal number to receive routine postoperative nursing care (the control group) and postoperative cluster nursing care based on the 10S DQI mode (the observation group), respectively. We recorded and compared the delirium scores of the patients at 2, 6, 12 and 24 hours after operation, their status of recovery, scores on Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS) and quality of life (QOL), and incidence of complications between the two groups. RESULTS: Compared with the controls, the patients in the observation group showed significantly lower delirium scores at 2 h (12.72±3.54 vs 10.65±2.87, P<0.05), 6 h (20.17±4.92 vs 14.19±4.64, P<0.01), 12 h (16.82±4.24 vs 10.69±3.18, P<0.01) and 24 h (13.61±2.86 vs 9.13±2.12, P<0.01) after operation, and shorter time to ambulation (ï¼»3.65±1.41ï¼½ vs ï¼»2.84±0.83ï¼½ d, P<0.01) and time of postoperative catheterization (ï¼»6.28±1.65ï¼½ vs ï¼»4.28±1.14ï¼½ d, P<0.01), bladder irrigation (ï¼»3.41±1.08ï¼½ vs ï¼»2.25±0.71ï¼½ d, P<0.01) and hospitalization (ï¼»10.33±2.41ï¼½ vs ï¼»7.82±2.06ï¼½ d, P<0.01). No statistically significant differences were observed between the two groups in either the SAS and SDS scores (P >0.05) or the QOL scores before operation (P >0.05), but the former two were dramatically decreased (P<0.01) while the latter one increased in the observation group postoperatively (P<0.01). Postoperative complications included delirium, bladder spasm, urethral pain, and secondary bleeding, with a significantly lower total incidence rate in the observation than in the control group (12.50% vs 52.08%, P<0.01). CONCLUSION: Cluster nursing care based on 10S CQI can promote the postoperative recovery of BPH patients, improve their psychological status and quality of life, and reduce the incidence of delirium and complications.
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Delirio , Complicaciones Posoperatorias , Hiperplasia Prostática , Mejoramiento de la Calidad , Calidad de Vida , Humanos , Masculino , Delirio/prevención & control , Delirio/epidemiología , Delirio/etiología , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Incidencia , Hiperplasia Prostática/cirugía , Resección Transuretral de la Próstata , Atención de Enfermería , AncianoRESUMEN
BACKGROUND: Delirium, marked by acute cognitive decline, poses a life-threatening issue among older individuals, especially after cardiac surgery, with prevalence ranging from 15 to 80%. Postoperative delirium is linked to increased morbidity and mortality. Although clinical trials suggest preventability, there is limited research on intranasal insulin (INI) for cardiac surgery-related delirium. INI has shown promise in managing cognitive disorders. It rapidly elevates brain hormone levels, enhancing memory even in non-impaired individuals. While effective in preventing delirium in gastrointestinal surgery, its impact after cardiac surgery remains understudied, especially for middle-aged patients. METHOD: This is a prospective randomized, double-blind, single-center controlled trial. A total of 76 eligible participants scheduled for elective on-pump cardiac surgery will be enrolled and randomly assigned in a 1:1 ratio to either receive Intranasally administered insulin (INI) or intranasally administered normal saline. The primary outcome of our study is the incidence of postoperative delirium (POD). Secondary outcomes include duration of ICU, postoperative hospital length of stay, all in-hospital mortality, the change in MMSE scores pre- and post-operation, and incidence of postoperative cognitive dysfunction at 1 month, 3 months, and 6 months after operation. Moreover, we will subjectively and objectively evaluate perioperative sleep quality to investigate the potential impact of nasal insulin on the development of delirium by influencing sleep regulation. DISCUSSION: Our study will aim to assess the impact of intranasal administration of insulin on the incidence of postoperative delirium in middle-aged patients undergoing on-pump elective cardiac surgery. If intranasal insulin proves to be more effective, it may be considered as a viable alternative for preventing postoperative delirium. TRIAL REGISTRATION: ChiCTR ChiCTR2400081444. Registered on March 1, 2024.
