Haloperidol prophylaxis for preventing aggravation of postoperative delirium in elderly patients: a randomized,open-label prospective trial

Purposes

The aim of this study was to evaluate the safety and efficacy of the early administration haloperidol in preventing the aggravation of postoperative delirium in elderly patients.

Methods

A total of 201 patients (age ≥75 years) who underwent elective surgery were enrolled. The patients were divided into two groups: the intervention group (n = 101) received prophylactic haloperidol (5 mg); the control group (n = 100) did not. Haloperidol was administered daily during postoperative days 0–5 to the patients who presented with NEECHAM scores of 20–24 when measured at 18:00. The primary endpoint was the incidence of severe postoperative delirium.

Results

The incidence of severe postoperative delirium in all patients was 25.1%. The incidence of severe postoperative delirium in the intervention group (18.2%) was significantly lower than that in the control group (32.0%) (p = 0.02). The difference between the two groups was larger when the analysis was limited to the 70 patients who had NEECHAM scores of 20–24 for at least one day during postoperative days 0–5. No adverse effects of the haloperidol were observed.

Conclusion

The prophylactic administration of haloperidol at the early stage of delirium significantly reduced the incidence of severe postoperative delirium in elderly patients. Clinical Trial Registration UMIN000007204.

     

Preoperative oral rofecoxib does not decrease postoperative pain or morphine consumption in patients after radical prostatectomy: a prospective, randomized, double-blinded, placebo-controlled trial

STUDY OBJECTIVES: To evaluate the analgesic efficacy of the rofecoxib po before radical prostatectomy. DESIGN: Prospective, randomized, double-blinded, placebo-controlled trial. SETTING: Teaching hospital. PATIENTS: Anesthetic management was standardized. Patients received either a 50-mg rofecoxib capsule or a placebo capsule po 1 hour before induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Patient-generated 10-cm visual analog scale (VAS) scores for pain were assessed at 1, 2, 4, 6, 8, and 24 hours after surgery. Morphine consumption was recorded from a patient-controlled analgesia device at the same time. A patient-generated overall pain relief score was obtained at 24 hours after surgery. We were unable to detect any differences between study groups with respect to postoperative morphine consumption, VAS score, or overall pain relief score. CONCLUSIONS: When rofecoxib is used po in maximum recommended doses before surgery, it does not provide significant analgesia that results in reduction in pain scores or analgesic requirements for patients after radical prostatectomy.     

Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 129 patients

The efficacy of a single dose of cefotiam, a cephalosporin of the second generation, as prophylaxis for postoperative infection was analyzed in a prospective randomized study of 129 patients undergoing cerebrospinal fluid shunting. The main focus of interest was the rate of shunt infection requiring operative shunt removal. Data were evaluated in the total group and subgroups formed for normal and high risk patients, respectively. The overall rate of shunt infection was 7.5% in the cefotiam group and 12.9% in the control group. In the high risk subgroup infection rate was 14.3% with and 26.3% without cefotiam as opposed to 4.3% and 6.9%, respectively, in the normal risk subgroup. Although our results do not reach statistical significance, there is a noticeable difference of infection rate between those patients who receive the antibiotic and those who do not. Therefore, we favor single dose antibiotic prophylaxis in shunting procedures.     

Nitrous oxide does not change the incidence of postoperative delirium or cognitive decline in elderly surgical patients

