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Perioperative dexmedetomidine reduces delirium in elderly patients after non-cardiac surgery: a systematic review and meta-analysis of randomized-controlled trials

  • Hao Pan
  • Chengxiao Liu
  • Xiaochun Ma
  • Yanbing Xu
  • Mengyuan Zhang
  • Yan WangEmail author
Review Article/Brief Review

Abstract

Background

Delirium is a frequent postoperative complication in elderly patients after non-cardiac surgery. We performed this updated meta-analysis to ascertain more precisely the efficacy of dexmedetomidine (DEX) on the incidence of postoperative delirium (POD) in elderly patients after non-cardiac surgery.

Methods

We searched PubMed, EMBASE, the Cochrane Library, Web of Science, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) from inception until February 24, 2019. In this meta-analysis, we included randomized-controlled trials comparing the effect of DEX vs normal saline (NS) or other anesthetic drugs on POD incidence in elderly (either ≥ 60 or ≥ 65 yr old) patients undergoing non-cardiac surgery. We performed subgroup analyses of the DEX dosing strategy (starting time, dose, and duration of administration, with or without loading dose) and the strategy of various control drugs. A random-effects model was used for all analyses.

Results

We included 11 studies involving 2,890 patients in our meta-analysis. The pooled results of these studies revealed that DEX significantly reduced the incidence of POD (relative risk [RR], 0.47; 95% confidence interval [CI], 0.38 to 0.58; P < 0.001) compared with the control group. Meanwhile, the incidences of hypotension (RR, 1.20; 95% CI, 1.04 to 1.39; P = 0.01) and bradycardia (RR, 1.33; 95% CI, 1.08 to 1.63; P = 0.007) were increased in the DEX group. Subgroup analyses revealed a decrease in POD incidence when DEX was administered intraoperatively (RR, 0.43; 95% CI, 0.33 to 0.57; P < 0.001) and postoperatively (RR, 0.38; 95% CI, 0.27 to 0.54; P < 0.001) with a loading dose (RR, 0.49; 95% CI, 0.36 to 0.69; P < 0.001) compared with NS (RR, 0.49; 95% CI, 0.37 to 0.64; P < 0.001) and other anesthetic drugs (RR, 0.40; 95% CI, 0.26 to 0.60; P < 0.001). There were significant differences in the time to extubation (standardized mean difference, -0.60; 95% CI, -1.17 to -0.03; P = 0.04) and the length of hospital stay (mean difference, -0.50 days; 95% CI, -0.97 to -0.03; P = 0.04). The amount of data for the duration of mechanical ventilation and length of intensive care unit stay were insufficient to perform a meta-analysis.

Conclusion

Perioperative dexmedetomidine reduces the incidence of POD in elderly patients after non-cardiac surgery, but this comes at the cost of an increased incidence of hypotension and bradycardia.

La dexmédétomidine périopératoire réduit le delirium chez les patients âgés après une chirurgie non cardiaque: revue systématique et méta-analyse d’études randomisées contrôlées

Résumé

Contexte

Le delirium est une complication postopératoire fréquente chez les patients âgés après une chirurgie non cardiaque. Nous avons réalisé cette méta-analyse mise à jour pour déterminer de façon plus précise l’efficacité de la dexmédétomidine (DEX) sur l’incidence de delirium postopératoire (DPO) chez les patients âgés après une chirurgie non cardiaque.

Méthode

Nous avons effectué des recherches dans les bases de données PubMed, EMBASE, Cochrane Library, Web of Science et dans le Cumulative Index of Nursing and Allied Health Literature depuis leur création et jusqu’au 24 février 2019. Dans cette méta-analyse, nous avons inclus les études randomisées contrôlées comparant l’effet de la DEX vs une solution physiologique salée (NS) ou d’autres médicaments anesthésiques sur l’incidence de DPO chez les patients âgés (soit ≥ 60 ou ≥ 65 ans) subissant une chirurgie non cardiaque. Nous avons réalisé des analyses de sous-groupes du régime posologique de la DEX (moment d’amorce, dose et durée de l’administration, avec ou sans dose de charge) et de la stratégie des divers médicaments témoin. Un modèle à effets aléatoires a été utilisé pour toutes les analyses.

Résultats

Nous avons inclus 11 études portant sur 2890 patients dans notre méta-analyse. Les résultats pondérés de ces études ont révélé que la DEX réduisait significativement l’incidence de DPO (risque relatif [RR], 0,47; intervalle de confiance [IC] 95 %, 0,38 à 0,58; P < 0,001) par rapport au groupe témoin. En revanche, les incidences d’hypotension (RR, 1,20; IC 95 %, 1,04 à 1,39; P = 0,01) et de bradycardie (RR, 1,33; IC 95 %, 1,08 à 1,63; P = 0,007) étaient plus élevées dans le groupe DEX. Les analyses de sous-groupe ont révélé une réduction de l’incidence de DPO lorsque la DEX était administrée en période peropératoire (RR, 0,43; IC 95 %, 0,33 à 0,57; P < 0,001) et postopératoire (RR, 0.38; IC 95 %, 0,27 à 0,54; P < 0,001) avec une dose de charge (RR, 0,49; IC 95 %, 0,36 à 0,69; P < 0,001) par rapport à la NS (RR, 0,49; IC 95 %, 0,37 à 0,64; P < 0,001) et aux autres médicaments anesthésiques (RR, 0,40; IC 95 %, 0,26 à 0,60; P < 0,001). Des différences significatives ont été observées dans le temps pour l’extubation (différence moyenne standardisée, -0,60; IC 95 %, -1,17 à -0,03; P = 0,04) et la durée de séjour à l’hôpital (différence moyenne, -0,50 jour; IC 95 %, -0,97 à -0,03; P = 0,04). La quantité de données concernant la durée de la ventilation mécanique et la durée de séjour à l’unité de soins intensifs était insuffisante pour réaliser une méta-analyse.

Conclusion

La dexmédétomidine périopératoire réduit l’incidence de DPO chez les patients âgés après une chirurgie non cardiaque, mais cette réduction vient au coût d’une incidence accrue d’hypotension et de bradycardie.

Notes

Acknowledgements

We would like to thank Dr. Bing Wang for her assistance and LetPub (www.letpub.com) for its linguistic assistance.

Conflicts of interest

None declared.

Editorial responsibility

This submission was handled by Dr. Philip M. Jones, Associate Editor, Canadian Journal of Anesthesia.

Author contributions

Hao Pan contributed to all aspects of this manuscript, including study conception and design, literature search, acquisition, analysis and interpretation of data, quality assessment of studies, and drafting and revising the manuscript. Mengyuan Zhang contributed to the study conception and design, literature search, acquisition, analysis and interpretation of data, quality assessment of studies, and drafting the manuscript. Yan Wang was involved in the literature search, acquisition, analysis and interpretation of data, and revising the manuscript. Chengxiao Liu, Xiaochun Ma and Yanbing Xu were involved in analysis and interpretation of data, drafting the manuscript and revising it for important intellectual content.

Financial support and sponsorship

None.

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Copyright information

© Canadian Anesthesiologists' Society 2019

Authors and Affiliations

  • Hao Pan
    • 1
  • Chengxiao Liu
    • 1
  • Xiaochun Ma
    • 1
  • Yanbing Xu
    • 1
  • Mengyuan Zhang
    • 1
  • Yan Wang
    • 1
    Email author
  1. 1.Department of AnesthesiologyShandong Provincial Hospital Affiliated to Shandong UniversityJinanChina

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