Asunto(s)
Administración Intranasal , Procedimientos Quirúrgicos Cardíacos , Delirio , Procedimientos Quirúrgicos Electivos , Insulina , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Método Doble Ciego , Estudios Prospectivos , Insulina/administración & dosificación , Delirio/prevención & control , Delirio/epidemiología , Delirio/etiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Persona de Mediana Edad , Incidencia , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Femenino , Masculino , Resultado del Tratamiento , Tiempo de Internación , Mortalidad HospitalariaRESUMEN
BACKGROUND: Nurses play an important role in the prevention and management of delirium episodes. However, some studies have reported that not all interventions recommended are applied due to time and resource constraints, resulting in patients receiving less care than required because other patients and/or interventions are prioritised. The concept of prioritization is part of the broader concept of decision-making as the ability to choose between two or more alternatives to ensure patient safety. Understanding the reasons influencing the prioritization process in patients at risk or with delirium may inform interventions to prevent and/or minimise the unfinished nursing care. AIM: The purpose of this study was to explore the reasons that inform the prioritisation process among nurses when they are challenged to make decisions for patients at risk and with delirium. METHODS: A descriptive qualitative study performed according to the COnsolidated criteria for Reporting guidelines, in 2021. An intentional sample of nurses working full-time with older patients in medical, geriatric, and post-acute care facilities affiliated with the National Health System was involved. Semi-structured interviews were conducted and narratives thematic analysed. RESULTS: A total of 56 nurses (55.4% in internal medicine, 26.8% in geriatrics and 17.8% in post-acute/intermediate care) participated with an average age of 31.6 years. The reasons informing the prioritisation process while providing preventive or managerial interventions towards a patient at risk of or with delirium are set at three levels: (1) unit level, as reasons belong to the inadequacy of the 'Environment', the 'Human Resources', and the 'Organisation and Work Processes', (2) nurse's level, as issues in 'Competencies' and 'Attitudes' possessed, and (3) patient level, due to the 'Multidimensional Frailty'. CONCLUSION: Nurses caring for patients at risk of and with delirium face several challenges in providing care. To prioritise preventive and managerial interventions, it is essential to implement multilevel and multifaced organizational and educational strategies.
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Delirio , Investigación Cualitativa , Humanos , Delirio/prevención & control , Delirio/enfermería , Masculino , Femenino , Adulto , Enfermeras y Enfermeros/psicología , Persona de Mediana Edad , Toma de Decisiones , Actitud del Personal de SaludRESUMEN
Importance: Delirium is common among older hospitalized adults. In addition to presenting immediate management issues, delirium can increase the long-term risk of dementia, institutionalization, and mortality. Delirium is associated with disrupted sleep, and prior studies suggest that some specific sleep-promoting agents may reduce delirium. Objective: To evaluate the orexin receptor antagonist suvorexant for reducing delirium in older adults at high risk for delirium after hospitalization. Design, Setting, and Participants: This double-blind, placebo-controlled, phase 3 randomized clinical trial was conducted at 50 hospitals in Japan between October 22, 2020, and December 23, 2022. The study population included Japanese adults aged 65 to 90 years who were at high risk for delirium (mild cognitive impairment or mild dementia, history of delirium at prior hospitalization, or both) and had been hospitalized for acute disease or elective surgery. Data analysis was performed between January 23 and March 13, 2023. Intervention: Participants were randomized 1:1 to suvorexant (15 mg) or placebo taken at bedtime for up to 7 days while in the hospital. Main Outcomes and Measures: Delirium, the primary end point, was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria while participants were hospitalized. The treatment difference in the proportion of participants with delirium was analyzed. Results: This study included 203 participants: 101 were treated with suvorexant (mean [SD] age, 81.5 [4.5]; years; 52 men [51.5%] and 49 women [48.5%]) and 102 received placebo (mean [SD] age, 82.0 [4.9] years; 45 men [44.1%] and 57 women [55.9%]). There were 17 participants with delirium (16.8%) in the suvorexant group compared with 27 (26.5%) in the placebo group (difference, -8.7% [95% CI, -20.1% to 2.6%]; P = .13). Adverse events were similar between the 2 groups. Conclusions and Relevance: In this randomized clinical trial of suvorexant in older adults at high risk for delirium after hospitalization, fewer participants taking suvorexant had delirium compared with placebo, but the difference was not statistically significant. Further studies are needed to determine whether suvorexant may be useful for reducing delirium, particularly delirium with a hyperactive component, in this population. Trial Registration: ClinicalTrials.gov Identifier: NCT04571944.
