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Strategies for prevention of postoperative delirium: a systematic review and meta-analysis of randomized trials.

Zhang H, Lu Y, Liu M, Zou Z, Wang L, Xu FY, Shi XY - Crit Care (2013)

Bottom Line: The PRISMA statement guidelines were followed.Meta-analysis showed dexmedetomidine sedation was associated with less delirium compared to sedation produced by other drugs (two RCTs with 415 patients, pooled risk ratio (RR)=0.39; 95% confidence interval (CI)=0.16 to 0.95).No difference in the incidences of delirium was found between: neuraxial and general anesthesia (four RCTs with 511 patients, RR=0.99; 95% CI=0.65 to 1.50); epidural and intravenous analgesia (three RCTs with 167 patients, RR=0.93; 95% CI=0.61 to 1.43) or acetylcholinesterase inhibitors and placebo (four RCTs with 242 patients, RR=0.95; 95% CI=0.63 to 1.44).

View Article: PubMed Central - HTML - PubMed

ABSTRACT

Introduction: The ideal measures to prevent postoperative delirium remain unestablished. We conducted this systematic review and meta-analysis to clarify the significance of potential interventions.

Methods: The PRISMA statement guidelines were followed. Two researchers searched MEDLINE, EMBASE, CINAHL and the Cochrane Library for articles published in English before August 2012. Additional sources included reference lists from reviews and related articles from 'Google Scholar'. Randomized clinical trials (RCTs) on interventions seeking to prevent postoperative delirium in adult patients were included. Data extraction and methodological quality assessment were performed using predefined data fields and scoring system. Meta-analysis was accomplished for studies that used similar strategies. The primary outcome measure was the incidence of postoperative delirium. We further tested whether interventions effective in preventing postoperative delirium shortened the length of hospital stay.

Results: We identified 38 RCTs with interventions ranging from perioperative managements to pharmacological, psychological or multicomponent interventions. Meta-analysis showed dexmedetomidine sedation was associated with less delirium compared to sedation produced by other drugs (two RCTs with 415 patients, pooled risk ratio (RR)=0.39; 95% confidence interval (CI)=0.16 to 0.95). Both typical (three RCTs with 965 patients, RR=0.71; 95% CI=0.54 to 0.93) and atypical antipsychotics (three RCTs with 627 patients, RR=0.36; 95% CI=0.26 to 0.50) decreased delirium occurrence when compared to placebos. Multicomponent interventions (two RCTs with 325 patients, RR=0.71; 95% CI=0.58 to 0.86) were effective in preventing delirium. No difference in the incidences of delirium was found between: neuraxial and general anesthesia (four RCTs with 511 patients, RR=0.99; 95% CI=0.65 to 1.50); epidural and intravenous analgesia (three RCTs with 167 patients, RR=0.93; 95% CI=0.61 to 1.43) or acetylcholinesterase inhibitors and placebo (four RCTs with 242 patients, RR=0.95; 95% CI=0.63 to 1.44). Effective prevention of postoperative delirium did not shorten the length of hospital stay (10 RCTs with 1,636 patients, pooled SMD (standard mean difference)=-0.06; 95% CI=-0.16 to 0.04).

Conclusions: The included studies showed great inconsistencies in definition, incidence, severity and duration of postoperative delirium. Meta-analysis supported dexmedetomidine sedation, multicomponent interventions and antipsychotics were useful in preventing postoperative delirium.

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Flow chart of identification, screening, review and selection of studies. *indicates the group of studies identified for meta-analysis.
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Figure 1: Flow chart of identification, screening, review and selection of studies. *indicates the group of studies identified for meta-analysis.

Mentions: The process of literature identification, screening and selection is summarized by Figure 1. Our primary search yielded 2,813 articles. After screening, 198 studies potentially met the inclusion criteria. After examining the full texts, 160 articles were excluded: 25 studies were not clinical trials; three studies had no control group; 40 studies did not include postoperative delirium as a study variable; three studies tested the diagnosis methods of delirium; 47 studies did not screen postoperative delirium using validated tools; seven studies recruited both surgical and nonsurgical patients; three studies did not provide the delirium data; 11 studies included patients with delirium prior to surgery; 12 studies included homogeneous patients with brain diseases, mental disorders or alcohol withdrawal syndrome; seven studies described ongoing trials; one study was retracted, and one study was identified as a duplicated publication. We ultimately included 38 RCTs [17-54] in our systematic review and meta-analysis.


