Intraoperative Infusion of Dexmedetomidine for Prevention of Postoperative Delirium and Cognitive Dysfunction in Elderly Patients Undergoing Major Elective Noncardiac Surgery: A Randomized Clinical Trial | Surgery | JAMA Surgery | JAMA Network
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Original Investigation
August 16, 2017

Intraoperative Infusion of Dexmedetomidine for Prevention of Postoperative Delirium and Cognitive Dysfunction in Elderly Patients Undergoing Major Elective Noncardiac Surgery: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
  • 2Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
  • 3Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
  • 4Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
  • 5Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
  • 6Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
  • 7Outcomes Research, Cleveland Clinic, Cleveland, Ohio
  • 8Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, Maryland
  • 9Department of Psychiatry, Yale University, New Haven, Connecticut
JAMA Surg. 2017;152(8):e171505. doi:10.1001/jamasurg.2017.1505
Key Points

Question  Does intraoperative dexmedetomidine reduce postoperative delirium?

Findings  Unlike its use as a sedative in the intensive care unit, intraoperative dexmedetomidine did not significantly reduce the incidence of delirium over saline placebo (12.2% vs 11.4%) in this randomized clinical trial.

Meaning  The administration of dexmedetomidine in the operating room does not prevent postoperative delirium, which may be due to the short-acting nature of the drug and loss of salutary effects after discontinuation of the infusion.

Abstract

Importance  Postoperative delirium occurs in 10% to 60% of elderly patients having major surgery and is associated with longer hospital stays, increased hospital costs, and 1-year mortality. Emerging literature suggests that dexmedetomidine sedation in critical care units is associated with reduced incidence of delirium. However, intraoperative use of dexmedetomidine for prevention of delirium has not been well studied.

Objective  To evaluate whether an intraoperative infusion of dexmedetomidine reduces postoperative delirium.

Design, Setting, and Participants  This study was a multicenter, double-blind, randomized, placebo-controlled trial that randomly assigned patients to dexmedetomidine or saline placebo infused during surgery and for 2 hours in the recovery room. Patients were assessed daily for postoperative delirium (primary outcome) and secondarily for postoperative cognitive decline. Participants were elderly (>68 years) patients undergoing major elective noncardiac surgery. The study dates were February 2008 to May 2014.

Interventions  Dexmedetomidine infusion (0.5 µg/kg/h) during surgery and up to 2 hours in the recovery room.

Main Outcomes and Measures  The primary hypothesis tested was that intraoperative dexmedetomidine administration would reduce postoperative delirium. Secondarily, the study examined the correlation between dexmedetomidine use and postoperative cognitive change.

Results  In total, 404 patients were randomized; 390 completed in-hospital delirium assessments (median [interquartile range] age, 74.0 [71.0-78.0] years; 51.3% [200 of 390] female). There was no difference in postoperative delirium between the dexmedetomidine and placebo groups (12.2% [23 of 189] vs 11.4% [23 of 201], P = .94). After adjustment for age and educational level, there was no difference in the postoperative cognitive performance between treatment groups at 3 months and 6 months. Adverse events were comparably distributed in the treatment groups.

Conclusions and Relevance  Intraoperative dexmedetomidine does not prevent postoperative delirium. The reduction in delirium previously demonstrated in numerous surgical intensive care unit studies was not observed, which underscores the importance of timing when administering the drug to prevent delirium.

Trial Registration  clinicaltrials.gov Identifier NCT00561678

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