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Azepinas , Delirio , Hospitalización , Triazoles , Humanos , Anciano , Masculino , Femenino , Delirio/tratamiento farmacológico , Delirio/prevención & control , Anciano de 80 o más Años , Método Doble Ciego , Hospitalización/estadística & datos numéricos , Triazoles/uso terapéutico , Azepinas/uso terapéutico , Antagonistas de los Receptores de Orexina/uso terapéutico , Japón , Fármacos Inductores del Sueño/uso terapéuticoAsunto(s)
Paquetes de Atención al Paciente , Humanos , Paquetes de Atención al Paciente/métodos , Paquetes de Atención al Paciente/normas , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Delirio/prevención & control , Delirio/etiología , Delirio del Despertar/prevención & control , Delirio del Despertar/etiologíaAsunto(s)
Hiperlipidemias , Complicaciones Posoperatorias , Humanos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Delirio del Despertar/prevención & control , Delirio del Despertar/etiología , Delirio del Despertar/epidemiología , Delirio del Despertar/diagnóstico , Factores de Riesgo , Delirio/etiología , Delirio/prevención & controlRESUMEN
PURPOSE: The aim of this study was to describe nurses' experiences of the prerequisites for implementing family-centered care to prevent pediatric delirium. DESIGN: The research employed a qualitative, descriptive study design. METHODS: A total of 10 nurses working in the pediatric intensive care unit at 1 university hospital participated in the study. The quality data were collected using individual semistructured interviews, and the data were then analyzed by inductive content analysis. RESULTS: The prerequisites for implementing family-centered care to prevent delirium among pediatric patients consisted of 30 subcategories that were grouped into 11 generic categories. The generic categories were further grouped into 5 main categories: (1) an environment that supports family presence, (2) psychosocial support for the family, (3) individual family involvement, (4) family participation in shared decision-making, and (5) nurses' professional competence. CONCLUSIONS: According to the nurses' experiences, the implementation of a family-centered approach to preventing delirium in pediatric patients requires creating a supportive environment for families, providing psychosocial support, encouraging family involvement in decision-making, and ensuring that all nurses have the necessary skills.
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Delirio , Enfermería de la Familia , Investigación Cualitativa , Humanos , Delirio/prevención & control , Delirio/enfermería , Niño , Personal de Enfermería en Hospital/psicología , Actitud del Personal de Salud , Adulto , Femenino , Relaciones Profesional-Familia , Enfermería Pediátrica , Masculino , Unidades de Cuidado Intensivo Pediátrico , Familia/psicología , Atención Dirigida al PacienteRESUMEN
OBJECTIVE: Postoperative delirium (POD), especially after cardiac surgery with cardiopulmonary bypass (CPB), is a relatively common and severe complication increasing side effects, length of hospital stay, mortality and healthcare resource costs. This study aimed to determine the impact of using mannitol serum in the prime of CPB for preventing the occurrence of delirium in patients undergoing coronary artery bypass surgery. METHODS: This study is a single-centre, double-blinded, randomised, controlled trial that was conducted from December 2022 to May 2023. Patients in the age range of 18-70 who underwent elective coronary artery bypass surgery were included in the study. In the control group (n=45), the prime solution included Ringer's lactate serum. In the intervention group (n=45), the prime solution consisted of 200 mL mannitol serum and Ringer's lactate serum. The primary outcome of the study was the incidence of POD. Secondary outcomes included the duration of mechanical ventilation, length of stay in the intensive care unit (ICU) and 30-day in-hospital mortality. RESULTS: There were no statistically significant differences in demographic characteristics and risk factors between the control and intervention groups (p<0.05). However, the incidence of POD was significantly lower in the intervention group compared with the control group (22.25% vs 42.2%, p=0.035). There were no significant differences between the two groups regarding CPB time, aortic cross-clamp time, duration of mechanical ventilation and length of stay in ICU (p<0.05). Additionally, mortality rates and rates of return to the operating room did not differ significantly between the two groups (p<0.05). CONCLUSIONS: This study concluded that adding mannitol to the prime of CPB pump can help reduce the incidence of delirium after cardiac surgery. TRIAL REGISTRATION NUMBER: IRCT20221129056660N1.
