Treatment of delirium in early postoperative cardiosurgical patients. Article

V.E. Rubinchik, I.Yu. Kasherininov, A.E. Bautin

Almazov National Medical Research Centre, St. Petersburg, Russia

For correspondence: Vadim E. Rubinchik — M. D., associate professor, the chief of the ICU#2 of Almazov National Medical Research Centre, St. Petersburg; e-mail: verubinchik@gmail.com

For citation: Rubinchik VE, Kasherininov IYu, Bautin AE. Treatment of delirium in early postoperative cardiosurgical patients. Article. Annals of Critical Care. 2019;3:77–83.

DOI: 10.21320/1818-474X-2019-3-77-83


Abstract

Background. Postoperative delirium is highly relevant in elderly patients who undergo cardiosurgical interventions with cardiopulmonary bypass (CPB), long stay in intensive care unit (ICU), suffering from widespread atherosclerosis and having a wide range of comorbidities.

In the world literature there is a lot of data on the successful use of dexmedetomidine for sedation, prevention and relief of delirium, including patients after open-heart interventions. Comparative evaluation of dexmedetomidine and neuroleptic sedation with “traditional” for Russian Federation management of cardiosurgical patients suffering from postoperative delirium seems to be a relevant clinical and research task.

Objectives. Comparative evaluation of the effectiveness of drug sedation with dexmedetomidine and propofol in cardiosurgical patients with postoperative delirium.

Material and Methods. An open prospective cohort study took place in 2017–2019 and included 42 patients who underwent open-heart intervention with CPB and had delirium in the postoperative period.

Exclusion criteria: severe brachiocephal artery atherosclerosis, acute period or consequences of stroke, signs of acute respiratory failure associated with the pathology of the respiratory system, severe cardiovascular failure, age over 80 years.

Detection and treatment of delirium were performed by an intensivist together with a psychiatrist. Haloperidol was used as the main antipsychotic. Depending on the drug used for medical sedation, the patients were divided into 2 groups: 22 patients underwent medical sedation with propofol, 20 with dexmedetomidine in the form of an extended infusion. According to the results of the study, the length of patients’ stay in the ICU and hospital, the need for vasopressor therapy, mechnical ventilation (MV), and the duration of delirium were analyzed.

Results. In patients of the dexmedetomidine group, compared with the propofol group, the following was observed: less need for vasopressors and the duration of their use, less frequent use of MV (27.2 % versus 10.0 % of cases, p < 0.05), shorter stay in ICU (4.4 ± 1.8 vs 7.2 ± 2.3 days, p < 0.05), and finally, more rapid relief of the delirium itself (34.7 ± 6.8 vs 52.6 ± 8.9 hours, p < 0.05). There was no statistically significant difference between the groups for the length of hospital stay.

Conclusions. In the early postoperative period of open-heart interventions, medical sedation using dexmedetomidine as a component of the delirium therapy seems to be preferable to propofol sedation. Using of dexmedetomidine during study was associated with more rapid relief of the delirium, more favorable hemodynamic profile, less need for MV and duration of MV, as well as shorter duration of stay in the ICU, compared with the use of propofol sedation, which allows us to recommend routine use of dexmedetomidine in the cardiosurgical ICU.

Keywords: cardiosurgery, postoperative period, delirium, sedation, dexmedetomidine.

Received: 26.03.2019

Accepted: 03.09.2019


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Organoprotective effects of the α2-adrenoreceptor agonist dexmedetomidine (literature review)

Vitik A.A.1, Shen N.P.2

Tyumen State Medical University, Tyumen

2 The branch of the Tomsk national research medical center “Tyumen Cardiology Research Center”, Tyumen

For correspondence: Shen N.P. — MD, Professor, head of Department of Obstetrics, Gynecology and critical care medicine with a course of KDL of the Institute of Continuing Professional Development of Tyumen State Medical University, Tyumen; e-mail: nataliashen@rambler.ru

For citation: Vitik A.A., Shen N.P. Organoprotective effects of the α2-adrenoreceptor agonist dexmedetomidine (literature review). Alexander Saltanov Intensive Care Herald. 2018;4:74–79.

DOI: 10.21320/1818-474X-2018-4-74-79


Currently, in experimental and clinical studies of critical states, scientists attend to the issues of protecting and preserving the functions of vital organs and systems. The pharmacological aspects of organoprotection with various drugs are considered separately. In this question, α2-adrenoreceptor agonists are of the greatest interest. The study is devoted to the analysis of domestic and foreign literature covering the efficacy of using dexmedetomidine adrenergic mimetic, its mechanisms of action and organ-preventive properties in ECMO patients with organic and mental disorders. Formulated aspects need to study the use of this drug in order to prevent neurocognitive and organ dysfunction in surgical and therapeutic patients who are in intensive care units.

Keywords: organoprotection, dexmedetomidine, α2-adrenoreceptor agonists, multiple organ dysfunction, delirium

Received: 05.10.2018


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Intraoperative hypotension

E.A. Leonova, G.B. Moroz, V.A. Shmyrev, V.V. Lomivorotov

E. Meshalkin National Medical Research Center, Ministry of Health of the Russian Federation, Novosibirsk

For correspondence: Vladimir Vladimirovich Lomivorotov — MD, PhD, Deputy Director for Research of E. Meshalkin National Medical Research Center; e-mail: vvlom@mail.ru

For citation: Leonova EA, Moroz GB, Shmyrev VA, Lomivorotov VV. Intraoperative hypotension. Alexander Saltanov Intensive Care Herald. 2018;3:87–96.

DOI: 10.21320/1818-474X-2018-3-87-96


The main objective of anesthesiologist is maintenance of patientʼs homeostasis during surgery. Among all the physiological parameters, only arterial pressure has such significant amplitude of oscillations, still the association between postoperative complications and blood pressure fluctuations is often unobvious. Furthermore, blood pressure is a modifiable parameter and can be easily regulated by fluids, vasopressor and inotropic agents in most cases.

Intraoperative decrease of blood pressure may occur due to the action of anesthetics, hypotensive drugs, nonphysiological positioning of the patient on the operating table, artificial ventilation, surgical procedures, cardiopulmonary bypass, hypovolemia, acid-base and electrolyte disorders, acute heart failure, arrhythmias, anaphylaxis and others factors.

The lack of consensus about the definition of hypotension makes difficulties in evaluation of its effect on human organism. More than 140 different absolute and relative values are used as hypotension thresholds. Nevertheless, the data accumulated over the past few years lead us to the conclusion that intraoperative decrease of blood pressure is associated with the development of various nervous, cardiovascular and renal complications, what ultimately leads to increased morbidity and mortality. Severity of adverse effects is a function of range and duration of blood pressure fall.

Every patient has an individual set of genetic, physiological and pathophysiological features that determine the optimal blood pressure level. Thus, another promising direction may be development of the strategy for individualized blood pressure management.

Keywords: blood pressure, hypotension, stroke, delirium, myocardial infarction, acute kidney injury

Received: 24.07.2018


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