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Au E, Zhao K, Belley-Côté E, Song Y, Al-Hazzani W, Sadeghirad B, Wang E, Young J, Kashani H, Kavosh M, Inami T, Beaver C, Kloppenburg S, Mazer D, Jacobsohn E, Um K, Spence J. The effect of perioperative benzodiazepine administration on postoperative nausea and vomiting: a systematic review and meta-analysis of randomised controlled trials. Br J Anaesth 2024; 132:469-482. [PMID: 38177006 DOI: 10.1016/j.bja.2023.11.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/30/2023] [Accepted: 11/07/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Despite recent systematic reviews suggesting their benefit for postoperative nausea, vomiting, or both (PONV) prevention, benzodiazepines have not been incorporated into guidelines for PONV prophylaxis because of concerns about possible adverse effects. We conducted an updated meta-analysis to inform future practice guidelines. METHODS We included randomised controlled trials (RCTs) of all languages comparing benzodiazepines with non-benzodiazepine comparators in adults undergoing inpatient surgery. Our outcomes were postoperative nausea, vomiting, or both. We assessed risk of bias for RCTs using the Cochrane Risk of Bias tool. We pooled data using a random-effects model and assessed the quality of evidence for each outcome using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS We screened 31 413 abstracts and 950 full texts. We included 119 RCTs; 104 were included in quantitative synthesis. Based on moderate certainty evidence, we found that perioperative benzodiazepine administration reduced the incidence of PONV (52 studies, n=5086, relative risk [RR]: 0.77, 95% confidence interval [CI] 0.66-0.89; number needed to treat [NNT] 16; moderate certainty), postoperative nausea (55 studies, n=5916, RR: 0.72, 95% CI 0.62-0.83; NNT 21; moderate certainty), and postoperative vomiting (52 studies, n=5909, RR: 0.74, 95% CI 0.60-0.91; NNT 55; moderate certainty). CONCLUSIONS Moderate quality evidence shows that perioperative benzodiazepine administration decreases the incidence of PONV. The results of this systematic review and meta-analysis will inform future clinical practice guidelines. SYSTEMATIC REVIEW PROTOCOL The protocol for this systematic review was pre-registered with PROSPERO International Prospective Register of Systematic Reviews (CRD42022361088) and published in BMJ Open (PMID 31831540).
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Affiliation(s)
- Emily Au
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Karen Zhao
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Côté
- Department of Medicine (Cardiology and Critical Care), Perioperative Research Division, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Yuri Song
- Faculty of Science, McMaster University, Hamilton, ON, Canada
| | - Waleed Al-Hazzani
- Departments of Critical Care, Medicine (Gastroenterology), Health Research Methods, Evaluation, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Behnam Sadeghirad
- Departments of Anesthesia and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Eugene Wang
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Hessam Kashani
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Morvarid Kavosh
- Department of Medicine, Coney Island Hospital, New York, NY, USA
| | - Toru Inami
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | | | | | - David Mazer
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Eric Jacobsohn
- Department of Anesthesia and Perioperative Medicine and Medicine (Critical Care), University of Manitoba, Winnipeg, MB, Canada
| | - Kevin Um
- Department of Medicine (Cardiology), McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, Perioperative Research Division, Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
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Spence J, Belley-Côté E, Jacobsohn E, Lee SF, D’Aragon F, Avidan M, Mazer CD, Rousseau-Saine N, Rajamohan R, Pryor K, Klein R, Tan E(CH, Cameron M, Di Sante E, DeBorba E, Mustard M, Couture E, Zamper R, Law M, Djaiani G, Saha T, Choi S, Hedlin P, Pikaluk R, Lam WY, Deschamps A, Whitlock R, Dulong B, Devereaux P, Beaver C, Kloppenburg S, Oczkowski S, McIntyre WF, McFarling M, Lamy A, Vincent J, Connolly S. Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free): A Protocol for a Multi-centre Randomized Cluster Crossover Trial. CJC Open 2023; 5:691-699. [PMID: 37744662 PMCID: PMC10516716 DOI: 10.1016/j.cjco.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/01/2023] [Indexed: 09/26/2023] Open
Abstract
Delirium is common after cardiac surgery and is associated with adverse outcomes. Administration of benzodiazepines before and after cardiac surgery is associated with delirium; guidelines recommend minimizing their use. Benzodiazepine administration during cardiac surgery remains common because of its recognized benefits. The Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free) trial is a randomized cluster crossover trial evaluating whether an institutional policy of restricting intraoperative benzodiazepine administration (ie, ≥ 90% of patients do not receive benzodiazepines during cardiac surgery), as compared with a policy of liberal intraoperative benzodiazepine administration (ie, ≥ 90% of patients receive ≥ 0.03 mg/kg midazolam equivalent), reduces delirium. Hospitals performing ≥ 250 cardiac surgeries a year are included if their cardiac anesthesia group agrees to apply both benzodiazepine policies per their randomization, and patients are assessed for postoperative delirium every 12 hours in routine clinical care. Hospitals apply the restricted or liberal benzodiazepine policy during 12 to 18 crossover periods of 4 weeks each. Randomization for all periods takes place in advance of site startup; sites are notified of their allocated policy during the last week of each crossover period. Policies are applied to all patients undergoing cardiac surgery during the trial period. The primary outcome is the incidence of delirium at up to 72 hours after surgery. The B-Free trial will enroll ≥ 18,000 patients undergoing cardiac surgery at 20 hospitals across North America. Delirium is common after cardiac surgery, and benzodiazepines are associated with the occurrence of delirium. The B-Free trial will determine whether an institutional policy restricting the administration of benzodiazepines during cardiac surgery reduces the incidence of delirium after cardiac surgery. Clinicaltrials.gov registration number: NCT03928236 (First registered April 26, 2019).