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Puente de Arteria Coronaria , Delirio , Manitol , Complicaciones Posoperatorias , Humanos , Manitol/administración & dosificación , Manitol/uso terapéutico , Manitol/efectos adversos , Masculino , Femenino , Puente de Arteria Coronaria/efectos adversos , Persona de Mediana Edad , Método Doble Ciego , Anciano , Delirio/prevención & control , Delirio/epidemiología , Delirio/etiología , Incidencia , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Adulto , Resultado del Tratamiento , Factores de Riesgo , Adolescente , Adulto Joven , Enfermedad de la Arteria Coronaria/cirugía , Mortalidad Hospitalaria , Factores de Tiempo , Tiempo de Internación , Estudios de SeguimientoRESUMEN
BACKGROUND: Over the last two decades, a large body of literature has focused on studying the prevalence and outcome of the postoperative delirium and sleep disturbance. The aim of this work was to evaluate the effect of intraoperative administration of Magnesium sulphate on the occurrence of post-operative delirium and insomnia in patients undergoing lumbar fixation. METHODS: This prospective randomized controlled trial was carried out on 80 patients indicated for lumbar fixation; 40 of them received conventional general anesthesia with extra administration of intraoperative magnesium sulphate (Mg sulphate group), and the other 40 received conventional general anesthesia only (control group). Both groups were submitted to pre-operative assessment of depression using Beck Depression inventory (BDI) scale, pre-operative assessment of fatigue using a fatigue questionnaire, pre- and post-operative assessment of insomnia using Insomnia severity index (ISI), post-operative assessment of delirium using Memorial delirium assessment scale (MDAS), post-operative assessment of pain using Visual Analogue Scale (VAS), and pre- and post-operative Quantitative electroencephalography (QEEG). RESULTS: Mg sulphate administration, age, pre-operative BDI, pre-operative ISI, and post-operative VAS were independent predictors of post-operative ISI (P-value < 0.001, 0.047, 0.021, < 0.001, and < 0.001 respectively). Age and post-operative VAS were independent predictors of post-operative MDAS (P-value = 0.008, 0.013 respectively). Mg sulphate administration and pre-operative ISI were independent predictors of post-operative VAS (P-value = 0.010, 0.006 respectively). CONCLUSION: There was a significant relationship between intraoperative Mg sulphate administration and both post-operative insomnia and pain in unadjusted and adjusted analysis.
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Cuidados Intraoperatorios , Sulfato de Magnesio , Trastornos del Inicio y del Mantenimiento del Sueño , Humanos , Sulfato de Magnesio/administración & dosificación , Femenino , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Cuidados Intraoperatorios/métodos , Vértebras Lumbares/cirugía , Adulto , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Anestesia General/métodos , Delirio/prevención & control , Anciano , Delirio del Despertar/prevención & control , Delirio del Despertar/epidemiología , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Dimensión del Dolor/métodosRESUMEN
BACKGROUND: Postoperative delirium remains prevalent despite extensive research through randomised trials aimed at reducing its incidence. Understanding trial characteristics associated with interventions' effectiveness facilitates data interpretation. METHODS: Trial characteristics were extracted from eligible trials identified through two systematic literature searches. Multivariable meta-regression was used to investigate trial characteristics associated with effectiveness estimated using odds ratios. Meta-analysis was used to investigate pooled effectiveness. RESULTS: We identified 201 eligible trials. Compared with China, trials from the USA/Canada (ratio of odds ratio, 1.89; 95% confidence interval, 1.45-2.45) and Europe/Australia/New Zealand (1.67; 1.29-2.18) had an 89% and 67% higher odds ratio, respectively, suggesting reduced effectiveness. The effectiveness was enhanced when the incidence of postoperative delirium increased (0.85; 0.79-0.92, per 10% increase). Trials with concerns related to deviations from intended interventions reported increased effectiveness compared with those at low risk (0.69; 0.53-0.90). Compared with usual care, certain interventions appeared to have reduced the incidence of postoperative delirium in low-risk trials with low-to-moderate certainty of evidence. However, these findings should be considered inconclusive because of challenges in grouping heterogeneous interventions, the limited number of eligible trials, the prevalence of small-scale studies, and potential publication bias. CONCLUSIONS: The effectiveness of postoperative delirium trials varied based on the region of trial origin, the incidence of delirium, and the risk of bias. The limitations caution against drawing definitive conclusions from different bodies of evidence. These findings highlight the imperative need to improve the quality of research on a global scale. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42023413984).
