Keith Naomi, Harrowell Lorenza, Alexandrou Evan, Aneman Anders, Frost Steven A
Intensive Care, Liverpool Hospital, Liverpool, Australia.
University of Wollongong, Wollongong, Australia.
Acta Anaesthesiol Scand. 2025 Jul;69(6):e70069. doi: 10.1111/aas.70069.
An acute episode of delirium among adults following cardiac surgery is associated with increased length of stay in intensive care, prolonged mechanical ventilation, and increased risk of mortality. This robust systematic review with Bayesian meta-analysis, including trial sequential analysis, has been undertaken to explore the use of dexmedetomidine to reduce the occurrence of delirium.
A systematic search for relevant published clinical trial reports was registered on PROSPERO (CRD42023460126) and guided by the PRISMA statement guidelines. Databases included Cochrane, CINAHL, PubMed, Embase, Medline and PsychInfo. Studies included were randomised controlled trials reporting on the adult population (> 18 years) undergoing cardiac surgery, comparing dexmedetomidine to another drug or placebo. Trials of paediatric populations, protocols and reviews were excluded. The primary outcome examined was the effect of dexmedetomidine on the incidence of delirium in postoperative cardiac surgery in the Intensive Care Unit (ICU). Secondary outcomes of interest were the occurrence of hypotension, bradycardia, length of ICU stay and sedation utilised in the control and comparator groups. Trial sequential analysis and meta-regression were used to explore heterogeneity. Risk ratios (RRs) and Bayesian posterior probabilities are presented. The prior for this was empirical, being based on distributions for emergency and critical care systematic reviews from the Cochrane Database. The Cochrane ROB-2 tool was utilised to assess risk of bias, and the GRADE approach for certainty of evidence is presented.
A total of 699 randomised control trials were identified. After the removal of duplicates and screening for eligibility, 27 studies were included in the meta-analysis. The Robust Bayesian Model Averaging summary effect for delirium prevention was estimated to be 0.76 (95% credible interval [CrI] 0.56-1.00) for using dexmedetomidine, with a posterior probability of 97% of any treatment effect. Meta-regression suggested that the baseline risk of delirium is a strong indicator of increased effectiveness, and trial sequential analysis indicates potential effectiveness. A low risk of bias was evident in 19 of the 27 studies, 6 studies had some risk of bias, and 2 studies were judged to be high risk. The certainty of evidence used across the 27 studies was determined to be low overall.
Dexmedetomidine may reduce the risk of delirium among adults following cardiac surgery; however, uncertainty remains due to heterogeneity. Therefore, adequately powered and well-designed multi-centre trials are needed to address this current uncertainty.
The effects of dexmedetomidine on postoperative delirium in adult cardiac surgical patients: a Bayesian meta-analysis and trial sequential analysis. This systematic review with meta-analysis concerning evidence for possible effects of dexmedetomidine on post-cardiac surgery delirium presents detailed analysis showing a possible treatment drug effect on reducing post-operative delirium in this type of cohort, though still with some uncertainty.
心脏手术后成人急性谵妄发作与重症监护病房住院时间延长、机械通气时间延长及死亡风险增加相关。本项采用贝叶斯荟萃分析（包括试验序贯分析）的全面系统评价旨在探讨右美托咪定在减少谵妄发生方面的应用。
在PROSPERO（CRD42023460126）上登记了对相关已发表临床试验报告的系统检索，并以PRISMA声明指南为指导。数据库包括Cochrane、CINAHL、PubMed、Embase、Medline和PsychInfo。纳入的研究为随机对照试验，报告对象为接受心脏手术的成年人群（>18岁），比较右美托咪定与另一种药物或安慰剂。排除儿科人群、方案和综述的试验。所研究的主要结局是右美托咪定对重症监护病房（ICU）心脏手术后谵妄发生率的影响。感兴趣的次要结局是对照组和比较组中低血压、心动过缓的发生情况、ICU住院时间以及使用的镇静情况。采用试验序贯分析和荟萃回归来探讨异质性。给出风险比（RRs）和贝叶斯后验概率。其先验为经验性的，基于Cochrane数据库中急诊和重症监护系统评价的分布情况。使用Cochrane ROB - 2工具评估偏倚风险，并给出证据确定性的GRADE方法。
共识别出699项随机对照试验。在去除重复项并筛选合格性后，27项研究纳入荟萃分析。使用右美托咪定预防谵妄的稳健贝叶斯模型平均汇总效应估计为0.76（95%可信区间[CrI] 0.56 - 1.00），任何治疗效果的后验概率为97%。荟萃回归表明谵妄的基线风险是有效性增加的有力指标，试验序贯分析表明存在潜在有效性。27项研究中有19项明显存在低偏倚风险，6项研究有一定偏倚风险，2项研究被判定为高风险。27项研究总体证据确定性较低。
右美托咪定可能降低心脏手术后成人谵妄风险；然而，由于异质性，不确定性仍然存在。因此，需要开展有足够效力且设计良好的多中心试验来解决当前的不确定性。
右美托咪定对成人心脏手术患者术后谵妄的影响：一项贝叶斯荟萃分析和试验序贯分析。这项关于右美托咪定对心脏手术后谵妄可能影响的证据的系统评价与荟萃分析进行了详细分析，显示在这类队列中该治疗药物可能对减少术后谵妄有效果，尽管仍存在一些不确定性。