Background. Postoperative delirium and cognitive decline arecommon in elderly surgical patients after non-cardiac surgery.Despite this prevalence and clinical importance, no specificaetiological factor has been identified for postoperative deliriumand cognitive decline. In experimental setting in a rat model,nitrous oxide (N₂O) produces neurotoxic effect at high concentrationsand in an age-dependent manner. Whether this neurotoxic responsemay be observed clinically has not been previously determined.We hypothesized that in the elderly patients undergoing non-cardiacsurgery, exposure to N₂O resulted in an increased incidenceof postoperative delirium than would be expected for patientsnot receiving N₂O. Methods. Patients who were 65 yr of age, undergoing non-cardiacsurgery and requiring general anaesthesia were randomized toreceive an inhalational agent and either N₂O with oxygen oroxygen alone. A structured interview was conducted before operationand for the first two postoperative days to determine the presenceof delirium using the Confusion Assessment Method. Results. A total of 228 patients were studied with a mean (range)age of 73.9 (65–95) yr. After operation, 43.8% of patientsdeveloped delirium. By multivariate logistic regression, age[odds ratio (OR) 1.07; 95% confidence interval (CI) 1.02–1.26],dependence on performing one or more independent activitiesof daily living (OR 1.54; 95% CI 1.01–2.35), use of patient-controlledanalgesia for postoperative pain control (OR 3.75; 95% CI 1.27–11.01)and postoperative use of benzodiazepine (OR 2.29; 95% CI 1.21–4.36)were independently associated with an increased risk for postoperativedelirium. In contrast, the use of N₂O had no association withpostoperative delirium. Conclusions. Exposure to N₂O resulted in an equal incidenceof postoperative delirium when compared with no exposure toN₂O. ⁴Present address: Staff Statistician, University of Pittsburgh,PA 15213, USA     

Dexamethasone for postoperative hyperbilirubinemia in patients after liver resection: An open-label,randomized controlled trial

Background

Although prophylactic glucocorticoids have been used before liver resection to minimize liver dysfunction, it is unknown whether treatment with glucocorticoids will accelerates recovery from hyperbilirubinemia after liver resection.

A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes. A prospective, randomized, controlled trial

BACKGROUND: Minimally invasive total hip arthroplasty has stirred substantial controversy with regard to whether it provides superior outcomes compared with total hip arthroplasty performed through longer incisions. The orthopaedic literature is deficient in well-designed scientific studies to support the clinical superiority of this approach. The objective of this study was to compare the results of a single mini-incision approach with those of a standard-incision total hip arthroplasty in the early postoperative period. METHODS: Two hundred and nineteen patients (219 hips) admitted for unilateral total hip arthroplasty between December 2003 and June 2004 were randomized to undergo surgery through a short incision of 相似文献   

Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 152 hydrocephalic patients

The authors report a prospective, randomized 18-month study on the effect of prophylactic antibiotic treatment in 152 hydrocephalic patients in whom clean shunt operations or revisions were done. The treated group received methicillin (totally 200 mg/kg) divided into six i.v. doses during 24 hours starting at the induction of anesthesia. Patients allergic to penicillin received erythromycin instead. Seventy-nine patients received antibiotics, and 73 (the control group) received none. All patients were followed at least 6 months after operation or to their death. Eleven patients developed signs of infection, giving an overall infection rate of 7.2%; however, the infection occurred less than 1 month after the operation in only half of these. Six of the patients had septicemia, 4 had peritonitis, and 1 had meningitis. In the treated group, the infection rate was 8.9%; in the control group, the rate was 5.5%. There was no statistically significant difference. The prophylactic antibiotic regimen in this investigation did not reduce the infection rate connected with cerebrospinal fluid shunting procedures.     

Pancreatic duct stenting for the duration of ERCP only does not prevent pancreatitis after accidental pancreatic duct cannulation: a prospective randomized trial

Background

Pancreatic duct stent placement during endoscopic retrograde cholangiopancreatography (ERCP) has been recommended in patients at risk for post-ERCP pancreatitis. However, the optimal duration of stent placement remains an open question. Our aim was to compare the efficacy of pancreatic stenting for the duration of ERCP only with spontaneous dislodgment/deferred endoscopic removal in preventing post-ERCP pancreatitis after accidental wire-guided pancreatic duct cannulation.

Methods

All patients in whom accidental wire-guided pancreatic duct cannulation had occurred during ERCP underwent immediate 5-Fr unflanged pigtail pancreatic duct stenting before attempting any other endoscopic maneuver. At the end of the ERCP, patients were randomly assigned to immediate stent removal (group A) or to leaving the stent in place (group B). Assessment of post-ERCP pancreatitis was blind.