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Affiliation(s)
- Jessica Spence
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University; and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Emilie Belley-Côté
- Departments of Medicine (Cardiology and Critical Care), and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Perioperative Medicine and Medicine (Critical Care), University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shun Fu Lee
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
| | - Frederick D’Aragon
- Département d'anesthésiologie, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michael Avidan
- Department of Anesthesia, Washington University at St. Louis, St. Louis, Missouri, USA
| | - C. David Mazer
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, and Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Raja Rajamohan
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kane Pryor
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Rael Klein
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Matthew Cameron
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Emily Di Sante
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Erin DeBorba
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mary Mustard
- St. Michael's Hospital, Toronto, Ontario, Canada
| | - Etienne Couture
- Département d'anesthésiologie, Université Laval, Quebec City, Quebec, Canada
| | - Raffael Zamper
- Department of Anesthesia, University of Western Ontario, London, Ontario, Canada
| | - Michael Law
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
| | - George Djaiani
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tarit Saha
- Department of Anesthesia, Queen's University, Kingston, Ontario, Canada
| | - Stephen Choi
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter Hedlin
- Department of Anesthesia, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ryan Pikaluk
- Department of Anesthesia, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Wing Ying Lam
- Department of Anesthesia, University of Alberta, Edmonton, Alberta, Canada
| | - Alain Deschamps
- Département d'anesthésiologie, Université de Montréal, Montréal, Quebec, Canada
| | - Richard Whitlock
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Braden Dulong
- Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada
| | - P.J. Devereaux
- Departments of Medicine (Cardiology and Critical Care), and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | | | - Simon Oczkowski
- Department of Medicine (Critical Care), McMaster University, Hamilton, Ontario, Canada
| | - William Finlay McIntyre
- Department of Medicine (Cardiology), McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Matthew McFarling
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Andre Lamy
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jessica Vincent
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stuart Connolly
- Department of Medicine (Cardiology), McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
| | - B-Free Investigators∗
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University; and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Departments of Medicine (Cardiology and Critical Care), and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Departments of Anesthesia and Perioperative Medicine and Medicine (Critical Care), University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
- Département d'anesthésiologie, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Anesthesia, Washington University at St. Louis, St. Louis, Missouri, USA
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, and Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Département d'anesthésiologie, Université de Montréal, Montréal, Quebec, Canada
- Department of Anesthesia, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
- Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- St. Michael's Hospital, Toronto, Ontario, Canada
- Département d'anesthésiologie, Université Laval, Quebec City, Quebec, Canada
- Department of Anesthesia, University of Western Ontario, London, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, Queen's University, Kingston, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Department of Anesthesia, University of Alberta, Edmonton, Alberta, Canada
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Sheridan College, Brampton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine (Critical Care), McMaster University, Hamilton, Ontario, Canada
- Department of Medicine (Cardiology), McMaster University, and Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Perioperative Research Division, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine (Cardiology), McMaster University, and Population Health Research Institute, Hamilton, Ontario, Canada