Strategies for prevention of postoperative delirium: a systematic review and meta-analysis of randomized trials.

Zhang H, Lu Y, Liu M, Zou Z, Wang L, Xu FY, Shi XY - Crit Care (2013)

Flow chart of identification, screening, review and selection of studies. *indicates the group of studies identified for meta-analysis.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3672487&req=5

Figure 1: Flow chart of identification, screening, review and selection of studies. *indicates the group of studies identified for meta-analysis.
Mentions: The process of literature identification, screening and selection is summarized by Figure 1. Our primary search yielded 2,813 articles. After screening, 198 studies potentially met the inclusion criteria. After examining the full texts, 160 articles were excluded: 25 studies were not clinical trials; three studies had no control group; 40 studies did not include postoperative delirium as a study variable; three studies tested the diagnosis methods of delirium; 47 studies did not screen postoperative delirium using validated tools; seven studies recruited both surgical and nonsurgical patients; three studies did not provide the delirium data; 11 studies included patients with delirium prior to surgery; 12 studies included homogeneous patients with brain diseases, mental disorders or alcohol withdrawal syndrome; seven studies described ongoing trials; one study was retracted, and one study was identified as a duplicated publication. We ultimately included 38 RCTs [17-54] in our systematic review and meta-analysis.

Bottom Line: The PRISMA statement guidelines were followed.Meta-analysis showed dexmedetomidine sedation was associated with less delirium compared to sedation produced by other drugs (two RCTs with 415 patients, pooled risk ratio (RR)=0.39; 95% confidence interval (CI)=0.16 to 0.95).No difference in the incidences of delirium was found between: neuraxial and general anesthesia (four RCTs with 511 patients, RR=0.99; 95% CI=0.65 to 1.50); epidural and intravenous analgesia (three RCTs with 167 patients, RR=0.93; 95% CI=0.61 to 1.43) or acetylcholinesterase inhibitors and placebo (four RCTs with 242 patients, RR=0.95; 95% CI=0.63 to 1.44).

View Article: PubMed Central - HTML - PubMed

ABSTRACT

Introduction: The ideal measures to prevent postoperative delirium remain unestablished. We conducted this systematic review and meta-analysis to clarify the significance of potential interventions.

Methods: The PRISMA statement guidelines were followed. Two researchers searched MEDLINE, EMBASE, CINAHL and the Cochrane Library for articles published in English before August 2012. Additional sources included reference lists from reviews and related articles from 'Google Scholar'. Randomized clinical trials (RCTs) on interventions seeking to prevent postoperative delirium in adult patients were included. Data extraction and methodological quality assessment were performed using predefined data fields and scoring system. Meta-analysis was accomplished for studies that used similar strategies. The primary outcome measure was the incidence of postoperative delirium. We further tested whether interventions effective in preventing postoperative delirium shortened the length of hospital stay.

Results: We identified 38 RCTs with interventions ranging from perioperative managements to pharmacological, psychological or multicomponent interventions. Meta-analysis showed dexmedetomidine sedation was associated with less delirium compared to sedation produced by other drugs (two RCTs with 415 patients, pooled risk ratio (RR)=0.39; 95% confidence interval (CI)=0.16 to 0.95). Both typical (three RCTs with 965 patients, RR=0.71; 95% CI=0.54 to 0.93) and atypical antipsychotics (three RCTs with 627 patients, RR=0.36; 95% CI=0.26 to 0.50) decreased delirium occurrence when compared to placebos. Multicomponent interventions (two RCTs with 325 patients, RR=0.71; 95% CI=0.58 to 0.86) were effective in preventing delirium. No difference in the incidences of delirium was found between: neuraxial and general anesthesia (four RCTs with 511 patients, RR=0.99; 95% CI=0.65 to 1.50); epidural and intravenous analgesia (three RCTs with 167 patients, RR=0.93; 95% CI=0.61 to 1.43) or acetylcholinesterase inhibitors and placebo (four RCTs with 242 patients, RR=0.95; 95% CI=0.63 to 1.44). Effective prevention of postoperative delirium did not shorten the length of hospital stay (10 RCTs with 1,636 patients, pooled SMD (standard mean difference)=-0.06; 95% CI=-0.16 to 0.04).

Conclusions: The included studies showed great inconsistencies in definition, incidence, severity and duration of postoperative delirium. Meta-analysis supported dexmedetomidine sedation, multicomponent interventions and antipsychotics were useful in preventing postoperative delirium.

Show MeSH
Related in: MedlinePlus