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Complicaciones Posoperatorias , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Delirio/prevención & control , Delirio/epidemiología , Delirio del Despertar/prevención & control , Delirio del Despertar/epidemiologíaRESUMEN
OBJECTIVE: This meta-analysis aimed to evaluate whether fascia iliaca compartment block (FIB) could reduce the incidence of postoperative delirium (POD) in elderly patients undergoing hip surgery. METHODS: This meta-analysis was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42023490399). The PubMed, Embase, Web of Science, and Cochrane Library databases were searched for randomized controlled trials (RCTs) till November 15, 2023. Review Manger 5.4 was used to analyze the data. RESULTS: A total of 10 RCTs with 930 elderly patients were included in this meta-analysis. This meta-analysis indicated that FIB could reduce the incidence of POD in elderly patients undergoing hip surgery without preoperative cognitive impairment (OR:0.46; 95%CI[0.22, 0.96], P = 0.04, I2 = 0%). Subgroup analysis of the incidence of POD showed that elderly patients who received FIB treatment before entering the operating room had a lower risk of developing POD(OR:0.48; 95%CI[0.30, 0.76], P = 0.002, I2 = 0%), and FIB could reduce the occurrence of POD in patients undergoing intravertebral anesthesia instead of general anesthesia (OR:0.37; 95%CI[0.20, 0.66], P﹤0.01, I2 = 0%). Moreover, FIB could reduce the MMSE score on the first day after surgery (SMD:1.07; 95%CI[0.15, 1.99], P = 0.02, I2 = 86%). In addition, FIB could reduce the pain score on the first and third day after surgery (SMD: -0.46; 95%CI[-0.74, -0.18], P = 0.001, I2 = 43%; SMD: -0.62; 95%CI[-0.97, -0.26], P﹤0.001, I2 = 58%), as well as after physical activity(SMD: -1.64; 95%CI[-3.00, -0.28], P = 0.02, I2 = 83%). CONCLUSION: FIB can reduce the incidence of POD in elderly patients undergoing hip surgery without pre-existing cognitive impairment. Additionally, it can lower the delirium scores and pain scores.