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Wang E, Belley-Côté EP, Young J, He H, Saud H, D'Aragon F, Um K, Alhazzani W, Piticaru J, Hedden M, Whitlock R, Mazer CD, Kashani HH, Zhang SY, Lucas A, Timmerman N, Nishi C, Jain D, Kugler A, Beaver C, Kloppenburg S, Schulman S, Borges FK, Kavosh M, Wada C, Lin S, Sibilio S, Lauw M, Benz A, Szczeklik W, Mokhtari A, Jacobsohn E, Spence J. Effect of perioperative benzodiazepine use on intraoperative awareness and postoperative delirium: a systematic review and meta-analysis of randomised controlled trials and observational studies. Br J Anaesth 2023; 131:302-313. [PMID: 36621439 DOI: 10.1016/j.bja.2022.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 11/07/2022] [Accepted: 12/02/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Benzodiazepine use is associated with delirium, and guidelines recommend avoiding them in older and critically ill patients. Their perioperative use remains common because of perceived benefits. METHODS We searched CENTRAL, MEDLINE, CINAHL, PsycInfo, and Web of Science from inception to June 2021. Pairs of reviewers identified randomised controlled trials and prospective observational studies comparing perioperative use of benzodiazepines with other agents or placebo in patients undergoing surgery. Two reviewers independently abstracted data, which we combined using a random-effects model. Our primary outcomes were delirium, intraoperative awareness, and mortality. RESULTS We included 34 randomised controlled trials (n=4354) and nine observational studies (n=3309). Observational studies were considered separately. Perioperative benzodiazepines did not increase the risk of delirium (n=1352; risk ratio [RR] 1.43; 95% confidence interval [CI]: 0.9-2.27; I2=72%; P=0.13; very low-quality evidence). Use of benzodiazepines instead of dexmedetomidine did, however, increase the risk of delirium (five studies; n=429; RR 1.83; 95% CI: 1.24-2.72; I2=13%; P=0.002). Perioperative benzodiazepine use decreased the risk of intraoperative awareness (n=2245; RR 0.26; 95% CI: 0.12-0.58; I2=35%; P=0.001; very low-quality evidence). When considering non-events, perioperative benzodiazepine use increased the probability of not having intraoperative awareness (RR 1.07; 95% CI: 1.01-1.13; I2=98%; P=0.03; very low-quality evidence). Mortality was reported by one randomised controlled trial (n=800; RR 0.90; 95% CI: 0.20-3.1; P=0.80; very low quality). CONCLUSIONS In this systematic review and meta-analysis, perioperative benzodiazepine use did not increase postoperative delirium and decreased intraoperative awareness. Previously observed relationships of benzodiazepine use with delirium could be explained by comparisons with dexmedetomidine. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42019128144.
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Affiliation(s)
- Eugene Wang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Côté
- Departments of Medicine (Cardiology and Critical Care), McMaster University, Hamilton, ON, Canada; Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada
| | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Henry He
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Haris Saud
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Frederick D'Aragon
- Départment d'anesthésiologie, Université de Sherbrooke, Quebec, QU, Canada
| | - Kevin Um
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Waleed Alhazzani
- Departments of Critical Care, Medicine (Gastroenterology), and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Joshua Piticaru
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthew Hedden
- Faculty of Arts and Science, Queen's University, Kingston, ON, Canada
| | - Richard Whitlock
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada; Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - C David Mazer
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Hessam H Kashani
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Amanda Lucas
- Department of Health Research Methods, Evaluation, and Impact; McMaster University, Hamilton, ON, Canada
| | | | - Cameron Nishi
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Davinder Jain
- Department of Anesthesiology, Trillium Health Partners, Toronto, ON, Canada
| | - Aaron Kugler
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | | | | | - Sam Schulman
- Department of Medicine (Hematology), McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, Population Health Research Institute, Hamilton, ON, Canada; Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Flavia K Borges
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada; Departments of Medicine and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Morvarid Kavosh
- Department of Medicine, Coney Island Hospital, Brooklyn, NY, USA
| | - Chihiro Wada
- Faculty of Arts, Waseda University, Tokyo, Japan
| | - Sabrina Lin
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Serena Sibilio
- Division of Cardiac Surgery, Instituto Clinico Sant'Ambrogio, Milan, Italy; Division of Cardiac Surgery, Centre Hospitalière Universitaire de Lille, Lille, France
| | - Mandy Lauw
- Population Health Research Institute, Hamilton, ON, Canada
| | - Alexander Benz
- Population Health Research Institute, Hamilton, ON, Canada
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Arastoo Mokhtari
- Department of Medicine (Cardiology), McMaster University, Hamilton, ON, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Perioperative Medicine and Medicine (Critical Care), University of Manitoba, Winnipeg, MB, Canada
| | - Jessica Spence
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada; Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.
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