Results

Post-ERCP pancreatitis occurred in 6/21 (29 %) patients in group A and in 0/19 patients in group B (P = 0.021); the two groups were well matched for their baseline characteristics. Post-ERCP pancreatitis was mild in two patients, moderate in two patients, and severe in two patients. Stents dislodged spontaneously in 14/19 (74 %) patients within 24–96 h; uneventful endoscopic removal was carried out after 96 h in 5 cases. Proximal stent migration did not occur in any case.

Conclusions

Pancreatic duct stent placement for the duration of ERCP only does not prevent post-ERCP pancreatitis. Pancreatic stents should be left in place until spontaneous dislodgment occurs or endoscopic removal is deemed timely. 5-Fr unflanged pigtail stents remain in place for a period sufficient to prevent post-ERCP pancreatitis and do not migrate proximally.     

Perioperative granulocyte colony-stimulating factor does not prevent severe infections in patients undergoing esophagectomy for esophageal cancer: a randomized placebo-controlled clinical trial

OBJECTIVE: Esophagectomy for esophageal cancer is associated with substantial postoperative morbidity as a result of infectious complications. In a prior phase II study, granulocyte colony-stimulating factor (G-CSF) was shown to improve leukocyte function and to reduce infection rates after esophagectomy. The aim of the current randomized, placebo-controlled, multicenter phase III trial was to investigate the clinical efficacy of perioperative G-CSF administration in reducing infection and mortality after esophagectomy for esophageal cancer. PATIENTS AND METHODS: One hundred fifty five patients with resectable esophageal cancer were randomly assigned to perioperative G-CSF at standard doses (77 patients) or placebo (76 patients), administered from 2 days before until day 7 after esophagectomy. The G-CSF and placebo groups were comparable as regards age, gender, risk, cancer stage, frequency of neoadjuvant radiochemotherapy, and type of esophagectomy (transthoracic or transhiatal esophageal resection). RESULTS: Of 155 randomized patients, 153 were eligible for the intention-to-treat analysis. The rate of infection occurring within the first 10 days after esophagectomy was 43.4% (confidence interval 32.8-55.9%) in the placebo and 44.2% (confidence interval 32.1-55.3%) in the G-CSF group (P = 0.927). 30-day mortality amounted to 5.2% in the G-CSF group versus 5.3% in the placebo group (P = 0.985). Similar results were found in the per-protocol analysis. CONCLUSION: Perioperative administration of G-CSF failed to reduce postoperative morbidity, infection rate, or mortality in patients with esophageal cancer who underwent esophagectomy.     

Cisapride does not prevent postoperative vomiting in children.

The peripherally acting prokinetic drug cisapride can overcome opioid-induced gastrointestinal paresis and may thereby eliminate a stimulus for postoperative vomiting. We conducted a prospective, randomized, double-blinded, controlled trial of 96 children undergoing inguinal surgery to determine whether cisapride would reduce the incidence of postoperative vomiting after general anesthesia supplemented with morphine. Group C1 patients (n = 38) received cisapride 0.3 mg/kg orally 1 h before surgery and placebo 6 h later, Group C2 (n = 28) received cisapride both before and after surgery, and Group P (n = 30) received placebo. Mean age (5.0 +/- 2.7 yr) and weight (21.0 +/- 8.6 kg), median pain scores and parent satisfaction scores, and incidence of rescue analgesic administration were similar across groups. Contrary to our hypothesis, incidences of postoperative vomiting in the hospital (32% vs 20%, P = 0.33) and at home (53% vs 46%, P = 0.33) did not vary by treatment group (with [C1 and C2] and without [P] cisapride, respectively). There was a trend toward more severe postoperative vomiting (three or more episodes) in children who received cisapride versus those who did not, both in hospital (6% vs 0%, P = 0.3) and at home (22% vs 8%) (P = 0.13). We conclude that cisapride does not prevent postoperative vomiting in this patient population and speculate that factors other than reduced gastrointestinal motility associated with general anesthesia and opioids are more important determinants of postoperative vomiting. IMPLICATIONS: Cisapride does not prevent postoperative vomiting in children and may increase its severity.     

