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Hung KC, Chen IW, Liu PH. Impact of ketamine on postoperative delirium: insights from trial sequential analysis. Int J Surg 2024; 110:1834-1835. [PMID: 38116703 PMCID: PMC10942144 DOI: 10.1097/js9.0000000000001010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 12/03/2023] [Indexed: 12/21/2023]
Affiliation(s)
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City
| | - Ping-Hsin Liu
- Department of Anesthesiology, E-Da Dachang Hospital, I-Shou University, Kaohsiung City, Taiwan
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Faisal H, Qamar F, Hsu ES, Xu J, Lai EC, Wong ST, Masud FN. Prevalence of Delirium After Abdominal Surgery and Association With Ketamine: A Retrospective, Propensity-Matched Cohort Study. Crit Care Explor 2024; 6:e1032. [PMID: 38222873 PMCID: PMC10786598 DOI: 10.1097/cce.0000000000001032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Abstract
IMPORTANCE Delirium is a common postoperative complication for older patients in the ICU. Ketamine, used primarily as an analgesic, has been thought to prevent delirium. OBJECTIVE Determine the prevalence and association of delirium with low-dose ketamine use in ICU patients after abdominal surgery. DESIGN Single-center, retrospective, propensity-matched cohort study. SETTING Eight hospital academic medical center. PATIENTS Cohort comprising 1836 patients admitted to the ICU after abdominal surgery between June 23, 2018 and September 1, 2022. MAIN OUTCOMES AND MEASURES Propensity score matching (PSM) with a 3:1 ratio between no-ketamine use and ketamine use was performed through a greedy algorithm (caliper of 0.005). Outcomes of interest included: delirium (assessed by Confusion Assessment Method-ICU), mean pain score (Numeric Pain Scale or Critical Care Pain Observation Tool score as available), mean opioid consumption (morphine milligram equivalents), length of stay (d), and mortality. RESULTS Prevalence of delirium was 47.71% (95% CI, 45.41-50.03%) in the cohort. Of 1836 patients, 120 (6.54%) used low-dose ketamine infusion. After PSM, the prevalence of delirium was 56.02% (95% CI, 51.05-60.91%) in all abdominal surgery patients. The ketamine group had 41% less odds of delirium (odds ratio [OR] = 0.59; 95% CI, 0.37-0.94; p = 0.026) than patients with no-ketamine use. Patients with ketamine use had higher mean pain scores (3.57 ± 2.86 vs. 2.21 ± 2.09, p < 0.001). In the subgroup analysis, patients in the ketamine-use group 60 years old or younger had 64% less odds of delirium (OR = 0.36; 95% CI, 0.13-0.95; p = 0.039). The mean pain scores were higher in the ketamine group for patients 60 years old or older. There was no significant difference in mortality and opioid consumption. CONCLUSIONS AND RELEVANCE Low-dose ketamine infusion was associated with lower prevalence of delirium in ICU patients following abdominal surgery. Prospective studies should further evaluate ketamine use and delirium.
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Affiliation(s)
- Hina Faisal
- Department of Surgery, Houston Methodist, Houston, TX
- Department of Surgery, Weill Cornell Medicine, New York, NY
| | - Fatima Qamar
- Department of Cardiothoracic Surgery, Houston Methodist, Houston, TX
| | - En Shuo Hsu
- Center for Health Data Science and Analytics, Houston Methodist, Houston, TX
| | - Jiaqiong Xu
- Center for Health Data Science and Analytics, Houston Methodist, Houston, TX
| | - Eugene C Lai
- Stanley H. Appel Department of Neurology, Houston Methodist, Houston, TX
| | - Stephen T Wong
- Department of Systems Medicine and Bioengineering and Houston Methodist Neal Cancer Center, Houston Methodist, Houston, TX
| | - Faisal N Masud
- Center for Critical Care, Houston Methodist, Houston, TX, USA
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY
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Kim SY, Lee J, Na HS, Koo BW, Lee KO, Shin HJ. The Impact of Regional Nerve Blocks on Postoperative Delirium or Cognitive Dysfunction following Thoracic Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:7576. [PMID: 38137648 PMCID: PMC10743822 DOI: 10.3390/jcm12247576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Regional nerve blocks (NBs) mitigate the occurrence of postoperative cognitive dysfunction (POCD) and postoperative delirium (POD) in adult patients undergoing thoracic surgery. This study aimed to determine the exact effect of NBs on POCD and POD. Electronic databases, including PubMed, EMBASE, CINAHL, Scopus, and Web of Science, were searched for studies. The primary outcome was the incidence of POD or POCD. The secondary outcome was pain scores assessed 24 and 48 h postoperatively. We calculated the log odds ratio (LOR) and standardized mean difference (SMD) with 95% confidence intervals (CIs). The LOR was converted to an odds ratio (OR). In the analysis of 1010 patients from seven randomized controlled trials, POD and POCD rates were 14.1% and 16.7%, respectively, in the NB group, and higher, at 27.3% and 35.2%, in the control group. NBs reduced the incidence of POD (OR, 0.44; 95%CI 0.30 to 0.64; p < 0.001; I2 = 0.00%) and POCD (OR, 0.43; 95%CI 0.24 to 0.76; p < 0.001; I2 = 0.00%). NBs reduced pain scores at 24 h (SMD, -2.60; 95%CI -3.90 to -1.30, p < 0.001; I2 = 97.68%) and 48 h (SMD, -1.80; 95%CI -3.18 to -0.41, p = 0.01; I2 = 98.14%) postoperatively. NBs mitigated the occurrence of POD and POCD in adult patients after thoracic surgery.
