Delirium Reduction by Volatile Anesthesia in Cardiac Surgery
Ključne besede
Povzetek
Opis
Delirium is a common neurologic complication after cardiac surgery. Up to 52% of postoperative cardiac surgery patients have delirium. The occurrence of postoperative delirium is associated with worse outcomes, including prolonged length of stay in the ICU and hospital, increased morbidity and mortality, compromised long-term cognitive function and physical ability, and elevated medical care costs. Morbidity of postoperative cognitive dysfunction and delirium mostly common in patients with age more than 60 years.
Several factors including cerebral anoxia, embolism, excessive excitatory neurotransmitter release, systemic inflammatory response, electrolyte and metabolic disorders and hemodynamic changes have been demonstrated to contribute to postoperative neurological dysfunction and delirium.
Previous studies have shown that inhalation anaesthesia and total intravenous anaesthesia (TIVA) may produce different degrees of cerebral protection in these patients. Effects of this two types of anaesthesia in cardiac surgery with CPB remain controversial and much debated.
Inhalation agents depress glucose metabolism, decrease cerebral metabolic rate and oxygen consumption. They also partially uncouple the reactivity of cerebral blood flow to CO2. The changes in cerebral blood flow (CBF) depend on the changes in cerebral metabolism and on direct vasodilatory effects. Cerebral autoregulation is dose-dependently altered. Volatile anaesthetics have been shown to initiate early ischemic preconditioning in neurons, but models of focal brain ischemia suggest it can take 24 h for preconditioning to develop fully.
Propofol is a well-known potentiator of GABAA receptors, it reduces cerebrovascular resistance, CBF and cerebral oxygen delivery during cardiopulmonary bypass. A neuroprotective effect of propofol has been shown to be present in many in vitro and in vivo established experimental models of mild/moderate acute cerebral ischemia.
In recent meta-analysis of 13 randomized controlled studies Chen et al compared the neuroprotective effects of inhalational anesthesia and those of total intravenous anesthesia (TIVA) in cardiac surgery with cardiopulmonary bypass. They have shown that anesthesia with volatile agents appeared to provide better cerebral protection than TIVA. As this meta-analysis had several limitations (small sample size of included studies, high heterogenity, etc.), further studies with larger clinically relevant sample-sizes are needed to demonstrate which anesthetics are more beneficial in terms of brain protection in cardiac surgery.
Datumi
| Nazadnje preverjeno: | 10/31/2019 |
| Prvič predloženo: | 10/02/2018 |
| Predviden vpis oddan: | 10/31/2018 |
| Prvič objavljeno: | 11/01/2018 |
| Zadnja posodobitev oddana: | 11/26/2019 |
| Zadnja posodobitev objavljena: | 12/01/2019 |
| Dejanski datum začetka študija: | 01/08/2019 |
| Predvideni datum primarnega zaključka: | 12/28/2021 |
| Predvideni datum zaključka študije: | 01/28/2022 |
Stanje ali bolezen
Intervencija / zdravljenje
Drug: Volatile anesthesia group
Drug: TIVA group
Faza
Skupine rok
| Roka | Intervencija / zdravljenje |
|---|---|
| Active Comparator: Volatile anesthesia group | Drug: Volatile anesthesia group Patients will receive volatile agent to provide general anaesthesia, including CPB period. Volatile agents will be administered from anesthesia induction to the end of surgery. Concentration (MAC) of volatile agent will be selected by anaesthesiologist according to clinical situation and patient features. |
| Active Comparator: TIVA group | Drug: TIVA group Patients will receive propofol and no volatile agent. Propofol will be used for induction and maintenance of anesthesia. |
Merila upravičenosti
| Starost, primerna za študij | 65 Years Za 65 Years |
| Spol, upravičen do študija | All |
| Sprejema zdrave prostovoljce | Da |
| Merila | Inclusion Criteria: - Males and females > 65 years - Written informed consent - Cardiac surgery with CPB Exclusion Criteria: - Emergency surgery - Surgery on aorta - Known allergy to components of anaesthesia - Pregnancy - Hemodynamically significant stenosis of carotid arteries - Parkinson's disease - Liver cirrhosis (Child B or C) - Current enrollment into another RCT (in the last 30 days) - Previous enrollment and randomization into the DELICATE trial - Poor language comprehension - Preoperative Medications: Anticholinergics (dimedrol, atropine, dramina), antidepressants, antiepileptics, antiparkinson drugs, chemotherapeutic agents |
Izid
Primarni izidni ukrepi
1. Postoperative delirium [5 days after surgery]
Ukrepi sekundarnega rezultata
1. Early postoperative cognitive dysfunction [7 days after surgery]
2. Delirium duration [10 days after surgery]
3. Duration of ICU stay [30 days]
4. Duration of hospital stay [60 days]
5. 30-day all-cause mortality [30 days]
6. One-year all-cause mortality [1 year]
7. Myocardial infarction (MI) [30 days]
8. Stroke [30 days]
9. Seizures [30 days]
10. Incidence of acute kidney injury (AKI) [30 days]
11. Renal replacement therapy [30 days]
12. Infectious complications [30 days]
13. Pain assessment with Behavioral Pain Scale (BPS) [5 days after surgery]
14. Pain assessment with Numerical Rating Scale (NRS) [5 days after surgery]