Effects of different BP management strategies on postoperative delirium in elderly patients undergoing hip replacement: A single center randomized controlled trial

Study objectivePostoperative delirium (POD) is a common after hip replacement. Intraoperative blood pressure management may affect postoperative delirium. The aim of this study was to compare the effects of different blood pressure management strategies on POD.DesignA single center randomized controlled trial.SettingThe Second Hospital of Anhui Medical University, Hefei, China.PatientsA total of 150 patients aged 65–80 years underwent hip arthroplasty.InterventionsA random number table was used to divide the patients into three groups: mean blood pressure (MAP) was maintained from 10% to 20% below the baseline (group D), MAP was maintained from baseline to 10% below the baseline (group M), and MAP was maintained from baseline to 10% above the baseline (group H).MeasurementsThe primary endpoint was POD at 1–3 days. The secondary endpoint was the intraoperative MAP and regional cerebral oxygen saturation (rSO₂) value, MAP, Visual Analogue Scale (VAS score) 1–3 days after surgery, the lengths of post anesthesia care unit (PACU) stay and hospital stay and emergence agitation were recorded.Main resultsPatients in group H showed a lower incidence of POD on the first day than those in groups D and M (22% and 16% vs 4%; P = 0.031). There is no difference of incidence of POD on the 2rd and 3rd day postoperatively. Patients in group H received a higher MAP as well as rSO₂ during the operation compared the other two groups (P < 0.05). Compared with groups D and M, emergence agitation was significantly reduced (P = 0.029) and the lengths of PACU stay (P = 0.018) and hospital stay (P = 0.008) were shortened in group H.ConclusionsMaintenance of intraoperative blood pressure from baseline to 10% above the baseline helps to reduce the incidence of POD and emergence agitation and shorten the lengths of PACU stay and hospital stay, and it may be related to increased rSO₂ during the operation.     

Short-term pre-operative smoking cessation intervention does not affect postoperative complications in colorectal surgery: a randomized clinical trial

Background Smokers have a higher risk of complicated tissue and wound healing after surgery than nonsmokers. We tested the hypothesis that short‐term pre‐operative cessation of smoking in colorectal surgery decreases the incidence of postoperative tissue and wound complications. Methods From February 1998 to March 2001, 60 patients, who smoked daily, undergoing colorectal resection were randomly assigned 2–3 weeks before scheduled surgery to either abstinence from smoking, counselling and nicotine replacement therapy or maintenance of daily smoking habits. Postoperative tissue and wound complications necessitating surgical or medical treatment were evaluated at discharge and 30 days after surgery by blinded outcome assessment. Results In the pre‐operative period of 15 days (8–24) (median, interquartile range (IQR)), 89% of the patients in the intervention group vs. 13% in the control group abstained from smoking or reduced by more than half (P < 0.05). In the postoperative period of 11 days (10–13), the corresponding figures were 92% and 50%, respectively (P < 0.05). Postoperative tissue and wound complications occurred in 33% (9 of 27) of the patients in the intervention group compared to 27% (8 of 30) in the control group (NS). Likewise, no difference in overall postoperative complication rate was found between the groups. Conclusion Short‐term cessation of smoking does not reduce the risk of complicated tissue and wound healing or other complications in colorectal surgery.     

老年髋部手术后谵妄发病率的Meta分析

目的:采用 Meta分析综合评价老年髋部手术术后谵妄的发病率。方法:检索2004年1月1日至2013年12月31日Pubmed数据库有关老年髋部手术术后谵妄发病率的临床研究文献。按照文献的纳入及排除标准进行文献的筛选,制定文献摘录表;采用Stata-12.0进行Meta分析。计算I2以检验研究之间的异质性,当I2>50%时,采用随机效应模型。按照年龄阶段、谵妄评估量表及文献统计区域进行亚组分析。各文献采用Begg方法检验发表偏倚。结果:最终纳入21篇文献。加权合并的老年髋部手术术后谵妄发病率为17%[95%CI(16%,18%)].其中纳入的5篇文献中髋部择期手术术后谵妄发病率与髋部急诊手术相比明显降低[OR=0.32,95%CI (22%,45%)].小于80岁与大于80岁的谵妄发病率分别为21%[95%CI(19%,23%)]和21%[95%CI(19%,24%)];CAM与其他评定量表的谵妄发病率分别为23%[95%CI(21%,26%)]和19%[95%CI(17%,21%)];亚洲区域与欧美区域的谵妄发病率分别为17%[95%CI(15%,20%)]和23%[95%CI(21%,25%)].Begg方法检验未见明显发表偏倚(P<0.05).结论:老年髋部术后谵妄发病率较高,尤其在于急诊术后。为了利于老年术后谵妄发病率的评估、降低异质性及可能的发表偏倚,需要制定更标准化的研究方法。     

