丙泊酚复合小剂量右美托咪定输注与老年心脏手术患者术后谵妄

Propofol plus low-dose dexmedetomidine infusion and postoperative delirium in older patients undergoing cardiac surgery.

机构信息

Department of Anaesthesiology; Cliniques Universitaires Saint Luc, Université Cathlique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium.

出版信息

Br J Anaesth. 2021 Mar;126(3):665-673. doi: 10.1016/j.bja.2020.10.041. Epub 2020 Dec 24.

DOI:10.1016/j.bja.2020.10.041

PMID:33358336

Abstract

BACKGROUND

Postoperative delirium (POD) is a frequent complication in older patients. Dexmedetomidine might be effective in decreasing the incidence of POD. We hypothesised that adding low-dose rate dexmedetomidine infusion to a propofol sedation regimen would have fewer side-effects and would counteract the possible delirium producing properties of propofol, resulting in a lower risk of POD than propofol with placebo.

METHODS

In this double-blind placebo-controlled trial, patients ≥60 yr old undergoing on-pump cardiac surgery were randomised 1:1 to the following postoperative sedative regimens: a propofol infusion and dexmedetomidine (0.4 μg kg h) or a propofol infusion and saline 0.9% (placebo group). The study drug was started at chest closure and continued for 10 h. The primary endpoint was in-hospital POD, assessed using the Confusion Assessment Method and chart review method.

RESULTS

POD over the course of hospital stay occurred in 31/177 (18%) and 33/172 (19%) patients in the dexmedetomidine and placebo arm, respectively (P=0.687; odds ratio=0.89; 95% confidence interval, 0.52-1.54). The incidence of POD in the intensive care alone, or on the ward alone, was also not significantly different between the groups. Subjects in the dexmedetomidine group spent less median time in a delirious state (P=0.026). Median administered postoperative norepinephrine was significantly higher in the dexmedetomidine group (P<0.001). One patient in the dexmedetomidine group and 10 patients in the placebo group died in the hospital.

CONCLUSIONS

Adding low-dose rate dexmedetomidine to a sedative regimen based on propofol did not result in a different risk of in-hospital delirium in older patients undergoing cardiac surgery. With a suggestion of both harm and benefit in secondary outcomes, supplementing postoperative propofol with dexmedetomidine cannot be recommended based on this study.

CLINICAL TRIAL REGISTRATION

NCT03388541.

摘要

背景

术后谵妄（POD）是老年患者的常见并发症。右美托咪定可能有助于降低 POD 的发生率。我们假设，在依托咪酯镇静方案中添加低剂量右美托咪定输注会减少副作用，并抵消依托咪酯可能产生的谵妄作用，从而降低 POD 的风险，而不是使用依托咪酯加安慰剂。

方法

在这项双盲安慰剂对照试验中，年龄≥60 岁接受体外循环心脏手术的患者按 1:1 随机分为以下术后镇静方案：依托咪酯输注和右美托咪定（0.4μgkg h）或依托咪酯输注和生理盐水 0.9%（安慰剂组）。研究药物在关胸前开始使用，并持续 10 小时。主要终点是住院期间 POD，使用意识混乱评估方法和图表回顾法进行评估。

结果

在住院期间，右美托咪定组和安慰剂组分别有 31/177（18%）和 33/172（19%）的患者发生 POD（P=0.687；优势比=0.89；95%置信区间，0.52-1.54）。两组患者在 ICU 或病房中发生 POD 的发生率也无显著差异。右美托咪定组患者处于谵妄状态的中位数时间较短（P=0.026）。右美托咪定组术后去甲肾上腺素中位数明显较高（P<0.001）。右美托咪定组 1 例患者和安慰剂组 10 例患者在院内死亡。