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Bloqueo Nervioso , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Anciano , Bloqueo Nervioso/métodos , Complicaciones Posoperatorias/prevención & control , Delirio/prevención & control , Artroplastia de Reemplazo de Cadera/efectos adversos , Delirio del Despertar/prevención & control , Fascia , Anciano de 80 o más AñosRESUMEN
BACKGROUND: Postoperative delirium (POD) following surgery is a prevalent and distressing condition associated with adverse patient outcomes and an increased healthcare burden. OBJECTIVES: To assess the effectiveness of the Safe Brain Initiative care bundle (SBI-CB) in reducing POD in the postanesthesia care unit (PACU). DESIGN: A multicenter, quality-improvement initiative with retrospective analysis of collected data. SETTING: The study was conducted in the operating rooms and postanesthesia care units (PACUs) of four hospitals across Denmark and Turkey. PATIENTS: The convenience sample of patients were aged ≥18 years, scheduled for surgery, and could communicate verbally. Age, sex, preoperative delirium, and the American Society for Anesthesiology physical status classification were used in statistical methods to control for potential confounding influences. INTERVENTION: The SBI-CB, 18 delirium-reducing recommendations aligned with international guidelines. The intervention included patient education, staff training, coordination meetings across centers, and a dashboard for the monitoring of outcomes in the PACU. MAIN OUTCOME MEASURES: The primary outcome was the POD trend in the PACU during implementation months, assessed through Nu-DESC screening at up to three time points in the PACU. We also examined the length of hospital stay. RESULTS: Data were collected from 18,697 adult patients across four hospitals. Initial POD incidence in the PACU after the first three months was 16.36% across all sites (n = 1021). POD in the PACU was observed across all age groups, with peak incidence in younger (18-35 years) and older (>75 years) patients. General anesthesia and longer surgical duration (>1 h) were identified as significant risk factors for POD in the PACU. Matched patients who experienced POD in the PACU had longer stays in hospital, with a mean increase from 35 to 69 h (p < 0.001). Implementation of the SBI-CB was associated with a decreased risk of POD in the PACU for each month of SBI-CB implementation (adjusted odds ratio 0.96, 95% confidence interval: [0.94, 0.97], p < 0.001). CONCLUSIONS: The presented pragmatic implementation of a multidisciplinary care bundle, encompassing pre-, intra-, and postoperative measures alongside outcome monitoring, has the potential to significantly reduce the incidence of POD in the PACU. Improved patient outcomes may be achieved for general surgical departments with patient cohorts not typically considered at risk for developing POD. TRIAL REGISTRATION: Clinicaltrials.gov, identifier NCT05765162.
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Delirio del Despertar , Tiempo de Internación , Paquetes de Atención al Paciente , Mejoramiento de la Calidad , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Paquetes de Atención al Paciente/métodos , Paquetes de Atención al Paciente/normas , Anciano , Adulto , Delirio del Despertar/prevención & control , Delirio del Despertar/diagnóstico , Delirio del Despertar/etiología , Tiempo de Internación/estadística & datos numéricos , Dinamarca , Turquía , Periodo de Recuperación de la Anestesia , Sala de Recuperación/organización & administración , Adulto Joven , Adolescente , Delirio/prevención & control , Delirio/epidemiología , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Educación del Paciente como AsuntoRESUMEN
BACKGROUND: Delirium is a common complication in intensive care unit (ICU) patients. It can lead to various adverse events. In this study, we investigated the effectiveness of combining the use of the PREdiction of DELIRium (PRE-DELIRIC) model for delirium risk assessment and the use of a multicomponent care bundle for delirium assessment, prevention, and care in terms of reductions in the incidence of delirium among surgical ICU patients. METHODS: This retrospective study included surgical ICU patients who had received PRE-DELIRIC-guided SMART/SmART care (SMART care: SmART bundle plus multidisciplinary team; SmART care: Sleep/sweet sense of home (creating a comforting and restful environment for patients), Assessment (regular and thorough evaluation of patient needs and conditions), Release (revised endotracheal tube care/removal, restraint device care, and immobility reduction for patient comfort), and Time (reorientation of time to optimize patient care schedules) in our hospital between May 2022 and March 2023 (intervention group) and individuals who had received usual care between January 2021 and April 2022 (historical control group). The SmART intervention involves providing care in the following domains: sleep/sweet sense of home, assessment, release, and time. Patients with a PRE-DELIRIC score of >30% received SMART care, which includes multidisciplinary (physicians, pharmacists, respiratory therapists, and physiotherapists) care in addition to SmART care. For the control group, usual care was provided following the guidelines for the prevention and management of pain, agitation, delirium, immobility, and sleep disruption. The primary outcome was delirium incidence during ICU stay, which was assessed using the Intensive Care Delirium Screening Checklist. The secondary outcomes were the duration of ICU stay, rate of unplanned self-extubation, and status of ICU discharge. RESULTS: The intervention and control groups comprised 184 and 197 patients, respectively; their mean ages were 63.7 ± 18.4 years and 62.4 ± 19.5 years, respectively. The incidence of delirium was significantly lower (p = 0.001) in the intervention group (22.3%) than in the control group (47.7%). CONCLUSION: Our findings suggest that the PRE-DELIRIC-guided SMART/SmART care intervention is effective in preventing and managing delirium among surgical ICU patients.