Anticholinergic prophylaxis does not prevent emesis following strabismus surgery in children

One hundred and twenty-one children were studied in this prospective, randomized double-blind, placebo-controlled comparison of the effectiveness of anticholinergic prophylaxis for the prevention of emetic symptoms following strabismus surgery. The children were allocated to three groups, to receive placebo (n= 40), glycopyrrolate (n= 40) or atropine (n= 41). The incidence of intraoperative oculocardiac reflex (OCR) and of postoperative emetic symptoms for 24 h was recorded. The incidence of OCR was 55% in the placebo group compared with 5% and 2% in the glycopyrrolate and atropine groups respectively (P < 0.05). Thirty percent (12/40) of patients in the placebo group, 25% (10/40) in the glycopyrrolate group, and 22% (9/41) in the atropine group experienced nausea and/or vomiting (difference not significant). It is concluded that prophylactic administration of anticholinergic agents during strabismus surgery in children despite being effective against the occurrence of the oculocardiac reflex, does not reduce the incidence of emetic symptoms.     

The hip fracture surgery in elderly patients (HIPELD) study to evaluate xenon anaesthesia for the prevention of postoperative delirium: a multicentre,randomized clinical trial

Background

Postoperative delirium occurs frequently in elderly hip fracture surgery patients and is associated with poorer overall outcomes. Because xenon anaesthesia has neuroprotective properties, we evaluated its effect on the incidence of delirium and other outcomes after hip fracture surgery.

Preoperative oral rofecoxib and postoperative pain in patients after laparoscopic cholecystectomy: a prospective, randomized, double-blinded, placebo-controlled trial

Cyclooxygenase-2 (COX-2) inhibitors are a class of drugs that may avoid some of the side effects of narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs). We performed a randomized, double-blinded, placebo-controlled trial giving a single oral dose of the COX-2 inhibitor rofecoxib 25 mg or placebo preoperatively to determine the impact upon postoperative pain, complications, narcotic use, and hospital stay after laparoscopic cholecystectomy. Investigators and patients were blinded. Pain was measured on a 10-point visual analogue scale. Eighty patients were randomized: 40 to the rofecoxib group and 40 to the placebo group. The amount of pain between the two groups postoperatively was equivalent. Pain was recorded at 1 hour, 4.03 +/- 1.93 in the rofecoxib group versus 4.38 +/- 1.34 in the placebo group (P = 0.36); at 6 hours, 3.00 +/- 1.12 in the rofecoxib group versus 2.78 +/- 0.78 in the placebo group (P = 0.42); and at 24 hours, 1.64 +/- 0.67 in the rofecoxib group versus 2.68 +/- 1.90 in the placebo group (P = 0.17). The amount of pain medication received and lengths of hospital stay was not significantly different between the two groups. Our data demonstrate no significant benefit of preoperative oral rofecoxib in patients undergoing laparoscopic cholecystectomy.     

应用小剂量右美托咪定预防老年髋骨折患者术后谵妄的前瞻性随机对照研究

目的 探讨应用小剂量右美托咪定预防老年髋骨折患者术后谵妄的有效性与安全性.方法 采用前瞻性随机对照研究方法.纳入2019年7月至2020年9月北京大学第四临床医学院北京积水潭医院重症医学科(ICU)收治的老年髋骨折术后患者127例,中位年龄86(83,89)岁.患者接受手术方式包括全髋关节置换术19例(15.0％),半...