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Affiliation(s)
| | | | | | | | | | - Hyun-Jung Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seoul 13620, Republic of Korea; (S.Y.K.); (J.L.); (H.-S.N.); (B.-W.K.); (K.O.L.)
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Zhu Y, Feng W, Kong Q, Sheng F, Li Z, Xu W, Li Q, Han Y, Wu X, Jia C, Guo J, Zhao Y. Evaluating the effects of S-ketamine on postoperative delirium in elderly patients following total hip or knee arthroplasty under intraspinal anesthesia: a single-center randomized, double-blind, placebo-controlled, pragmatic study protocol. Front Aging Neurosci 2023; 15:1298661. [PMID: 38099265 PMCID: PMC10720081 DOI: 10.3389/fnagi.2023.1298661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Postoperative delirium (POD) is an acute, transient brain disorder associated with decreased postoperative quality of life, dementia, neurocognitive changes, and mortality. A small number of trials have explored the role of S-ketamine in the treatment of POD due to its neuroprotective effects. Surprisingly, these trials have failed to yield supportive results. However, heterogeneity in delirium assessment methodologies, sample sizes, and outcome settings as well as deficiencies in S-ketamine use methods make the evidence provided by these studies less persuasive. Given the severe impact of POD on the health of elderly patients and the potential for S-ketamine to prevent it, we believe that designing a large sample size, and rigorous randomized controlled trial for further evaluation is necessary. Methods This is a single-center, randomized, double-blind, placebo-controlled, pragmatic study. Subjects undergoing total hip or knee arthroplasty will be randomized in a 1:1 ratio to intervention (n = 186) and placebo (n = 186) groups. This trial aims to explore the potential role of S-ketamine in the prevention of POD. Its primary outcome is the incidence of POD within 3 postoperative days. Secondary outcomes include the number of POD episodes, the onset and duration of POD, the severity and subtype of POD, pain scores and opioid consumption, sleep quality, clinical outcomes, and safety outcomes. Discussion To our knowledge, this is the first pragmatic study that proposes to use S-ketamine to prevent POD. We reviewed a large body of literature to identify potential preoperative confounding variables that may bias associations between the intervention and primary outcome. We will use advanced statistical methods to correct potential confounding variables, improving the test's power and external validity of test results. Of note, the patient population included in this trial will undergo intraspinal anesthesia. Although large, multicenter, randomized controlled studies have found no considerable difference in the effects of regional and general anesthesia on POD, patients receiving intraspinal anesthesia have less exposure to at-risk drugs, such as sevoflurane, propofol, and benzodiazepines, than patients receiving general anesthesia. At-risk drugs have been shown to negatively interfere with the neuroprotective effects of S-ketamine, which may be the reason for the failure of a large number of previous studies. There is currently a lack of randomized controlled studies evaluating S-ketamine for POD prevention, and our trial helps to fill a gap in this area.Trial registration: http://www.chictr.org.cn, identifier ChiCTR2300075796.
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Affiliation(s)
- Youzhuang Zhu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Wei Feng
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Qinghan Kong
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Fang Sheng
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Zhichao Li
- Department of Anesthesiology, Cancer Hospital Chinese Academy of Medical Science, Beijing, China
| | - Weilong Xu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Qun Li
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yan Han
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xiuyun Wu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Changxin Jia
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Jie Guo
- Department of Anesthesiology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Yang Zhao
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
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